CANCER

Large Group of Diseases

Epidemiology
Affects every age group - Most > 65 yo > in men than women > industrialized sectors & nations. > 1.5 million Americans diagnosed each year > 560,000 die annually of malignant process Men - Lung, prostate, colorectal Women - Lung, breast, colorectal 5 year survival rate

NEOPLASIA
Any new or continued cell growth not needed for normal development or for replacement of dead and damaged tissues Neoplasia is always abnormal The new cells could be benign or malignant Neoplastic cells develop from normal cells

Pathophysiology
Hypertrophy is cell growth that causes tissue to increase in size by enlarging each cell Hyperplasia is growth that causes tissue to increase in size by increasing the number of cells Neoplasia is any new or continued cell growth not needed for normal development or replacement of dead and damaged tissues

Characteristics of Normal Cells

Have limited cell division normal cells divide for one of two reasons To develop normal tissue To replace lost or damaged tissue Show specific morphology

Have a small nuclear-cytoplasmic ratio

Perform specific differentiated functions

How are cancer cells different from normal cells?

They follow no rules They exhibit the following characteristics Dysplasia Hyperplasia Metaplasia

Characteristics of Cancer Cells

Lose some or all differentiated function. Cancer cells have no useful purpose
Adhere loosely together Grow by invasion invasion and persistent growth make untreated cancer deadly

Characteristics of Cancer Cells

Carcinogenesis is another name for cancer development Transformation of a normal cell into a cancer cell involves mutation of the genes (DNA) of the normal cell Only one cell has to undergo malignant transformation for cancer to begin Benign tumors grow by expansion, whereas malignant tumors grow by invasion

Key Concepts
Primary prevention of cancer involves avoiding exposure to know causes of cancer Secondary prevention of cancer involves screening for early detection Tobacco use is a causative or permissive factor in 30% of all malignant neoplasms Tumors that metastasize from the primary site into another organ are still designated as tumors of the originating tissue

Basic Features of Cancer Cells

Unregulated cell growth Ability to invade other tissues Ability to initiate new growth at distant sites Ability to escape detection and destruction by the immune system

Cell Characteristics
Normal Cell No rapid division Contact inhibited Adhere tightly together Do not break loose or migrate Differentiated and have specific function Malignant Cell Rapid growth Do not recognize or respect tissue borders Break off and migrate Lose differentiation Reproduction out of control

How Do Cancers Get Started?

It is called carcinogenesis It is the process by which normal cells become malignant cells Many factors can cause cancer or contribute to the transformation of a cell from normal to malignant

Tumor Doubling Times

Once the cancer goes through about 30 doublings, it has reached roughly the size of a marble, about 1 cm in diameter This size tumor contains about one billion cancer cells This is about the earliest stage a cancer can be detected Much of the life span of a cancer is silent

Metastasis
Metastasis occurs through a progression of steps: Extension into surrounding tissue Blood vessel penetration Release of tumor cells Invasion Local seeding Bloodborne metastasis Lymphatic spread

Cancer Classification
Cancer grading and staging help standardize diagnosis, treatment, and prognosis Grading on the basis of cell appearance and activity compares the cancer cell with its normal parent tissue

Staging classifies clinical aspects of the cancer and determines exact location and degree of metastasis at diagnosis

Cancer Development
Carcinogenesis takes years and depends on several tumor and client factors. Three interacting factors influence cancer development: Chemical carcinogenesis Dietary factors Personal factors

Cancer Development
Viral Carcinogenesis Only a few viruses are proven to be carcinogenic, there are many more that are suspected to play major roles in cancer development When viruses infect body cells, they break the DNA chain and insert their own genetic material into the DNA chain

Viruses that cause cancer are oncoviruses

Malignancies Associated with a Known Viral Origin

Epstein-Barr virus-- nasopharyngeal carcinoma
Hepatitis B virusPrimary liver carcinoma Human Papilloma virusCervical carcinoma, and other genital carcinomas

