CELLULAR ABERRATION

By Mark Vincent C. Cenita, RN,MN

Safeguards against cancer  Steps in controlling cancer  Diet  Early detection



CELLULAR ABERRATION


A group of disorders characterized by abnormal cell growth and the ability to metastasize with potential in killing the host.

CANCER


The term cancer refers to the group of diseases in which cells grow and spread unrestrained throughout the body. Derives from the latin crab which means cancer Synonymous with neoplasm

CANCER


Acquire invasive characteristics, changes in occurring in surroundings. Is not a single disease with a single cause. CARCINOGENESIS
-

Process of transformation from normal cell to a neoplastic cell

INVASION  Occurs when cancer cells infiltrate adjacent tissues surrounding the neoplasm. METASTASIS  Occurs when malignant cells travel through the blood or lymph and invade other tissues and organs to form a secondary tumor. DIFFERENTIATION  Refers to the process whereby cells develop specific structures and function is order to specialized in certain task.

Top 5 cancer incidence by site & sex:

Male Female

1. Prostate 2. Lungs 3. Colon 4. Urinary Tract 5. Leukemia

1. Breast 2. Lungs 3. Colon 4. Uterus 5. Leukemia & Lymphoma

MEN
High incidence of cancer of the lung and bladder  Most common neoplasm aged 20 to 34 is TESTICULAR CANCER


WOMEN


BREAST CANCER followed by lung and brochus, colon and rectum

Classification of Tumor:
1.

Benign- are tumors designated by attaching the suffix oma to the cells of origin. e.g. Fibroma Chondroma Osteoma

Classification of Tumor:
2.

Malignant- tumors that are capable of spreading by invasion and metastasis. e.g. Fibrosarcoma Chondrosarcoma

COMPARISON OF THE CHARACTERISTICS OF BENIGN AND MALIGNANT NEOPLASM

CHARACTERISTICS BENIGN MALIGNANT

Speed of growth

Slow growth Grows by expansion

Aggressive growth; rapid division and growth Establish new lesions site

cells

malignant

Mode of growth Cell characteristic Metastasis

Localized and encapsulated Well differentiated It does not metastasized No tissue damage

Invade surrounding tissues With poor cell differentiated Ability to migrate, cells move to distant areas of the body Destroy surrounding tissues Poor prognosis Can lead to death unless interventions are taken

Prognosis

Very good prognosis Does not cause death unless localization affect vital function

Benign Tumor

Malignant Tumor

CLASSIFICATION OF CANCER
1.

2.

CARCINOMA - Refers to a tumor arises from epithelial tissue, the name of the cancer identifies the location, e.g. basal cell carcinoma SARCOMA - Refers to a tumor arising from supportive tissue; the name of the cancer identifies the specific tissue affected

3.

4.

5.

LEUKEMIA - A malignant disorder of the blood-forming tissues of the bone marrow, spleen, and lymph system characterize by unregulated proliferation of WBCs and their precursors. LYMPHOMA - A group of malignant neoplasm that affects the lymphatic system resulting in the proliferation of lymphocytes MYELOMA

NOMENCLATURE OF TUMORS
Tissue of Origin Connective tissue and derivatives Benign Fibroma Lipoma Chondroma Osteoma Blood Vessels Lymph vessels Brain coverings Hematopoietic cells Hemangioma Lymphangioma Meningioma Malignant Fibrosarcoma Liposarcoma Chondrosarcama Osteogenic Sarcoma Angiosarcoma Lymphangiosarcoma Invasive Meningioma Leukemias

Lymphoid tissue Smooth muscles Striated Muscles Epithelial tumors Squamos cell Stratified squamous papilloma Basal cells Liver cells Placental epethelium (trophoblast) Liver cell adenoma Hydatidiform mole Leiomyoma

Malignant Lymphomas Leiomyosarcoma

RhabdomyoRhabdomyoma sarcoma

Squamos cell carcinoma Basal cell carcinoma Hepatocellular carcinoma

Choriocarcinoma

PATHOGENESIS OF CANCER
Cellular Transformation and Derangement Theory  Failure of the Immune Response Theory


Cellular Transformation and Derangement Theory



conceptualizes that normal cells may be transformed into cancer cells due to exposure to some etiologic agents

Failure of the Immune Response Theory



advocates that all individuals possess cancer cells. However, the cancer cells are recognized by the immune response system. So, the cancer cells undergo destruction. Failure of the immune response system leads to inability to destroy the cancer cells.

