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MALIGNANCIES OF THE FEMALE REPRODUCTIVE SYSTEM

OUTLINE
INTRODUCTION PATHOPHYSIOLOGY OF CANCERS SECTION A BREAST CANCER SECTION B CERVICAL CANCER

CANCERS
Cancers are abnormal growth that can occur in any part of the body which can be benign or malignant Cancers can affect female breast Cancers can also occur in any part of the female reproductive systemthe vulva, vagina, cervix, uterus, fallopian tubes, or ovaries. These cancers are called gynecologic cancers.

PATHOPHYSIOLOGY
It is a disease process that begins with abnormal cells transformed by the genetic mutation of cellular DNA The cells may acquire invasive characteristics and infiltrate tissues and other organs or structures surrounding it or far away from it Factors implicated in carcinogenesis include viruses and bacteria, physical agents

SECTION A- CANCER OF THE BREAST

Review of anatomy and physiology Diagostic assesment of cancer of the breast Management of cancer of breast Nursing management of cancer of the breast

THE FEMALE BREAST

SUMMARY OF A/P OF THE FEMALE BREAST


Structures of the breasts
Nipple
Located at center of each breast Consists of sensitive erectile tissue

Tissues of the breasts


Adipose Connective Glandular

Lactiferous ducts
Narrow tubular structures of the breast that transport milk to the nipple for breastfeeding

Areola
Darker pigmented area surrounding the nipple Montgomerys tubercles

Breast Cancer
Breast cancer is second only to lung cancer in its rate of occurrence in women. There are about 150,000 to 175,000 cases yearly and about 45,000 deaths. The rate increases with age; a woman who lives to age 85 has about a 1 in 9 chance of developing breast cancer. Overall the cumulative risk of developing breast cancer is 10.2%; the risk of dying from the disease is about 3.6%. Much of the risk is after age 75.

Breast cancer 2
Breast cancer is usually classified by the extent of its spread and by the kind of tissue in which the cancer starts. Carcinoma in situ means cancer in place. It is the earliest stage of breast cancer. Carcinoma in situ may be large and may even affect a substantial area of the breast, but it has not invaded the surrounding tissues or spread to other parts of the body. More than 15% of all breast cancers diagnosed in the United States are carcinoma in situ. It is usually detected during mammography.

Breast cancer 3
Invasive cancer is further classified as follows. -Localized: The cancer has invaded surrounding tissues but is confined to the breast. -Regional: The cancer has invaded tissues near the breasts, such as the chest wall or lymph nodes. -Distant (metastatic): The cancer has spread from the breast to other parts of the body

Breast cancer contd


There are several different kinds of tumors, some slow-growing, some more rapidly growing. history (first degree relatives) is a risk factor. Other possible risk factors include early menarche, late first childbirth (first child after 30), late menopause, and a diet high in fat and alcohol.

Diagnostic asesment
History and physical examination Screening Histological examination of cancer cells Radiological examinations

Screening

Because breast cancer rarely causes symptoms in its early stages and because early treatment is more likely to be successful, screening is important. Screening is the hunt for a disorder before any symptoms occur.

How to Do a Breast Self-Examination


While standing in front of a mirror, look at the breasts. The breasts normally differ slightly in size. Look for changes in the size difference between the breasts and changes in the nipple, such as turning inward (an inverted nipple) or a discharge. Look for puckering or dimpling.

2
Watching closely in the mirror, clasp the hands behind the head and press them against the head. This position helps make subtle changes caused by cancer more noticeable. Look for changes in the shape and contour of the breasts, especially in the lower part of the breasts.

3
Place the hands firmly on the hips and bend slightly toward the mirror, pressing the shoulders and elbows forward. Again, look for changes in shape and contour.

Many women do the next part of the examination in the shower because the hand moves easily over wet, slippery skin.

Raise the left arm. Using three or four fingers of the right hand, probe the left breast thoroughly with the flat part of the fingers. Moving the fingers in small circles around the breast, begin at the nipple and gradually move outward. Press gently but firmly, feeling for any unusual lump or mass under the skin. Be sure to check the whole breast. Also, carefully probe the armpit and the area between the breast and armpit for lumps.

5
5. Squeeze the left nipple gently and look for a discharge. (See a doctor if a discharge appears at any time of the month, regardless of whether it happens during breast self-examination.)

Repeat steps 4 and 5 for the right breast, raising the right arm and using the left hand.