Cancer Prevention
Avoidance of known of potential carcinogens
Modification of associated factors

Removal of at-risk tissues

Screening programs Gene therapy

Influence of Immunosurveillance on Cancer Development

It is believed that we all have single cell mutations that could develop into cancers if the immune system did not attack the tumor cells Various carcinogens may transform cells to malignant potential, but the immune system effectively nips it in the bud before the cancer can grow

Benign Neoplasm Characteristics

Cells resemble normal cells of tissue from which it originated Does not infiltrate Is encapsulated Rate of growth is usually slow Does not spread by metastasis Does not recur when removed

Carcinogenesis: Malignant Transformation

Three-step cellular process: Initiation Promotion Progression

Ability To Metastasize Requires Multiple Steps

Invasion of adjacent tissues through basement membranes Entrance into nearby vessels Evasion of the immune system Reentrance into distant tissues Implantation of malignant cell in new tissue

Cancer Prevention & Detection

External Factors Causing Cancer

Chemical Carcinogenesis Some chemicals are complete carcinogens Some chemicals are pure initiating agents, or incomplete carcinogens. Cancers of nerve tissue, cardiac muscle, and skeletal muscle are rare. These cells do not normally undergo cell division

Risk Factors For Cancer

Over 70% of all cancers are associated with lifestyle choice

Cigarette smoking is the most preventable cause of cancerrelated death in the US

Primary and Secondary Levels of Cancer Prevention

Primary prevention refers to simple measures taken early to avoid the development of cancer Secondary prevention targets specific populations and refers to activities such as testing or screening

Diagnosis
Diagnosis of cancer requires a tissue biopsy
Types: Needle, incisional & excisional

Tumor Staging
TNM system of the American Joint Committee on Cancer is preferred for solid tumors T = The extent of the tumor Characteristics of a given tumor N = The extent of spread to the lymph nodes Presence or absence of involved nodes M = Presence or absence of metastases

Reasons for Staging

The extent to which a disease has spread is prognostic Extent of disease often dictates treatment Accurate staging allows collection of data that eventually provide information about treatment outcomes for each type of cancer and each stage of disease.

How Is Staging Done?

Begins with History & Physical CBC, chemistry tests of liver & kidney function and a Urine Analysis A wide variety of tests is available to evaluate the extent of a particular disease X-rays Computerized axial tomography (CAT) scans Magnetic resonance imaging (MRI) scans Nuclear medicine scans

Tumor Markers
Biochemical indicators of neoplastic activity found in the blood Alpha-fetoprotein (AFP) Carcinoembryonic antigen (CEA) Colon, rectum, pancreas, stomach, lung, breast & ovary CA 125 Epithelial ovarian neoplasms, breast, colorectal CA 19-9 Colorectal, pancreas, stomach, liver Human chorionic gonadotropin (HCG) testicular teratoma Prostate-specific antigen (PSA) Adenocarcinoma of prostate

Teratoma

Tests To Evaluate Extent of the Cancer

X-Rays CAT scans

Magnetic Resonance Imaging (MRI) Nuclear Med Scans Fluroscopic Studies

Principles Of Therapy
Major treatment modalities Surgery Radiation therapy Chemotherapy Hormonal therapy

Curative and Palliative Treatment

Curative Tx
Intent is to eradicate malignant dx Therapy should be aggressive

Palliative Tx
Given when the disease is not curable Survival time is limited To alleviate symptoms Improve quality of life

Adjuvant Therapy
The use of a therapy, usually chemotherapy, along with another treatment modality Adjuvant therapy is given with curative intent

Pharmacology of Chemotherapy Agents

Chemotherapy Drugs Interfere with steps of the cell cycle

Chemotherapy is classified according to the pharmacologic action of effect on cellular reproduction Cell-cycle specific Cell-cycle nonspecific drugs See Table Antineoplastic Agents