Flow Chart Depicting Molecular Basis of Cancer

Acquired (environmental) DNA damaging agent: --Chemicals -Radiation -Viruses NORMAL CELL
Successful DNA repair DNA Damage Failure of DNA repair Mutation of the cell

Activation of oncogenes

Alteration of genes

Inactivation of cancer suppressor genes

Expression of altered gene products

Malignant neoplasm

Carcinogenesis
Steps: 1. Imitation 2. Promotions 3. Latency 4. Progression 5. Invasion to neighboring organs

Stages of Tumor Progression



HYPERTROPY
-

Increase in size of normal cells Shrinkage of cell size Increase in number of normal cells

ATROPHY
-

HYPERPLASIA
-

METAPLASIA
-

Conversion from the normal pattern of differentiation of one type of cells into another type of cell not normal for that tissue Alteration in the shape, size, appearance, and distribution of cells

DYSPLASIA
-

ANAPLASIA
-

Disorganized, irregular cells that have no structure and have lots of differentiation; the result is almost malignant

Classification, Grading & Stages



TNM Classification T (extent of primary tumor) TX cannot be adequately assessed TO no evidence of primary tumor TIS Tumor in situ localized; no spread T1- 4 progressive increase in size 1:5 cm < 2:6-9 cm 3:10-15 cm 4:15 cm >

Classification, Grading & Stages



TNM Classification N (regional Lymph Node) Nx cannot be assessed clinically NO no evidence of regular node metastasis N1 4 increasing involvement of nodes

Classification, Grading & Stages



Stages 0 benign state I spread to nearby tissue II 2-5 cm sometimes involve lymph III more than 5 cm spread advanced spread to connective tissue. IV - Mestastasis

Types of Metastasis


Extension & Invasion 1. Lymphatic Spread 2. Seeding of body cavities & surfaces 3. Hematogenous spread

ETIOLOGIC FACTORS (Carcinogens)

1. 2. 3. 4. 5.

Viruses Chemical carcinogens Physical agents Hormones Genetics

Viruses
oncogenic viruses  Prolonged or frequent viral infections may cause breakdown of the immune system or overwhelm the immune system.


Chemical carcinogens



1.

act by causing cell mutation or alteration in cell enzymes and proteins E.g.
Industrial compounds vinyl chloride, polycyclic aromatic hydrocarbons, fertilizers, weed killers, dyes, drugs Hormones estrogen, diethylstilbestrol (DES) Foods, preservatives nitrites, talc, food sweeteners, nitrosomines, aflatoxins, polycyclic hydrocarbons

2. 3.

Physical agents
1.

2.

Radiation x-ray or radioactive isotopes, sunlight/UV rays Physical irritation or trauma pipe smoking, multiple deliveries, jagged tooth, irritation of the tongue, overuse of any organ/body part

Hormones


estrogen as replacement therapy increases incidence of vaginal and cervical adenocarcinoma

Genetics


oncogene when exposed to carcinogens changes in cell structure becomes malignant

PREDISPOSING FACTORS
1.

2.

3.

Age older individuals are more prone to cancer Sex women (more prone to breast, uterus and cervical cancer) while men (prostate and lung cancer) Urban vs. Rural residence cancer is more common among urban dwellers

4.

5. 6.

Geographic distribution due to influence of environmental factors such as national diet, ethnic customs, type of solutions. Occupation Heredity greater risk with positive familial history

7.

8.

9.

Stress depression, grief, anger, aggression, despair of life stresses Precancerous lesions may undergo transformation cancer lesions and tumors Obesity studies have linked obesity to breast and colorectal cancer

ASSESSMENT
1. 2. 3.

NURSING HISTORY PHYSICAL ASSESSMENT DIAGNOSIS ASSESSMENT

NURSING HISTORY
   

any previous exposure to known or suspected risk factor health history lifestyle familial history

PHYSICAL ASSESSMENT
a. Identify WARNING SIGNAL OF CANCER C- change in bladder and bowel habits A- a sore that does not heal U- unusual bleeding or discharges T- thickening or lump in the breast I- Indigestion and difficulty in swallowing O- overt changes in wart or mole N- nagging cough and hoarseness of voice

        

C A U U U T I O N

change in bowel habits or bladder function a sore that does not heal unusual bleeding or discharge unexplained sudden weight loss unexplained anemia thickening or lump in breast or other body parts indigestion or difficulty of swallowing obvious change in wart or mole nagging cough or hoarseness of voice

Assessment
b. Implement SAFEGUARD AGAINST CANCER
BASIC. Annual physical exam and blood examination.
  


SKIN. Avoid overexposure to sunlight. ORAL. Annual oral examination. BREAST. Monthly BSE from age 20.
COLON. Digital rectal exam for persons over age 40. Rectal biopsy and proctoscopic examination, Guaiac stool exam for persons age 50 and above. UTERUS. Annual Pap s smear from age 40.

