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Disturbances in Cellular Functioning

DEFINITION OF TERMS

A. Anaplasia a change in the structure and

orientation of cells, characterized by a loss of differentiation and reversion to a more primitive form. Anaplasia is characteristic of malignancy. B. Biologic Response Modifier (BRM) Therapy use of agents or treatment methods that can alter the immunologic relationship between the tumor and the host to provide a therapeutic benefit. C. Biopsy a diagnostic procedure to remove a small PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS A. PATHO sample of tissue to be examined microscopically to 1. Predisposing/etiologic factors detect malignant cells. 2. Genetic mutation of cellular DNA D. Brachytherapy delivery of radiation through 3. Transformation of normal cell to abnormal internal implants. cell E. Carcinogenesis process of transforming normal 4. Abnormal cells form a clone and proliferate cells into malignant cells. abnormally (Pressure, obstruction, pain, F. Chemotherapy use of drugs to kill tumor cells by effusion, ulceration and necrosis, vascular interfering with cellular functions and reproduction. thrombus, embolus, thrombophlebitis) G. Cytokines substances produced by cells of the 5. Further proliferation and invasion of immune system to enhance production and surrounding tissues functioning of components of the immune system. 6. Gain access to lymph and blood vessels 7. Metastasis H. Dysplasia abnormal development of B. PROLIFERATIVE PATTERNS tissues/organs. 1. During the lifespan, various body tissues I. Extravasation leakage of medication from the normally experience periods of rapid or veins into the subcutaneous tissues. proliferative growth that must be distinguished J. Hyperplasia an increase in the number of cells of from malignant growth activity. a body part that result from an increased rate of 2. Cancerous cells are described as malignant cellular division. neoplasms. They demonstrate uncontrolled cell K. Metaplasia the reversible conversion of normal growth that follows no physiologic demand. tissue cells into another, less differentiated cell type C. CHARACTERISTICS OF MALIGNANT CELLS in response to chronic stress or injury. 1. The cell membranes are altered in cancer L. Metastasis spread of cancer cells from the cells. primary tumor to distant sites. 2. Cell membrane of malignant cells contains M. Myelosuppression suppression of the blood cell proteins called tumor-specific antigen. These producing functions of the bone marrow. proteins distinguish the malignant cell from a N. Nadir lowest point of WBC depression after benign cell of the same tissue type. therapy that has toxic effects on the bone marrow 3. Malignant cellular membranes also contain less fibronectin - a cellular cement. O. Neoplasia the new and abnormal development of 4. Nuclei of cancer cells are large and cells that may be benign or malignant. irregularly shaped (pleomorphism). P. Neutropenia abnormally low absolute neutrophil 5. Nucleoli, structures within the nucleus that cnt. house RNA, are larger and more numerous in Q. Oncology field of study of cancer. malignant cells, perhaps because of increased R. Palliation relief of symptoms associated with RNA synthesis. cancer. 6. Mitosis (cell division) occurs more frequently S. Thrombocytopenia decrease in the number of in malignant cells than in normal cells. As the circulating platelets; associated with the potential cells grow and divide, more glucose and oxygen for bleeding. are needed. T. Vesicant substance that can cause tissue necrosis D. INVASION AND METASTASIS and damage, particularly when extravasated. 1. by circulatory patterns and by specific U. Xerostomia dry oral cavity resulting from affinity for certain malignant cells to bind to decreased function of salivary glands. molecules in specific body tissue. 2. Invasion, which refers to the growth of primary tumor into the surrounding host tissues, occurs in several ways. Mechanical EPIDEMIOLOGY pressure exerted by rapidly proliferating

A. most cancers occur in people older than 65 years of age. B. Higher in men and higher in industrialized sectors and nations. C. The leading causes of cancer deaths in the United States are lung, prostate, and colorectal for men and lung, breast, and colorectal for women.

