Hand Book of Oncology Nursing - Cancer Nursing Book

HAND BOOK OF
ONCOLOGY NURSING
[Cancer Nursing]
Prof. Dr. Ram Sharan Mehta
Available at:
www.slideshare.net/rsmehta
RS Mehta

HAND BOOK OF
ONCOLOGY NURSING
For B.Sc. Nursing, BNS, M.Sc. Nursing, CN &
Oncology Nurses
College of Nursing, Medical-Surgical Nursing Department
B.P. Koirala Institute of Health Sciences, Nepal

About the Author
Prof. Dr. Ram Sharan Mehta, RN, M.Sc. Nursing is currently working in the post of Head, Medical
Surgical Nursing Department, College of Nursing, BP Koirala Institute of Health Sciences,
and involved in nursing profession for 27 years. He has vast experiences of teaching
Basic Nursing Concepts, Medical-Surgical Nursing, Leadership and Management,
Nursing Research, Nursing Education to both Under-graduate and post-graduate nursing
students. He had experiences of teaching Oncology Nursing to M. Sc. Nursing, B.Sc.
Nursing students, Post Basic BN and Certificate Nursing students. He has conducted
many research related to cancer and Presented Papers on various scientific sessions of
national as well as international conferences. He has completed his B.N. from Nursing
Campus Maharajganj with distinction and M.Sc. nursing from Punjab University
(PGIMER, Chandigarh) NINE, India. He has completed his PhD from Tribhuvan
University Kathmandu Nepal.
He has worked in many hospitals of Nepal and visited various nursing colleges of India.
He has conducted many research projects, presented papers in scientific forms and
participated in national as well as international conferences. He has visited Singapore,
Hong Kong, Australia, Switzerland, Belgium, France, Belgrade, China, USA, Sri-Lanka
and most of the city of India. He has been awarded with “Vice-Chancellor Gold Medal,
Mahendra Bidya Bhushan, Meradevi Rana Gold Medal” due to his outstanding
performance in nursing education. He has also written the books; Basic Nursing
Concepts, Handbook of Diagnostic Procedures, Leadership and Management,
Nursing Research, Entrance Guide for nurses.
This book Oncology Nursing covers almost all topics of cancer and provides useful tips
for nursing students as well as oncology nurses. This book will be very useful for
graduate and undergraduate students and other health professionals involved in the care
of cancer patients. In this second edition many new chapters and concepts in treatment
protocols has been added and many new updates are also included.

Preface
Cancer is emerging as a public health problem around the world. Cancer is a major public health
problem worldwide and is the second leading cause of death in the United States. 8.8 million People
worldwide died from cancer in 2015. That is nearly 1 in 6 of all global deaths. 30-50% of cancers could
be prevented. Cancer is the second leading cause of death globally, and was responsible for 8.8 million
deaths in 2015. Globally, nearly 1 in 6 deaths is due to cancer. Approximately 70% of deaths from
cancer occur in low- and middle-income countries. Tobacco use is the most important risk factor for
cancer and is responsible for approximately 22% of cancer deaths It has been expected that cancer
problem will increase especially in the developing countries, where there is lack of cancer prevention
programme or given less priority. Illiteracy, poverty, ignorance, limited access to health care services are
found to be directly or indirectly associated with cancer.
Cancer management is an interdisciplinary endeavor, thus an understanding of the principles of
oncology nursing is fundamental to the effective practice of all other oncology subspecialties. Oncology
nurses are engaged in collaborative practice with all members of the healthcare team to provide optimal
management of patients with cancer. Oncology nurses have key roles as caregivers, as well as providers
of patient and family education. Cancer nurses also are continuously involved in the enhancement of
nursing practice through research, continuing education, and advanced education. They practice in
association with a number of oncology disciplines, including surgical oncology, radiation oncology,
gynecologic oncology, pediatric oncology, and medical oncology.
This book, “Oncology Nursing” has been written keeping in view the common cancer problems, their
introduction, Pathophysiology clinical characteristics, diagnostic approaches, nursing intervention and
the role of nurse as per need of the client in the preventive, promotive, therapeutic and rehabilitative care
through various approaches.
This book will be most useful to the students of Bachelor Nursing (B.Sc. Nursing and Post Basic.
Bachelor in nursing) and Master nursing students. This book will be also useful for the Diploma and
certificate nursing students. This book will be very helpful to update the knowledge of oncology nurses
as well as other nurses involved in the care of cancer patients. The other professionals will also benefit
from this book.
. The suggestions and corrections form the readers will be highly appreciated and proper care will be
taken in next edition. I want to express my sincere thanks, to Mrs. Poonam Mehta for helping in typing
the manuscript.
Finally, I want to convey my thanks to all those who have directly or indirectly help in publishing the
book.

Table of Contents: Brief
1. Introduction of the Cell, Cell Cycle and Pathogenesis of Cancer
2. Etiology and Risk Factors of Cancer
3. Cancer Specific Diagnostic Tests
4. Carcinoma of Oral Cavity
5. Ear Nose Throat (ENT) Cancers
6. Brain Tumor
7. Pituitary Tumors
8. Breast Cancer
9. Stomach Cancer
10. Colorectal Cancer
11. Ovarian Cancer
12. Leukemia
13. Cervical Cancer
14. Uterine Cancer
15. Endometrial cancer
16. Vulval cancer
17. Carcinoma of Penis
18. Prostate Cancer
19. Childhood Cancer
20. Skin Cancer
21. Gland Cancer
22. Anal Cancer
23. Urinary Bladder Cancer
24. Bone Cancer
25. Spinal Cord Tumors
26. Pancreatic Cancer
27. Kidney Tumors
28. Thyroid cancer
29. Hepatocellular (Liver) carcinoma
30. Gallbladder Cancer
31. Lymphoma
32. Lung Cancer
33. Nutrition Therapy for Cancer Patients
34. Pain Management
35. Chemotherapy
36. Radiotherapy
37. Oncologic Emergency
38. Nursing Management of Patient with Cancer
39. Warning Signs and Prevention of Cancer
40. Breaking Bad News and Counselling to the Patients
Appendix: - I. Terminology related to cancer.
Appendix: - II. Oncology Nursing as a Specialty
Appendix: - III. Professional Standards of Oncology Nursing Practice & Role of Nurse
Bibliography

Contents
S.N. Chapter Page
1. Introduction of the Cell, Cell Cycle and Pathogenesis of Cancer 1
2. Etiology and Risk Factors of Cancer 11
3. Cancer Specific Diagnostic Tests 16
4. Carcinoma of Oral Cavity 25
5. Ear Nose Throat (ENT) Cancers 30
6. Brain Tumor 36
7. Pitutary Tumors 48
8. Breast Cancer 55
9. Stomach Cancer 67
10. Colorectal Cancer 74
11. Ovarian Cancer 84
12. Leukemia 92
13. Cervical Cancer 105
14. Uterine Cancer 113
15. Endometrial Cancer 119
16. Vulval Cancer 126
17. Carcinoma Penis 129
18. Prostate Cancer 132
19. Childhood Cancer 137
20. Skin Cancer 139
21. Gland Cancer 146
22. Anal Cancer 148
23. Urinary Bladder Cancer 152
24. Bone Cancer 160
25. Spinal Cord Tumors 163
26. Pancreatic Cancer 165

27. Kidney Tumors 171
28. Thyroid Cancer 181
29. Hepatocellular (Liver) Carcinoma 192
30. Gallbaldder Cancer 199
31. Lymphoma 201
32. Lung Cancer 210
33. Nutrition Therapy for Cancer Patients 218
34. Pain Management 228
35. Chemotherapy 231
36. Radiotherapy 249
37. Oncologic Emergencies 261
38. Nursing Management of Patient with Cancer 265
39. Warning Signs & Prevention of Cancer 274
40. Breaking Bad News and Counselling to the Patients 278
Appendix I 285
Appendix II 289
Appendix III 293
Bibliography 297

Text book of Oncology Nursing
1
Unit : 1
INTRODUCTION OF THE CELL, CELL CYCLE
AND PATHOGENESIS OF CANCER
Introduction of Cell
Cells consist of cytoplasm enclosed within a membrane, which contains many biomolecules such as
proteins and nucleic acids. Organisms can be classified as unicellular or multicellular. While the
number of cells in plants and animals varies from species to species, humans contain more than 10
trillion cells. Most plant and animal cells are visible only under the microscope, with dimensions
between 1 and 100 micrometres.
Cells are of two types, eukaryotic, which contain a nucleus, and prokaryotic, which do not.
Prokaryotes are single-celled organisms, while eukaryotes can be either single-celled or multicellular.
The components of cell:
1. Organelles: structures in a cell that act like, “little organs.”
2. Cytoplasm: the jelly-like fluid where the organelles “float.”
Figure: Animal Cell

Introduction of the Cell, Cell Cycle and Pathogenesis of Cancer
2
3. Organelles: structures in a cell that act like “little organs.”
4. Cytoplasm: the jelly-like fluid where the organelles “float.”
5. Inside the Nucleus:
• Nuclear Envelope: membrane that surrounds the nucleus
• Chromatin: consists of DNA wrapped around proteins
• Chromosomes: condensed string-like structure that forms from DNA just before the cell
divides
• Nucleolus: structure within the nucleus that makes ribosomes
6. Ribosomes: made of RNA and protein
7. Endoplasmic reticulum: internal membrane system of the cell. Lipids, proteins, and other
products are made here; Rough ER has ribosomes and Smooth ER has no ribosomes.
8. Golgi apparatus: modifies, sorts, and packages proteins.
9. Lysosomes: small organelles filled with enzymes. Digest molecules to be used by the cell.
10. Vacuoles: store materials.
11. Mitochondria: organelle that converts chemical energy stored in food into compounds that are
more convenient for the cell to use. “Powerhouse of the Cell!”
12. Chloroplasts: organelles that capture energy from sunlight and convert it into chemical energy.
Photosynthesis: Found only in plants.
13. Cytoskeleton: helps cell to maintain shape, move, and move organelles.
14. Centrioles: help organize cell division. Not found in plants.
15. Cell Boundaries: The Cell membranes are thin, flexible membrane that surrounds the cell and
the Cell walls are rigid layer around the membrane found only in bacteria, fungi and plants.
16. Cell Membrane: Controls what enters/leaves cell, provides support/protection. It has Lipid
Bilayer, double-layered sheet of phospholipids.
Cell cycle
The cell cycle or cell-division cycle is the series of events that take place in a cell leading to its division
and duplication of its DNA (DNA replication) to produce two daughter cells. A eukaryotic cell cannot
divide into two, the two into four, etc. unless two processes alternate; Doubling of its genome (DNA) in
S phase (synthesis phase) of the cell cycle and Halving of that genome during mitosis (M phase).
Stages in Cell cycle:
 G0 = A resting phase where the cell has left the cycle and has stopped dividing.
 G1 = growth and preparation of the chromosomes for replication;
 S = synthesis of DNA and duplication of the centrosome;
 G2 = preparation for
Collectively these 3 stages are called interphase (the cell grows, accumulating nutrients needed
for mitosis, preparing it for cell division and duplicating its DNA.)
• M = mitosis (the cell splits itself into two distinct daughter cells).
• C = cytokinesis (the new cell is completely divided). To ensure the proper division of the cell,
there are control mechanisms known as cell cycle checkpoints.

3
Figure: Phases of Cell Cycle
1. Interphase - G1 Stage
• 1st growth stage after cell division
• Cells mature by making more cytoplasm & organelles
• Cell carries on its normal metabolic activities
• The G1 checkpoint control mechanism ensures that everything is ready for DNA synthesis.
2. Interphase – S Stage
• Synthesis stage
• DNA is copied or replicated
3. Interphase – G2 Stage
• 2nd Growth Stage
• Occurs after DNA has been copied
• All cell structures needed for division are made (e.g. centrioles)
• Both organelles & proteins are synthesized
• The G2 checkpoint control mechanism ensures that everything is ready to enter the M
(mitosis) phase and divide.
4. Mitosis
• Division of the nucleus: also called karyokinesis
• Only occurs in eukaryotes: has four stages
• Doesn’t occur in some cells such as brain cells

4
• A checkpoint in the middle of mitosis (Metaphase Checkpoint) ensures that the cell is ready to
complete cell division.
Four Mitotic Stages
• Prophase
• Metaphase
• Anaphase
• Telophase
Cell cycle and check points:
 Regulation of the cell cycle involves processes crucial to the survival of a cell, including the
detection and repair of genetic damage as well as the prevention of uncontrolled cell division.
 The molecular events that control the cell cycle are ordered and directional; that is, each process
occurs in a sequential fashion and it is impossible to "reverse" the cycle.
 Two key classes of regulatory molecules, cyclins and cyclin-dependent kinases (CDKs), determine
a cell's progress through the cell cycle.
A. Cyclins
• G1 cyclins (D cyclins)
• S-phase cyclins (cyclins E and A)
• Mitotic cyclins (B cyclins)
• Their levels in the cell rise and fall with the stages of the cell cycle.
B. Cyclin-dependent kinases (Cdks)
• a G1 Cdk (Cdk4)
• an S-phase Cdk (Cdk2)
• an M-phase Cdk (Cdk1)
Their levels in the cell remain fairly stable, but each must bind the appropriate cyclin (whose levels
fluctuate) in order to be activated.
Phenotypic Characteristics of Cancer Cells:
 Deregulated cell proliferation: Failure to differentiate
 Loss of normal apoptosis pathways: Genetic instability
 Loss of replicative senescence: Increased angiogenesis
 Invasion: Metastasis
 Evasion of the immune system
Types of Cancer Genes and their role:
 Two major types; Oncogenes and Tumor-Suppresor genes.
 Genes that positively influence tumor formation- Oncogenes
 Genes that negatively impact tumor growth- Tumor-Suppresor genes
 Although the mechanism is complex, both oncogenes and tumor-suppresor genes exert their
effects on tumor growth through their ability to control cell division and apoptosis.

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 In cancer, mutation of oncogenesis (tightly controlled in normal cell) typically relieve their control
and lead to increased activity of the gene products which acts in dominant fashions.
 In contrast, the normal function of TSG is usually to restrain cell growth, but this function is lost in
cancer eading to a resessive mechanism of cellular level.
 Subset of TSG, ‘caretaker genes’, do not affect cell growth directly but rater control the ability
of cell to maintain the integrity of its genome
 Hence, cells with a deficiency in these genes have increased rate of mutations throughout their
genomes, including oncogenes and TSG.
Carcinogenesis: Carcinogenesis or oncogenesis or tumorigenesis is the formation of a cancer; where,
normal cells are transformed into cancer cells. The process is characterized by changes at the cellular,
genetic, and epigenetic levels and abnormal cell division, in some cancers forming a malignant mass.
In order for a normal cell to transform into a cancer cell, the genes that regulate cell growth and
differentiation must be altered. The affected genes are divided into two broad categories:
Oncogenes and Tumor suppressor genes. Typically, changes in multiple genes are required to
transform a normal cell into a cancer cell. Oncogenes are genes that promote cell growth and
reproduction. Tumor suppressor genes are genes that inhibit cell division and survival.
Malignant transformation can occur through the formation of oncogenes, the inappropriate over-
expression of normal oncogenes, or by the under-expression or disabling of tumor suppressor genes.
DNA repair genes gets turned off: DNA repair genes help healthy cells know if something is wrong
with its DNA and fix it. When these genes get turned off the cell can’t fix any problems with its DNA.
Change of the proto-oncogens to oncogenes: Proto-oncogenes are genes that are coded to
maintain normal cell growth. Oncogenes are a gene that has changed to make the cells grow and
divide faster. In cancer cells the cell grows and divides very quickly. And are expressed at
inappropriately high levels in patients with cancers or there may be altered or changed normal genes
due to mutation.
Tumor suppressor genes get turned off: Tumor suppressor genes are a part of a healthy cells DNA
that help stop cancer from forming in healthy cells. Tumor suppressor genes help slow down cell
growth. When these genes are turned off, the cell will grow and divide very quickly.
Genomic amplification: Sometimes there may be genomic amplification. Here a cell gains many
copies (often 20 or more) of a small chromosomal locus, usually containing one or more oncogenes
and adjacent genetic material.
Translocation: Translocation is process when two separate chromosomal regions become abnormally
fused, often at a characteristic location. Common example of translocation of chromosomes 9 and 22
which occurs in chronic myelogenous leukaemia.
Molecular Process: Malignant transformation, or carcinogenesis, is thought to be three-step cellular
process, involving: initiation, promotion, and progression.
Initiation: During initiation, initiators (carcinogens), such as chemicals, physical factors, and biologic
agents, escape normal enzymatic mechanisms and alter the genetic structure of the cellular DNA.
Normally, these alterations are reversed by DNA repair mechanisms or the changes initiate
programmed cellular death. Occasionally, cells escape these protective mechanisms, and permanent
cellular mutations occur. These mutations usually are not significant to cells until the second step of
carcinogenesis

6
Promotion
 Promotion occurs with additional assaults to the cells, resulting in further genetic damage.
 During promotion, repeated exposure to carcinogens causes the expression of abnormal or
mutant genetics information even after long periods.
 Cellular oncogenes are responsible for the vital cellular functions of growth and differentiation.
Cellular proto-oncogenes act to maintain normal cell growth.
 Oncogenes are influenced by multiple growth factors that stimulate cell proliferation, such as
epidermal growth factor (EGF) and transforming growth factor alpha.
 Just as Oncogenes “turn on” cellular growth, cancer suppressor genes “turn off,” or regulate,
unneeded cellular proliferation.
 When suppressor genes mutate or lose their regulatory capabilities, malignant cells are allowed
to reproduce.
 The p53 (TP53) gene is a tumor suppressor gene that is frequently implicated in many human
cancers.
 This gene determines whether cells will live or die after their DNA is damaged.
Progression
 During progression, the altered cells exhibit increased malignant behavior.
 These cells have a propensity to invade adjacent tissues and to metastasize.
 The cell membranes are altered which affect fluid movement in and out of the cell.
 The cell membrane also contains proteins called tumor-specific antigens (eg, carcinoembryonic
antigen [CEA] and prostate-specific antigen [PSA]), which develop over time as the cells become
less differentiated (mature).
 Malignant cellular membranes also contain less fibronectin, cellular cement. They are therefore
less cohesive and do not adhere to adjacent cells readily.
 Pathophysiology of the Malignant Process
Cancer is a disease process that begins when an abnormal cell is transformed by the genetic mutation
of the cellular DNA. There may be increased activity of genes involved in cellular proliferation
(oncogenes) or loss of growth inhibitory (tumor suppressor) genes or both.
Proliferative Patterns: An increase in the number of cells as a result of cell growth and cell division.
Several patterns of cell growth exist: hyperplasia, metaplasia, dysplasia, and neoplasia. Cancerous
cells are described as malignant neoplasms. They demonstrate uncontrolled cell growth. This
abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-regulating signals
surrounding the cell. Benign and malignant growths are classified and named by tissue of origin. E.g.,
benign tumors of the meninges are called meningioma and malignant tumors of the meninges are
called meningeal sarcoma.
Invasion and Metastasis: Malignant cells acquire invasive characteristics, and changes occur in
surrounding tissues. Malignant diseases invade surrounding tissues and allow the spread or transfer of
cancerous cells from one organ or body part to another by invasion and metastasis.

7
Invasion: Refers to the growth of the primary tumor into the surrounding host tissues. Mechanical
pressure exerted by rapidly proliferating neoplasms may force fingerlike projections of tumor cells
into surrounding tissue and interstitial spaces.
As malignant cells are less adherent and may break off from the primary tumor and invade adjacent
structures. Malignant cells produce specific destructive enzymes (proteinases), such as collagenases
(specific to collagen), plasminogen activators (specific to plasma), and lysosomal hydrolyses. These
enzymes are thought to destroy surrounding tissue, including the structural tissues of the vascular
basement membrane, facilitating invasion of malignant cells.
Metastasis: Dissemination of malignant cells from the primary tumor to distant sites by direct spread
of tumor cells to body cavities or through lymphatic and blood circulation. Tumors growing in or
penetrating body cavities may shed cells or emboli that travel within the body cavity and seed the
surfaces of other organs. The cells infiltrate these tissues and gain access to lymph and blood vessels,
which carry the cells to other areas of the body; Eg. in ovarian cancer, when malignant cells enter the
peritoneal cavity and seed the peritoneal surfaces of such abdominal organs as the liver or pancreas.
Lymphatic Spread: Lymph and blood are key mechanisms by which cancer cells spread. Lymphatic
spread is the most common mechanism of metastasis. Tumor emboli enter the lymph channels by way
of the interstitial fluid, which communicates with lymphatic fluid. Malignant cells also may penetrate
lymphatic vessels by invasion. After entering the lymphatic circulation, malignant cells either lodge in
the lymph nodes or pass between the lymphatic and venous circulations. Breast tumors frequently
metastasize by lymph through axillary, clavicular, and thoracic lymph channels.
Hematogenous spread: Hematogenous spread is the dissemination of malignant cells via the
bloodstream and is directly related to the vascularity of the tumor. Few malignant cells can survive
the turbulence of arterial circulation, insufficient oxygenation, or destruction by the body’s immune
system. Those malignant cells that do survive are able to attach to endothelium and attract fibrin,
platelets, and clotting factors to seal themselves from immune system surveillance. The endothelium
retracts, allowing the malignant cells to enter the basement membrane and secrete lysosomal
enzymes. These enzymes destroy surrounding body tissues, allowing implantation.
Angiogenesis: Angiogenesis is the growth of new capillaries from the host tissue by the release of
growth factors and enzymes such as vascular endothelial growth factor (VEGF). These proteins
rapidly stimulate formation of new blood vessels, which helps malignant cells obtain the necessary
nutrients and oxygen. It is also through this vascular network that tumor emboli can enter the systemic
circulation and travel to distant sites. Large tumor emboli that become trapped in the microcirculation
may further metastasize to other sites.
Warning Signs of Cancer:
Seven early warning signs of cancer: CAUTION
 Change in bowel or bladder habits.
 A sore that does not heal.
 Unusual bleeding or discharge.
 Thickening or lump in the breast, testicles, or elsewhere.

8
 Indigestion or difficulty swallowing.
 Obvious change in the size, colour, shape, or thickness of a wart, mole, or mouth sore.
 Nagging cough or hoarseness.
The following symptoms may also signal the presence of some form of cancer:
 Coughing-up blood
 Persistent headaches
 Unexplained loss of weight or appetite
 Chronic pain in bones
 Persistent fatigue, nausea, or vomiting
 Persistent low-grade fever, either constant or intermittent
 Repeated instances of infection
Detection and Prevention of Cancer:
Nurses and physicians have traditionally been involved with tertiary prevention, the care and
rehabilitation of the patient after cancer diagnosis and treatment. In recent years, however, the
American Cancer Society, the National Cancer Institute, clinicians, and researchers have placed
greater emphasis on primary and secondary prevention of cancer.
(a) Primary Prevention:
• It is concerned with reducing the risks of cancer in healthy people.
• By acquiring the knowledge and skills necessary to educate the community about cancer risk,
nurses in all settings play a key role in cancer prevention.
• Assisting patients to avoid known carcinogens is one way to reduce the risk for cancer.
• Another way involves adopting dietary and various lifestyle changes that epidemiologic and
laboratory studies show inuence the risk for cancer.
• Several clinical trials have been undertaken to identify medications that may help to reduce
the incidence of certain types of cancer.
Risk Factors: Taking Steps to Reduce Cancer Risk
When teaching individual patients or groups, nurses can recommend the following cancer
prevention strategies:
• Increase consumption of fresh vegetables (especially those of the cabbage family) because
studies indicate that roughage and vitamin-rich foods help to prevent certain kinds of cancer.
• Increase ber intake because high-ber diets may reduce the risk for certain cancers (eg,
breast, prostate, and colon).
• Increase intake of vitamin A, which reduces the risk for esophageal, laryngeal, and lung
cancers.