Treatment Issues
Drug dosagecalculated according to the type of cancer and the clients size Drug scheduleregular basis and are timed to maximize cancer cell kill and minimize damage to normal cells. The entire planned schedule is the course of chemotherapy Drug administrationmostly IV due to rapid effects and agents are irritating and damaging to tissues

Serious Side Effects of Chemotherapy

Alopecia (hair loss) Nausea and vomiting Open sores on mucous membranes (mucositis) Altered bowel elimination Decreased mobility Hematopoietic system changes Bone marrow suppression Decreased leukocyte numbers Decreased numbers of circulating erythrocytes (anemia) Thrombocytopenia Immunosuppression places the client at extreme risk for infections and is the major dose-limiting side effect of cancer chemotherapy Most infections that develop in a client with neutropenia result from overgrowth of the clients own normal flora

Principles For Use of Combination Chemotherapy

Only drugs that are active against the tumor to be treated are included The drugs should have a different mechanism of action to minimize the possibility of drug resistance The drugs should have different toxic side effects, thus allowing administration of full doses of each active agent Each drug should be given at an optimal dose & schedule & at consistent intervals

Multible Cycles of Chemotherapy

According to the log cell kill hypothesis:
Treatment must be repeated many times to achieve control At any given exposure chemotherapy drugs kill only a fraction of the cells

Hormonal Therapy An Example

Testosterone converts into Dihydrotestosterone (DHT) DHT is a hormone believed to contribute to the development of prostate cancer The goal of hormone manipulation is to inhibit the formation of testosterone

Radiation Therapy
Goal is to destroy tumor cells while sparing normal cells
Radiation is delivered from a distance by a machine OR close to the patient via an implanted or injected radioactive source (Brachytherapy Internal Radiation)

Brachytherapy or Internal Radiation

Placement of sealed radioactive sources close to the tumor to provide a high dose of radiation directly to the tumor

Does not cause irreparable damage to radiosensitive normal tissues

Currently used for cancers of the cervix, prostate, lung, breast, brain and melanomas of the eye

Nursing Care
Pain management Pain may result from a variety of stimuli Careful assessment is critical in order to identify the physical causes and psychosocial factors that modulate pain intensity & its perception

Cancer Pain
Bone Metastasis Nerve compression Lymphatic or venous obstruction Ischemia Organ obstruction Skin inflammation, ulceration, infection, necrosis

Nutritional Support
Protein-calorie malnutrition Occurs when this macronutrient intake cannot meet the bodys metabolic needs From 40 80 % of all cancer patients experience some degree of malnutrition

Factors that Lead to Development of Cancer Cachexia

Taste changes Altered hypothalamic control of appetite Psychological & emotional factors Pain Mechanical interference from tumor or treatment side effects

Nursing Care
Decreasing fatigue Improving body image & self-esteem Grieving Potential complications
Infection Septic shock Bleeding & hemorrhage

Promoting home & community-based care.

Teaching patient self-care Continuing care home care/hospice

General Interventions for

Clients with Cancer

General Disease-Related Consequences of Cancer

Cancers that are left untreated cause Impaired immune and hematopoietic (blood producing) function Altered gastrointestinal structure and function Motor and sensory deficits Decrease respiratory function

Surgery as Cancer Treatment

Oldest form of cancer treatment used for: Prophylaxis Diagnosis (biopsy) Cure Control Palliation Determining efficacy of therapy Reconstruction

Radiation Therapy for Cancer

Purpose: to destroy cancer cells with minimal exposure of the normal cells to the damaging actions of radiation Mechanism of action Killing Effect Teletherapy Brachytherapy

CYBER KNIFE
A form of radiation therapy Non invasive alternate to surgery Delivers high dose radiation Uses a Robotic radiosurgery system No simulation necessary prior to treatment Method of painting the tumor Shorter treatment time Minimal side effects

Side Effects of Radiation Therapy

Vary according to the site Local Skin Changes Altered Taste Sensations Fatigue Inflammatory Responses