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neoplasms may force fingerlike projections of 1. Viruses are thought to incorporate tumor cells into surrounding tissue and themselves in the genetic structure of cells, interstitial spaces. thus altering future generations of that cell 3. Malignant cells are less adherent and may population break off from the primary tumor and invade B. Physical agents adjacent structures. 1. Include exposure to sunlight or radiation, 4. Malignant cells are thought to possess or chronic irritation or inflammation, and tobacco produce specific destructive enzymes use. (proteinases), such as collagenases (specific to C. Genetic and familial factors collagen), plasminogen activators (specific to 1. May be due to genetics, shared plasma), and lysosomal hydrolyses environments, cultural or lifestyle factors, or E. METASTATIC MECHANISMS chance alone. 1. Lymph and blood are key mechanisms by D. Dietary factors which cancer cells spread. 1. Dietary substances can be proactive 2. The most common mechanism of metastasis (protective), carcinogenic, co-carcinogenic is lymphatic spread, which is transport of tumor 2. Dietary substances associated with an cells through the lymphatic circulation. increased cancer risk include fats, alcohol, salt3. Tumor emboli enter the lymph channels by cured or smoked meats, foods containing way of the interstitial fluid that communicates nitrates and nitrites, and a high caloric dietary with lymphatic fluid. intake 4. Malignant cells also may penetrate 3. Foods to reduce cancer risk are: high fiber lymphatic vessels by invasion. foods, cruciferous vegetables, carotenoids and 5. Malignant cells either lodge in the lymph vitamins C & E nodes or pass between lymphatic and venous 4. Benzopyrene charcoal broiled meat or fish circulation. or foods fried in repeatedly used cooking oil. 6. Tumors arising in areas of the body with 5. Nitrosamines powerful carcinogens used as rapid and extensive lymphatic circulation are at preservatives for tocino, longganisa, bacon and high risk for metastasis through lymphatic hotdog. Formation may be inhibited by taking channels (breast tumors). antioxidants like Vitamin C 7. Another metastatic mechanism is E. Chemical agents hematogenous spread, by which malignant cells 1. Polycyclic hydrocarbons found in cigarette are disseminated through the bloodstream. smoke, industrial agents and smoked foods 8. Hematogenous spread is directly related to 2. Aflatoxin found in peanuts and peanut the vascularity of the tumor. butter 9. Malignant cells also have the ability to 3. Other chemicals include asbestos, induce the growth of new capillaries to meet formaldehydes, pesticides their needs for nutrients and oxygen 4. Most hazardous chemicals produce their (angiogenesis). toxic effects by altering the DNA structure in F. CARCINOGENESIS body sites distant from chemical exposure. 1. A three-step cellular process: initiation, Liver, lungs, kidneys are the organs systems promotion, and progression. most often affected 2. Initiation carcinogens escape normal F. Hormonal agents enzymatic mechanisms and alter the genetic 1. Tumor growth may be promoted by structure of the cellular DNA. The alterations disturbances in hormonal balance either by the are reversed by DNA repair mechanisms or bodys own (endogenous) hormone production apoptosis but others escape these protective or by administration of exogenous hormones mechanisms. 3. Promotion repeated exposure to promoting WARNING SIGNS OF CANCER BY THE AMERICAN agents (co-carcinogens) causes the expression CANCER SOCIETY (CAUTION US) of abnormal or mutant genetic information. A. C Change in bowel or bladder habits 4. Progression the cellular changes formed 1. Changes in stream/flow of urine or its color during initiation and promotion now exhibit and amount increased malignant behavior. These cells now 2. Changes in the caliber and color of stools show a propensity. 3. Presence of blood in stools 4. Difficulty in urination and defecation ETIOLOGY B. A A sore that does not heal 1. Skin irritations are usually self-limiting. If A. Viruses and bacteria changes in the skin and underlying muscles

Disturbances in Cellular Functioning

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C.

D. E. F. G. H. I.

take time to heal, it is recommended to have it examined. U Unusual bleeding or discharge 1. Unusual discharges in the breast, for nonbreastfeeding women T Thickening or lump in the breast I Indigestion and difficulty in swallowing O Obvious change in wart or mole N Nagging cough or hoarseness of voice U Unexplained anemia S Sudden weight loss

Disturbances in Cellular Functioning


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If you notice any changes from one month to the next, notify your physician or nurse practitioner.