9
• Increase intake of foods rich in vitamin C, such as citrus fruits and broccoli, which are thought
to protect against stomach and esophageal cancers.
• Practice weight control because obesity is linked to cancers of the uterus, gallbladder,
breast, and colon.
• Reduce intake of dietary fat because a high-fat diet increases the risk for breast, colon, and
prostate cancers.
• Practice moderation in consumption of salt-cured, smoked, and nitrate-cured foods; these
have been linked to esophageal and gastric cancers.
• Stop smoking cigarettes and cigars, which are carcinogens.
• Reduce alcohol intake because drinking large amounts of alcohol increases the risk of liver
cancer. (Note: People who drink heavily and smoke are at greater risk for cancers of the
mouth, throat, larynx, and esophagus.)
• Avoid overexposure to the sun, wear protective clothing, and use a sunscreen to prevent skin
damage from ultraviolet rays that increase the risk of skin cancer.
(b) Secondary Prevention:
• It involves detection and screening to achieve early diagnosis and prompt intervention to halt
the cancer process.
• The evolving understanding of the role of genetics in cancer cell development has contributed
to prevention and screening efforts.
• To provide individualized education and recommendations for continued surveillance and
care in high-risk populations, nurses need to be familiar with ongoing developments in the
eld of genetics and cancer.
• Public awareness about health-promoting behaviors can be increased in a variety of ways.
Key Requirements of a Screening Programme:
 Acceptable to the majority of the target population
 A high enough detection rate of early tumours to be effective
 Low false-positive rate (reducing unnecessary interventions)
 Affordable by the health-care system
 An effective intervention
 Deliverable

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Algorithm for genetic testing in a family with cancer predisposition:

Patients from family with a known cancer syndrome, from a family with a history of cancer
and with early onset cancer
Pretest counseling
Review of family history to confirm/identify possible cancer syndromes and candidate
genes
Informed consent
Testing of cancer patient
Identification of disease-causing mutation Failure to identify
mutations
Screening of asymptomatic
family members
Negative test: family
member has no increased
risk of cancer
End of testing, non-
informative
Positive test: family member
requires increased screening or
other interventions

11
Unit : 2
ETIOLOGY AND RISK FACTORS OF CANCER
Cancer is a class of diseases characterized by out-of-control cell growth. There are over 100
different types of cancer, and each is classified by the type of cell that is initially affected.
Cancer harms the body when altered cells divide uncontrollably to form lumps or masses of tissue
called tumors (except in the case of leukemia where cancer prohibits normal blood function by
abnormal cell division in the blood stream). Tumors can grow and interfere with the digestive, nervous,
and circulatory systems and they can release hormones that alter body function. Tumors that stay in
one spot and demonstrate limited growth are generally considered to be benign.
More dangerous, or malignant, tumors form when two things occur:
1. A cancerous cell manages to move throughout the body using the blood or lymphatic systems,
destroying healthy tissue in a process called invasion
2. That cell manages to divide and grow, making new blood vessels to feed itself in a process
called angiogenesis.
When a tumor successfully spreads to other parts of the body and grows, invading and destroying
other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the
result is a serious condition that is very difficult to treat.
According to the American Cancer Society, Cancer is the second most common cause of death in the
US and accounts for nearly 1 of every 4 deaths. The World Health Organisation estimates that,
worldwide, there were 4 million new cancer cases and 8.2 million cancer-related deaths in 2012
(their most recent data).
Individual types of cancer: There are said to be over 200 different types of cancer.
Fast facts on cancer: Here are some key points about cancer.
 More than 575,000 people die of cancer, and more than 1.5 million people are diagnosed with
cancer per year in the US.
 Cancer is considered to be one of the leading causes of morbidity and mortality worldwide.
 The financial costs of cancer in the US per year are an estimated $263.8 billion in medical costs
and lost productivity.
 African Americans are more likely to die of cancer than people of any other race or ethnicity.
 It is believed that cancer risk can be reduced by avoiding tobacco, limiting alcohol intake,
limiting UV ray exposure from the sun and tanning beds and maintaining a healthy diet, level of
fitness and seeking regular medical care.
 Screening can locate cervical cancer, colorectal cancer and breast cancer at an early, treatable
stage.
 Vaccines such as the human papillomavirus (HPV) vaccine assist in preventing some cervical,
vaginal, vulvar, and oral cancers. A vaccine for hepatitis B can reduce liver cancer risk.
 According to the World Health Organization (WHO), the numbers of new cancer cases is
expected to rise by about 70% over the next 20 years.

Etiology and Risk Factors of Cancer
12
 The most common sites of cancer among men are lung, prostate, colon, rectum, stomach and liver.
 The most common sites of cancer among women are breast, colon, rectum, lung, cervix and
stomach.
The etiology of cancer can be viewed from two perspectives: its molecular origins within individual
cells and its external causes in terms of personal and community risks. Together, these perspectives
form a multidimensional web of causation by which cancers arise from the interplay of causal events
occurring in tandem over time.
Host Factor:
A. Genetic Factors: 5-10% of adult cancers arise in hereditary setting. Genes underlying
hereditary cancer are involved in control of cell growth & differentiation or in DNA repair and
maintenance of genomic integrity. They are oncogenes, tumor suppressor genes and DNA repair
genes.
1. Inactivation of tumor suppressor gene: e.g. Retinoblastoma has two hit hypothesis Mutation
of WTI Gene-wilms tumor, Mutations of FAP Gene–FAP.
2. Activation of oncogene: e.g. MEN type Za & 2b – RET Oncogene hereditary Papillary –
met oncogene, Renal carcinoma, familial Melanoma – CDK 4
3. DNA repair defects: e.g. Xeroderma Pigmentisum – skin cancer. Ataxia, telengiectasia,
leukemias and blooms syndrome.
Characteristics of hereditary cancers include early age onset, multiple and bilateral, family
history, specific constellation of tumors are part of known cancer syndrome, evidence of
autosomal dominant transmission of cancer susceptibility.
B. Hormones: Endogenous hormones have received considerable research attention with respect to
cancers of breast, ovary, and endometrium in women and those of prostate and testes in men,
Neoplasia is a consequence of prolonged hormonal stimulation of the particular target organ,
the normal growth and function of which is controlled by one or more steroid or polypeptide
hormones. Female cancer sites, demonstrate a clear etiologic role for endogenous estrogen
(estradiol) in both breast and endometrial cancers and a probable role for gonadotropin in
ovarian cancer. In breast cancer, association of increased cancer risk with low parity, late age at
first birth, early menarche, late menopause, all of which are due to heightened exposure to
endogenous estrogen. In endometrial cancer, the etiological role of estrogen is supported
strongly by the fact that postmenopausal risk is increased greatly by estrogen replacement
therapy in the absence of progesterone replacement. For Ovarian cancer, estrogens do not
appear to increase risk, although increased risk with nulliparity and decreased risk with oral
contraceptive use suggest a role for gonadotropin. It is well –known, of course that the synthetic
hormone diethylstilbestrol can cause clear-cell carcinoma of the vagina and cervix in women
exposed in utero.
C. Immune Mechanisms: The occurrence of particular types of cancer under various conditions of
immunologic impairment supports the general concept that normal mechanisms of immuno-
surveillance are important for control of carcinogenesis. Certain cancers, especially Non-
Hodgkin’s Lymphoma (NHL) occur with increased frequency in persons treated with
immunosuppression for tissue transplantation etc. The Acquired Immunodeficiency Syndrome
(AIDS) is accompanied by this same spectrum of cancers NHL, Kaposi’s sarcoma, cancer of
cervix, anus, etc.

13
Environmental Factors:
A. Chemical Factors: Chemical origin of human malignancies – observation of unusual cancer
incidences in certain occupational groups. Chemical carcinogens are organ specific and target
epithelial cells. They are genotoxic (Cause genetic damage) activate endogenous mutagenic
pathways or nongenotoxic. Genotoxic carcinogens have high chemical reactivity, can be
metabolized to reactive intermediate by the host, form covalent adducts with macromolecules;
target DNA in the nucleus & mitochondria. Mechanism of action of nongenotoxic carcinogens is
controversial.
Known/suspected Chemical Carcinogens in Humans:
Lung - Tobacco smoke, arsenic, asbestos
Pleura - Asbestos
Oral Cavity - Tobacco smoke, alcohol, nickel compounds
Esophagus - Tobacco, alcohol, Smoked, salted, pickled foods
Colon - Heterocyclic amines
Liver- Afactoxin, vinylchloride tobacco, alcohol
Kidney - Tobacco smoke, phenacetin
Prostate - Cadmium
Skin - Arsenic, coal tar, soot, PUVA
Bone marrow - Benzene, tobacco smoke, antineoplastic agents
B. Physical Factors
1. Radiation: Ionizing radiation – X-rays, rays, electrons, protons, nonionizing radiation –
U.V.rays. Exposure to ionizing radiation can be due to occupational exposure (Radiologists,
Nuclear workers, Radiation technologists), medical exposure (diagnostic – chest x-ray dose
= 0.16 mgy, mammography dose = 1.16 mgy and therapeutic – Hodgkin, breast cancer,
cervical cancer, childhood cancer).
Mechanism of carcinogenesis is predominantly base damage and single or double strand
DNA breaks. Age at exposure (younger age at exposure greater risk), dose of radiation
and genetic susceptibility e.g. RT induced osteosarcoma in hereditary retinoblasoma are
important factors.
2. U.V. Rays: Ultraviolet rays are a form of non-ionizing radiation known to cause skin cancer.
Xeroderma pigmentosum and Cockayne’s syndrome have increased risk due to defective
nucleotide excision repair. Mechanisms of carcinogenesis are due to the formation of
dimmers between adjacent pyrimidines in DNN; e.g. Cyclobutane dimmer, 6-4
photoproduct.
Asbestos:
Chrysolite and Amphibole fibers are commonly linked with mesothelioma and lung cancer (most
common adenocarcinoma – lower lobe). Other cancers associated with asbestos exposure are:
larynx, oropharynx, kidney, oesophagus, GB and bileduct. Mechanism of carcinogenesis includes
DNA damage through free radical formation (Double strand breaks, mutations and chromosomal
damage)

Etiology and Risk Factors of Cancer
14
C. Viral Oncogenesis: Viruses are obligate intracellular parasites
Oncogenic Human Viruses
DNA Viruses:
1. Hepadna Viruses - HBV–Hepatocellular carcinoma
2. Herpes Virus - HBV-Burkitts –immunoblastic lymphoma NPC, primary CNS Lymphoma, HIV 8
Kaposis sarcoma body cavity lymphoma Castle man’s disease
3. Papilloma virus - HPV –16, 18, 33, 39 – anogenital and upper airway Ca 5, 8, 17 – Skin
Cancer
4. Adenovirus - Laboratory animals
RNA Viruses
1. Flavivirus – HCV – Hepatocellular carcinoma
2. Retrovirus – Oncovirinae – HTLV I/II – Adult T cell lymphoma /leukemia,
Lentivirinae – HIV
D. Diet: Major role of diet and nutrition in influencing cancer risk is well established. The various
dietary carcinogens are
a. Naturally Occurring Dietary Carcinogens:
1. Natural pesticides: Allyl isothiolynate in cabbage, cauliflower etc. Hydrazines in
mushrooms and pyrrolizidine in herbal tea.
2. Mycotoxins: Aflatoxins in corn, peanuts, Ochratoxins in grains
b. Products of Food Preparation and Processing: Urethene in all fermented foods, Heterocyclic
aromatic amines in barbecued, chicken etc and Nitroso –compounds in cured meats, dairy
cheese products.
c. Synthetic Carcinogens in Diet (Synthetic additives):
Intentional: colorants, flavorants, sweetness.
Unintentional: pesticides, solvents, and packaging derived chemicals.
E. Trauma and inflammation: Role of trauma in causation of cancer is a subject fraught with gross
exaggerations and contradictions. Skin cancer from mechanical injury: e.g. Kangri burn cancer,
scar carcinoma in lung secondary to fibrosis and stricture esophagus is known to be complicated
by squamous cell carcinoma.
How cancer spreads:
Scientists reported in Nature Communications (October 2012 issue) that they have discovered an
important clue as to why cancer cells spread. It has something to do with their adhesion (stickiness)
properties. Certain molecular interactions between cells and the scaffolding that holds them in place
(extracellular matrix) cause them to become unstuck at the original tumor site, they become dislodged,
move on and then reattach themselves at a new site.
The researchers say this discovery is important because cancer mortality is mainly due to metastatic
tumors, those that grow from cells that have traveled from their original site to another part of the
body. These are called secondary tumors. Only 10% of cancer deaths are caused by the primary
tumors.
The scientists, from the Massachusetts Institute of Technology, say that finding a way to stop cancer
cells from sticking to new sites could interfere with metastatic disease, and halt the growth of
secondary tumors.

15
Malignant cells are more agile than non-malignant ones: Scientists from the Physical Sciences-
Oncology Centers, USA, reported in the journal Scientific Reports (April 2013 issue) that malignant
cells are much “nimbler” than non-malignant ones. Malignant cells can pass more easily through
smaller gaps, as well as applying a much greater force on their environment compared to other cells.
Professor Robert Austin and team created a new catalogue of the physical and chemical features of
cancerous cells with over 100 scientists from 20 different centers across the United States.
The authors believe their catalogue will help oncologists detect cancerous cells in patients early on,
thus preventing the spread of the disease to other parts of the body.
Prof. Austin said "By bringing together different types of experimental expertise to systematically
compare metastatic and non-metastatic cells, we have advanced our knowledge of how metastasis
occurs."
Cancer classification: There are five broad groups that are used to classify cancer.
1. Carcinomas are characterized by cells that cover internal and external parts of the body such
as lung, breast, and colon cancer.
2. Sarcomas are characterized by cells that are located in bone, cartilage, fat, connective tissue,
muscle, and other supportive tissues.
3. Lymphomas are cancers that begin in the lymph nodes and immune system tissues.
4. Leukemias are cancers that begin in the bone marrow and often accumulate in the bloodstream.
5. Adenomas are cancers that arise in the thyroid, the pituitary gland, the adrenal gland, and
other glandular tissues.
Cancers are often referred to by terms that contain a prefix related to the cell type in which the
cancer originated and a suffix such as -sarcoma, -carcinoma, or just -oma. Common prefixes include:
 Adeno- = gland
 Chondro- = cartilage
 Erythro- = red blood cell
 Hemangio- = blood vessels
 Hepato- = liver
 Lipo- = fat
 Lympho- = white blood cell
 Melano- = pigment cell
 Myelo- = bone marrow
 Myo- = muscle
 Osteo- = bone
 Uro- = bladder
 Retino- = eye
 Neuro- = brain


Cancer Specific Diagnostic Tests
16
Unit : 3
CANCER SPECIFIC DIAGNOSTIC TESTS
The first step in the diagnostic process is obtaining a complete history and physical examination. Some
cancers are linked with certain genetic and environmental factors. Therefore, learn about the health
of the client’s family members, the work history of the client, and the environment in which the client
lives for health history and physical assessment. When a malignant tumor is in its early stages, there
are often few manifestations. Clinical manifestations usually appear once the tumor has grown to a
sufficiently large size to cause one or more of the following problems:
 Pressure on surrounding organs or nerves,
 Distortion of surrounding tissues
 Obstruction of lumen of tubes
 Interference with the blood supply of surrounding tissues
 Interference with organ function
 Disturbance of body metabolism
 Patristic use of the body’s nutritional supplies
 Mobilization of the body’s defensive responses resulting in inflammatory changes
Common clinical manifestations that may arise secondary to cancer:
It includes weight loss, weakness or fatigue, CNS alterations, pain and hamatologic and metabolic
alterations. Close assessment of such manifestations may reveal that they are directly or indirectly
related to the tumor growth.
Anorexia, weight loss, weakness, and fatigue are related to the body’s inability to consume and use
nutrients appropriately. Mechanical interference by tumors, malabsorption, paraneoplastic endocrine
secretions (such as excessive secretion of thyroid hormones) and tumor use of ruptad to avoid general
physical debilitation.
The client who has difficulty with vision, speech coordination, or memory may be experiencing
primary or metastatic CNS disease. Increased in cranial pressure caused by tumor growth may cause
headache, lethargy, nausea, and vomiting.
Investigations related to cancer
A. Tumor Marker Test: A number of tumor markers are currently being used for a wide range of
cancer types. Tumor markers that are currently in common use are listed below:
Alpha-fetoprotein (AFP)
• Cancer types: Liver cancer and germ cell tumors
• Tissue analyzed: Blood
• How used: To help diagnose liver cancer and follow response to treatment; to assess stage,
prognosis, and response to treatment of germ cell tumors

17
Beta-2-microglobulin (B2M)
• Cancer types: Multiple myeloma, chronic lymphocytic leukemia, and some lymphomas
• Tissue analyzed: Blood, urine, or cerebrospinal fluid
• How used: To determine prognosis and follow response to treatment
Beta-human chorionic gonadotropin (Beta-hCG)
• Cancer types: Choriocarcinoma and testicular cancer
• Tissue analyzed: Urine or blood
• How used: To assess stage, prognosis, and response to treatment
CA15-3/CA27.29
• Cancer type: Breast cancer
• How used: To assess whether treatment is working or disease has recurred
CA19-9
• Cancer types: Pancreatic cancer, gallbladder cancer, bile duct cancer, and gastric cancer
• How used: To assess whether treatment is working
CA-125
• Cancer type: Ovarian cancer
• How used: To help in diagnosis, assessment of response to treatment, and evaluation
ofrecurrence
Calcitonin
• Cancer type: Medullary thyroid cancer
• How used: To aid in diagnosis, check whether treatment is working, and assess recurrence
Carcinoembryonic antigen (CEA)
• Cancer types: Colorectal cancer and breast cancer
• How used: To check whether colorectal cancer has spread; to look for breast cancer
• Recurrence and assess response to treatment
CD20
• Cancer type: Non-Hodgkin lymphoma
• How used: To determine whether treatment with a targeted therapy is appropriate
Estrogen receptor (ER)/progesterone receptor (PR)
• Tissue analyzed: Tumor

18
• How used: To determine whether treatment with hormonal therapy (such as tamoxifen) is
appropriate
Fibrin/fibrinogen
• Cancer type: Bladder cancer
• Tissue analyzed: Urine
• How used: To monitor progression and response to treatment
HE4
• Cancer type: Ovarian cancer
• How used: To assess disease progression and monitor for recurrence
HER2/neu
• Cancer types: Breast cancer, gastric cancer, and esophageal cancer
• How used: To determine whether treatment with trastuzumab is appropriate
Prostate-specific antigen (PSA)
• Cancer type: Prostate cancer
• How used: To help in diagnosis, assess response to treatment, and look for recurrence
Thyroglobulin
• Cancer type: Thyroid cancer
• How used: To evaluate response to treatment and look for recurrence
Urokinase plasminogen activator (uPA) and plasminogen activator inhibitor (PAI-1)
• How used: To determine aggressiveness of cancer and guide treatment
B. Biopsy: The process of removing tissue from living patients for diagnostic examination. The tissue
is generally examined under a microscope by a pathologist, and can also be analyzed
chemically. When an entire lump or suspicious area is removed, the procedure is called
an excisional biopsy. When only a sample of tissue is removed with preservation of
the histological architecture of the tissue’s cells, the procedure is called an incisional
biopsy or core biopsy. When a sample of tissue or fluid is removed with a needle in such a way
that cells are removed without preserving the histological architecture of the tissue cells, the
procedure is called a needle aspiration biopsy. Biopsies are most commonly performed for
insight into possible cancerous and inflammatory conditions.
• Sentinel Lymph Node Biopsy: Removal and examination of the sentinel nodes, which are the
first lymph nodes to which cancer cells are likely to spread from a primary tumor.

19
• Punch Biopsy: Removal of a small oval core of skin for laboratory analysis using a sharp,
hollow instrument.
• Shave Biopsy: Removal of a sample of skin for laboratory analysis using a scalpel to slice
the specimen from the site.
• Endoscopic Retrograde Cholangiopancreatography (ERCP): ERCP is a technique that
combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of
the biliary or pancreatic ductal systems. Through the endoscope, the physician can see the
inside of the stomach and duodenum, and inject radiographic contrast into the ducts in the
biliary tree and pancreas so they can be seen on X-rays. ERCP is used primarily to diagnose
and treat conditions of the bile ducts and main pancreatic duct, including gallstones,
inflammatory strictures (scars), leaks (from trauma and surgery), and cancer. ERCP can be
performed for diagnostic and therapeutic reasons.
• Endoscopic Ultrasound (EUS): Procedure using an ultrasound imaging device on the tip of an
endoscope for evaluation of the bowel wall and adjacent structures.
• Magnetic Resonance Cholangiopancreatography (MRCP): Procedure using magnetic
resonance imaging and an injectable dye to examine problems in the bile ducts, gallbladder,
and pancreas
• Lymph Node Biopsy: Removal of lymph node tissue for pathologic evaluation
• Bone Marrow Aspiration: Removal of a small amount of fluid and cells from inside the bone
with a needle and syringe
• Bone Marrow Biopsy: Removal and evaluation of a small amount of bone along with fluid
and cells from inside the bone
• Lumbar Puncture (LP): The process of inserting a needle into the subarachnoid space of the
lumbar spine to obtain cerebrospinal fluid for analysis; used to determine if leukemic cells
are present.
• Thoracoscopy, syn. Pleuroscopy: A thoracoscopy examines the chest (thoracic) cavity using
an endoscope. Video-assisted thoracoscopy (VAT) or video-assisted thoracic surgery (VATS)
uses a thoracoscope with a small video camera attachment for surgical purposes. Samples
are removed from the body for examination under a microscope to determine whether
cancerous or other abnormal cells are present
• Transrectal Ultrasound (TRUS): TRUS may also be called prostate sonogram or endorectal
ultrasound. A TRUS may be done to determine if the prostate is enlarged or to diagnose
prostate cancer.
• Cervical Conization, syn. Cone Biopsy: Biopsy of the cervix in which a cone-shaped sample
of tissue is removed from the cervix.
• Colposcopy: Visual examination of the tissues of the cervix and vagina using a lighted
microscope (colposcope) to identify abnormal cell growth and, if necessary, remove a tissue
sample for biopsy.
• Endometrial Biopsy: Procedure whereby a sample of the endometrium of the uterus is
removed from the body and examined under a microscope; used to check for uterine cancer.