6
Lie flat on the back with a pillow or folded towel under the left shoulder and with the left arm overhead. This position flattens the breast and makes it easier to examine. Examine the breast as in steps 4 and 5. Repeat for the right breast.

Routine self-examination enables women to detect lumps at an early stage. However, self-examination alone does not reduce the death rate from breast cancer, and it does not detect as many early cancers as routine screening with mammography.

Mammography Process of examining with x-ray the soft tissue of the breast to detect various benign and/or malignant growths before they can be felt

A breast examination is a routine part of a physical examination. A nurse inspects the breasts for irregularities, dimpling, tightened skin, lumps, and a discharge.

Staging of breast cancer


In situ carcinoma 0 The tumor is confined, usually to a milk duct or milk-producing gland, and has not invaded surrounding breast tissue. Localized and regional invasive cancer I The tumor is less than inch (2 centimeters) in diameter and has not spread beyond the breast.

Staging of breast cancer2


IIA The tumor is inch or less in diameter, and it has spread to one to three lymph nodes in the armpit, microscopic amounts have spread to lymph nodes near the breastbone on the same side as the tumor, or both. or The tumor is larger than inch but smaller than 2 inches (5 centimeters) in diameter but has not spread beyond the breast.

Staging of breast cancer 3


IIB The tumor is larger than inch but smaller than 2 inches in diameter, and it has spread to one to three lymph nodes in the armpit, microscopic amounts have spread to lymph nodes near the breastbone on the same side as the tumor, or both. or The tumor is larger than 2 inches in diameter but has not spread beyond the breast.

Staging of breast cancer 4


IIIA The tumor is 2 inches or less in diameter and has spread to four to nine lymph nodes in the armpit or has enlarged at least one lymph node near the breastbone on the same side as the tumor. or The tumor is larger than 2 inches in diameter and has spread to up to nine lymph nodes in the armpit or to lymph nodes near the breastbone. IIIB The tumor has spread to the chest wall or skin or has caused breast inflammation (inflammatory breast cancer).

Staging of breast cancer5


IIIC The tumor can be any size plus at least one of the following: It has spread to 10 or more lymph nodes in the armpit. It has spread to lymph nodes under or above the collar bone. It has spread to lymph nodes in the armpit and has enlarged at least one lymph node near the breastbone on the same side as the tumor. It has spread to four or more lymph nodes in the armpit, and microscopic amounts have spread to lymph nodes near the breastbone on the same side as the tumor. Metastatic cancer IV The tumor, regardless of size, has spread to distant organs or tissues, such as the lungs or bones, or to lymph nodes distant from the breast.

Management of breast cancer


Medical management : a systemic treatment with chemotherapy is based on patients menopausal status and presence of hormone receptors Surgery: which is done to eradicate the local presence of the cancer - post surgery chemotherapy Radiation therapy Hormonal therapy

Nursing management
Assessment Assess patients needs for Acceptance of diagnosis Development of coping mechanisms Emotional support from family members and health workers etc

Assessment leads to identification of specific nursing diagnosis

Possible nursing diagnosis


Post operatively

Pre-operatively Knowledge deficit Anxiety Ineffective coping

Pain (Acute ) Risk for infection Risk of impaired adjustment Disturbed body image Self care deficit etc

planning
Draw a nursing care plan on identified problem

Implementation
Implement care based on identifeid problems

Pre-op Explain breast cancer and treatment options Reduce anxiety and fear Improve coping ability Promoting decision making ability

Post op Relieve pain and discomfort Prevent infection Promote participation in care Promote positive body image

Evaluation
Pre-op Expected patient outcome may include Exhibits knowlegde about diagnosis and traetmnet optiions Verbalizes willingness to deal with anxiety and fears Demonstrtaes ability to cope Demonstrates ability to make decisions

Section b
Cervical cancer Review of anatomy and physiology Overview of cervical cancer Staging of cervical cancer Management

OVERVIEW OF A/P OF FEMALE REPRODUCTIVE SYSTEM

External Genitalia
Mons pubis
Fatty tissue that covers and cushions symphysis pubis

Labia majora
Two folds of skin containing fatty tissue and covered with hair
Located on either side of the vaginal opening, extending from the mons pubis to the perineum

External Genitalia
Labia minora
Two thin folds of tissue located within the folds of the labia majora
Extends from the clitoris downward toward the perineum

Bartholins glands
Located on either side of the vaginal orifice
Secrete a mucous substance that lubricates the vagina