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EARLY DETECTION A. BREAST SELF EXAMINATION 1. Performed every 7 to 10 days after menses 2. Postmenopausal clients or clients who have had a hysterectomy should select a specific day of the month and perform BSE monthly on that day 3. First while in the shower or bath, when the skin is slippery with soap and water, examine your breasts, use the pads of your second, third, fourth fingers to press every part of the breast firmly. 4. Second look at your breasts in a mirror stand with your arms at your side 5. Third raise your arms overhead and check for any changes in the shape of your breasts, dimpling of the skin, or any changes in the nipple. 6. Fourth place your hand on your hips and press down firmly, tightening the pectoral muscles. Observe for asymmetry or changes, keeping in mind that your breasts probably do not match exactly. 7. Fifth while lying down, feel your breasts as described in 1. When examining your right breast, place a folded towel under your right shoulder and put your right hand behind your head. 8. Mark your calendar that you have completed your breast self examination. Note any changes or unique characteristics you want to check with your health care provider. B. TESTICULAR SELF EXAMINATION 1. The best time to perform this examination is right after a shower when your scrotal skin is moist and relaxed, making the testicles easy to feel 2. gently lift each testicle. Each one should feel like an egg, firm but not hard, and smooth with no lumps 3. using both hands, place your middle fingers on the underside of each testicle and your thumb on top 4. Gently roll the testicle between the thumb and fingers to feel for any lumps, swelling, or mass

DIAGNOSTIC TESTS A. Biopsy 1. Is the definitive means of diagnosing cancer and provides histological proof of malignancy. 2. Involves the surgical incision of a small piece of tissue for microscopic examination. B. Fine needle aspiration 1. Is the aspiration of cells and tissue fragments through a needle that has been guided to a suspected malignant tissue. 2. Is the procedure of choice if high risk of malignancy. 3. Well tolerated with little trauma. 4. A local anesthetic may be used. 5. May be guided by CT scan or ultrasound. C. Needle core biopsy 1. This involves obtaining a core of tissue through a specially designed needle introduced into a suspected malignant tissue. 2. A local anesthetic is used. D. Incisional biopsy 1. Removal of a small wedge of tissue from a larger tumor mass. 2. Is the preferred method for diagnosing soft tissue and bony sarcomas and used for large tumors that will need major surgery. E. Excisional biopsy 1. Excision of the entire suspected tumor mass with no attempt to obtain generous margins of adjacent normal tissue. 2. Procedure of choice for small accessible tumors. 3. Following excision, a frozen section or a permanent paraffin section is prepared to examine the specimen. 4. The advantage of the frozen section is the speed with which the section can be prepared and the diagnosis made, because only minutes are required for this test. 5. Permanent paraffin section takes about 24 hours; however, it provides clearer details that the frozen section. 6. Procedure is usually performed in an outpatient surgical setting. 7. Obtain an informed consent. F. Complete blood count (CBC) G. Computed tomography (CT) scan 1. Use of narrow beam x-ray to scan successive layers of tissue for a cross sectional view H. Magnetic resonance imaging (MRI) 1. Use of magnetic fields and radiofrequency signals to create sectioned images of various body structures I. Tumor marker identification

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Analysis of substances found in blood or other body fluids that are made by the tumor or by the body in response to the tumor. Fluoroscopy 1. Use of x-rays that identify contrasts in body tissue densities; may involve the use of contrast agents. Ultrasonography 1. High frequency sound waves echoing off body tissues are converted electronically into images; used to assess tissues deep within the body. Endoscopy 1. Direct visualization of a body cavity or passageway by insertion of an endoscope into a body cavity or opening; allows tissue biopsy, fluid aspiration and excision of small tumors; both diagnostic and therapeutic Positron emission tomography (PET scan) 1. Computed cross sectional images of increased concentration of radioisotopes in malignant cells provide information about biologic activity of malignant cells; help distinguish between benign and malignant processes and responses to treatment. Radioimmunoconjugates 1. Monoclonal antibodies are labeled with a radioisotope and injected intravenously into the patient; the antibodies that aggregate at the tumor site are visualized with scanners.