20
C. Mammography: The goal of mammography is the early detection of breast cancer, typically
through detection of characteristic masses and/or microcalcifications. Screening mammograms
are used to check for breast cancer in women who have no signs or symptoms of the disease.
Diagnostic mammograms are used to check for breast cancer after a lump or other sign or
symptom of the disease has been found.
Screening mammography can help reduce the number of deaths from breast cancer among
women ages 40 to 74. Mammography should be done every year starting at the age of 40.
Clinical breast examination should be done every 1-3 years between the age 25-39 and every
year starting at the age 40.
Note: Women at higher risk may need to get screened earlier and more frequently than
recommended here.
D. Computed Tomography (CT) Scan: Computed tomography (CT) is an imaging procedure that
uses special x-ray equipment to create a series of detailed pictures, or scans, of areas inside the
body. It is also called computerized tomography and computerized axial tomography (CAT)
scanning. In cancer, CT may be used to help detect abnormal growths; to help diagnose tumors;
to provide information about the extent, or stage, of disease; to help in guiding biopsy
procedures or in planning treatment; to determine whether a cancer is responding to treatment;
and to monitor for recurrence.
E. Magnetic Resonance Imaging: Magnetic resonance imaging (MRI), nuclear magnetic resonance
imaging (NMRI), or magnetic resonance tomography is a medical imaging technique used
in radiology to investigate the anatomy and physiology of the body in both health and disease.
MRI scanners use strong magnetic fields and radiowaves to form images of the body. The
technique is widely used in hospitals for medical diagnosis, staging of disease and for follow-up
without exposure to ionizing radiation. MRI is the investigation of choice in the
preoperative staging of rectal and prostate cancer, and has a role in the diagnosis, staging,
and follow-up of other tumors.
F. Positron emission tomography: Positron emission tomography (PET) is a nuclear
medicine, functional imaging technique that produces a three-dimensional image of functional
processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-
emitting radionuclide (tracer), which is introduced into the body on a biologically active
molecule. Three-dimensional images of tracer concentration within the body are then constructed
by computer analysis. In modern PET-CT scanners, three dimensional imaging is often
accomplished with the aid of a CT X-ray scan performed on the patient during the same session,
in the same machine. If the biologically active molecule chosen for PET
is fluorodeoxyglucose (FDG), an analogue of glucose, the concentrations of tracer imaged will
indicate tissue metabolic activity by virtue of the regional glucose uptake. Use of this tracer to
explore the possibility of cancer metastasis (i.e., spreading to other sites) is the most common
type of PET scan in standard medical care (90% of current scans). FDG-PET can be used for
diagnosis, staging, and monitoring treatment of cancers, particularly in Hodgkin's
lymphoma, non-Hodgkin lymphoma, and lung cancer. For recurrence after a known highly active
primary tumor is removed.

21
Cancer Screening:
Early Detection of Cancer Helps: Not all cancers are noticeable in the early stages. Cancers deep
in the body are not easily detected unless special examinations and check-ups are undertaken
consistently. This means routine cancer related check-ups are your breast means of detecting cancers
early. Although many cancers cannot be prevented, death can be prevented through early detection.
When cancerous tumor grows, it goes through an initial phase when it is small in size. If we can detect
the cancer at this early stage, it probably has not spread elsewhere and hence it is easier to treat.
Besides being easier to treat, there are several other advantages for detecting a cancer early:
Better survival, less mutilating surgery, less toxic chemotherapy or avoiding chemotherapy altogether,
less expensive treatment and A person can feel more reassured if no cancer is detected by screening.
Time for Screen for Cancer: As cancer is more common in the older age group, cancer screening is
generally recommended for people above 40 years of age. People who belong to a high risk group,
such as those with a family history of cancer, should consider starting screening in their 30s Screening
tests vary from determination of tumor markers in blood, X-rays and interventional methods of
Endoscopy.
Cancer Screening: Risk factors such as: positive family history of a certain type of cancer, age group,
abnormal findings on a previous cancer screening test or warning signs, such as: A sore that refuses to
heal , A lump or thickening in the breast or elsewhere , Any unusual bleeding or discharge , Any
change in normal bowel habits , Any change in a mole or a wart , Persistent indigestion or difficulty in
swallowing , Persistent hoarseness of voice or cough , Onset of impaired hearing, with persistent noise
in the same ear.
Screening Methods for the Top Three Common Cancers
Types of Cancer screening tests/Investigations who should be tested
Lung 1. Chest x-ray • Heavy smokers
2. Sputum Cytology • Persons exposed to certain cancer
causing chemicals
3. Blood tumor marker (CEA)
determination
Colorectal 1. Fecal occult blood test (FOBT) • Persons aged 45and above
2. Blood tumor marker
determination
• Those with strong family history
may be tested earlier
3. Colonoscopy
Breast 1. Breast examination by doctor • Women aged 40 and above
2. Mammography or ultrasound
scan
• Those who experience breast lump
should see a doctor immediately
3. Blood tumor marker CA 15.3
determination

22
Selected Tumor markers for diagnosis of malignant diseases
Laboratory tests Associated malignancy
ENZYMES
1. Lactic dehydrogenase Lymphoma, seminoma, acute leukemia
2. Prostatic acid phosphatase Metastatic cancer of prostate, lung cancermyeloma
3. Placental alkaline phosphatase
4. Creatinine kinase Breast, colon, ovary, prostate cancer
HORMONES
5. Parathyroid hormone Lung, pancreas
6. Calcitonin Medullary thyroid cancer, breast cancer
7. Antidiuretic hormone Small cell lung cancer, adenocarcinoma
8. Adrenocorticotropic hormone Lungcancer, prostatecancer, gastrointestinal cancer,
neuroendocrine cancer
9. Human chorionic gonadotrophin Choriocarcinoma, germcell testicular tumor
METABOLIC PRODUCTS
10. 5Hydroxyindoleacetic acid
(5HIAA)
Carcinoid lung
11. Vanilymandelic acid (VMA) Neuroblastoma
PROTEINS
12. IgG IgG myeloma
13. IgA IgA myeloma
14. IgM Waldenstroms macroglobulinemia
15. IgD IgE myeloma
16. IgE Advanced lymphoma
17. Beta-2 microglobulin Myeloma,lymphoma
ANTIGENS
18. Alpha Feto Protein (AFP) Nonseminomatous germcell testicular carcinoma,
choriocarcinoma, cancer of pancreas, colon, liver
19. Carcinoembryonic antigen (CEA) Ca of colon, rectum, stomach, prostate, lungs, breast
20. Prostate specific antigen (PSA) Prostate cancer
21. Tissue polypeptide antigen(TPA) Breast, colon, lung, pancreatic cancer
22. CA-125 Ovary, pancreas, colon cancer
23. CA-19-9 Pncreas, colon, gastric cancer
24. CA-15-3 Breast cancer
25. CA-72-4 Gastric cancer
OTHERS
26. Lipid –associated sialic acid Leukemia, ymphoma, melanoma,
27. Chromosome rearrangements Melanoma, renal and testicular cancer, liposarcoma

23
Site Specific Cancer Screening and Early Detection Guidelines
Site Screening and Detection
1. Stomach Occult blood testing, complete blood count
2. Testis Testicular self-examination, testicular USG
3. Vulva Visual and manual inspection of external genitalia,
colposcopic exam in women with HPV
4. Pancreas Blood glucose test, physical examination
5. Prostate Digital Rectal Examination(DRE)
Transrectal USG(TRUS)
Prostate Specific Antigen(PSA)
6. Skin (nonmelanoma) Extensive skin examination
Mole mapping
7. Soft tissue sarcoma(bone or
muscle)
Annual physical examination
Awareness of cancer early signs
8. Hodgkin’s Lymphoma Physical Examination, complete blood count
9. Non-Hodgkin’s Lymphoma Physical Examination, complete blood count
10. Multiple myeloma Annual physical examination, Radiologic tests
11. Ovary Genetic testing:BRCA genes
Pelvis USG(with vaginal probe)
Elevated serum markers:carcinoembryonic antigen(CEA) CA-
125 ANTIGEN
12. Leukemia acute CBC, Platelet count, Physical Examination
13. Chronic CBC, Platelet count, Physical Examination
14. Liver Annual Physical Examination,USG,Awareness of risk factors
15. Lung Chest X-ray
Computed tomography scan
Positron emission tomography scan
16. Esophagus Esophagoscopy with staining techniques
Brush biopsy
Radio isotopes in tumor scanning
17. Head and Neck Semi annual dental/oral examination
18. HIV/AIDS related Kaposi
sarcoma (KS)
High risk groups
Appearance of skin lesions
HIV serum testing
Oral examination

24
19. Central Nervous System CT of brain,MRI,CSF analysis
20. Cervix PAP test,Pelvic Examination
21. Colon and Rectum DRE annually after age 40,Stool occult blood testing annually
age 50 and older
Flexible Sigmoidoscopy
22. Endometrium Annual Pelvic Examination ages 40-49 Aspiration Curettage
23. Biliary tract (gall bladder
and bile ducts)
Physical Examination, USG
24. Bladder Urinalysis, Urine cytology, PE
25. Brain Physical Examination,
Prompt follow-up with onset of signs and symptoms
26. Breast Consists of 3 modalities:
1. Breast Self Examination: monthly at the age of 20 and
older
2. Clinical examination ages 20-40:every 3 years; over 40
every year
3. Mammography ages 40-49 every 1-2 year; ages 50
and over every year baseline mammogram at age 25
recommended for genetically predisposed women: Fine
Needle Aspiration Cytology (FNAC), USG and Genetic
testing (BRCA genes).


25
Unit : 4
CARCINOMA OF ORAL CAVITY
Cancer of the oral cavity may occur in any part of the mouth or throat, is curable if detected early.
This type of cancer is commonly associated with the use of alcohol and tobacco. Oral cancer is one of
the ten most common cancers is the world. Cancers of the oral cavity account for less than 5% of total
cases of body malignancies. Oral cancer is most frequently seen among fifth and sixth decades of life
affecting men more frequently than women. Oral cancer is a major problem in India and accounts for
50%–70% of all cancers diagnosed as compared to 2% to 3% in UK and USA. In India the incidence
is 18%–20%.
Types of Oral Carcinoma:
Basal Cell Carcinoma: Basal cell Carcinoma of the oral cavity occurs primarily in the lips. It starts as
a small scab that develops into an ulcer with characteristic pearly border.
Incidence: Basal cell carcinoma is the second most common oral cancer.
Aetiology: Basal cell carcinoma primarily occurs as a result of excessive exposure to sunlight. It tends
to occur more commonly in fair skinned individuals who are exposed to sunlight.
Squamous Cell Carcinoma: Squamous cell carcinoma is a malignant growth arising from tiny and flat
squamous cells that line mucous membranes.
Incidence: Squamous cell carcinoma is the leading type of oral cancer. Most tumors occur in clients
older than 45 years of age. Common sites of Squamous cell carcinoma include the lower lip and the
tongue. Approximately 95% of cancers found on the tongue are Squamous cell carcinomas. The
tongue represents 1 to 1.5% of all malignancies in the U.S.
Aetiology: The primary cause is chronic irritation of the mucous lining of the mouth and oral cavity.
The overuse of alcohol and tobacco are the primary causes of oral irritation. In combination, tobacco
and alcohol are extremely destructive to the oral mucosa.
Risk Factors: Poor oral hygiene with bacterial irritation, Physical trauma, as from jagged teeth or
improperly fitting dentures, Chemical and thermal trauma from tobacco, alcohol, oral tobacco and
snuff or hot or spicy foods or drinks, Malnutrition, Syphilis or cirrhosis of liver and Family history of
oral cancer are common risk factors for squamous cell carcinoma.
Patho-physiology: Squamous cell carcinoma develops from tiny cells that line the oral cavity.
Squamous cell carcinoma is usually well differentiated direct infiltration of local lymph nodes and can
extend into the buccal fat and even to the mandible.
Clinical Manifestations: Many oral cancers exhibit no symptoms in the early stages. The most
frequent complaint of the patient is a painless sore or mass that will not heal. A typical lesion in oral
cancer is a painless indurate ulcer with raised edges. As the cancer progresses, the patient may
complain of tenderness, difficulty in chewing, swallowing or speaking, coughing of blood – tinged
sputum or enlarged cervical lymph nodes, pain in the tongue or ear. Red appearing (erythroplakia)
Squamous cell carcinomas may not be well delineated and often bleed easily. Because Squamous cell
carcinomas usually grow slowly there may be large symptoms when they are detected.

Carcinoma of Oral Cavity
26
Diagnosis:
 Only biopsy of lesion positively confirms a diagnosis of oral cancer
 Cytologic examination of suspicious mucosa
 Cytologic examination must be followed by biopsy
 Laryngoscopic examination is performed to diagnose carcinoma at the base of the tongue
Management:
The survival rate for clients with oral cancer depends on the site and staging of the tumor.
Management of oral cancers includes radiation therapy, chemotherapy and surgery and again
depends on the site and staging of the tumor. Treatment of oral cancers with radiation can be given
by external beam or interstitial radiation therapy. The external beam passes through the skin or
mucous membrane to the tumor. Interstitial radiation involves implanting radioactive seeds into the
tissue for a specific period of time. Because interstitial radiation affects local tissue, it is used for small
lesions that have into infiltrated the surrounding tissue. The client with interstitial radiation is
hospitalized and placed on radiation precautions while the materials are active. In cancer of the lip,
small lesions are usually excised liberally larger lesions involving greater than 1/3rd of the lip may
be more.
Surgical Management: Small tumors in the anterior floor of the mouth can be excised and the area
reconstructed with the use of split-thickness skin graft. A thin layer of skin, usually from the anterior
things, can line the surgical site, allowing the client to maintain good mobility and function of the
tongue. Xeroform gauge is usually placed over the skin graft and sutured into place. This can restrict
the tongue, causing aspiration of secretions. Because of this packing and as a result of post operative
edema, a tracheotomy tube is placed until edema subsides and the oral cavity is patent. The client
receives nothing by mouth for 7 to 10 days after surgery to allow for healing. Nasogastric /
gastrostomy are used to provide nutrition unitil the client can resume oral feedings.
Invasive tumors require extensive surgical excision and usually involve removal of associated lymph
nodes. Depending on the location, procedures may include a glossectomy (removal of the tongue)
mandibulectomy (removal of the mandible), hemi mandibulectomy (partial removal of the mandible)
or hemiglossectomy. A radical neck dissection is an extensive procedure that involves removal of all
tissue under the skin, from the jaw down to the clavicle, and from the anterior border of the trapezius
muscle to the mid-line. A modified radial neck dissection involves removal of the Lymph node only and
is preferred when the disease is confined to mobile lymph nodes.
Pharmacological Management:
The effectiveness of chemotherapy for the treatment of oral cancers remains to be determined. Several
chemotherapeutic agents are used to treat clients with head and neck cancers. They are: Bleomycin,
Cisplatin, Cyclophosphamide, Doxorubicin (Adriamycin), 5–Flurouracil, Hydroxyurea, Methotrexate and
Vincristine
Nursing Management
Nursing Assessment: Obtain health history to determine the patients teaching and learning needs
concerning preventive and hygiene as well as to identify symptoms requiring medical evaluation, the
history includes questions about the patients, Normal bushing and flossing routine, Frequency of dental
visits, Awareness of any lesions or irritated areas in the mouth, tongue or throat, Recent history of sore
throat or bloody sputum, Discomfort caused by certain foods, Daily food intake and Use of alcohol

27
and tobacco and their amount and frequency.
Physical Examination: During physical assessment, both the internal and external structures of the
mouth and throat are inspected and palpated. The examinations begin with inspection of the lips for
moisture, hydration, Colour, texture, symmetry and the presence of ulceration or fissures. Lips should
be moist, pink, smooth and symmetric. The gums are inspected for inflammation, bleeding, reaction
and discoloration. The odor of the breath is also noted. The hard palate is examined for Colour and
shape. The dorsum (back) of the tongue is inspected for texture, Colour and lesions. A thin, white coat
and large Vallate papillae in a ‘V’ formation on the distal portion of the dorsum of the tongue are
normal findings. The patient is instructed to protrude his or her tongue and move it laterally to
estimate the tongue’s size as well as its symmetry and strength. Further inspection of the ventral
surface of the tongue and the floor of the mouth is accomplished by asking the patient to touch the
roof of the mouth with the tip of tongue. Any lesions of the mucosa or any abnormalities like white or
red plaque, an indurated ulcer or a warty growth. A tongue depressor is used to visualize pharynx.
The tonsils, uvula and posterior pharynx viewed and inspected for Colour, symmetry, evidence of
exudates, ulceration or enlargement.
Nursing Diagnoses: Based on all the assessment data, major nursing diagnoses may include the
following:
1. Altered oral mucous membrane related to a pathologic condition, infection, or chemical or
mechanical trauma.
2. Altered nutrition, less than body requirements, related to inability to ingest adequate nutrient
secondary to oral or dental conditions.
3. Body image disturbances related to a physical change in appearance resulting from disease
condition or its treatment.
4. Fear of pain and social isolation related to disease or change in physical appearance
5. Pain related to oral lesion or treatment
6. Impaired verbal communication related to treatment
7. Risk for infection related to disease or treatment
8. Knowledge deficit about disease process and treatment plan
Over all Nursing Goals:
1. To facilitate improvement in the condition of the oral mucous membrane.
2. To improve the nutritional status of the patient.
3. To help the patient to attain a positive self image
4. To provide comfort.
5. To facilitate alternate communication methods
6. To prevent infection
7. To understand the disease and it’s treatment
Nursing Interventions:
Promoting Mouth Care: There is need to identify the oral complications and to assist the patient to
decrease complications. Instruct the patient the importance and techniques of preventive mouth care.
Use of soft tooth brush is preferable to the use of a four sponge stick. If a patient cannot tolerate

Carcinoma of Oral Cavity
28
brushing or flossing, an irrigating solution of 1 tsf baking soda to 8 ounce of warm water, half
strength H2O2 or normal saline solution is recommended. In case of bacterial or fungal infections,
administer appropriate medication as prescribed and instruct the patient in how to administer these
medications at home.
Xerostomia: (Dryness of mouth) is a frequent sequala of oral cancer, particularly when salivary
glands have been exposed to radiation or major surgery. To minimize this problem, the patient is
advice to avoid dry, bulk and irritating foods and fluids as well as alcohol and tobacco. To increase
intake of fluids is not contraindicated. To use a humidifier during sleep, Use synthetic saliva, a
moisturizing antibacterial gel such as Oral Balance or a saliva production stimulant such as Salogen
may be helpful.
Stomatitis: Is often a side effect of chemotherapy or radiation therapy. Prophylactic mouth care is
started when the patient begins receiving treatment. Some research studies suggest that using
benzydamine hydrochloride rinse or topical prostaglandin E2 may decrease stomatitis. If a patient
receiving radiation therapy has poor dentition, extraction of the teeth is often recommended to
prevent infection before treatment is initiated. Many radiation therapy centers recommend the use of
fluoride treatments for patients receiving radiation to the head and neck.
Assuring food and fluid intake: Research with patients receiving treatment for cancer of the head
and neck has determined that (i) eating disabilities are common and (II) patients develop strategies to
maintain adequate nutrition.
 Record patients height, age, level of activity to determine nutritional intake
 Promote small, frequent feedings
 Administer an analgesic 30 to 45 min prior to a meal, if pain associated with eating
 Provide oral care before and after meals to remove oral odors and debris.
Minimizing Discomfort and Pain: Instruct the patient to minimize discomfort by avoiding foods that
are spicy, hot or hard, Instruct about importance of Mouth care, provide the patient an analgesic such
as viscous Lidocaine or options as prescribed and Reduce fear of pain by advising the patient
regarding pain control methods.
Promoting Infection Control: Leucopoenia may result from radiation, chemotherapy, AIDS which
makes the patient to become more susceptible to infections.
 Evaluate Laboratory results frequently
 Check the patients body temperature
 Visitors who may transmit micro-organisms are prohibited
 Skin tissues are protected from trauma to maintain skin integrity and prevent infection
 Follow strict aseptic technique when required
 Provide adequate nutrition
 Administer prescribed antibiotics
Supporting a positive self-image: Patient who has a disfiguring oral condition or has undergone
disfiguring surgery may experience an alternation in self image. Encourage patient to verbalize the
perceived change in body appearance and to discuss actual changes or losses.
 Support while the patient verbalizes fears and negative feelings (withdrawal, depression,
anger)

29
 Listen attentively and determine if the patient’s needs are primarily psychosocial or cognitive-
perceptual. This will help to individualize a plan of care.
 Reinforce patients strengths, achievements and positive attributes
 Determine the patient’s major anxieties concerning interpersonal relationship, to recommend
specific ways for the patient to interact with others.
 Refer to support groups /psychiatrist /social worker to help the patient to cope with anxieties
and fears.
 Emphasize that the patient’s worth is not diminished by physical change in a body part.
 Be alert to signs of grieving and record emotional changes
 Provide an atmosphere of acceptance and support to encourage the patients to express changes
in feeling of self esteem.
Promoting Effective Communication: For the patient undergoing radical surgical procedures for oral
cancer, the potential for loss of verbal communication is high. Therefore, patients’ ability to
communicate in writing is assessed preoperatively. Provide slate or pen and paper post operatively
to those patients who can use them to communicate successfully. Preoperatively a communication
board with common used words or pictures and give to post operative patients who are unable to
write consult a speech therapist post operatively.
Patient Education and Home Care Considerations: The post hospital objectives of patient care are
similar to those that apply during hospitalization. The patient who is recovering from treatment of a
mouth condition needs to breathe, obtain nourishment, avoid infection and be alert for adverse signs
and symptoms. The patient, family members or the person responsible for home care, the nurse and
other health care professional need to work together to prepare an individualized plan of care. If
any equipment is needed, determine what equipment is needed and where it can be obtained. The
patient and family are taught how to use the equipment. Methods of preparing foods that are
nutritious, properly seasoned, and of the right temperature can be explained. Commercial baby food
can also be used. The patient who is unable to take foods orally may need to be instructed in the use
of enteral or parental feedings. The use and care of prostheses must be understood. The importance
of keeping the dressings clean is reviewed, as is the need to practice strict oral hygiene. The patient
and the care provider at home need to know the signs of infections.


Ear Nose Throat (ENT) Cancers
30
Unit : 5
EAR NOSE THROAT (ENT) CANCERS
Tumors of External Ear
Of all the cases of Ear carcinoma, 85% occur on the pinna, 10% in the external ear canal and 5% in
the middle ear. Tumors of the external ear may arise from the pinna or external auditory canal.
Tumors of auricle
Benign:
• Preauricular cyst or sinus • Sebaceous cyst
• Dermoid cyst • Keloid
• Hemangioma • Papilloma
• Cutaneous horn • Malignant:
• Squamous cell carcinoma • Basal cell carcinoma
• Melanoma
 Preauricular sinus or cyst: It results from faulty union of hillocks of the first and second branchial
arches during the development of pinna. Surgery is indicated if there is unsightly swelling or
infection. Cyst or sinus must be excised completely to avoid recurrence.
 Sebaceous cyst: Common site: post auricular sulcus or below and behind the ear lobule.
Treatment is to total surgical excision.
 Dermoid cyst: Usually present as a rounded mass over the upper part of mastoid behind the
pinna
 Keloid: Often follows trauma: piercing the ear lobule, surgical incision, Genetic susceptibility,
Black races: more affected, surgical excision with injection of triamcinolone into the surgical site
or immediate post operative radiation of 300 rads.
 Hemangiomas: Congenital tumors often seen in childhood, capillary hemangiomas and
Cavernous are its type.
 Papilloma: Viral in origin. Surgical excision or curettage with cauterisation of its base.
 Cutaneous horn: Present as “horn shaped tumor”. Often seen at the rim of helix in elderly
people. Surgical excision
 Keratoacanthoma: Present as a raised nodule with a central crater. Initially grows rapidly but
slowly regresses leaving a scar. Surgical excision
 Neurofibroma: Present as a nontender firm swelling and may be associated with von
Recklinghausen’s disease, Surgical excision.