Nursing Care of Clients Undergoing Radiation Therapy

Teach accurate objective facts to help client cope Do not remove markings Administer skin care Do not use lotions or ointments Avoid direct exposure of the skin to the sun Care for xerostomia (dry skin) Bone exposed to radiation is more vulnerable to fracture

Hormonal Manipulation
Some hormones make hormone-sensitive tumors grow more rapidly Some tumors require specific hormones to divide, therefore decreasing the amount to these hormones to hormone-sensitive tumors can slow the cancer growth rate and increase survival time

Side Effects of Hormone Therapy

Androgens and antiestrogen receptor drugs cause masculinizing effects in women For men and women receiving androgens, acne may develop, hypercalcemia is common, and liver dysfunction may occur with prolonged therapy Feminine manifestations often appear in men who take estrogens Testicular and penile atrophy also occurs.

Immunotherapy: Biological Response Modifiers (BMRs)

Drugs that modify the clients biological responses to tumor cells Cytokines: enhance the immune system, make it work better Two types of BRMs Interleukinscharge up Interferonsslow down

Gene Therapy
Experimental as a cancer treatment Renders tumor cells more susceptible to damage or death by other treatments Injection into tumor cells, enabling the immune system to better recognize cancer cells as foreign and kill them Targeted therapycombine biologic therapy and gene therapy Side effect allergic reaction

Loss & Grief

Kubler Ross Stages of Grieving

Denial Anger Bargaining Depression Acceptance

Dr. Roberta Temes Stages of Grieving

Numbness Disorganization Reorganization

Culture and death

Grieving used to be much more ritualistic than it is today. In generations past there were set periods of time when certain customs must be observed: Widows wore all black clothing for one year and drab colors forever after. Mourners could not attend social gatherings for months. Laughter and gaiety were discouraged for weeks or months. Some may be religious in nature, others family or traditions

Palliative Care
Terminology Palliative care Broad concept of care that focuses on the comfort of the patient Hospice care Dying is a normal process and should not be hastened or postponed End-of-life care

Assessment of Loss & Grief

Define the nature of findings and symptoms Perform history and physical examination Evaluate problem Discuss care options

Symptoms at the End of Life

Pain Dyspnea Delirium Depression Fatigue and weakness Sleep disturbances Cachexia

End-of-Life Symptom Management: Pain

Incidence Etiology and assessment Pharmacologic management Opioid and adjuvant analgesics Analgesic dosing Analgesic rescue dosing Nonpharmacologic management

End-of-Life Symptom Management: Dyspnea

Incidence Etiology and assessment Pharmacologic management Opioids, anti-anxiety agents, bronchodilators, corticosteroids Nonpharmacologic management Oxygen therapy

End-of-Life Symptom Management: Delirium

Incidence Etiology and assessment Pharmacologic management Nonpharmacologic management Hydration Oxygenation

End-of-Life Symptom Management: Depression

Incidence Etiology and assessment Pharmacologic management Nonpharmacologic management Psychotherapy Cognitive-behavioral techniques

End-of-Life Symptom Management: Fatigue/Weakness

Incidence Etiology and assessment Pharmacologic management Nonpharmacologic management Modify exercise, activity, and rest patterns Self-care activity assistance

End-of-Life Symptom Management: Sleep Disturbances

Incidence Etiology and assessment Pharmacologic management Nonpharmacologic management Avoid stimulants and interruptions Establish a regular sleep schedule Keep mentally and physically active

End-of-Life Symptom Management: Cachexia-Anorexia Syndrome

Incidence Etiology and assessment Pharmacologic management Nonpharmacologic strategies Dietary supplements

Role of Nurses
Nursing role Establish trust Work with interdisciplinary team Focus on quality of life, control symptoms Be available, nonjudgmental, and nonthreatening Listen, advocate, empower Support the caregivers

Support of the Grieving Family: Tasks of Mourning

Accepting the reality of the loss Experiencing the pain of the loss Adjusting to the environment in which the deceased is missing Finding a way to remember the deceased while moving forward with life