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Disturbances in Cellular Functioning mikEL rlh mantong 2. N the absence or presence and extent of
regional lymph node metastasis a. NX regional lymph nodes cannot be assessed b. N0 no regional lymph node metastasis c. N1, N2, N3 increasing involvement of regional lymph nodes 3. M the absence or presence of distant metastasis a. MX distant metastasis cannot be assessed b. M0 no distant metastasis c. M1 distant metastasis DIFFERENT TYPES OF CANCER A. SKIN CANCER 1. Is a malignant lesion of the skin, which may or may not metastasize 2. Skin cancer causes include chronic friction and irritation to a skin area and exposure to ultraviolet rays. 3. Diagnosis is confirmed by a skin biopsy that is positive for cancer cells 4. Types: a. Basal cell the most common type, basal cell cancer arises from the basal cell contained in the epidermis. 1) Waxy border 2) papule, red, central crater 3) metastasis is rare b. Squamous cell the second most common type of skin cancer in whites; squamous cell cancer is the tumor of the epidermal epidermal keratinocytes and can infiltrate surrounding structures, metastasize to lymph nodes, and subsequently be fatal. 1) Oozing, bleeding, crusting lesion 2) Potentially metastatic 3) Large tumors associated with a higher risk for metastasis c. Malignant melanoma may occur any place on the body, especially where birthmarks or new moles are apparent. Cancer of the melanocytes can metastasize to the brain, bones, lung, liver and skin and is ultimately fatal. 1) Irregular, circular, bordered lesion with hues of tan, black or blue 2) Rapid infiltration into tissue, rapid metastasis, significant rate of morbidity and mortality 5. Instruct the client regarding preventive measures 6. Instruct the client to monitor for lesions that do not heal or that change characteristics 7. Instruct the client to have moles or lesions removed that are subject to chronic irritation 8. Instruct the client to avoid contact with chemical irritants

TUMOR STAGING AND GRADING A. Grade 1. Grade 1 cells differ slightly from normal cells and are well differentiated (mild dysplasia) 2. Grade 2 cells are more abnormal and are moderately differentiated (moderate dysplasia) 3. Grade 3 cells are very abnormal and are poorly differentiated (severe dysplasia) 4. Grade 4 cells are immature and undifferentiated; cell of origin is difficult to determine (anaplasia) B. Stage 1. Stage 0 carcinoma in situ 2. Stage 1 tumor limited to the tissue of origin; localized tumor growth 3. Stage 2 limited local spread 4. Stage 3 extensive local and regional spread 5. Stage 4 distant metastasis C. TNM CLASSIFICATION 1. T the extent of the primary tumor a. TX primary tumor cannot be assessed b. T0 no evidence of primary tumor c. Tis carcinoma in situ d. T1, T2, T3, T4 increasing size and/or local extent of the primary tumor

Instruct the client to wear layered clothing and use sunscreen lotions with an appropriate skin protection factor when outdoors 10. Instruct the client to avoid sun exposure between 11 AM and 3 PM 11. Assist with surgical excision of the lesion as prescribed B. BREAST CANCER 1. Is classified as invasive when it penetrates the tissue surrounding the mammary duct and grows in an irregular pattern 2. Metastasis occurs via lymph node 3. Diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the tumor with microscopic examination of malignant cells 4. Assessment a. Mass felt during BSE b. Asymmetry, with the affected breast being higher c. Bloody or clear nipple discharge d. Skin dimpling, retraction, or ulceration e. Skin edema or peau dorange skin f. Axillary lymphadenopathy g. Lymphedema of the affected arm 5. Non surgical interventions a. Chemotherapy b. Radiation therapy c. Hormonal manipulation via the use of medication in post-menopausal women or other medications such as tamoxifen (Nolvadex) for estrogen receptor-positive tumors. 6. Surgical interventions a. 1. Lumpectomy 1) tumor is excised and removed 2) lymph node dissection may also be performed b. 2. simple mastectomy 1) breast tissue and the nipple are removed 2) lymph nodes are left intact c. 3. modified radical mastectomy 1) breast tissue, nipple, and lymph nodes are removed 2) muscles are left intact 7. monitor vital signs 8. position the client in Semi-Fowlers position 9. turn from the back to the unaffected side, with the affected arm elevated above the level of the heart to promote drainage and prevent lymphedema 10. encourage coughing and deep breathing 11. if a drain (usually Jackson Pratt) is in place, maintain suction and record the amount of drainage and drainage characteristics 12. assess operative site for infection, swelling, or presence of fluid collection under the skin flaps or in the arm