31
Malignant tumors
 Squamous cell carcinoma: Site of predilection-helix, May present as a painless nodule or an
ulcer. More common in males in their fifties who had prolonged exposure to direct sunlight, Fair
complex ioned people are more prone
Treatment:
Small lesions: local excision
Larger lesions: may require total amputation of pinna often with en bloc removal of parotid
gland and cervical lymphnodes.
 Basal cell carcinoma: Common sites: Helix and tragus, More common in men beyond 50 years
of age. Present as a nodule with central crust, Lesions may penetrate deeper, involving cartilage
or bone.
Treatment: Lesions not involving cartilage can be irradiated; Lesions involving cartilage-may
require surgical excision
 Melanoma: More common in men of light complexion exposed to sun. Metastases: 16-50%cases
Treatment: Superficial (<1 cm) Wedge resection and primary closure, superficial melanoma (>1
cm): Pinna resection, parotidectomy and radical neck dissection, Tumors of external auditory
canal
External auditory canal
Benign:
 Osteoma: Arise from cancellous bone and present as a single, smooth, bony hard, pedunculated
tumor. Treatment of choice is surgical removal.
 Exostoses: Multiple bilateral smooth sessile bony swellings in deeper meatus. Arise from
compact bone. M:F =3:1. Treatment: Small and asymptomatic-no treatment, Larger ones-remove
with high speed drills.
 Ceruminoma: Present as a smooth, firm, skin covered polypoid swelling in the outer part of the
meatus. Obstructs the meatus leading to retention of wax and debris. Treatment: Wide surgical
excision
 Sebaceous adenoma: Arises from sebaceous galnd of the meatus. Treatment: Surgical excision
Malignant
 Squamous cell carcinoma: Most often seen in cases of long standing ear discharge. Presenting
symptoms are blood staining of hitherto mucopurulent or purulent discharge and severe earache.
Regional lymphnodes may be involved. Treatment includes En bloc wide surgical excision with
post operative radiation. Basalcellcarcinoma, Adenocarcinoma, Malignant melanoma are Rare.
 Ceruminoma: Malignant type is twice as common as benign
Tumors of middle Ear
Malignant tumors:
 Squamous cell carcinoma is the commonest. Symptoms: Blood stained otorrhoea, Earache,
Rapidly progressing hearing loss. Treatment: partial or total temporal bone resection followed
by radiotherapy. Prognosis is Poor.

32
 Glomus tumor: Usually arises from the tympanic plexus. Symptoms: unilateral tinnitus and
hearing loss and later bleeding from the ear. Management: Surgical excision.
 Langerhans Cell Histiocytosis: Involves the temporal bone including the middle ear and mastoid
Symptoms: pain and blood stained discharge from the ear. Treatment: Combination of
radiotherapy, chemotherapy and steroids.
 Osteomas: Rare, Mostly asymptomatic, only symptomatic osteomas need to be excised.
Carcinoma of Nose and Paranasal Sinuses
Tumors of nasal cavity: Benign
• Squamous papilloma
• Inverted papilloma Schwanomma
• Meningioma
• Haemangioma
• Chondroma
• Angiofibroma
• Encephalocele
• Glioma
• Dermoid
Squamous papilloma:
 Verrucous lesions similar to skin warts
 Can arise from nasal vestibule or lower part of nasal septum
 May be single or or multiple, pedunculated or sessile
 Treatment: Local excision, Cryosurgery or laser
Inverted papilloma
 Mostly seen between 40-70 years with male preponderance.
 Arises from the lateral wall of nose and is always unilateral.
 Has a marked tendency to recur after surgical removal.
 Treatment: Wide surgical excision by lateral rhinotomy or medial maxillectomy and en bloc
ethmoidectomy.
Pleomorphic adenoma:
 Rare
 Arises from nasal septum
 Treatment: wide surgical excision
Schwannoma and meningioma:
 Uncommon
 Found intranasally
 Treatment: Surgical excision by lateral rhinotomy

33
Haemangioma:
 Capillary and cavernous
Chondroma:
 Arise from the ethmoid, nasal cavity or nasal septum.
 Pure chondromas: smooth, firm and lobulated
 Others: may be mixed type fibro, osteo, or angiochondromas
 Treatment: Surgical excision
 For recurrent or large tumors: Wide excision
Intranasal meningoencephalocele:
 Herniation of brain tissues and meninges through foramen caecum or cribiform plate.
 Present as a smooth polyp in the upper part of nose between the septum and middle turbinate,
usually in infants and young children.
 CT scan is essnetial to demonstrate a defect in the base of skull
 Treatment: Frontal craniotomy
Gliomas:
 Of all gliomas, 30% are intranasal, and 10% are both intranasal and extranasal
 Seen in infants and children
Nasal Dermoid:
 Present as widening of upper part of ansal septum with splaying of nasal bones and
hypertelorism.
Malignant:
Carcinoma of nasal cavity:
 Primary carcinoma is rare.
 Squamous cell variety is the most common seen in about 80% of cases.
 Rest may be adenoid cystic carcinoma or an adenocarcinoma.
Squamous cell carcinoma
 May arise from the vestibule, anterior part of the nasal septum or the lateral wall of nasal
cavity.
 Most of them are seen in men past 50 years of age.
 Vestibular: Arises from lateral wall of nasal vestibule
 Septal: Mostly arises from mucocutaneous junction and causes burning and soreness in the nose
 Often termed as “Nose picker’s Cancer”
 Lateral wall: Most commonly involved site
 Easily extends into ethmoid or maxillary sinuses.
 Metastases: rare
 Treatment: Combination of radiotherapy and surgery

34
Adenocarcinoma and adenoid cystic carcinoma:
 Arise from the glands of mucous membranes or minor salivary glands
Malignant melanoma:
 Usually seen in those above 50 years of age
 Both sexes are equally affected.
 Grossly presents as a slatygrey or bluish-black polypoid mass.
 Most frequently occurs in anterior part of nasal septum.
 Treatment: Wide surgical excision
Olfactory neuroblastoma
 Presents as a cherry red polypoidal massin the upper third of the nasal cavity.
 Vascular tumor and bleeds profusely on biopsy
 Treatment: Surgical excision followed by radiation
 Craniofacial resection may be required for tumors of the cribiform plate.
Hemangiopericytoma:
 Rare tumor of vascular origin
 Arise from a pericyte
 Treatment: wide surgical excision
Others:
 Lymphoma
 Plasmacytoma
 Sarcomas (osteogenic sarcoma, Chondrosarcoma, Rhabdomyosarcoma, Angiosarcoma etc)
Neoplasms of paranasal sinuses
Benign:
• Osteoma
• Fibrous dysplasia
• Ossifying fibroma
• Ameloblastoma
Osteomas:
 Most commonly seen in frontal sinus.
 May remain asymptomatic
 Treatment: Indicated when they become symptomatic causing obstruction to the sinus ostium,
formation of mucocele etc.
 Fibrous dysplasia:
 Mostly involves maxillary sinus.
 Patient seeks advice for disfigurement of face, nasal obstruction and displacement of eye.
 Treatment: Surgical resculpturing of the involved bone.

35
Ossifying fibroma:
 Seen in young adults
Ameloblastoma:
 Locally progressive tumor
 Invades maxillary sinus
 Treatment: Surgical incision
Others:
 Inverted papilloma
 Meningioma
 Hemangioma
Malignant: Malignancy of paranasal sinuses accounts for 15% of all the neoplasms of the upper
respiratory tract.most frequently involved are the maxillary sinuses followed in turn by ethmoid,
frontal and sphenoid.
Diagnosis: Squamous cell carcinoma of head and neck, esophagus, cervix, skin, penis
Protocol-PF: Regimens of Chemotherapy in Practice
Frequency: 4 weekly
S.N. Drug Day 1 Day 2-5
1. Inj NS 2000 ml with each 500 ml add inj KCL 10 meq/L + MgSO4
250 mg over 8-10 hours IV prehydration
XXX
2. Tab lorazepam 1 mg PO BD XXX
3. Inj ondem 16 mg IV before Chemo XXX
4. Inj dexona 16 mg IV before chemo
5. Inj ranitidine 50 mg IV push
6. Inj cisplatin 100mg/m2 + 500 ml NS IV over 2 hours infusion XXX
7. Inj mannitol 20% 350 ml IV over 1 hour XXX
8. Inj ondem 8 mg IV push stat XXX
9. Inj dexona 8 mg IV push stat XXX
10. Inj 5 FU 100 mg/m2 + 1000 ml NS IV 24 hours infusion XXX
11. Inj NS 2000 ml with each 500 ml add inj KCL 10 meq/L + Mgso4
250 mg over 8-10 hours IV posthydration for cisplatin
XXX
Hydration amount and rate can be adjusted if necessary


Brain Tumor
36
Unit : 6
BRAIN TUMOR
The diagnosis of a brain tumor begins for uncertainty, fear, and hope for the patient and his or her
family. There is significant loss of neurological function and quality of life.
Incidence and etiology: Intracranial tumours are found in people of all ages. Peak of incidence
occurring in early childhood, in the fifth, sixth, and seventh decades. The incidence is slightly higher in
men than in women. A higher incidence of malignant gliomas and neuromas is found in men, whereas
the incidence of meningiomas and pituitary adenoma is higher in women.
The cause of primary brain tumour is unknown. Certain tumours appear to have a congenital basis
(epidermoid, dermoid, and teratoid tumours and craniopharyngiomas). Others may be related to
hereditary factors.
Classification of Brain tumours:
1. Primary versus secondary Brain tumours: Primary brain tumours originate from the various
cells and structures normally found within the brain. Metastasis brain tumours originate from
structures outside the brain, most often from primary tumours of the lungs, breast, gastrointestinal
tract and genitourinary tract.
2. Neuroembryonic Origins: The nervous system originates from the ectodermal (outer) layer of
the embryo. The neuroblasts are the basic unit of structure in the nervous system. The glioblasts
support, insulate and metabolically assist the neurons. They are collectively called Glial cells and
the three categories arising from it are: astrocytoma, oligodendrogliomas and ependymomas.
3. Intra-axial versus ectra-axial Brain tumours: Intra-axial brain tumours and located within the
central neuraxia (cerebral hemispheres, brain stem, and cerebellum). They arise from neuroglial
precursor cells and are found mostly in the white matter. Extra-axial brain tumours are located
outside the central neuraxis. They arise from the cranial nerves, pituitary gland, or meninges.
Figure: Brain Tumors

37
Anatomical location refers to the location of the lesion in reference to the tentorium or to cerebral
tissue. One classification system that uses the tentorium as a reference point differentiates between
supratentorial, which signifies a tumour located above the tentorium (cerebral hemispheres), and
infratentorial which denotes a tumour located below the tentorium (brain stem and cerebellum). A
second way of it is by the actual site of the lesion, such as frontal as frontal lobe temporal lobe, pons,
or cerebellum.
Histological Origin:
1. Intracerebral Tumours: Gliomas
a. Astrocytomas (grades I and II) – 10%
b. Glioblastoma multiforme (also called astrocytoma grades III and IV)–20%
c. Oligodendrocytoma (grades I to IV) – 5%
d. Ependymoma (grades I to IV) – 6%
e. Medulloblastoma – 4%
2. Tumours arising from the supporting structure
a. Meningiomas – 15%
b. Neuromas (acoustic neuroma, schwannoma) – 7%
c. Pituitary adenomas – 7%
3. Developmental (congenital) tumours
a. Dermoid epidermoid, teratoma, craniopharyngioma -4%
b. Angoioma – 4%
4. Metastatic lesions – 6%
5. Other
a. Unclassified (mostly gliomas) - 6%
b. Sarcomas – 4%
c. Miscellaneous (pinealoma, chordoma, granulaom) 3%
Pathophysiology:
Regardless of the origin, tumour extends in an irregular fashon
↓
Infiltrates and compresses normal brain tissue.
↓
Cerebral edema, >ICP, focal neurological deficit, obstruction to CSF
& pituitary dysfunction
Key features of common brain tumors:
Cerebral tumors:
 Headache (more common features)
 Vomiting unrelated to food intake
 Changes in visual acuity and visual fields; diplopia (visual changes caused by pailloedema)

Brain Tumor
38
 Hemi paresis or hemiplegia
 Hyperkinesias
 Hyperesthesia, paresthesiam decreased tactile discrimination
 Seizures
 Aphasia
Brain Stem Tumors
 Hearing loss (acoustic neuroma)
 Facial pain and weakness
 Dysphagia, decreased gag reflex
 Hoarseness
 Ataxia and dysarthria (cerebellar tumors)
BRAIN TUMOURS: Detailed Description
TYPE OF TUMOURS DESCRIPTION LOCATION OR
DEMOGRAPHIC
DATA
SIGNS AND
SYMPTOMS
TREATMENT
Common brain tumours
Astrocytoma (grades I
and II
Grade I: well –defined
cells
Grade II: cells
differentiation less
defined
Usually found in the
cerebrum,
hypothalamus, and
pons
Neurological deficits
depending on the
location
Surgery:
Complete
removal and
partial removal
irradiation
Glioblastoma
multiforme (GBM)
Malignant, rapidly
growing. Necrotic areas
with multiple lysis and
hemorrhagic areas
within tumour (GBM)
Usually involves a
cerebral hemisphere
Depend on specific
location and size
Diffuse cerebral
symptoms
Seizures
Surgery resection
and debunking
irradiation and
chemotherapy
Astrocytoma of the
cerebellum (grades I-
II)
Cystic tumour
Slow growing
Considered benign if
completely excised
Cerebellar region:
found
Paralysis of the
abducens CN
hemiplegia
Sensory loss
Gazedisorders
Cerebellar dysfunction
Surgery,
Irradiation and
Shunting
procedures
Astrocytoma of the
optic nerves and
chiasma
(spongioblastoma)
As the tumour grows, it
enlarges the optic
foramen with little
distortion of the
surrounding structures
Slow-growing tumour
Found along the
optic nerves; girls
are affected twice
as often as boys
Early symptoms Include:
Dimness of vision
Hemianopia
Optic atrophy
Blindness
Proptosis
Hypothalamic
imbalance
Surgery
irradiation
Ependymoma (grades
I-IV)
A gliomas arising from
the lining of the
ventricles
Slow-growing tumour
In centrioles,
particularly the
fourth
ICP raised secondary
to obstruction of CSF
flows
Decreased LOC
Surgery,
Irradiation,
Shunting
procedures,

39
Papillary changes
Hemiplegia
Sensory deficits
Vital sign changes
(respiration,
bradycardia)
Blood pressure and
widening of pulse
pressure
Ataxia or in
coordination
(cerebellar dysfunction)
High-dose
cyclophosphamide
Oligodendoroglioma Calcification noted on
radiological
examination in about
50% of patients. slow-
growing
Cerebral
hemispheres,
particularly the
frontal and temporal
lobes
Seizures are the first
symptoms in 50% of
patients
Surgery
irradiation or
both
Medulloblastoma Rapidly growing tumour
that can obstruct CSF
flow
Seeding into the third
and lateral ventricles
Almost exclusively in
the cerebellar
vermise
Visual disturbances
ataxia and in
coordination
Surgery
Irradiation
Shunting
procedures
Chemotherapy
Meningioma Firm, encapsulated
tumour arising from
arachnoid
granulations/meninges
Slow-growing rarely
causes compression of
the brain
Prediction for areas
proximal to the
venous sinuses
Neurological deficits
caused by compression
that depend on the
area involved
Surgery
Irradiation and
chemotherapy
Metastatic brain
tumours
10% of all brain
tumours metastatic from
other parts of the body
(lungs, breast, stomach,
lower GI tract,
pancreas, and kidney.
Spread to the brain by
blood
- Depend on location Surgery
Irradiation:
Gamma knife
radio surgery
Malignant melanomas - Cerebral
hemispheres from a
primary lesion in the
skin
Depend on the location Surgery,
irradiation
Chemotherapy
Primary cerebral
lymphoma (secondary
cerebral lymphomas
may be seen in
patients with AIDS).
Cellular tumour
Behaves much like a
glioblastoma
May arise in any
part of the brain,
may be either
monofocal or
multifocal
Behavioral and
personality changes
Focal signs
Seen on CT scan or MRI
Radiation and
steroid therapy
effective
Rapid response to
steroids
Current
chemotherapy

Brain Tumor
40
Cerebellopontine angle tumours
Acoustic neuroma
(schwannoma)
Arises from the sheath
of Schwann cells
Size of a pea to that of
a walnut
Considered a benign
tumour But located in
an often inaccessible
area
Slow-growing tumours
Tumourmay entwine
other cranial nerves that
would cause severe
deficits if the tumour
were completely
excised
Seen most often in
the fourth or fifth
decades.
Involves Vesicular
branch of CN VIII
Small tumours are
confined to the
Internal auditory
canal and involve
CN VIII
Small tumours (confined
to internal auditory
canal).
Tinnitus/vertigo
Hearing loss
Dizziness
Large tumour (outside
the auditory meatus):
Loss of taste to
anteanterior tongue
Difficulty closing lower
eyelid
Facial weakness
paresthesia/anesthesia
to face
Difficulty chewing
CNS IX and X (glosso-
pharyngeal and vagus
nerves
Difficulty swallowing
Hoarseness
Cerebellar involvement
Ataxia
In coordination
Hydrocephalus may
occur with larger
tumours
ICP from obstruction of
CSF flow secondary to
displacement of pons
and medulla
Surgery
Microsurgical
technique
Translabyrinthine
approach for
larger tumours
Irradiation: proton
beam
Gamma knife
Chordoma Found in clivus (35%)
dorsum of sellae to
foramen magnum
and sacrococcygeal
area (50%)
Surgery, excision
irradiation
Pituitary tumours
Pituitary adenomas
Tumours in the
anterior lobe
Visual disorders
headache
Various endocrine
disorders
Surgery
For smaller
tumours
Transsphenoidal
microsurgery
For large tumours
Tran frontal
craniotomy
Radiation proton
beam
Conventional
radiation therapy
Hormonal
replacement
Hemangioblastoma Vascular tumour slow-
growing
Cerebellum Dizziness
Unilateral ataxia
Surgery
Irradiation

41
Treatment:
Conventional surgery: However, malignancy and surgical accessibility are equally important when
judging prognosis. Some tumours, although histologically benign, cannot be completely removed;
nonetheless, even a partial resection will relieve symptoms temporally. Obstruction of CSF flow may
require a shunting procedure to relieve CSF pressure.
Craniotomy: It is surgical opening into the skull. It is a craniotomy (removal of portion of cranium) is
sometimes performed for decompression. General anaesthesia is used during surgery client’s head is
supported in a special frame and a laser or ultrasonic aspiratory is used to minimize the trauma to
the normal brain tissue. A catheter in the brain to drain access fluid or blood from a ventricle or other
fluid filled space is placed. A Jackson-pratt suction drain is surgically inserted if a large cavity
remains after removal of a tumour or large haematoma.
Transsphenoidal hypophysectomy: This is most common procedure. It is performed from anterior
upper gum or nose to avoid entering the cranium. The nose is packed to control bleeding. After
surgery the client is positioned with the head elevated. Mouth care is especially important. He may
require replacement pituitary hormones if the gland is non functional.
Laser surgery: Laser surgery is increasingly being used to treat brain tumours. Use of lasers may be
combined with conventional surgery to treat the patient. The advantage of using lasers for treatment
of brain tumours is that they enable the neurosurgeons to dissect or shrink tumors without inflicting
injury to the surrounding tissue.
Radiation therapy (Steriotactic radiosurgery):
It is application of ionizing beams of radiation focused with the help of intracranial guiding devices.
Three techniques are used: Bragg peak photon beam, Liner accelerator radiosurgery and Gamma
knife radiosurgery.
A course of postoperative radiation therapy may be recommended for the following tumours;
astrocytoma, ependymoma; oligodendrogiloma; sarcoma: craniopharyngioma, and chordoma. The
total tumour dose range is usually from 4,000 to 7,000 rad, administered over 4 to 8 weeks. The
area to be irradiated depends on the anatomical extent of the tumour. If irradiation is not preceded
by surgery, large doses of corticosteroids may be sued as an adjunct to reverse temporarily and
control symptoms of increased ICP.
Chemotherapy:
The purpose of chemotherapy is to destroy tumour cells, either by destroying actual cells or affecting
their ability to replicate. Chemotherapeutic agents are classified into cells cycle-specific agents
(active during certain phases of the cell’s life cycle) and cells cycle nonspecific (effective during all
phases of the cell cycle).
Special concerns when treating a malignant lesion of the brain and using chemotherapeutic
agents include the following:
 Wide excision of a brain tumour is not possible because there is no excess tissue within the brain,
and regeneration is not possible within the brain.
 Wide excision of Glial tumours is not possible because the tumour has infiltrated normal brain
tissue, although this can’t be seen by scan.
 The location of the tumour in the brain affects choice of treatment
 Cerebral oedema affects drug entry into the tumour.
 Brain tumours rarely metastasize outside the CNS

Brain Tumor
42
 Malignant tumours (GBM are composed of diverse (heterogeneous) cells; this results in
differences in the chemosensitivity of cells within the tumours.
 Many drug cannot cross the blood –brain barrier
Nursing Interventions
Knowledge Deficit Related To Surgical Procedure
Expected outcome Nursing Interventions
Client Will Understand
Preoperative and
Postoperative Routines
• Provide preoperative teaching
• Answer questions
• Reinforce information
• Explain preoperative preparation
• Explain anaesthesia procedures
• Tell the client and the family about the length of the surgery
• Discuss how the client will look after the surgery
• Take the consent if possible, arrange visit to the critical care visit
for the client and the family
Nursing Diagnose: High Risk For Altered Tissue Perfusion Related To The Surgical Procedure
Expected outcome Nursing Interventions
Client’s level of
consciousness and
neurological status will
improve
• Check vital and neurological signs every hour postoperatively.
Report changes to the physician
• Monitor for signs of increased ICP
• Implement nursing measures to prevent increased ICP
 Elevate head of the bed
 Avoid extreme flexion of the hip or neck
 Maintain head in mid-line, neutral position
 Avoid clustering nursing activities
 Provide quite environment
• Record intake output.
• Monitor serum electrolyte levels, serum and urine osmolality and
urine specific gravity
• Check the head dressing for drainage
PAIN RELATED TO THE SURGICAL PROCEDURE
Expected outcomes Nursing Interventions
The client will experience an
alleviation or reduction of
pain
• Give pain medications as ordered
• Use non drug pain relief measures such as distraction, music and
relaxation, exercises and imagery
• Organize plan of care to allow uninterrupted periods of rest
• Apply ice pack to the eyes
• Provide comfort measures like back rub and cooled
• Compress to forehead
• Encourage frequent mouth care
• Provide ice chips