External Genitalia
Clitoris
Short, elongated organ composed of erectile tissue Located just behind the upper junction of the labia minora Homologous to the penis

Urinary orifice
Not true part of female reproductive system, but part of the vulva

External Genitalia
Vaginal orifice
Located in lower portion of the vestibule, below the urinary meatus Also known as the vaginal introitus

Perineum
Area between vaginal orifice and anus Consists of muscular and fibrous tissue and serves as support for pelvic structures

Internal Genitalia
Vagina
Muscular tube that connects the uterus with the vulva
Rests between bladder (anteriorly) and rectum (posteriorly)

Stretchable folds of inner lining known as rugae


Capable of expanding during childbirth to permit passage of babys head without tearing lining

Internal Genitalia
Uterus
Pear-shaped, hollow, muscular organ that houses the fertilized implanted ovum as it develops throughout pregnancy
Source of monthly menstrual flow if pregnancy does not occur

Internal Genitalia
Uterus
Three identifiable portions
Fundus
Small dome-shaped upper portion

Body
Central portion

Cervix
Narrower, necklike portion at lower end

Internal Genitalia
Wall of uterus contains three layers
Perimetrium
Outermost serous membrane layer

Myometrium
Middle, muscular layer

Endometrium
Innermost layer, highly vascular

Internal Genitalia
Fallopian tubes
Also known as uterine tubes or oviducts Serve as passageway for the ova as they exit the ovary enroute to the uterus Free end of each tube ends in fingerlike projections called fimbriae
Fimbriated ends draw ovum into tube through wavelike motions when ovum is released from ovary

Internal Genitalia
Ovaries
Female sex cells = female gonads Almond-shaped pair of ovaries, held in place by ligaments Responsible for:
Producing mature ova and releasing them at monthly intervals Producing hormones necessary for normal growth and development of female Producing hormones necessary for maintaining pregnancy should it occur

Cervical Cancer
Cervical cancer is the second most common malignancy of the female reproductive tract. The Pap test can detect 90% or more of early cervical neoplasia (pre-invasive changes in cervical cells) and its use has reduced deaths from cervical cancer by more than 50%. Cervical cancer could be eliminated as a cause of death in all women if they had annual Pap tests (beginning no later than age 20); however, fewer than 40% of women do.

Cervical cancer 2
Most risk factors for cervical neoplasia are related to sexual activity. The sexually active are at higher risk; cervical neoplasia is virtually unknown among nuns. Women who are sexually active early (mid-teens or earlier) and those with three or more sexual partners before the age of 35 (or with sexual partners with three or more partners) are at increased risk. Recently several subtypes of the human papilloma virus have been implicated as causative in cervical neoplasia. Genital herpes infection is also a risk factor.

STAGING OF CERVICAL CANCER


Stage I Only in the cervix Stage II Spread outside the cervix (including the upper part of the vagina) but still within the pelvis Stage III Spread throughout the pelvis (including the lower part of the vagina), sometimes blocking the ureters Stage IV Spread to the bladder or rectum (A) or distant organs (B)

Diagnostic assessment
History taking and physical examination Biopsy Pelvic examination Papanicolaou smear
Microscopic examination of cells scraped from within the cervix, from around the cervix, and from the posterior part of the vagina to test for cervical cancer

Radiological examinations

Management
Medical At the pre-invasive stage , medical treatment is conservative consisiting of Monitoring
Cryotherapy (Destruction of tissue by rapid freezing with substances such as liquid nitrogen)

Laser therapy

Management 2
At the invasive stage, treatment depends on stage of lesion, patient s age and genearl health. This may include Radition surgery

Nursing management
Assesment Asess client needs for Knowledge about regular pap smears for early detection Emotional support before, during and after diagnostic procedures and treatment Relief of pain and discomfort Sexual dysfunction

Possible nursing diagnosis


Knowlegde deficit Anxieyt Disturbed body image Risk of infection Situation low self esteem etc

planning
Draw a nursing care plan on identified problem

implementation
Provide information on ned for regular medical tests for early detection Provide information on possible causes of condition nd preferred treatment modality Acknowlegd need for emotional support Assist with perineal care etc

Evaluation
Expected patient outcome Demonstration of understanding of treatment modality Verbalizing curent situational improvement in self worth Feeling comfortable with proceduree etc

conclusion
The unit has specifically covered the malignancies of female reproductive system with special reference to cancer of breast and cervix.

For further reading log on to http://www.merckmanuals.com/h ome/womens_health_issues/breas t_disorders/breast_cancer.html

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