LUNGS. Avoid cigarette smoking; annual chest xray

Assessment
c. Identify classification of cancer according to type of tissue evolve from. - carcinoma or sarcoma d. Identify systemic effects 1. Anorexia, weakness, weight loss, muscle wasting. 2. Metabolic disturbances 3. Fluid and electrolyte imbalances 4. Pain 5. Hormonial imbalances e. Assist in diagnostic test

DIAGNOSIS ASSESSMENT
A. B. C. D.

TISSUES SAMPLING IMAGING TECHNIQUES LABORATORY STUDIES ROUTINE LAB EXAMS

TISSUES SAMPLING
1.

2.

Exfoliative cytology used to study cells that the body has shed during the normal sequence of body tissue growth and development Biopsy surgical removal of a piece of tissue for microscopic examination. The most definitive method for diagnosing CA

3 KINDS:
a.

b.

c.

Needle biopsy cells are aspirated through placed in the tissue Incisional biopsy removing or taking a small sample out of tissues mass Excisional biopsy involves removal all of the know tumor

IMAGING TECHNIQUES
DIRECT VISUALIZATION  INDIRECT VISUALIZATION


DIRECT VISUALIZATION
involves introduction of fiber optic endoscopy tubes into hollow organs to view internal surfaces
1. 2. 3. 4.

Bronchoscopy Esophagoscopy Gastroscopy Sigmoidoscopy Colonoscopy

INDIRECT VISUALIZATION
includes radiologic and imaging test
1. 2. 3. 4.

Mammography Barium enema BSE GI SERIES

5. 6. 7. 8.

Computed Tomography MRI Radioisotope studies Ultrasound

LABORATORY STUDIES
TUMOR MARKERS  Biochemical substance synthesized and release by tumor cell
1. 2. 3. 4.

Oncofetal antigen Hormones Isoenzymes Tissue

ROUTINE LAB EXAMS



E.g. ALT, CBC, BILIRUBIN, bleeding time, HCG,

TREATMENT MODALITIES
  

 

SURGERY RADIATION BONE MARROW TRANSPLANTATION CHEMOTHERAPY BIOLOGIC RESPONSE MODIFIER

SURGERY
Often the primary treatment for CA and may be performed for various purposes.  May be
1. 2. 3. 4.

Preventive Diagnostic Curative Palliative

RADIATION


Often high energy ionizing radiation to treat tumors Used to kill the tumor, reduce the tumor size, relieve obstruction or decrease pain, causes lethal injury to DNA, so it can destroy rapidly multiplying CA cells as well as normal cells e.g. x rays, gamma rays & radioactive particles

THREE SAFETY PRINCIPLES :



Time refers to the length of exposure minimize time spent in close proximity to the radiation source (30 mins in 8 hr. shift) Distance minimum distance of 6 ft., from the radiation source Shielding - use lead shields and other precautions to reduce exposure to radiation

SOURCES
 

EXTERNAL (Teletherapy) INTERNAL (Brachytherapy sealed)

SOURCES OF INTERNAL RADIATION :

  

Implanted into affected tissue or body cavity Ingested as a solution, ingested as solution Injected as a solution into the bloodstream or body cavity Introduced thru a catheter into the tumor


Sealed involves temporarily implanting sealed applicators that contain radioactive substance into various organs of the body Unsealed involves the administration of isotopes orally or by injection

SIDE EFFECTS :


Alopecia
1.

2.

Wear wig, hat, bonnet, bandana, scarf or anything that could be worn as a head dress. Inform patient that hair will eventually grow back after chemotherapy.

Skin reactions (erythema, dry/moist desquamation)

1.

2. 3.

4.

Observe for early signs of skin reaction and report. Keep area dry. Wash area with WATER ONLY and pat dry. Do not apply ointments, powders or lotions.

5.

6. 7.

Do not apply heat, avoid direct sunshine or cold. Use soft cotton fabrics for clothing. Do not erase markings on the skin. These serve as guide for areas of irradiation.

Infection
1. 2.

3.

Monitor blood counts weekly. Good personal hygiene, nutrition and adequate rest. Teach signs of infection to report to physician.

Hemorrhage
1. 2. 3. 4.

5.

Monitor platelet count. Avoid physical trauma or use of aspirin. Teach signs of hemorrhage. Monitor stool and skin for signs of hemorrhage. Use direct pressure over injection sites until bleeding stops.

Fatigue


Plenty of rest and good nutrition.

Weight loss due to anorexia, nausea and vomiting

1. 2. 3. 4. 5.

Arrange meal times Encourage bland foods Provide small attractive meals Avoid extremes of temperature Administer antiemetics as ordered before

meals

Ulceration of oral mucosa (Stomatitis)

1. 2. 3. 4. 5.