43
RISK FOR FLUID VOLUME DEFICIT
Expected outcomes Nursing interventions
Client will demonstrate signs
of adequate fluid volume as
evidence by:
Consuming adequate
calories
Incision healing within 12 –
14 days
Hemoglobin levels within
normal limits
1. Begin clear liquid diet and progress to a diet as tolerated
2. fluid intake curtailed to minimize cerebral oedema
3. Enteral feedings may be prescribed who are enabling to eat.
4. TPN may be ordered the advantage of which is high calorie,
high protein
ALTERED THOUGHT PROCESSES RELATED TO SURGICAL RESECTION
Expected outcomes Nursing interventions
1. Client will recognize
limitation
2. He will be
participating in
therapies
3. He will verbalize
limitations and
adaptations
1. Complete hours of sleep would be given due attention
2. Give suggestions how to live with limitation
3. For any brain function change (verbal thought, memory),
neuropsychological testing helps establish parameters of
dysfunction.
NURSING MANAGEMENT OF OTHER COMMON PROBLEMS IS:
Nursing Diagnosis Nursing Interventions Expected Outcome(s)
Knowledge deficit related to
purpose, method, and goals
of treatment protocol
• Ask the patient to tell his or
her understanding of the
treatment protocol
• Clarify misconceptions
• Expand on areas of partial
understanding
• Introduce new information as
necessary
• Encourage the patient to ask
questions
• Refer questions to a resource
person, as necessary
• Develop a written teaching
plan.
The patient will be able to
verbalize and describe the
purpose, goals, and method of
administering the prescribed
protocol
Anxiety related to
approaching or current
treatment
• Observe the patient for
verbal and nonverbal ones
indicating anxiety.
• Provide emotional support
• Anticipate the needs of the
patient
The patient’s anxiety will be
reduced or controlled

Brain Tumor
44
Altered comfort: Acute
nausea/vomiting R/T
chemotherapy
• Assess the patient for nausea
• Provide small, frequent
feedings that are easy to
digest
• Administer antiemetics as
ordered (prophylactically and
as necessary)
• Give nothing by mouth if
vomiting occurs
• Offer mouth care frequently
Nausea will be controlled or
minimized: vomiting will be
absent or controlled
Altered Nutrition: less than
body requirements, R/T
nausea and vomiting
• Assess the patient’s nutritional
intake on 24 hour bases
• Assess the patient’s dietary
likes and dislikes
• Offer mouth care frequently
(choose easy to digest foods)
The patient will maintain
adequate nutritional intake
Altered Oral Mucous
Membrane, R/T stomatitis
• Provide frequent mouth care
• Administer a sooting oral rinse
or topical solution for oral
comfort, such as glycerin
swabs or viscous Xylocaine
suspension, as directed
• Avoid irritating foods such as
citrus fruits
• Provide a soft, bland diet
Discomfort from Ostomatitis will
be eliminated or controlled
Body image Disturbances
R/T hair loss
• Discuss the cause of Alopecia,
as well as the regrowth
process
• Provide for meticulous
personal hygiene
• Encourage female patients to
use make up and wear
attractive head coverings
• Suggest the use of wigs when
the patient is able to wear
one
• Correct any misconceptions
• Allow the patient to verbalize
feelings
The patient will accept altered
body image

45
Fatigue R/T chemotherapy
or irradiation
• Allow the patient to express
his or her feelings about
general malaise
• Encourage and plan a
schedule that allows for
frequent rest periods
• Assess the patient’s ability to
perform activities of daily
living (ADLs). Provide for
frequent rest periods
• Adjust the patient’s schedule
as necessary to conserve
energy
The feeling of fatigue will be
minimized by frequent rest
periods
Altered cerebral perfusion
R/T cerebral oedema.
• Assess the patient’s
neurological signs periodically
• Identify any signs of
neurological deterioration;
report any such changes to the
physician, and document
findings in record
• Elevate the head of the bed
30 degree
• Administer drugs and other
protocols as ordered
• Continue to monitor the
patient
Neurological changes will be
identified early and definitive
action taken to control
deterioration
Risk for infection R/T bone
marrow depression
• Protect the patient from
exposure to infections
• Monitor the patient for signs
and symptoms of infection
• Teach the patient and family
the meaning of a decreased
white blood cell count and
nadir
The patient and family will
verbalize an understanding of
preventive measures
Risk for injury R/T
thrombocytopenia
• Monitor the complete blood
count (white blood count,
platelet count) and
coagulation study results
• Be aware of an discuss with
the patient delayed onset of
bone marrow suppression
(after 3 wk).
The patient and family will
verbalize an understanding of
the precautions against and the
risk factors for injury.

Brain Tumor
46
• Assess the patient for occult
bleeding f0r stools, urine,
gastric.
• Assess the patient for easy
bruising, petechial bleeding,
nosebleeds, and bleeding
from the gums.
Risk for impaired skin
integrity R/T radiation
induced dermatitis (With
radiation dermatitis, the skin
becomes reddened, tanned,
desquamatized, and
sensitive).
• Institute special precautions
for skin care at the site of
irradiation
• Protect: the skin from rubbing,
application of tape and
exposure to sunlight.
• Do not use alcohol, powder,
cream, or cosmetics on this
area.
• Do not wash off the skin
markings used to localize the
radiation exposure site.
Skin integrity will be maintained
Knowledge Deficit R/T
discharge an follow-up care
• Develop a written teaching
plan for discharge
• Stress the importance of
follow–up care.
• Provide a written list of signs
and symptoms that should be
reported to the physician
• Caution against use of any
drugs (e.g. aspirin) without
prior approval of the
physician
• Help the patient understand
that some side effects of the
treatment have a delayed
onset.
• Arrange for a follow-up
appointment
The patient will verbalize an
understanding of the discharge
plans and care
Note: Some of the nursing diagnoses listed may not apply to all patients; however, those identified
are inclusive of major nursing concerns
Effects on patient and family
 Loss of autonomy
 Cannot drive

47
 Neurological deficit
 Confusion and personality change
 Family lose the person they knew
 Financial loss
 Social loss
 Effects of treatment – steroids, anti epileptics, surgery and radiation.
 Invasion of space by supportive teams
 Death
 Genetic consequences
Prognosis: For people ages 15-44 five year survival rate is 55%, for people ages 45-64 five year
survival rate is 16% and for people over 65 five year survival rate is 5%.
Complications: A brain tumor can cause complications depending on the part of your brain that's
affected. Complications can include:
 Weakness: A brain tumor can damage any part of the brain leading stroke.
 Vision changes: Due to damage visual cortex.
 Headaches: A brain tumor that causes increased pressure within the brain can cause headaches.
 Personality changes: Tumors in certain areas of the brain may cause personality changes or
changes in behavior.
 Hearing loss: Brain tumors that affect the auditory nerves, especially acoustic neuromas may
cause hearing loss in the ear on the involved side of the brain.
 Seizures: A brain tumor can cause irritation to the brain that can result in a seizure.
Rehabilitation after treatment for brain tumors:
 Rehabilitation can be a very important part of the treatment plan.
 The goals of rehabilitation depend on the person's needs and how the tumor has affected daily
activities.
 The health care team makes every effort to help the patient return to normal activities as soon
as possible.
 Several types of therapists can help:
Physical therapists: Brain tumors and their treatment may cause paralysis.
 They may also cause weakness and problems with balance.
 Physical therapists help patients regain strength and balance.
 Speech therapists: Speech therapists help patients who have trouble speaking, expressing
thoughts, or swallowing.
 Occupational therapists: Occupational therapists help patients learn to manage activities of
daily living, such as eating, using the toilet, bathing, and dressing.


Pitutary Tumors
48
Unit : 7
PITUTARY TUMORS
Introduction: Most tumours are benign pituitary adenomas, although the differential includes
malignant variants, craniopharyngioma, meningioma, aneurysm and Rathke’s cleft cyst.
Epidemiology:
 Pituitary tumors represent anywhere between 10% - 15% of all intracranial tumors.
 Incidental pituitary tumors are found in approximately 10% of autopsies.
 The incidence of acromegaly is approximately 3 per million. Acromegaly has no sex
predilection.
 Most pituitary tumors occur in young adults, but they may be seen in adolescents and elderly
persons.
Pathophysiology
 Multiple oncogene abnormalities may be involved in pituitary tumorigenesis.
 G-protein abnormalities, ras gene mutations, p53 gene deletions, mutations, and
rearrangements, and the association of pituitary tumors with the syndrome of multiple endocrine
neoplasia have been described and are involved in the development of adenomas in the
pituitary gland.
Classification
On the basis of size:
 Microadenomas: Less than 10 mm (1cm) in size and usually present incidentally or with
endocrine effects.
 Macroadenomas: Tumors more than 10mm (1cm) in diameter. Thirty per cent of adenomas are
prolactinomas, 20 per cent are non-functioning, 15 per cent secrete growth hormone and 10 per
cent secrete adrenocorticotropic hormone (ACTH).
On the basis of staining characteristics
 Eosinophilic cells,
 Basophilic cells,
 Chromophobic cells (ie, cells with no affinity for either eosinophilic or basophilic stains).
 However, this classification has proven to be of no clinical value and now has been replaced by
a more functional classification that involves electromicroscopy and immunohistochemistry.
Pathogenesis
 Pituitary adenomas are benign neoplasms that arise from one of the five anterior pituitary cell
types.
 The clinical and biochemical phenotype of pituitary adenomas depend on the cell type from
which they are derived.

49
 Thus, tumors arising from lactotrope (PRL), somatotrope (GH), corticotrope (ACTH), thyrotrope
(TSH), or gonadotrope (LH, FSH) cells hypersecrete their respective hormones.
Clinical manifestations
History
 Mass effect and pressure on surrounding structures in macroadenomas
 Fifty to sixty percent present with visual symptoms due to compression of optic nerve structures.
 Nonspecific headache can be seen.
 Lateral extension can result in compression of the cavernous sinuses and may cause
ophthalmoplegia, diplopia, and/or ptosis.
 Extension into the sphenoid sinuses can cause spontaneous cerebrospinal fluid (CSF) rhinorrhea.
 In addition to visual symptoms, endocrine dysfunction can result.
Physical
 Visual acuity can be decreased in one or both eyes.
 Color vision can be affected.
 Prolactinomas
• In females, galactorrhea may be present. Women undergoing an infertility evaluation may
be found to have a prolactinoma.
• In males, galactorrhea is infrequent; testicles may be decreased in size and may be soft to
palpation.
 Acromegaly
 Cushing disease: Findings are prominent and include obesity, centripetal fat deposition,
proximal myopathy, moon facies, buffalo hump, posterior subcapsular cataracts, arterial
hypertension, bruises, and skin striae.
 Hypopituitarism
• Chronic hypopituitarism results in hypotension, generalized weakness, hypothermia, malaise,
and depression.
• Acute sudden hypopituitarism (ie, pituitary apoplexy) is associated with shock, coma, and
death.
Eosinophilic tumors
 Develop early in life result in gigantism. If the disorder begins during adult life, the excessive
skeletal growth results in acromegaly.
 Decalcification of the skeleton, muscular weakness, and endocrine disturbances, similar to those
occurring in patients with hyperthyroidism
Basophilic tumors
 Give rise to Cushing’s syndrome
Chromophobic tumors
 Represent 90% of pituitary tumors. These tumors usually produce no hormones but destroy the
rest of the pituitary gland, causing hypopituitarism.
 People with this disease are often obese and somnolent and exhibit fine, scanty hair, dry, soft
skin, a pasty complexion, and small bones.

Pitutary Tumors
50
 They also experience headaches, loss of libido, and visual defects progressing to blindness.
 Other signs and symptoms include polyuria, polyphagia, a lowering of the basal metabolic rate,
and a subnormal body temperature.
Diagnosis
 Careful history and physical examination
 Features of note include any history of galactorrhoea (suggestive of prolactinoma), and
Cushingoid or acromegalic features pointing to ACTH- or growth hormone secreting tumours,
respectively.
 Baseline assessment of pituitary function should include serum prolactin, follicle-stimulating
hormone and luteinising hormone together with testosterone in males or oestradiol in females,
thyroid function tests, and fasting serum growth hormone and cortisol.
 Diagnosis of ACTH-secreting tumours can be difficult, and may require the use of specialised
tests, such as petrosal sinus sampling and the dexamethasone suppression test.
 Computed tomography (CT) and magnetic resonance imaging (MRI) are used to diagnose the
presence and extent of pituitary tumors.
 Serum levels of pituitary hormones may be obtained along with measurements of hormones of
target organs (eg, thyroid, adrenal) to assist in diagnosis if other information is inconclusive.
Petrosal sinus sampling
 Inferior petrosal sinus sampling (IPSS) is an invasive procedure in which adrenocorticotropic
hormone (ACTH) levels are sampled from the veins that drain the pituitary gland; these levels
are then compared with the ACTH levels in the peripheral blood to determine whether a
pituitary tumor (as opposed to an ectopic source of ACTH) is responsible for ACTH-dependent
Cushing syndrome.
 IPSS can also be used to establish on which side of the pituitary gland the tumor is located.
Treatment
 Effective treatment requires close cooperation between the neurosurgical team and an
endocrinologist.
Figure: Pituitary tumor

51
 Prolactinomas are managed initially with dopamine agonists, such as bromocryptine and
cabergoline.
 Growth hormone secreting tumours may also respond to dopamine agonists, or to somatostatin
analogues, such as octreotide.
 Replacement therapy for decreased or absent hormones should be instituted as needed.
 All hormone-based treatment should be directed by a consulting endocrinologist.
Surgical management
 Surgical resection is usually performed by a trans-sphenoidal approach, using a microscope or
endoscope. Sometimes large tumours also require a craniotomy.
Figure: Trans-sphenoidal Approach
 Stereotactic radiation therapy, which requires use of a neurosurgery-type stereotactic frame,
may be used to deliver external-beam radiation therapy precisely to the pituitary tumor with
minimal effect on normal tissue
 Prolactinomas/Microprolactinomas: Transsphenoidal resection of the tumor offers a chance for
a cure without the need for long-standing dopamine agonist therapy.
 Acromegaly: Transsphenoidal surgery decreases GH levels to less than 5 mcg/L in 60% of
cases.
 Cushing disease: Transsphenoidal tumor resection is the first line of treatment in patients with
basophilic adenomas of the pituitary gland. It is curative in 80% of cases.
 Pituitary irradiation is required in the remaining cases to prevent the development of Nelson
syndrome.
 In children, pituitary irradiation and adrenalectomy are highly effective.
Management:
 Where it is suspected, the patient will require hourly measurement of urine output, and blood
and urine samples for calculation of sodium concentration and osmolality.

Pitutary Tumors
52
 If confirmed, the condition can be managed with DDAVP (desmopressin) in consultation with
endocrinology.
 Urgent intervention is generally reserved for patients with deteriorating vision.
Pituitary apoplexy
 Syndrome associated with haemorrhagic infarction of a pituitary tumour.
 It presents with sudden headache, visual loss and ophthalmoplegia with or without impaired
conscious level.
 Intravenous steroids and urgent surgical decompression are required
Vestibular schwannoma (acoustic neuroma)
 These are nerve sheath tumours arising in the cerebellopontine angle, which present with hearing
loss, tinnitus and balance problems.
 Facial numbness and weakness are less common, while large tumours may present with features
of brainstem compression or hydrocephalus.
 The differential diagnosis includes meningioma, metastasis and epidermoid cyst.
 Small intracanalicular tumours (within the internal auditory canal) may be managed with
surveillance.
 For intermediate size tumours, radiosurgery is an alternative to operation.
 Large lesions (>4 cm), especially with brainstem compression, will require excision and
consideration of ventriculoperitoneal shunt to relieve hydrocephalus.
 Translabyrinthine, retrosigmoid and middle fossa approaches are possible, the latter options
offering potential preservation of hearing in smaller tumours with some intact function at
presentation.
 In removing larger tumours, it is often impossible to preserve hearing, or indeed facial nerve
function.
Follow up
 Adjustment of hormonal therapy is necessary following transsphenoidal resection of the
adenoma. This may be accomplished in the weeks following surgery by the consulting
endocrinologist.
 Assess the need for replacement of cortisol 4 weeks after the resection. This is done by
measuring the cortisol levels following an IV injection of 250 mcg of tetracosactin. Cortisol levels
greater than 500 nmol/L indicate sufficient endogenous steroid production.
 Low thyroid levels are an indication for replacement. The same is true for low testosterone levels
in symptomatic males and low estrogen/progesterone levels in females.
 Periodic neuro-ophthalmologist follow-up is essential, particularly when residual tumor is present.
Visual fields and fundus photographs should be obtained before and immediately after tumor
resection. These parameters provide a baseline for follow-up examinations.
Nursing Management
Nursing Assessment
 Obtain history of signs and symptoms.
 Perform thorough neurologic examination and general physical examination to identify signs of
hormone deficiency or excess.

53
 Assess patient's understanding of the management plan, coping with the diagnosis, and support
from others.
Nursing Diagnoses
 Anxiety related to ablation treatment
 Readiness for enhanced management of therapeutic regimen
Post surgery
 Risk for Injury related to complications of surgery
 Risk for Infection secondary to invasive procedure
 ICP monitoring
Reducing Anxiety
 Provide emotional support through the diagnostic process and answer questions about treatment
options.
 Prepare patient for surgery or other treatment by describing nursing care thoroughly.
 Stress likelihood of positive outcome with ablation therapy.
Promoting Management of the Therapeutic Regimen
 Teach patient the nature of hormonal deficiencies after treatment and the purpose of
replacement therapy.
 Instruct patient about the early signs and symptoms of cortisol or thyroid hormone deficiency or
excess and the need to report them.
 Describe and demonstrate the correct method of administering prescribed medications.
 Encourage patient in assuming active role in self-care through information-seeking and problem-
solving.
Care of the patient undergoing transsphenoidal hypophysectomy
Preoperative Management
 Sinus infection is assessed and treated, if necessary.
 Hydrocortisone may be given preoperatively because the source of ACTH is being removed.
 The patient is prepared physically and emotionally for surgery.
• Deep-breathing exercises.
• Avoid coughing and sneezing postoperatively to prevent CSF leak.
Postoperative Management
 Vital signs, visual acuity, and neurologic status are monitored.
 Urine output and specific gravity and serum electrolytes and osmolality are monitored for
development of DI or SIADH.
 Drainage from nose is monitored for signs of infection or CSF leak (clear fluid).
Protecting Against Complications
 Monitor vital signs, visual acuity, and neurologic status frequently for signs of increasing
intracranial pressure.
 Monitor fluid intake and output, and report any increase in output and decrease in specific
gravity, which may indicate DI.

Pitutary Tumors
54
 Report persistent clear fluid from nose and increasing headache; could signal CSF leak.
 Teach patient signs of complications and to report them immediately and to follow-up as
scheduled.
 Assess level of pain and administer analgesic or supervise patient-controlled analgesia.
Preventing Infection
 Observe for signs of infection. Check incision within inner aspect of upper lip for drainage or
bleeding.
 Note frequency of nasal dressing changes and character of drainage. Prepare patient for
packing removal one to several days postoperatively.
 Encourage the use of a humidifier to prevent drying from mouth breathing.
Evaluation: Expected Outcomes
 Vital signs stable, urine specific gravity 1.010, no clear drainage from nose
 No purulent drainage noted
 States rationale for treatment, asks appropriate questions
 Demonstrates correct medication administration
Patient Education
 Advise patient on temporary limitations in activities.
 Teach patient the need for frequent initial follow-up visits and lifelong medical management
when on hormonal therapy.
 If the patient has no new symptoms or problems beyond about 5 years after beginning
treatment, follow-up visits can be less frequent.
 If applicable, advise patient on the need for postsurgery radiation therapy and periodic follow-
up MRI and visual field testing.
 Teach patient to notify health care provider if signs of thyroid or cortisol imbalance become
evident.
 Advise patient to wear MedicAlert bracelet.
 Help patient identify sources of information and support available in the community.


55
Unit : 8
BREAST CANCER
Breast cancer is the group of malignant diseases that commonly occur in the female breast and
infrequently in the male breast. One in every eight women is expected to develop breast cancer.
Because of the improvement in early detection and treatment, the five year survival rate for breast
cancer has improved. Breast cancer is the leading cause of cancer deaths in women between the ages
of 14 and 54 years. Lung cancer is the leading cause of cancer deaths in all the women, breast
cancer is the second.
Etiology
 Geographical: occurs commonly in the western world
 Age: Carcinoma of the breast is extremely rare below the age of 20 years but, thereafter, the
incidence steadily rises so that by the age of 90 years nearly 20% of women are affected.
 Gender: Less than 0.5% of patients with breast cancer are male.
 Genetic: common among those who have positive family history.
 Diet: diet low in phytoestrogen, alcohol
 Endocrine: nulliparous women, exogenous hormones, Early menarche, childbirth after 30 years
of age, and late menopause
 Previous radiation: exposure to radiation
Risk Factors for Breast Cancer
 BRCA-1 or BRCA-2 genetic mutation
 Increasing age: occurs after age 50
 Risk of developing breast cancer in the other breast increases about 1% per year.
 Risk increases two fold if first-degree female relatives (sister, mother, or daughter) had breast
cancer
 Risk increases if the mother was affected with cancer before 60 years of age.
 Risk increases four to six times if breast cancer occurred in two first-degree relatives.
 Early menarche-before 12 years of age
 Nulliparity and late maternal age at first birth
 Women having their first child after 30 years of age have twice the risk for breast cancer as
women having first child before 20 years of age.
 Late menopause- Menopause after 55 years of age but women with bilateral oophorectomy
before 35 years of age has one third the risk.
 History of benign proliferative breast disease
 Early menarche-before 12 years of age
 Nulliparity and late maternal age at first birth
 Women having their first child after 30 years of age have twice the risk for breast cancer as
women having first child before 20 years of age.

Breast Cancer
56
 Late menopause- Menopause after 55 years of age but women with bilateral oophorectomy
before 35 years of age has one third the risk.
 History of benign proliferative breast disease
 Exposure to ionizing radiation between puberty and 30 years of age.
 Obesity- estrogen is stored in body adipose tissue, and dietary fat increases pituitary prolactin,
thus increasing estrogen production.
 Hormone replacement therapy.
 Older women taking estrogen supplements for more than 5 years may have an increased risk;
addition of progesterone to estrogen replacement decreases the incidence of endometrial
cancer, but it does not decrease the risk of breast cancer.
 Alcohol intake- young women who drink alcohol are more vulnerable in later years.
Types of malignant breast cancer
 Carcinoma in situ (Noninvasive): Breast cancer is detected more frequently with the
widespread use of screening mammography, characterized by the proliferation of malignant
cells within the ducts and lobules, without invasion into the surrounding tissue. There are two types
of in situ carcinoma: ductal and lobular.
 Ductal Carcinoma in Situ: capacity to progress to invasive cancer, the most traditional treatment
is total or simple mastectomy or lumpectomy
 Lobular Carcinoma in Situ: Characterized by proliferation of cells within the breast lobules,
incidental finding discovered on pathologic evaluation of a breast biopsy. Commonly associated
with multicentric disease and is rarely associated with invasive cancer. Historically, treatment was
bilateral total mastectomy, but current thinking that LCIS is a marker of increased risk for the
development of an invasive cancer
 Invasive Carcinoma
Infiltrating Ductal Carcinoma
• The most common histologic type of breast cancer and account for 75% of all breast cancers.
• These tumors are notable because of their hardness on palpation.
• They usually metastasize to the axillary nodes.
• Prognosis is poorer than for other cancer types.
Infiltrating Lobular Carcinoma
• Accounts for 5% to 10% of breast cancers.
• These tumors typically occur as an area of ill-defined thickening in the breast, as compared
with the infiltrating ductal types.
• Most often multicentric; that is, several areas of thickening may occur in one or both breasts.
• Infiltrating ductal and infiltrating lobular carcinomas usually spread to bone, lung, liver, or
brain
Medullary Carcinoma
• Constitutes about 6% of breast cancers
• Grows in a capsule inside a duct.
• This type of tumor can become large, but the prognosis is often favorable.
Mucinous Cancer (colloid cancer)
• Accounts for about 3% of breast cancers.