Dealing with Loss

Losses occur throughout life, but their cumulative effects may be ACUTELY felt in later years Each loss represents a small death

Types of Loss
Concrete or tangible Death Removal of a body part Changes in physical health Divorce or separation Property loss Relocation or job layoff

Types of Loss
Psychological, symbolic or intangible Ones prestige, power, dreams, plans, ambition, confidence, security & pride

Death of a spouse or life partner

Roles that can be lost:
Friend / lover Confidant Homemaker Comforter

Adults /Grieving Process

Everyone experiences grief in different ways It is a process in which a person experiences loss & sadness associated with that loss This sadness may seem overwhelming and disabling at times It can include feelings of anger, frustration, guilt, and sorrow

Grieving Process
A number of authors have described stages or phases of grieving Grieving is manifested in thoughts, feelings, and behaviors There is no one timetable by which a person progresses through the grief process

Recovery from grief - Best Predictors

Sufficient finances Social supports Being on the younger end of the age

continuum
Higher levels of education Living in a smaller/supportive community

Physical needs of the Dying Client

Comfort Pain control Relief for respiratory difficulties Nutrition / starvation Hydration / dehydration

Physical Signs of Impending Death

Loss of muscle tone Slowing of the circulation Changes in respirations Sensory impairment

Psychosocial needs of the Dying Client and family

Acceptance of often conflicting, confusing and often overwhelming emotions Freedom to express these emotions

Emotional Impact of Death & Loss on the Nurse

Affects the emotions and equilibrium of the caregiver
Reminded of ones own mortality Many find it easy to relieve physiological symptoms but difficult to become involved at the interpersonal level

Nurses Self Care

Understand the grieving process Acknowledge ones own personal limits Formulate a philosophy of life (with regard to self) Know when to get away & take care of self Need to have a personal support system

Legal-Ethical Responsibilities

Euthanasia - implies that under some circumstances death is preferable to life Passive - Removing support or withholding Rx Active - An act of commission

 Living will

Advance Directives

Durable power of attorney for health care Provides specific instructions

Health care proxy

A witnessed statement appointing someone else (relative or trusted friend) to manage health care Rx decisions when client is unable to. Appointed health care proxy may not witness the

documentation.

Autopsy (Legal Aspects)

Required by law when: Person dies with 24 hours of admission to hospital Suicide Homicide Unknown cause Suspected child abuse Criminal activity

Organ & Tissue Donation

National Organ Transplant Act, 1984 Consent Voluntary Harvest Time

Specific Cancers

Bone Cancer
Malignant bone tumors may be primary or secondary Primary tumors of the prostate, kidney, thyroid and lung often metastasize to the bone Metastatic tumors greatly outnumber primary malignant bone tumors

Bone Cancer
Osteosarcoma or osteogenic sarcoma

Ewings Sarcoma

Bone Cancer
Chondrosarcoma typically affects the pelvis and proximal femur Fibrosarcoma an uncommon; slow growing tumor that can metastasize to the lungs

Breast Cancer
Leading cause of death in women in the US Considered non-invasive when it remains within the duct Classified as invasive when it penetrates the tissue surrounding the duct and grows in an irregular pattern

Breast Cancer
Heredity or genetically related susceptibility Hormone regulation
Sex hormones may act as tumor promoters
Hormone replacement therapy

Breast Cancer Collaborative Care

Axillary Node Dissection
Often performed regardless of treatment selected Provides most powerful prognostic data Helps define further treatment

Breast Cancer Etiology and Risk Factors

Factors under study Alcohol Fat intake Obesity Physical inactivity Environmental factors Pesticides Chemical exposure Radiation exposure

Increasing age increases risk Most women who develop breast cancer have none of the identifiable risk factors

Breast Cancer
Medullary carcinoma Colloid carcinoma Inflammatory carcinoma Common site of metastatic disease are bone, lungs, brain, and liver