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Disturbances in Cellular Functioning

13. place a sign above the bed stating: No IVs, No injections, No BPs, No venipuncture in affected arm; the affected arm is protected and any intervention that could traumatize the affected arm is avoided. 14. Consult with the physician and physical therapist regarding the appropriate exercise program and assist client with prescribed exercise 15. Client instruction following mastectomy: 16. Avoid overuse of the arm during the first few months 17. To prevent lymphedema, keep the affected arm elevated 18. Encourage the client to perform BSE on the remaining breast 19. Protect the affected hand and arm 20. Do not let the affected arm hang dependent 21. Do not carry pocketbook or anything heavy over the affected arm 22. Avoid trauma, cuts, or bruises, or burns to the affected side 23. Avoid wearing constricting clothing or jewelry on the affected side 24. Wear gloves when gardening 25. Use thick oven mitts when cooking 26. Use a thimble when sewing C. LUNG CANCER 1. About Lung Cancer a. Malignant tumor of the bronchi and peripheral lung tissue, is a leading cause of cancer-related deaths in men and women in the United States b. The lungs are a common target for metastasis from other organs c. Bronchogenic cancer (tumors originate in the epithelium of the bronchus) spreads through direct extension and lymphatic dissemination d. Classified according to histological cell type, there are two main types of lung cancer, small cell lung cancer and nonsmall cell lung cancer. e. Diagnosis is made by a chest x-ray, CT scan, or MRI, which will show a lesion or mass and by bronchoscopy and sputum studies, which will demonstrate a positive cytological study for cancer cells 2. CAUSES a. Cigarette smoking, exposure to passive tobacco smoke b. Exposure to environmental and occupational pollutants 3. ASSESSMENT a. Cough b. Wheezing, dyspnea c. Hoarseness d. Hemoptysis e. Chest pain

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f. Anorexia g. Weakness h. Diminished or absent breath sounds, respiratory changes 4. INTERVENTIONS a. Monitor vital signs b. Monitor for breathing patterns and breath sounds c. Place in a fowlers position to help ease breathing d. Administer oxygen as prescribed and humidification to moisten and loosen secretions e. Monitor pulse oximetry f. provide a high calorie, high protein, high vitamin diet g. provide activity as tolerated, rest periods, and active and passive range of motion exercises h. monitor for bleeding and infection 5. NONSURGICAL INTERVENTIONS a. radiation therapy may be prescribed for localized intrathoracic lung cancers and for palliation of hemoptysis, obstructions, dysphagia, superior vena cava syndrome, and pain b. chemotherapy may be prescribed for treatment of nonresectable tumors or as adjuvant therapy 6. SURGICAL INTERVENTIONS a. laser therapy: to relieve endobronchial obstruction b. thoracentesis and pleurodesis: to remove pleural fluid and relive hypoxia c. thoracotomy with pneumonectomy: surgical removal of one entire lung d. thoracotomy with segmental resection: surgical removal of a lobe segment D. PROSTATE CANCER 1. About Prostate Cancer a. A slow growing malignancy of the prostate gland; most prostate tumors are adenocarcinoma arising from androgendependent epithelial cells b. The risk increases in men with each decade after the age of 50 years c. Can spread by direct invasion of surrounding tissues or by metastasis, through the blood stream and lymphatics, to the bony pelvis and spine d. The cause of prostate cancer is unclear, but advancing age, heavy metal exposure, smoking, and history of sexually transmitted disease are contributing factors 2. ASSESSMENT a. Asymptomatic in early stages b. Hard, pea-sized nodule or irregularities palpated on rectal examination

Disturbances in Cellular Functioning

c. Gross, painless hematuria

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