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• A mucin producer, it is also slow-growing
• More favorable prognosis than many other types.
Tubular Ductal Cancer
• Accounts for only 2% of cancers.
• It’s called tubular breast cancer because the cancer cells look
• Tube-like when examined under the microscope.
• Axillary metastases are uncommon with this histology, prognosis is usually excellent.
Inflammatory Carcinoma
• Rare type of breast cancer (1% to 2%) with symptoms different from those of other breast
cancers.
• The localized tumor is tender and painful, and the skin over it is red and dusky.
• The breast is abnormally firm and enlarged.
• This is the result of blockage of the subdermal lymphatics with carcinoma cells.
• Often, edema and nipple retraction occur. These symptoms rapidly grow more
• In its early stages, inflammatory breast cancer is often mistaken for mastitis and treated as
an infection with antibiotics.
• If the symptoms are caused by cancer, they will not improve, and a biopsy will find cancer
cells.
• Because there is no actual lump, it might not show up on a mammogram and tends to have a
higher chance of spreading and a worse outlook
• Paget’s disease of the nipple
• Superficial manifestation of an underlying breast carcinoma.
• Presents as an eczema-like condition of the nipple and areola, which persists despite local
treatment.
• The nipple is eroded slowly and eventually disappears. If left, the underlying carcinoma will
sooner or later become clinically evident.
• Microscopically, Paget’s disease is characterised by the presence of large, ovoid cells with
abundant, clear, pale-staining cytoplasm in the epidermis.
The spread of breast cancer
• Local spread- other portion of breast, skin, muscle
• Lymphatic metastasis
• Spread by the bloodstream- bones, liver, lungs, brain
Clinical Manifestations
 Breast cancers occur anywhere in the breast, but most are found in the upper outer quadrant,
where most breast tissue is located.
 Generally, the lesions are nontender rather than painful, fixed rather than mobile, and hard with
irregular borders rather than encapsulated and smooth.
 Complaints of diffuse breast pain and tenderness with menstruation are usually associated with
benign breast disease. Marked pain at presentation, however, may be associated with breast
cancer in the later stages.

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 With the increased use of mammography, more women are seeking treatment at an earlier
stage of disease. These women may have no symptoms and no palpable lump, but abnormal
lesions are detected on mammography.
In late stage
 Dimpling or for a peau d’orange (orange-peel) appearance of the skin (a condition caused by
swelling that results from obstructed lymphatic circulation in the dermal layer).
 Nipple retraction and lesions fixed to the chest wall may also be evident. Involvement of the skin
is manifested by ulcerating lesions.
Assessment and Diagnostic Findings
 History
 Physical examination
 Breast self examination
 Mammography
 Galactography
 Ultrasonography
 Magnetic resonance imaging (MRI)
 Fine-needle aspiration
 Stereotactic biopsy
 Surgical Biopsy- excisional, incisional, Tru-Cut Core Biopsy
 Wire needle localization
TNM Staging
Primary tumor (T):
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ or Paget's disease of the nipple with no associated tumor.
T1: Tumor 2.0 cm or less in greatest dimension
T1mic: Microinvasion 0.1 cm or less in greatest dimension
T1a: Tumor more than 0.1 but not more than 0.5 cm in greatest dimension
T1b: Tumor more than 0.5 cm but not more than 1.0 cm in greatest dimension
T1c: Tumor more than 1.0 cm but not more than 2.0 cm in greatest dimension
T2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension
T3: Tumor more than 5.0 cm in greatest dimension
T4: Tumor of any size with direct extension to (a) chest wall or (b) skin
Note: Chest wall includes ribs, intercostal muscles, and serratus anterior muscle but not pectoral
muscle.
• T4a: Extension to chest wall
T4b: Edema (including peau d'orange) or ulceration of the skin of the breast or skin nodules
confined to the same breast
• T4c: Both of the above (T4a and T4b) T4d: Inflammatory carcinoma*

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Regional lymph nodes (N):
NX: Regional lymph nodes cannot be assessed (e.g., previously removed)
N0: No regional lymph node metastasis
N1: Metastasis to movable ipsilateral axillary lymph node(s)
N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
N3: Metastasis to ipsilateral internal mammary lymph node(s)
Distant metastasis (M):
MX: Presence of distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes)
AJCC stage groupings
Stage 0 Tis, N0, M0
Stage I-T1, N0, M0,
Stage IIA -T0, N1, M0 T1, T2, N0, M0
Stage IIB-T2, N1, M0,T3, N0, M0
Stage IIIA-T0, N2, M0,T1 N2, M0, T2 N2M0 ,T3 N1M0 ,T3 N2 M0
Stage IIIB- T4, Any N, M0, Any T, N3, M0
Stage IV- Any T, Any N, M1
It occurs majority in the upper outer quadrant where most of breast tissue is located. These are more
common in the left breast.
 The mass is usually painless, nontender, hard irregular in shape and non-mobile
 Nipple discharge and retraction, edema with “peau d’ orange” skin, and dimpling may be
present.
 A palpable mass, which is found by the client, is the presenting feature in 64% to 70% of cases
of breast cancer, 4% to 30% of lesions are found by mammography.
 Metastasis to the skin is manifested by ulcerating and fumigating lesions. Certainly these classical
signs and symptoms characterize breast cancer in the late stages.
Management
The multidisciplinary team approach
 A joint venture between the surgeon, medical oncologist, radiotherapist and allied health
professionals such as the clinical nurse specialist.
Surgery:
Mastectomy
 The radical Halsted mastectomy
 Total mastectomy
 The modified radical Patey mastectomy

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 Conservative breast cancer surgery- lumpectomy and quadrantectomy
 Sentinel node biopsy
Medical Management
 The 2000 Consensus Development Conference Statement stated that all women with invasive
breast cancer should consider systemic chemotherapy, not just women with tumors larger than 1
cm. Decisions regarding local treatment with either mastectomy or breast-conserving surgery with
radiation still vary widely.
 Radiotherapy- external beam: Radiation begins about 6 weeks after the surgery to allow the
incision to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after
completion of the chemotherapy. External-beam irradiation provided by a linear accelerator
using photons is delivered on a daily basis over 5 to 7 weeks to the entire breast region
Hormonal Therapy
 Normal breast tissue contains receptor sites for estrogen. About two thirds of breast cancers are
estrogen dependent, or ER-positive (ER+).
 An ER+ assay indicates that tumor growth depends on estrogen supply; therefore, measures that
reduce hormone production may limit the progression of the disease, and these receptors can be
considered prognostic indicators.
 ER+ tumors may grow more slowly in general than those that do not depend on estrogen (ER−);
thus, having an ER+ tumor indicates a better prognosis. A value less than 3 fmol/mg is
considered negative. Values of 3 to 10 are questionable, and values greater than 10 are
considered positive.
 Premenopausal women and perimenopausal women are more likely to have non–hormone-
dependent lesions; postmenopausal women are likely to have hormone-dependent lesions.
 Hormonal therapy may include surgery to remove endocrine glands (eg, the ovaries, pituitary, or
adrenal glands) with the goal of suppressing hormone secretion.
 Tamoxifen is the primary hormonal agent used in breast cancer treatment today.
 Anastrazole (Arimidex), letrozole (Femara), leuprolide (Lupron), megestrol (Megace),
diethylstilbestrol (DES), fluoxymesterone (Halotestin), and aminoglutethimide (Cytadren) are
other hormonal agents used to suppress hormone-dependent tumors.
Chemotherapy
 The chemotherapeutic agents most often used in combination -cyclophosphamide (Cytoxan) (C),
methotrexate (M), fluorouracil (F), and doxorubicin (Adriamycin) (A). Paclitaxel (Taxol) (T)
 Additionally, a newer taxane, docetaxel (Taxotere) (T)
Some of the most commonly used drug combinations for early breast cancer are:
 CAF (or FAC): cyclophosphamide, doxorubicin (Adriamycin), and 5-FU
 TAC: docetaxel (Taxotere), doxorubicin (Adriamycin), and cyclophosphamide
 AC → T: doxorubicin (Adriamycin) and cyclophosphamide followed by paclitaxel (Taxol) or
docetaxel (Taxotere).
 FEC → T, 5-FU, epirubicin, and cyclophosphamide followed by docetaxel (Taxotere) or
paclitaxel (Taxol).

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 TC: docetaxel (Taxotere) and cyclophosphamide
 TCH: docetaxel, carboplatin, and trastuzumab (Herceptin) (this is only used in patients with HER2
positive tumors)
Other combinations that are less often used for early breast cancer include
 CMF: cyclophosphamide (Cytoxan), methotrexate, and 5-fluorouracil (fluorouracil, 5-FU)
 A → CMF: doxorubicin (Adriamycin), followed by CMF
 EC: epirubicin (Ellence) and cyclophosphamide
 AC: doxorubicin (Adriamycin) and cyclophosphamide
Reconstructive Breast Surgery
 Reduction mammoplasty: The surgeon then removes the excess tissue and transplants the nipple
to a new location.
 Augmentation mammoplasty: It is performed through an incision along the undermargin of the
breast, in the axilla, or at the border of the areola. The breast is then elevated, and a pocket is
formed between the breast and the chest wall into which various types of synthetic materials are
inserted to enlarge and uplift the breast.
Reconstructive Procedures after Mastectomy
 Tissue Expanders With Permanent Implants
 Tissue Transfer Procedures-transverse rectus abdominis myocutaneous flap (TRAM flap), gluteal
muscle, or latissimus dorsi muscle
 Nipple–Areola Reconstruction-A nipple is created using a skin graft from the inner thigh or labia
because this skin has darker pigmentation than the skin on the reconstructed breast.
Carcinoma of the male breast
 Accounts for less than 0.5% of all cases of breast cancer.
 The known predisposing causes include gynaecomastia and excess endogenous or exogenous
oestrogen.
 As in the female it tends to present as a lump and is most commonly an infiltrating ductal
carcinoma.
Treatment
 Stage for stage the treatment is the same as for carcinoma in the female breast and prognosis
depends upon stage at presentation. Adequate local excision, because of the small size of the
breast, should always be with a ‘mastectomy’.
Prognosis
 Generally, the smaller the tumor, the better the prognosis.
 It starts with a genetic alteration in a single cell. It can take about 16 doubling times for a
carcinoma to become 1 cm or larger, at which point it becomes clinically apparent. Assuming
that it takes at least 30 days for each doubling time, it would take a minimum of 2 years for a
carcinoma to become palpable.
 The 5-year survival rate for women diagnosed with metastatic disease is 16%.
 Distant metastasis can affect any organ, but the most common sites are bone (71%), lung (69%),
liver (65%), pleura (51%), adrenals (49%), skin (30%), and brain (20%)

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 The presence of estrogen and progesterone receptor proteins is associated with an improved
prognosis; their absence is associated with a poorer prognosis.
Prophylactic Mastectomy
 Some women who are at high risk for breast cancer may elect to undergo prophylactic
mastectomy. This procedure can reduce the risk for cancer by 90%
 The procedure, performed by a breast surgeon, consists of a total mastectomy (removal of
breast tissue only).
 Possible candidates are women with a strong family history of breast cancer, a diagnosis of
LCIS, a diagnosis of BRCA-1 or BRCA-2 gene mutation, an extreme fear of cancer (“cancer
phobia”), or previous cancer in one breast. Many women opt for immediate reconstruction with
the mastectomy.
 The woman needs to understand that this surgery is elective and not emergent.
Prevention
 Regular, vigorous exercise has been shown to decrease risk, perhaps because it can delay
menarche, suppress menstruation, and, like pregnancy, reduce the number of ovulatory menstrual
cycles. Also, exercise decreases body fat, where estrogens are stored and produced from other
steroid hormones. Thus, decreased body fat can decrease extended exposure to estrogen.
 Breastfeeding is also thought to decrease risk because it prevents the return of menstruation,
again decreasing exposure to endogenous estrogen.
 Having had a full-term pregnancy before the age of 30 years is also thought to be protective.
Protective hormones are released after delivery of the fetus, with the purpose of reverting to
normal the proliferation of cells in the breast that occur with pregnancy.
Nursing Care to the Patients
Assessment
 How is the patient responding to the diagnosis?
 What coping mechanisms does she find most helpful?
 What psychological or emotional supports does she have and use?
 Is there a partner, family member, or friend available to assist her in making treatment choices?
 What are the most important areas of information she needs?
 Is the patient experiencing any discomfort?
Preoperative Nursing Diagnoses
 Deficient knowledge about breast cancer and treatment options
 Anxiety related to cancer diagnosis
 Fear related to specific treatments, body image changes, or possible death
 Risk for ineffective coping (individual or family) related to the diagnosis of breast cancer and
related treatment options
 Decisional conflict related to treatment options
Postoperative Nursing Diagnoses
 Acute pain related to surgical procedure

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 Impaired skin integrity due to surgical incision
 Risk for infection related to surgical incision and presence of surgical drain
 Disturbed body image related to loss or alteration of the breast related to the surgical
procedure
 Risk for impaired adjustment related to the diagnosis of cancer, surgical treatment, and fear of
death
 Self-care deficit related to partial immobility of upper extremity on operative side
 Disturbed sensory perception (kinesthesia) related to sensations in affected arm, breast, or chest
wall
 Risk for sexual dysfunction related to loss of body part, change in self-image, and fear of
partner’s responses
 Deficient knowledge: drain management after breast surgery
 Deficient knowledge: arm exercises to regain mobility of affected extremity
 Deficient knowledge: hand and arm care after an axillary lymph node dissection
Preoperative Nursing Interventions
Explaining Breast Cancer and Treatment Options
 the patient must be given time to absorb the significance of the diagnosis and any information
 Discusses about medications, the extent of treatment, management of side effects, possible
reactions after treatment, frequency and duration of treatment, and treatment goals.
 Methods to compensate for physical changes related to mastectomy (eg, prostheses and plastic
surgery) are also discussed and planned.
Reducing Fear and Anxiety and Improving Coping Ability
 In case of mastectomy, information about various resources and options is provided like
prostheses, reconstructive surgery, and groups.
 Discussion with a plastic surgeon about the various options for reconstructive surgery
 Provides anticipatory teaching and counseling at each stage of the process and identifies the
sensations that can be expected during additional diagnostic procedures.
 Discusses the implications of each treatment option and how it may affect various aspects of the
patient’s treatment course and lifestyle.
Promoting Decision-Making Ability
 Careful guidance and supportive counseling
 Encouraging the patient to take one step of the treatment process
 Some patients may need a mental health consultation before surgery to assist them in coping
with the diagnosis and impending treatment.
Postoperative Nursing Interventions
Relieving Pain and Discomfort
 Ongoing nursing assessment of pain and discomfort
 Moderate elevation of the involved extremity to decreases tension on the surgical incision,
promotes circulation, and prevents venous congestion in the affected extremity.
 Intravenous or intramuscular or oral opioid analgesic agents as prescribed

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 Medications such as acetaminophen) before exercises or at bedtime and also to take a warm
shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort
that comes from referred muscle pain.
Maintaining Skin Integrity and Preventing Infection
 In the immediate postoperative period, the patient will not have tight dressing over the surgical
site and one or more drainage tubes in place. The dressings and drains should be inspected for
bleeding and the extent of drainage monitored regularly.
 If a hematoma develops, it usually occurs within the first 12 hours after surgery; thus, monitoring
the incision is important. If either of these complications occurs, the surgeon should be notified
and an ice pack applied.
 Initially, the fluid in the surgical drain appears bloody, but it gradually changes to a
serosanguinous and then a serous fluid during the next several days. The drain is usually left in
place for 7 to 10 days and is then removed after the output is less than 30 mL in a 24-hour
period.
 The patient is discharged home with the drains in place; therefore, teaching of the patient and
family is important to ensure correct management of the drainage system
 Explains the care of the incision, sensations to expect, and the possible signs and symptoms of an
infection.
 The patient may shower on the second postoperative day and wash the incision and drain site
with soap and water to prevent infection. A dry dressing should be applied to the incision each
day for 7 days.
 The patient needs to know that sensation is decreased in the operative area because the nerves
were disrupted during surgery and that gentle care is needed to avoid injury.
 After the incision is completely healed (usually 4 to 6 weeks), lotions or creams may be applied
to the area to increase skin elasticity.
 After the incision is fully healed, the patient may again use deodorant on the affected side,
although many women note that they no longer perspire as much as before the surgery.
Promoting Positive Body Image
 Privacy is a consideration when assisting the woman to view her incision
 Explaining that her feelings are a normal response to breast cancer surgery may be reassuring
to the patient.
 With short hospital stays, many women will view the incision for the first time with the home care
nurse or ambulatory care nurse at the time of postoperative follow-up visits.
Promoting Positive Adjustment and Coping
 Assisting the patient in identifying and mobilizing her support systems is important.
 The patient’s spouse or partner may need guidance, support, and education as well.
 Encouraging the patient to discuss issues and concerns with other patients
 Another important aspect of promoting the patient’s adjustment and coping includes answering
questions and addressing her concerns about the treatment options that may follow surgery.
 Refocusing the patient on the recovery from surgery, while addressing her concerns and
answering her questions can be helpful.
 Counseling or consultation with a mental health practitioner may be indicated.
Promoting Participation in Care
 Ambulation is encouraged when the patient is free of postanesthesia nausea and is tolerating
fluids.

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 Exercises (hand, shoulder, arm, and respiratory) are initiated on the second postoperative day,
although instruction occurs on the first postoperative day.
 Postmastectomy exercises like wall hand climbing, rope turning, rod or broomstick lifting and
pulley tugging are usually performed three times daily for 20 minutes at a time until full range
of motion is restored (generally 4 to 6 weeks).
 Showering before exercising loosens stiff muscles, and taking an analgesic agent 30 minutes
before beginning exercise increases the patient’s ability to comply with the regimen.
 Also, self-care activities, such as brushing the teeth, washing the face, and combing and brushing
the hair, are physically and emotionally therapeutic because they aid in restoring arm function
and a sense of normalcy for the patient.
Managing Postoperative Sensations
 Because nerves in the skin are cut during breast surgery, patients experience a variety of
sensations.
 Common sensations are tightness, pulling, burning, and tingling along the chest wall, in the axilla,
and along the inside aspect of the upper arm usually persist for several months up to a year and
then begin to diminish.
 Explaining to the patient that this is a normal part of healing helps to reassure her that these
sensations are not indicative of a problem.
 Performing the exercises may decrease the sensations.
 Acetaminophen as needed
Improving Sexual Functions
 Open discussion and clear communication about how the patient sees herself and about possible
decreased libido related to fatigue, anxiety, or nausea may help to clarify issues for her and
her partner.
 Encouraging discussion about fears, needs, and desires may reduce the couple’s stress.
Suggestions regarding varying the time of day for sexual activity or assuming positions that are
more comfortable
 Referral to a psychosocial resource
Monitoring and Managing Potential Complications
Lymphedema
 Occur any time after an axillary lymph node dissection if functioning lymphatic channels are
inadequate to ensure a return flow of lymph fluid to the general circulation.
 If lymphedema occurs, the patient should contact the surgeon or nurse to discuss management
because she may need a course of antibiotics or specific exercises to decrease the swelling.
 Emphasis should be placed on early intervention. Management consists of arm elevation with the
elbow above the shoulder and the hand higher than the elbow, along with specific exercises,
such as hand pumps.
 A referral to a physical therapist or rehabilitation specialist may be necessary for a custom-
made elastic sleeve, exercises, manual lymph drainage, or a special pump to decrease swelling.
Hematoma Formation
 Monitors the surgical site for excessive swelling and monitors the drainage device, if present.
Gross swelling or output from the drain may indicate hematoma formation
 Surgeon should be notified promptly.

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 Depending on the surgeon’s assessment, an Ace wrap may be applied for compression of the
surgical site along with ice packs for 24 hours, or the patient may be returned to surgery to
identify the source of bleeding.
 The nurse monitors the site and reassures the patient that this complication is rare but does occur
and that she will be assisted through its management.
Infection
 Infection follows breast surgery in about 1 in 100 patients. Due to (diabetes, immune disorders,
advanced age) and exposure to pathogens.
 Both preoperatively and before discharge, patients are taught to monitor for signs and
symptoms of infection (redness, foul-smelling drainage, temperature greater than 100.4°F) and
to contact the surgeon or nurse for evaluation.
 Treatment consists of oral or intravenous antibiotics for 1 or 2 weeks, depending on the severity
of the infection.
 Cultures are taken of any foul-smelling discharge.
Teaching Patients Self-Care
 Most patients are discharged 1 or 2 days after the surgery with the drains in place.
 Avoid blood pressures, injections, and blood draws in affected extremity.
 Use sunscreen (higher than 15 SPF) for extended exposure to sun.
 Apply insect repellent to avoid bug bites.
 Wear gloves for gardening.
 Use cooking mitt for removing objects from oven.
 Avoid cutting cuticles; push them back during manicures.
 Use electric razor for shaving armpit.
 Avoid lifting objects greater than 5–10 pounds.
 If a trauma or break in the skin occurs, wash the area with soap and water, and apply an over-
the-counter antibacterial ointment (Bacitracin or Neosporin).
 Observe the area and extremity for 24 hours; if redness, swelling, or a fever occurs, call the
surgeon or nurse.
 Teach regarding side effects and management of chemo and radiotherapy.
Continuing Care
 Referral for home care may be indicated to assist the patient and family caregiver with
postoperative care at home.
 Follow-up visits to the physician after diagnosis and treatment Visits every 3 months for 2 years,
followed by every 6 months up to 5 years, may be then extended to annual examinations,
depending on the patient’s progress and the physician’s preference.
 Patients are also encouraged to do BSE on the remaining breast (and operative side if breast-
conserving surgery was done) and the chest wall (after mastectomy) between appointments
because the risk for cancer in the remaining breast (or recurrence in the operative breast) is
about 1% per year after the original diagnosis.
 Additional screening is done with annual mammography. Ultrasound and MRI are being used
more commonly with women who have survived breast cancer.