Breast Cancer
Risk factors for breast cancer include Age Nulliparity Early menarche Late menopause Family history of breast cancer Exposure to ionizing radiation History of benign breast disease First birth after age 30 A high alcohol and fat intake may increase the risk for breast cancer

Cervical Cancer
A reproductive cancer can be preinvasive or invasive Preinvasive cancer Invasive cancer Metastasis is usually confined to the pelvis Risk factors Low socioeconomic status Early age at first sexual contact or first pregnancy Multiple sex partners Intrauterine exposure to DES (diethylstilbestrol) PAP test for screening

Colorectal Cancer
Cancer of the colon develops as a multistep process Tumors occur in all areas of the colon Tumors spread by direct invasion Risk factors Genetic predisposition Personal risk factors such as age and presence of adenomatous polyps Dietary factors related to high intake of foods such as red meat and animal fat, refined carbohydrates, or fried or broiled red meats and fish Black individuals have an increase incidence

Liver Cancer
Primary hepatic carcinoma is rare in the US Usually develops as a metastatic process from primary cancer site Symptoms Epigastric or RUQ abdominal pain Fatigue Anorexia Jaundice Ascites Bleeding Detected by nuclear radioisotope liver scan, needle biopsy confirms

Lung Cancer
Metastasize by direct extension through the blood and invading lymph glands and vessels 4 major types of lung cancer Small cell lung cancer (SCLC) Epidermiod (squamous cell) Adenocarcinoma Large cell carcinoma The last 3 types are referred to as non-small cell lung cancers (NSCLCs) because of their similar response to treatment Lung cancers occur as a result of repeated exposure to inhaled substances that cause chronic tissue irritation or inflammation

Ovarian Cancer
Leading cause of death from female reproductive organ malignancies The most common is the serous adenocarcinoma Grows rapidly, spreads quickly, and are often bilateraly, with the worst prognosis of all epithelial tumors

Spreads by 1. Peritoneal seeding 2. Direct spread to other organs in the pelvis 3. Distal spread through the lymphatic drainage

Pancreatic Cancer
Highly malignant Primary tumors are generally adenocarcinomas Grow rapidly and spread to surrounding organs (stomach, duodenum, gallbladder, and intestine) May result from metastasis

Renal Cancer
Referred to as adenocarcinoma of the kidney Systemic effects include anemia, erythrocytosis, hypercalcemia, liver dysfunction with elevated liver enzymes, increased sedimentation rate, hypertension, and other hormonal effects Metastasis through the bone or lymph to the liver, lungs, and long bones

Skin Cancer
Overexposure to sunlight is the major cause of skin cancer The most common skin cancers include; Actinic or solar keratoses common in chronic sun damaged skin and may progress to squamous cell carcinoma Squamous cell carcinoma Predisposed by sun exposure and chronic epithelial damage form repeated injury or irritation

Skin Cancer
Basal cell carcinomas Arising primarily form ultraviolet light, radiation exposure, genetic predisposition, and chronic irritation

Melanomas Risk factors include genetic predisposition and precursor lesions, which resemble unusual moles

The ABCDEs of melanoma skin cancer are

Asymmetry Border irregularity Color Diameter Evolution

Stomach Cancer
Malignant neoplasms found in the stomach Adenocarcinomas are the most common type, followed by lymphomas and sarcomas In advanced disease, invasion extends to the stomach muscle or beyond

Thyroid Cancer
There are 4 types of thyroid cancers Papillary carcinoma A slow growing tumor Good prognosis if localized Follicular carcinoma Primarily affects older clients Invades blood vessels and metastasizes Can adhere to the trachea, neck muscles, great vessels, and skin resulting in dysphagia and dyspnea Fair prognosis if metastasis is minimal

Thyroid Cancer
Medullary carcinoma Primarily affects clients over 50 years of age Involves metastasis that occurs via regional lymph nodes and invades surrounding structures Anaplastic carcinoma A rapidly growing, extremely aggressive tumor Directly invades adjacent structures, causing stridor, hoarseness, and dysphagia Poor prognosis