Administer analgesics before meals. Bland diet No smoking/alcohol Good oral hygiene (saline rinses q2) Sugarless lemon drops or mint to increase salivation.

Diarrhea
1.

2. 3. 4.

Encourage low residue, bland, highprotein foods Administer antidiarrheal drugs as ordered Provide good perineal care Monitor electrolytes particularly Na, K, Cl

Anorexia, nausea and vomiting - arrange meal times - encourage bland foods - provide small attractive meals - avoid extremes of temperature - administer antiemetics as ordered before meals Headache Social isolation

BONE MARROW TRANSPLANTATION



It is used in the treatment of leukemia, in conjunction with radiation or chemotherapy, it is usually harvested from the iliac crest then transfused intravenously.

TYPES :
1.

2.

3.

Autologous the client is infused with own bone marrow harvested during remission disease Syngeneic marrow donor is an identical twin Allogenic the client is infused with donor bone marrow harvested from a healthy individual

SIDE EFFECTS :
1. 2. 3.

Malnutrition Infection related to immunosuppression Thrombocytopenia

Nursing Mgt .
1.

2. 3.

Provide private room for the hospitalized client for 6 8 wks Encourage contact with significant others Management of side effects

CHEMOTHERAPY


Uses antineoplastic agents to treat CA cells locally and systematically Provides palliative measure for the pt. Who has widespread metastasis Disrupts the cell cycle in various phases, interfering with cellular metabolism and reproduction.

Cell kill hypothesis



During each cycle a fixed percentage of cells are killed by chemotherapy, leaving some tumor cells remaining, this necessitates the repeated dosages of chemotherapy in order to reduce the number of cells, allowing the body s immune system to destroy any remaining tumor cells.

CONTRAINDICATIONS
     

Infection Recent Surgery Impaired renal or hepatic function Recent radiation therapy Pregnancy Bone marrow depression

Safety precautions in handling chemotherapeutic agents



All used and unused equipment and drugs should be treated as hazardous wastes. Place contaminated material in leak proof labeled as hazardous waste.

Prepare chemotherapeutic agents in a private and clean setting. Strict use of body protection techniques includes gloves, garment with close front, cuffed long sleeves, face shield and mask.

Prevent spillage, use luer lock fitting on syringes and IV sets. Flush immediately with water if it comes in contact with skin and mucous membranes.

5 MAJOR CATEGORIES
   

Alkylating agents Antimetabolites Antitumor antibiotics Hormones and hormones antagonists Vinca Alkaloids

Nursing Interventions
1.


GI SYSTEM
Nausea and vomiting - Administer antiemetics. Diarrhea - Replace fluid electrolyte losses, low fiber diet. Constipation Increase OFI and fiber in diet.

2.


INTEGUMENTARY SYSTEM
Pruritus, uriticaria Provide good skin care. Stomatitis Provide oral care and avoid hot and spicy food. Alopecia Reassure that it is only temporary and encourage to wear wigs, hats or head scarf.

Skin pigmentation Inform that it is temporary. Nail changes Reassure that nails may grow normally after chemotherapy.

3.
 

HEMATOPOIETIC SYSTEM
Anemia Provide frequent rest periods. Neutropenia Protect from infection and avoid people with infection. Thrombocytopenia Protect from trauma and avoid ASA (Aspirin).

4.


GENITO-URINARY SYSTEM
Hemorrhagic cystitis Provide 2 to 3 L of fluids per day. Urine color changes Reassure that it is harmless.

5.


REPRODUCTIVE SYSTEM
Premature menopause or amenorrhea Reassure that menstruation resumes after chemotherapy.

BIOLOGIC RESPONSE MODIFIER



agents that make CA pts. Biologic response to the tumor cell more effective.
1. 2.

Immunotherapy Biotherapy

Immunotherapy
Stimulates the body s natural immune system that restrict and destroy CA cells
a. b.

Nonspecific Monoclonal antibody

c.

Cytokines - substance that immune system cells produce to enhance the immune system, normal growth regulating molecules possessing anti tumor abilities 1. Interleukin - 2(IL-2) 2. Interferons 3. Hematopoietic growth factors

Biotherapy
Involves replacing altered genes.

DIETARY RECOMMENDATIONS AGAINST CANCER Avoid obesity.  Cut down on total fat intake  Eat more high fiber foods raw fruits and vegetable, whole grain cereals.


Include foods rich in Vitamin A & C in daily diet.  Include cruciferous vegetables in the diet (broccoli, cabbage, cauliflower, brussel sprouts)


Be moderate in the consumption of alcoholic beverages.  Be moderate in the consumption of salt (cured, smoked and nitrate-cured foods).