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Unit : 9
STOMACH CANCER
Stomach cancer, also known as gastric cancer, is the accumulation of an abnormal (malignant,
cancerous) group of cells that form a tumor in any part of the stomach. In most cases it refers to
cancer that starts off in the mucus-producing cells on the lining of the inside of the stomach
(adenocarcinoma). According to the World Health Organization, 800,000 cancer-related deaths are
caused by stomach cancer each year globally. It is the fourth most common cancer worldwide, but the
second leading cause of cancer-related deaths in the world.
Gastric cancer is more common among males, and people in developing nations compared to
industrialized countries, the exception being Japan and South Korea, where the disease is much more
common than in the USA, Canada or Europe. The majorities (80%-90%) of people diagnosed with
stomach cancer either already have metastasis or eventually develop it. Metastasis is when the cancer
spreads beyond its site of origin, to other parts of the body.
Types of stomach cancer
There are several types of stomach cancers. These include:
 Adenocarcinoma of the stomach: Between 90% to 95% of all stomach cancers are of this type.
The cancer develops from the cells that form the mucosa, the innermost lining of the stomach.
 Lymphoma of the stomach: Lymphoma of the stomach accounts for 4% of stomach cancers.
Cancerous cells form in the immune tissue (lymphatic tissue) that is sometimes found in the wall of
the stomach. Lymphatic tissue drains away fluid and helps fight infection.
 Gastrointestinal stromal tumor (GIST): Gastrointestinal stromal tumors form in the muscle or
connective tissue of the stomach wall (interstitial cells of Cajal). Some of these tumors may be
benign (non-cancerous). GISTs can also be found in other parts of the digestive tract.
 Neuroendocrine tumors: The cancerous cells collect and form tumors in the hormone-making
cells, usually in the digestive tract (including the stomach). This type of stomach cancer is rare; the
most common is carcinoid tumor.
 Other types of stomach cancer: Other types of very rare cancer of the stomach include,
squamous cell carcinoma, leiomyosarcoma, and small cell carcinoma.
Symptoms of stomach cancer
A symptom is something the patient feels and describes, such as a stomachache, while a sign is
something others, including doctors and nurses can detect, such as a rash. There are several symptoms
associated with stomach cancer. However, as they also exist in many other much less serious conditions
and illnesses, gastric cancer may be difficult to recognize initially.
It is for that reason that so many patients are not diagnosed until the disease is already well
advanced.
Early symptoms of stomach cancer may include:
 A sensation of being very full (and rapidly full) during meals

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 Dysphagia (swallowing difficulties)
 Feeling bloated after meals
 Frequent burping
 Heartburn
 Indigestion that does not go away
 Stomachache, or pain in the sternum (breastbone)
 Trapped wind
 Vomiting (may contain blood).
The following alarm signs and symptoms in people at increased risk of developing stomach cancer
should be taken seriously:
 Dysphagia
 Indigestion in combination with at least one of the symptoms/signs of unexpected weight loss,
being sick or anemia (patient usually feels tired and possibly out of breath).
Individuals who develop indigestion and have at least one of the following in their medical history
should see a doctor:
 A close relative who has/had stomach cancer
 Barret's esophagus
 Dysplasia: abnormal collection of cells. They are not cancerous but could become cancerous
eventually
 Gastritis: inflammation of the lining of the stomach
 Pernicious anemia - the stomach does not absorb vitamin B12 properly from food
 Undergone previous surgery for stomach ulcers.
When the stomach cancer becomes more advanced, the following signs and symptoms typically
become more apparent:
 Accumulation of fluid in the stomach: stomach feels "lumpy"
 Anemia
 Black stools, or blood in stools
 Fatigue
 Loss of appetite
 Weight loss
Risk factors associated with stomach cancer
A risk factor is a condition, disease, lifestyle, or situation which increases the risk of developing a
disease or condition. For example, a risk factor for type 2 diabetes is being obese, i.e. obese people
have a higher risk of developing diabetes.
Risk factors linked to stomach cancer include:
a. Having certain medical conditions: These include conditions such as Esophagitis, GERD
(gastroesophageal reflux disease), Peptic stomach ulcer, Barrett's esophagus, chronic gastritis,
Stomach polyps.

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b. Smoking: According to the UK's National Health Service, regular long-term smokers have one-
and-a-half times the risk of developing stomach cancer compared to lifetime non-smokers.
c. Helicobacter pylori infection: About 50% of the world's population is thought to carry this
bacterium. It is harmless for most people. However, it can cause infection and cause stomach
ulcers in some individuals, as well as recurring episodes of indigestion or atrophic gastritis
(chronic inflammation of the stomach lining). Patients with severe atrophic gastritis have the
highest risk of eventually developing gastric cancer (even in such cases, the risk is still relatively
small).
d. Family history: Having a close relative who has/had stomach cancer. In about 2% of stomach
cancer cases, patients share a genetic mutation in the E-cadherin gene. People with blood type
A also have a higher risk - we inherit our blood type from one of our parents.
e. Consuming foods which contain aflatoxin fungus: These may occur in crude vegetable oils,
cocoa beans, treenuts, groundnuts, figs and other dried foods, and spices.
f. Diet: People who regularly eat salted fish, salty foods, smoked meats, and pickled vegetables
have a higher risk of developing gastric cancer. In Japan and South Korea such foods are
popular. The World Cancer Research Fund reported that if people in the UK reduced their salt
intake to the recommended daily amount, 1 in every 7 stomach cancer cases could be
prevented.
g. Age: The risk of developing stomach cancer increases significantly after the age of 55 years. In
the USA, Canada and Western Europe, the average age of diagnosis is about 70.
h. Sex: Men have twice the risk of developing stomach cancer compared to women. Scientists from
MIT said that estrogen protects women from the gastric inflammation that can lead to cancer.
i. Already having or having had another type of cancer: Patients who have/had esophagus
cancer or non-Hodgkin's lymphoma are more likely to eventually develop stomach cancer. Men
who have/had prostate, bladder or testicular cancer are at higher risk, as do females who
have/had cervical, ovarian or breast cancer.
j. Some surgical procedures: Some surgical procedures, especially surgery to the stomach or a
part of the body that affects the stomach, can increase the risk of gastric cancer. Examples
include partial gastrectomy (when part of the stomach is removed), surgery to remove part of
the vagus nerve, or surgery to treat a stomach ulcer.
Causes of stomach cancer
Cancer starts off when the structure of DNA changes. DNA provides the cells in our body with a basic
set of instructions, a bit like a computer program, such as when to reproduce, grow, etc. When the
DNA structure changes, also known as a mutation, it can mess up the instructions that control the
growth of cells. Cells that should die may not do so, and cells that should be newly created may be
produced too rapidly - in other words, cells reproduce in an uncontrollable way. There is an
accumulation of too many cells, i.e. a tumor. Experts are not sure why some stomach cells mutate and
become cancerous. Why only a few people develop stomach cancer is still a mystery too.
Metastasis of stomach Cancer
When stomach cancer spreads, when it metastasizes, it will do so in one of three ways:
 In the blood - in such cases the cancer spreads into the liver

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 Through the lymphatic system - the lymphatic system is a series of nodes (glands) located at
various points in the body. The lymphatic system is a kind of parallel circulatory system to the
circulation of blood (but without a heart as a pump). The nodes produce cells that fight off
infection
 Directly - stomach cancer can spread directly out of the stomach and into surrounding tissues
and/or organs, such as the small intestine, colon or pancreas
Diagnosis of stomach cancer:
People with some of the signs and symptoms listed above should see their doctor as soon as possible.
In most cases, the first visit is to a primary care physician (general practitioner, GP). The physician will
ask the patient about the symptoms, family history, possibly some lifestyle characteristics (eating
habits), medical history, and carry out a physical examination to check for stomach tenderness or
lumpiness.
If the primary care physician suspects possible stomach cancer, the patient will be referred to a
specialist for tests. As stomach cancer requires prompt and early treatment, the referral needs to be
done as soon as possible.
The stomach specialist, a gastroenterologist, will probably order the following diagnostic tests:
Gastroscopic exam: The specialist looks at the inside of the patient's stomach with a fiber optic
camera. The instrument is called an endoscope - a long, thin, flexible tube with a camera at the end.
The procedure, which lasts about 15 minutes, is called an endoscopy. The patient will be asked to fast
(not eat or drink) for between four to eight hours beforehand, to make sure that the duodenum and
the stomach are empty.
In the majority of cases, the patient remains awake during the whole procedure. A sedative may be
injected. Some patients may have a local anesthetic sprayed onto the back of their throat.
The endoscope goes down the patient's throat and into his/her stomach so that the doctor can have a
good look for signs of cancer, stomach ulcers, and anything unusual. Some tissue samples may be
taken if the doctor suspects cancer - this is called a biopsy. The sample is examined in the laboratory
to determine whether there are any malignant (cancerous) cells. Non-cancerous cells are called
benign. It usually takes at least one week before the test results come back.
Ultrasound scan: If cancer is suspected in the top part of the stomach, the specialist may carry out an
ultrasound scan (endoscopic ultrasound). The scan helps determine the stage of the cancer.
Barium meal X-ray: (Barium swallows) - the patient swallows a liquid which contains barium. Barium
helps the stomach show up during an X-ray. The patient will have to fast for at least six hours before
the procedure. The procedure takes approximately 15 minutes.
Breath test: Very much one for the future. Researchers from China and Israel have described a simple
breath test that analyzes the chemical signature of a patient's exhaled breath to help diagnose
stomach cancer.
Laparoscopy: The specialist may want to look inside in more detail to determine whether and by how
much the cancer has spread. In a procedure called a laparoscopy, the patient is placed under a
general anesthetic and a laparoscope (thin tube with a camera at the end) is inserted through a small
incision in the lower part of the stomach.
CT scan or PET scan: A CT scanner and PET scanner can be used to take a series of X-ray pictures of
the inside of the body.

71
A computer is then used to put them together, creating a very detailed picture. They help the
specialist determine how advanced the cancer is, and where in the body it has spread to. These types
of scans also help the doctor decide on the best and most appropriate treatment.
Ultrasound scan: A liver ultrasound scan may be recommended if the doctor thinks that the cancer
may have spread to the liver.
Stomach cancer stages
Sometimes the cancer stage cannot be accurately determined until the patient undergoes surgery
and/or starts treatment. There are different ways cancers are staged.
STAGES OF STOMACH CANCER
Figure: Staging for Adenocarcinoma Stomach Cancer
 Stage I - the tumor lies within the layer of tissue lining the inside of the stomach. Some cancer
cells may have made their way to some nearby lymph nodes.
 Stage II - the cancer has spread into the muscles of the stomach wall, as well as to more lymph
nodes.
 Stage III - the cancer cells may have spread through all the stomach layers, as well as into the
lymph nodes. In some cases, the cancer has not spread much in the stomach, but has done so
extensive into the lymph nodes.
 Stage IV - the cancer has spread well beyond the stomach, into nearby tissue and organs. It
could also be a small cancer that has spread much further into distant parts of the body.
Most patients are diagnosed at stage 3- at this stage a complete cure is extremely rare. According
to the UK's National Health Service, there are three grades of stomach cancer:

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 Low grade - a slow-growing cancer
 Medium grade - the cancer grows faster than a low-grade one, but less quickly than the high
grade.
 High grade - this is an aggressive cancer that is likely to grow rapidly.
Treatments for stomach cancer: The type of treatment for stomach cancer the doctor may
recommend depends on several factors, including the stage of the cancer, the grade of the cancer,
and the patient's overall health and preferences. Treatments may include surgery, chemotherapy,
radiation therapy, medications and taking part in clinical trials.
Surgery: The surgeon's aim is to surgically remove the stomach cancer from the body as well as a
margin of health tissue (necessary to make sure no cancerous cells are left behind). Examples include:
 Taking out tumors from the stomach lining in early stage cancer - the surgeon will use
endoscopy to remove very small tumors that are confined to the inside lining of the stomach - this
is called endoscopic mucosal resection.
 Subtotal gastrectomy - a part of the stomach is surgically removed. Obviously, this involves only
the part of the stomach with cancer.
 Total gastrectomy - the whole stomach is surgically removed. The surgeon then connects the
esophagus to the small intestine directly. This option is recommended if a large part of the
stomach has cancerous tumors.
 To help relieve symptoms - this is performed in patients with advanced cancer to relieve the
signs and symptoms. If there is a large amount of cancer in the stomach, there may be blockages
which prevent food from being digested properly. A blocked stomach can also cause stomach
pain, vomiting and a feeling of bloating and being full after eating. The aim in this type of
surgery is to make the patient more comfortable, not to cure.
Any surgery involving the stomach involves a major operation and a long period for recovery.
Patients will typically have to stay in hospital for about two weeks after the procedure. This will be
followed by several weeks recovering at home.
Radiation therapy (radiotherapy): Beams of energy, such as X-rays, are target at cancer cells - the
aim is to destroy them. The patient lies on a table and a machine moves around directing energy
beams into specific parts of the body.
Radiotherapy is not commonly used for the treatment of stomach cancer because of the risk of
harming other organs close to the body. However, if the cancer is advanced, for example, and
causing bleeding or pain, radiotherapy is an option.
Neoadjuvant radiation: Neoadjuvant radiation refers to the use of radiation therapy before surgery
to make the tumors smaller so that they can be removed more easily.
Adjuvant radiation: Adjuvant radiation is radiation therapy used after surgery. The aim is to kill off
any remaining cancer cells around the stomach.
Radiation therapy is commonly used alongside chemotherapy. It may also be used to relieve the
symptoms and side effects caused by large tumors in advanced cancer. Patients may experience
indigestion, nausea, vomiting and diarrhea as a consequence of undergoing radiation therapy.
Chemotherapy: Chemotherapy is a specialist treatment that uses drugs to stop rapidly-growing
cancer cells from dividing and multiplying - these drugs are known as cytotoxic medicines.

73
The medication travels throughout the patient's body and attacks cancer cells that have metastasized.
Neoadjuvant chemotherapy: Neoadjuvant chemotherapy is administered before surgery. The aim is
to make a tumor small so that it can be surgically removed more easily.
Adjuvant chemotherapy: Adjuvant chemotherapy is administered after surgery to destroy any
cancerous cells that may have remained behind. Chemotherapy may also be administered in patients
with advanced cancer to relieve the signs and symptoms of the disease. Some patients may only
receive chemotherapy (no surgery or radiation therapy), examples include some with gastrointestinal
stromal tumors or gastric lymphoma. Patients may experience side effects as a consequence of
chemotherapy. The type of side effects depends on which chemotherapy medications are
administered. Researchers have designed a way of effectively attacking cancer with an arsenic-
based chemo drug, with minimum damage to the ovaries.
Preventing Stomach Cancer
 Early detection is the key to surviving stomach cancer.
 Lifestyle changes, such as smoking cessation and eating a diet rich in fruits and vegetables, can
potentially reduce the risk of stomach cancer.
 Treatment of H. pylori infection (a common bacterial infection of the stomach) can decrease the
risk of stomach cancer development.
 Knowing your family history and discussing it with your healthcare provider can help determine
if you are at risk for inherited cancer syndromes.
Diagnosis: Stomach Cancer
Protocol ELF: Regimens of Chemotherapy in Practice
Frequency: 4 weekly
S.N. Drug Day 1-3
1. Inj ondem 16 mg IV before chemo
3. Inj etoposide 120 mg/m2 +500 ml NS over 1 hour infusion
4. Inj leucovorin 300mg/m2 IV push over 10 min
5. Inj 5 FU 500 mg/m2 IV push over 10 min
 Cycle is repeated every 4 weeks for a maximum of 6 cycles


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Unit : 10
COLORECTAL CANCER
Introduction: Cancer of the colon is usually adenocarcinoma. Tumors of the small intestine are rare;
conversely, tumors of the colon and rectum are relatively common. Colorectal cancer is now the
second most common cause of death from cancer in United States and UK. It is a disease of western
cultures. Colon cancer affects more than twice as many people as does rectal cancer.
Incidence: The incidence increases with age (most patients are over age 55) and is higher in persons
with a family of colon cancer and in those with chronic inflammatory bowel disease or polyps. The
incidence of cancer in the sigmoid and rectal areas has decreased whereas the incidence in the
ascending and descending colon has increased.
Etiology: Exact cause of colon rectal cancer is unknown. There are identifiable predisposing /risk
factors. Epidemiologic studies indicate that diet may be major factor in the development of cancer of
the large bowel. Some researchers propose that metabolic and bacterial and products are
carcinogenic and that constipation allows a longer contact with the bowel wall thus increasing the
probability of cancer developing.
Risk factors: The common risk factors for colorectal cancer are: Family History of colon cancer,
previous colon cancer, Overage 40 years, Ulcerative colitis, High fat, low residue diet that is high in
refined foods, Familial polyposis, living in high industrialized, urban societies and Blood in stool
The possible risk factors for colorectal factors are:
 Being elderly - the older you are the higher the risk is.
 A diet that is very high in animal protein.
 A diet that is very high in saturated fats.
 A diet that is very low in dietary fiber.
 A diet that is very high in calories.
 A diet that is very high in alcohol consumption.
 Women who have had breast, ovary and uterus cancers.
 A family history of colorectal cancer.
 Patients with ulcerative colitis.
 Being overweight /obese.
 Smoking. This study found that smoking is significantly associated with an increased risk for
colorectal cancer and death.
 Being physically inactive.
 Presence of polyps in the colon/rectum. Untreated polyps may eventually become cancerous.
 Having Crohn's disease or Irritable Bowel Disease have a higher risk of developing colorectal
cancer.
 Most colon cancers develop within polyps (adenoma). These are often found inside the bowel
wall.

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Distribution of cancer
In large intestine:
 Ascending colon : 15%
 Transverse colon : 5%
 Descending colon : 9%
 Sigmoid colon : 20%
 Rectum : 50%
Types of cancer found in the large bowel
1. Adenocarcinoma: accounts for 95% malignancies
2. Squamous cell carcinoma: rare in the colon but occurs at the anal canal. Presenting slight
thickening or small, nodular elevation. May have central ulceration. Slow growing and may
resemble fistulas, fissures or hemorrhoids.
3. Basal cell carcinomas: Originate in the basal cell layer of the skin, occurring at the anal verge or
in the perianal region and appear as deeply ulcerated lesions.
4. Malignant Melanoma: Rare, ectodermal in origin and appear in the perianal region.
Pathophysiology: Cancers of the colon almost always develop from adenomatous polyps. As this
tumor become malignant, it increases in size within the lumen and begin to invade the bowel wall.
Malignant bowel tumors spread by (I) direct extension to a nearby organ, as to the stomach from the
transverse colon. (2) Lymphatic and hematogenic channels usually to the liver. (3) Seeding or
implanting of cells into the peritoneal cavity. The urinary bladder, Ureters, reproductive organs are
frequently involved by direct extension. Also, the foundation of a fistula between the bladder and the
bowel or between the bowel and vagina is not uncommon. Blood borne metastasis extends most
frequently to the liver but also may involve the lungs, kidneys and bones.
Duke’s classification of colon cancer:
 With duke’s A, having an 80 – 90% 5 year survival rate (tumor limited mucosa and submucosa).
 With duke’s B, about a 60%, 5 year survival rate (penetration through bowel wall).
 With duke’s C, 25 – 40%, 5 year survival rate (invasion into regional draining lymph system).
 With Duke’s D, less than, 1–5%, 5 year survival rate (advanced and wide spread regional
metastasis).
Clinical manifestations:
1. The most common presenting symptom is a change in bowel habits.
2. Anorexia
3. Wt: Loss
4. Fatigue
5. Unexplained Anemia
Symptoms most commonly associated with:
Rt. Sided Lesions Lt. Sided Lesions
Wt. loss, Anorexia, Nausea Rectal bleeding
Anemia Changed bowel habits
Palpable mass Intestinal obstruction
Dull abdominal pain Tenesmus
Maelena Bright red blood in stool

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Common Symptoms of colorectal cancer
 Going to the toilet more often.
 Diarrhea.
 Constipation.
 A feeling that the bowel does not empty properly after a bowel movement.
 Blood in feces (stools).
 Pains in the abdomen.
 Bloating in the abdomen.
 A feeling of fullness in the abdomen (maybe even after not eating for a while).
 Vomiting.
 Fatigue (tiredness).
 Inexplicable weight loss.
 A lump in the tummy or a lump in the back passage felt by your doctor.
 Unexplained iron deficiency in men, or in women after the menopause.
Diagnostic Assessment:
1. Digital rectal examination: 1/3rd of malignant tumors of the distal colon and rectum can be felt
with the examining finger
2. Stool Test: A stool guaiac test is done to test for GI bleeding
3. Carcinoembryonic Antigen (CEA): CEA is found elevated in colon cancer and aids in
determining the progress of the disease. With complete excision of the tumor the elevated CEA
level should return to normal within 48 hrs. Elevation of CEA level at a latter date suggest
recurrence
4. X-ray studies (Barium enema): X-ray studies of the colon may show either a filling defect or a
stricture.
5. Ultrasound and CT: Help to establish tumor size and metastasis
6. Colonoscopy: Sigmoidoscopy followed by using double contrast barium enema. Sigmoidoscopy
can identify more than one half of the tumors.
7. Sigmoidoscopy: Sigmoidoscopy followed by using double contrast barium enema.
Sigmoidoscopy can identify more than one half of the tumors.
8. Biopsy: Flexible fibreoptic scopes permit better visualization into the right colon, extend the
diagnostic capabilities of the procedure, and allow biopsy.
Early detection improves the survival rate. Early detection include routine annual digital rectal
examination beginning at age 40, an annual stool guaiac test at age 50, and a sigmoidoscopy every
3 – 5 years and the importance of reporting symptoms such as rectal bleeding and a change in
bowel habits to their physician.
Management:
Medical management: The primary treatment for colon cancer in surgery. However, medical
treatments used as an adjunct to improve survival in tumors cannot be completely removed. The
patient with symptoms of intestinal obstruction is treated with IV fluids and Nasogastric suction. If
there has been significant bleeding, blood component therapy may be required.

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Radiotherapy: Radiation therapy is often given before surgery in the hope that the malignant cells
will not metastasize and to reduce the size of the tumor and thus make it more respectable.
Radiotherapy before surgery improves outcomes in rectal cancer. A short (one week) course of
preoperative radiotherapy reduces local recurrence by 40% and improves survival rates by 40%.
Post-operative radiotherapy which is currently used is significantly less effective. Although it reduces
local recurrence there is no clear evidence that it improves survival and a randomized controlled trial
comparing the two methods found that adverse effects were more severe.
Adjuvant chemotherapy: Chemotherapy normally a six-month course of 5–fluorouracil and folic acid
improves survival rates among patients with later stage cancers and its use is likely to increase.
Surgery may be curative or palliative. Cancers limited to one site are removable through the
colonoscope. Laproscopic colostomy with polypectomy minimizes the extent of surgery needed in
some cases. A laparoscope is used as a guide in making an incision into the colon; the tumor mass is
then excised. Bowel resection is indicated for most class-A lesions and all class B and C lesions.
Surgery is recommended for class D colon cancer.
The type of surgery depends on the location and size of the tumor. The surgical procedures of choice
are the following (Doughty & Jackson, 1993).
 Segmental resection with anastomosis (removal of the tumor and portions of the bowel on either
side of the growth, as well as the blood vessels and lymphatic nodes).
 Abdominoperineal resection with permanent sigmoid colostomy (removal of the tumor and a
portion of the sigmoid and all of the rectum and anal sphincter).
 Temporary colostomy followed by segmental resection and anastomosis and subsequent re-
anastomosis of the colostomy (allowing for initial bowel decompression and bowel preparation
before resection).
 Permanent colostomy or iliostomy (for palliation of unrespectable obstructing lesion).
Fecal diversions for cancer of the colon and rectum: Due to improved surgical techniques,
colostomies are performed on less than one third of patients with colorectal cancer. A colostomy is the
surgical creation of an opening (stoma) into the colon. It can be created as a temporary or permanent
diversion. A temporary colostomy is made most commonly at the mid point of the left colon or the
transverse colon whereas a permanent colostomy is usually placed in the sigmoid colon.
A colostomy may also be single or double barreled. When only one loop of bowel is opened onto the
abdominal surface it is called an end colostomy. A double – barreled colostomy is one in which both
loops, distal and proximal are open on the abdominal wall. A double – barreled colostomy can be
two separate stomas, a loop with one stoma with two openings or one stoma and a Hartman’s pouch
(distal bowel closed off and placed left intra-abdominal). The consistency of the drainage from
colostomy is related to the placement of colostomy.
Nursing Management
Assessment:
1. A health history is taken to obtain information about:
• The feeling of fatigue
• The presence and character of abdominal or rectal pain (location, frequency, duration,
association and eating or defecation).