Pediatric cancers

Neuroblastoma

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Solid tumor found only in infants and children Most common tumor in children located outside the cranium Embryonal tumor arising from neural crest cells Boys > girls, white > incidence Peak age 22 mos Approx. 80% present with metastasis

Neuroblastoma
About 50% of neuroblastomas develop in the adrenal gland. Symptoms also result from the tumor spreading to different parts of the body. Neuroblastoma may spread to bone, bone marrow, liver, skin and lymph nodes.

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Neuroblastoma

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Prognosis is based on childs age and staging of the tumor Process of classifying tumors w/respect to: Degree of differentiation Potential for responding to treatment Patient prognosis Children < 1 yr have a better prognosis

Neuroblastoma
Etiology and pathophysiology Cause is unknown

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Although environmental factors Prenatal drug exposure, is implicated Tumor is often silent leading to late diagnosis and poor prognosis

Neuroblastoma - Diagnosis
CT Bone marrow aspiration Urine testing

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Neuroblastoma - Treatment
Depends on staging
Surgery is used for tumor removal following biopsy Radiation therapy
In more advanced cases
And may be palliative w/metastasis

Chemotherapy

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Neuroblastoma - Prognosis
Age at diagnosis important indicator < 1 year better Stage I/II 80% - 90% Disseminated disease & > 1 yr 10% - 30%

Assessing the Child with Wilms Tumor

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Usually asymptomatic Most frequent admitting symptom is an abdominal mass; parent often finds the mass, which is located to one side of the midline of the abdomen Pain and hematuria may be present HTN is present approx. 25%, because of > renin production

Wilms Tumor
Nephroblasoma

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Encapsulated tumor of kidney Unilateral or bilateral Originates from renal parenchyma and extends into surrounding tissues Grow rapidly Peak incidence 3 to 4 years Prognosis depends on stage at time of dx Metastasis to lungs and liver Often assoc. with congenital anomalies

Assessing the child with Wilms Tumor (Nephroblastoma)

Avoid palpitation during assessment Excessive manipulation can cause seeding of the tumor

Diagnosis of Wilms Tumor

US of abdomen and IVP CT and MRI of lungs To detect metastasis

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Treatment Wilms Tumor

Unless bilateral tumors are present Surgery (nephrectomy) Look for metastasis Radiation to the abdomen and chemotherapy can be used before and/or after surgery Prognosis Good (can exceed 90%)

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Child & Family Education

Avoid palpation of abd prior to surg. Provide parents with info Nature of the disease Tx options Therapeutic and S/E of chemotherapy Need to protect the remaining kidney S/S of UTI Avoid contact sports

Osteosarcoma
Most common bone cancer in children Peak incidence between 10-25 yrs of age Associated w/rapid growth spurt of adolescence Most frequently affects the distal portion of femur; also the humerus, tibia, jaw and phalanges Localized pain in affected site Often relived by flexing the extremity Progressive, insidious or intermittent pain at tumor site Limping, limited ROM, palpable mass, eventually pathological fracture Frequently metastasizes to the lungs

Osteosarcoma

Diagnosis Ct or MRI to detect areas of metastasis X-rays following traumatic injury may be first indication of disease
Femur has a large mass involving the metaphysis of bone. Tumor has destroyed the cortex.

Therapeutic Management
Goals Remove tumor and prevent spread of disease Treatment may include radical resection and amputation Depending on location and/or surgeon may try limb-salvaging procedures w/prosthetic replacement Chemotherapy before and after surgery Thoracotomy if metastasis to the lung Cure rate 75% without metastasis

Nursing Care
Comfort, pain management Phantom limb pain if amputation Utilize straightforward approach when amputation is indicated Allow for verbal expression for feelings Emotional support pre and post-operative important Body image concerns Especially in teens Encourage early interaction with peers