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• Past and present elimination patterns
• Description of color, odor, consistency of stool including presence of blood or mucus
• Past history of chronic inflammatory bowel disease or colorectal polyps
• Family history of colorectal disease
• Current medication therapy
• Dietary habits
• History of weight loss
2. Objective assessment
• Auscultation of abdomen for bowel sounds
• Palpation of abdomen for areas of tenderness distension, solid masses
• Inspection of stool specimens for character and presence of blood
Nursing Diagnosis: Based on all the assessment data, the patient’s major nursing diagnosis may
include the following:-
 Constipation related to obstructing lesion
 Pain related to tissue compression secondary to obstruction
 Fatigue related to anemia and anorexia
 Altered nutrition, less than body requirements, related to nausea and anorexia
 Risk for fluid volume deficit related to vomiting and dehydration
 Anxiety related to impending surgery and the diagnosis of cancer
 Knowledge deficit concerning the diagnosis, the surgical procedure, and self care after
discharge
 Impaired skin integrity related to the surgical incisions, formation of a stoma and frequent fecal
contamination of periostomal skin
 Body image disturbance related to colostomy
Potential complications: Based on assessment data, potential complications may include:
Intraperitonal infection, Complete large bowel obstruction, Bowel perforation and
Peritonitis/abscess/sepsis.
Planning and implementation
Nursing Goals:
1. To maintain adequate elimination of body waste products
2. To reduce/alleviate pain
3. To maintain optimal level of nutrition
4. To maintain fluid and electrolyte balance
5. To reduce anxiety
6. To help the patient to acquire information about the diagnosis, surgical procedure and self care
after discharge
7. To maintain optimal tissue healing
8. To give adequate protection to periostomal skin

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9. To explore and help the patient verbalize of his/her feelings and concerns about colostomy and
impact on self
10. To prevent complications
Preoperative nursing interventions:
1. Maintaining elimination:
• Frequency and consistency of bowel movements are monitored
• Laxatives and enemas are administered as prescribed
• Patients who show signs of progressing to total obstruction are prepared for surgery
2. Relieving pain:
• Analgesics are administered as prescribed
• The environment is made conducive
• Additional comfort measures are offered: (position changes, a back rub and relaxation
techniques)
3. Increasing activity tolerance
• Assess patients activity tolerance
• Activities are modified and scheduled to allow for adequate rest periods
• Administer blood component therapy if anemic
4. Providing Nutritional measures:
• Provide a diet high in calories, protein, and carbohydrates and low in residue is given
preoperatively for several days
• Provide liquid diet 24 – 48 hrs prior to surgery
• Daily wt record of the patients
5. Maintaining fluid and electrolyte balance:
• Maintain intake and output chart accurately
• Oral intake is restricted to prevent vomiting
• Administer IV fluids as required
• Administer antiemetics
• Monitor Sr. electrolytes
• Assess hydration status of the patient
6. Reducing Anxiety:
• Assess patients level of anxiety, coping mechanism used to deal with stress
• Supportive effects include providing privacy and instructing the patient in relaxation
exercises
• Arrange meetings with member of the cleargy/physicians/enterostomal therapist
• All tests and procedures are explained in language the patient understands and all questions
are answered.

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7. Preventing infections:
• Antibiotics (kantrex, Erythrocin, Neomycin sulfate) are administered as prescribed to reduce
the bacterial content of the colon and to soften and decrease the bulk of the contents of the
colon
• Cleansing of the bowel by laxatives, enemas
8. Preoperative patient education:
• Assess the present knowledge
• Give information about physical preparation for surgery, the expected appearance and
care of the wound post operatively, the technique of colostomy care, dietary restrictions,
pain control and medication management
Post-operative nursing interventions:
Wound care: The abdominal wound is examined frequently during the first 24 hrs for infection,
dehiscence, hemorrhage, excessive edema:
 Change the dressings as needed to prevent infection
 Assist the patient to splint the abdominal incision during coughing and deep breathing to lesson
tension on the edges of the incision
 Record vital signs
 Examine stoma for excessive swelling, color (a healthy stoma is pink), discharge (small amount of
oozing is normal) and bleeding (an abnormal sign).
 Peristomal skin is cleansed gently and protective skin barrier is applied before attaching the
drainage bag.
Patient education and home care considerations:
 Patients being discharged from the hospital are given specific information, individualized to their
needs, about colostomy care and complications for which to observe.
 Dietary instructions to help patients identify and eliminate irritating foods that can cause
diarrhea or constipation.
 Teach about prescribed medications
 Treatments (irrigation, wound cleansing) and dressing changes are reviewed and the family is
encouraged to participate
 Give specific instructions about when to call the physician and complications which require
prompt attention (bleeding, abdominal distension and rigidity, diarrhea and dumping syndrome)
and possible side effects of radiotherapy
Positive body image:
 Encourage patients to verbalize feelings and concerns and to discuss the surgery and stoma (if
created).
 Teach colostomy care so that patient can begin to plan for incorporating stoma care into daily
life
 Provide supportive environment and attitude in promoting the patients adaptation to the
changes brought about by the surgery.

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Monitoring and managing complications:
 Assess the abdomen frequently for decreasing or changing bowel sounds and increasing
abdominal girth
 Monitor vital signs; rectal bleedings
 Monitor Hb and Hct; Administer blood component as prescribed
 Report if any abrupt change in abdominal pain, which may indicate perforation
Patient requiring a colostomy: Preoperative nursing interventions
Psychosocial support: A patient diagnosed with cancer of the colon or rectum may require a
permanent colostomy and may grieve about the diagnosis and the impending surgery. Patients
undergoing surgery for a temporary colostomy may express similar fears and concerns. All members
of the health team including enteronstomal therapist and the family should be available for assistance
and support. Anticipated changes in body image and life style often are profoundly disturbing and
patients may need empathetic support in trying to adjust to them.
The nurse can help to reduce this apprehension by presenting factual information about the surgical
procedure and the creation management of the colostomy. If the patient is receptive diagrams,
photographs and appliances may be used to explain and clarify. Because the patient is experiencing
emotional stress, the nurse may need to repeat some of the information. Time should be provided for
the patient to ask questions. The nurse acceptance and understanding of the patients concerns and
feelings convey a caring, competent attitude that promotes confidence and cooperation. Consultation
with an enterostomal therapist during the preoperative period can be extremely helpful.
Preparation for surgery:
 High calorie, low residue diet is given for several days
 Preoperative measures taken are similar to those for general abdominal surgery
 Preoperative nasogastric intubations to minimize abdominal distention
 Indwelling urinary catheter is inserted to aid in keeping post operative perineal dressing dry.
Post Operative Nursing Interventions:
 Care is similar to nursing care for any abdominal surgery
 In addition, patient is monitored for signs of the complications like leakage from an anastomotic
site, prolapse of the stoma, perforation, stoma, retraction, fecal impaction, skin irritation
 Assess for signs of returning peristalsis and initial stool characteristics
 Patients are assisted out of bed on the 1st postoperative day and encouraged to participate in
managing the colostomy
 Return to normal diet is rapid. At least 2 lit of fluid/day is suggested
 Every effort is made to encourage the patient to live as he or she did before surgery.
Managing the colostomy: Colostomy function will begin 3–6 days postoperatively. The nurse
manages till the patient can take over its care. Skin care must be taught along with how to apply the
drainage pouch and manage irrigation.
Skin care: Patient is advice to protect the peristomal skin by frequently washing the area with a mild
soap, applying a protective skin barrier (wafer, paste or powder) around the stoma, and securely
attaching the drainage pouch. Nystatin powder can be dusted highly on the peristomal skin if
irritation or yeast growth is present. Patient may be permitted to bathe or shower before putting on
the clean appliance.

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Applying the drainage pouch: The stoma is measured to determine the correct size for the pouch.
The pouch opening should be about 0.3 cm larger than the stoma. The skin is cleansed and peristomal
skin barrier is applied. The backing from the adherent surface of the pouch is removed and the bag is
pressed down over the stoma for 30 sec.
Managing the Drainage Pouch: Colostomy bags may be worn immediately after irrigation. Wide
varieties of pouches are available depending on their individual needs. Most pouches are disposable
and odor resistant.
Colostomy bags may not be necessary if patient has learned a routine for evacuation. Closed ostomy
pouch or a simple dressing of disposable tissue (often covered with with plastic warp) is used, held in
place by an elastic belt. Colostomy plugs are available.
Removing the appliance: The drainage appliance is changed when it is one third to one fourth full to
avoid causing the pouch to separate from the adhesive disc. The patient assumes a sitting or standing
position and gently pushes the skin down from the faceplate while pulling the pouch u and away from
the stoma.
Irrigating the colostomy: Regulating the passage of fecal material is achieved either by irrigating
the colostomy or allowing the bowel to evacuate normally without irrigations. The choice depends on
the individual and the nature of colostomy. The purpose of irrigating a colostomy is to empty the
colon of gas, mucus, feces so that the patient can carryout social and business activities without fear of
fecal drainage. By irrigating the stoma at a regular time, there is less gas and retention of irrigating
fluids. The time for irrigating the colostomy should be consistent with the schedule the person will
follow after leaving the hospital.
Patient education and home care considerations: Family members should be informed of the
procedure involved in stoma care and the adjustments they will need to make in their daily lives once
the patient comes home. They also need to understand the importance of making the necessary
adjustments to enable the patient to deal with the change or in body image and the need to take
proper care of colostomy.
Nutritional status: The diet is individualized as long as it is well balanced and does into cause
diarrhea or constipation. Foods that cause excessive odor and gas are avoided. Patient is assisted to
identify any foods or fluids that may be causing diarrhea such as fruits, high fiber foods, soda,
coffee, tea or carborated beverages. For constipation, prune or apple juice or a mild laxative is
effective.
Sexuality and sexual function: The patient is encouraged to discuss feelings about sexuality and
sexual function. Alternative sexual positions are recommended as well as alternative methods of
stimulation to satisfy sexual drives. If the nurse is uncomfortable to discuss, it may be appropriate to
seek assistance from an entero therapist, sex counselor.
Body image: Three main aspects make up a person’s body image (price, 1990):
 Body reality
 Body ideal
 Body presentation
Body reality concerns the body as it is. This always changes but is also associated with underlying
disease or trauma and the effect these can have on the external and internal body stomas affect
both. Body ideal relates to how people would like other people to see their bodies.
Body presentation centers on a person’s reach for a balance between the real and the ideal. Fashions
influences this stomas should be sited so that they do not prevent patients from wearing fashionable
clothes (Black 1997). Support of family and friends can help to overcome physical and emotional
problems.
Bereavement: Stoma surgery can result in a multitude of losses. An essential part of coming to terms
with them is bay allowing the patient to work through the stages defined by cubler Ross.

83
 Denial
 Anger
 Bargaining
 Depression
 Acceptance
The professional’s role is to support the patient through each of these stages. The nurse becomes both
the patient advocate and counselor.
Counseling: The task of counseling is to give the client the opportunity to explore, discuss, and clarify
ways of living more satisfyingly and resourcefully. Counseling is not about giving advice but about
exploring all options so that patients can make informed decisions. Counseling can enhance the
natural coping mechanism, helping patients to accept their body image and elimination needs and
clarify ways towards greater well being. A variety of communication skills need to be used, including
listening and being sensitive to non-verbal cause such as eye contact, fascial expressions and body
language. Counseling is as integral to patient care as teaching them about new appliances.
A nursing framework: A shared philosophy and holistic patient centered approach derived from a
formal nursing model can influence quality of care. Roper et al’s 1995 model can be divided into
four key concepts: the person, health the role of the nurse and the environment. The person is defined
by his or her movement form independence to a greater or lesser degree of dependence according
to age, circumstances and the environment. In conjunction with the patient, the nurse assesses where
the patient is positioned on the independence/ dependence continuum taking into account social,
environmental and emotional circumstances.
Complications of colostomy: The incidence of complications is bout half that seen with ileostomies.
Some common complications are:
1. Prolapse of the stoma (usually due to obesity)
2. Perforation (due to improper stoma irrigation)
3. Stoma retraction, fecal impaction and skin irritation
Conclusion: It is important for nurses to recognize and understand all the patient’s problems, both physical
and emotional. One these have been acknowledged and discussed with the patient, a tailored programme
of care can be developed to meet individual needs and overcome problems.
Diagnosis: Rectum Cancer
Protocol- 5 FU + leucovorin: Regimens of Chemotherapy in Practice
Frequency – 4 weekly
S.N. Drug Day 1-3
1 Inj metoclopramide 10 mg IV before chemo
2 Inj dexona 8 mg IV before chemo
3 Inj leucovorin 20 mg/m2 IV push before 5 FU
4 Inj 5 FU 425 mg/m2 IV push IV bolus
5 Tab domperidone 10 mg PO TDS
Cycle is repeated every 4 weeks for a max of 6 cycles


Ovarian Cancer
84
Unit : 11
OVARIAN CANCER
The ovaries and all other organs of the body are made of tiny building blocks called cells. When
some of these cells start multiplying too much, too quickly and in an uncontrolled way, a tumour forms.
A tumour of the ovary is either benign or malignant. Benign tumours do not have cancer cells in them
and are not life threatening. However, benign tumour can still cause health problems and may require
removal. Malignant tumours do contain cancer cells. They invade normal tissues, may spread to other
parts of the body (metastasis), and can be live threatening. Cancer cells from a malignant ovarian
tumour can spread into nearby tissues around the abdomen or more distant parts of the body through
the blood or through the lymph fluid. If ovarian cancer spreads, it is usually around the abdomen due
to growth directly onto nearby tissues or through the lymph vessels and nodes.
Figure: Cross section of mature ovary
Ovarian cancer is the eighth most common cancer among women in Australia. While ovarian cancer
can occur at any age, most women who have it are older than 55 and have gone through
menopause. In most patients the disease is advanced when first diagnosed. The most common type
occurs in the outside lining of the ovary. Its name is "epithelial ovarian cancer". The other type occurs
in the egg-making cells (germ cells) in the ovary. Its name is "germ cell cancer". Most patients with this
cancer are young women or teenage girls. Usually only one ovary is affected. The doctor will need to
determine which type of cancer is present.
Three main types of ovarian cancers (tumors): Epithelial ovarian cancer is by far the most common
form of ovarian cancer. Germ cell and stromal ovarian cancers are much less common.

85
Ovarian cancer can also result from a cancer somewhere else in the body that has spread:
 Epithelial ovarian cancer (epithelial ovarian tumors): derived from cells on the surface of the
ovary. It occurs mainly in adults.
 Germ cell ovarian cancer (germ cell ovarian tumors): derived from the egg-producing cells
within the body of the ovary. This rare type of cancer more commonly affects children and
teenage girls.
 Stromal ovarian cancer (sex cord stromal tumors): develops within the cells that hold the
ovaries together.
 Cancers from other organs in the body can spread to the ovaries - metastatic cancers: a
metastatic cancer is one that spreads from where it first arose as a primary tumor to other
locations in the body.
Causes and risk factors:
About one woman in 90 will develop ovarian cancer at some time in her life. Although the exact
cause of ovarian cancer is unknown:
Age is the most cases of ovarian cancer are diagnosed in postmenopausal women older than 55
having no children, or having the first birth after the age of 35. A personal history of endometrial
cancer (cancer of the lining of the womb), bowel cancer or breast cancer. A family history of ovarian
cancer or breast cancer. If two more close blood relatives have it. Gene mutations (called BRCAI and
BRCA 2) which occurs only in certain families.
Women have and increased risk if they have a close blood relative (such as their mother or sister)
who has had ovarian cancer or breast cancer, especially if the relative developed the cancer before
the age of 50. For women with one close blood relative who has had ovarian cancer, about one
woman in 70 is likely to develop ovarian cancer at some point in their lives. Of every 100 cases of
ovarian cancer, only five are linked to family history. If a woman has more than one close blood
relative who had ovarian cancer or breast cancer, then a regular check-up May be helpful.
Protective factors: Factors which may protect against ovarian cancer are:
 At least one full-tem pregnancy
 Use of The Pill (oral contraceptive)
 Breastfeeding
 Hysterectomy
 Tubal legation (female sterilization)
All of these reduce the number of times women ovulated between onset of periods in youth
(menarche0 and the change of life in middle age (menopause).
Counseling about risk:
Women who have history of ovarian cancer in their family may need counseling from a cancer
specialist, a genetic counselor, or other qualified specialist about the risk. In some of these women, the
risk of developing cancer can be very high, but use of the contraceptive pill or removal of the ovaries
may reduce this risk. After discussion with their doctor, at-risk women who are finished having children
may decide to have their ovaries removed as a means of reducing their high risk of developing
ovarian cancer; this called a "prophylactic oophorectomy". However, in women who have not gone
through menopause, the removal of ovaries can cause increased risks of heart disease and thinning of
bones (osteoporosis).

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86
These women will have to consider going on hormone replacement therapy (commonly called HRT and
also called estrogen replacement therapy). These issued are best discussed with the treating doctor
and genetic counselor.
Symptoms:
The symptoms of ovarian cancer are usually vague. Most women with cancer of one or both ovaries
do not have any symptoms for some time. N some women, the discovery of ovarian cancer may be
made by chance during a pelvic examination by her doctor or during surgery.
Symptoms may include one or more of the following:
 Enlargement or swelling of the abdomen
 Discomfort or pressure in the lower part of the abdomen
 Indigestion or a bloated feeling
 A change in bowel function and habits; constipation or Diarrhoea
 Feeling full after meals
 An urge to pass urine more frequently; feeling of pressure on the bladder
 Nausea and loss of appetite
 Unexplained loss of weight
 Shortness of breath
 Abnormal vaginal bleeding that is not part of a period
 Pain during sexual intercourse
 A lump or nodule in the groin or navel (umbilicus)
Diagnosis:
As the symptoms are often vague, ovarian cancer can be difficult for doctors to diagnose. First, the
doctor will take the women's complete medical history and do a physical examination. This will include
an internal examination via the vagina (pelvic examination) to feel for lumps or swelling. Sometimes a
rectal examination may also be needed. Blood may be taken for testing. To help doctors see whether
changes have occurred in the ovaries and organs around them, pictures may be made using one or
more of the following methods:
 Ultrasound (transvaginal ultrasound or "TVS", and transabdominal ultrasound), including Colour
flow Doppler imaging
 CT scan (computerized tomography)
 MRI scan (magnetic resonance imaging)
 CA 125
These tests are performed by specialist doctors called radiologists. A patient who needs one or more
of these tests does not have to be admitted to hospital. Some tests can take several hours.
Ultrasound: This method uses sound waves to make a picture of the ovaries and nearby organs.
Transvaginal ultrasound (TVS) and transabdominal ultrasound are the most useful.
Colour flow Doppler imaging: This test is used to see if blood flow is normal in vessels near the
ovaries. It takes about five minutes.

87
CT scan: A CT scan is a type of X-ray examination. A computer is used to turn the X-ray images into
pictures that show the ovaries and nearby organs. If cysts or tumour are present, they are usually
seen easily. A CT scan is painless, but the patient has to lie still for 30 to 40 minutes. The patient has
to receive a dye injection and swallow a contrast medium. The procedure can take up three hours.
MRI scan: A MRI scan can produce high quality pictures of the pelvic organs, including ovaries, uterus
and lymph nodes. The scan is painless, but the patient has to lie still for up to an hour.
CA 125: CA125 is a protein found in the blood. Raised levels of CA 125 may be an indication of
ovarian cancer. An increased blood level of CA125 is detected in eight out of ten women who have
ovarian cancer. However, if ovarian cancer is still in the early stage, the blood level of CA 125 is
raised in less than half the patients. Blood levels of CA125 are important to check. However, a raised
blood level of CA125 does not tell for certain that a woman has ovarian cancer. Blood levels of
CA125 may also be high in patients with conditions unrelated to cancer, such as pelvic inflammatory
disease, endometriosis or pregnancy. Women with benign tumours of the ovary may also have high
level of CA125.
Other tests to assist diagnosis: The doctor may do the following procedures to assist diagnosis:
 Laparoscopy
 Abdominal fluid aspiration
Laparoscopy: This operation allows to inspect the ovaries and other nearby organs for any signs of
disease. Wile the patient is under a general anesthetic, the doctor makes a small cut in the abdomen
and inserts a thin, small telescope called a laparoscopy. The doctor can look through the laparoscope
to see the ovaries and other organs. Laparoscopy is commonly called "key-hole surgery". It is a safe
and effective diagnostic procedure.
Abdominal fluid aspiration: If fluid has built up in the abdomen (known as ascites), some of it can be
taken out using a needle. Before the needle is passed through the skin over the fluid build-up, the
doctor will use a local anesthetic to numb the area. The fluid is than checked in a laboratory to see if
cancer cells are present.
Screening: Doctors do not currently recommend screening the general population for ovarian cancer
because current methods are not accurate enough. TVS, measurement of CA125 and Colour flow
Doppler imaging are not sensitive or specific enough, and are too costly to be useful for routine
screening. Women without ovarian cancer who have abnormal results from tests may suffer severe
and needless anxiety.
Surgery may be performed because of abnormal test results, but then no cancer is found. Such
unnecessary surgery can cause risks to health.
Early detection: Early detection is important. If ovarian cancer is diagnosed and treated early, the
patient is more likely to have a remission or cure. Transvaginal ultrasounds and tests for blood levels
of the tumour marker CA125 can assist with periodic screening of individual women with a family
history.
Although the Pap test is very helpful in the detection of cervical cancer, it rarely detects ovarian
cancer.
Emotions, support and care after diagnosis: When a woman finds out she has ovarian cancer, she is
likely to have rage of feelings, such as shock, denial, anger, fear, depression and resentment. These
feelings are perfectly normal. Relatives and friends have similar feelings and concerns.

Ovarian Cancer
88
The distress usually eases as patients and their families learn more about ovarian cancer and when
treatment begins. Any treatment can be physically and emotionally draining. Many women find that
their therapy and new restrictions on life lead to anxiety, frustration and anger. These reactions are
normal but many distress the patient and other around her. Talking with close relatives and friends
can help greatly in easing this stress. When patients and their family and friends share feeling, they
are better able to support one another. Patient support groups, social workers, nurses and ministers of
religion can also be very helpful.
Stages of Ovarian Cancer: To perform accurate staging in many patients, the surgeon will do a
laparotomy (open surgery) and thoroughly inspect the ovaries and other abdominal organs for the
presence of cancer. During the laparotomy, the surgeon will usually remove organs, which have
cancer. Other tissue may be removed and inspected under a microscope to see if it contains cancer
cells.
The 4 stages of ovarian cancer: in brief
 Stage 1: Cancer is confined to one or both ovaries
 Stage 2: Cancer is found in one or both ovaries, the fallopian tubes and the womb. It may have
spread to other organs in the pelvis such as the bladder, rectum and vagina.
 Stage 3: Cancer has spread outside the pelvis to other organs in the abdomen such as the
bowels, the liver, the diaphragm and lymph nodes.
 Stage 4: Cancer is found in one or both ovaries, has spread to other organs in the abdomen,
and / or has spread to other areas of the body beyond the abdomen, such as the chest.
The 4 stages of ovarian cancer: In details
Ovarian cancer is classified into four stages, with stage 4 being the most advanced.
 Stage 1 - the cancer is confined to one or both ovaries. This is subdivided into three groups:
• Stage 1a - the cancer is confined to just one ovary (contained inside it).
• Stage 1b - the cancer is confined to both ovaries (contained inside them).
• Stage 1c - either 1a or 1b, but there is come cancer on the surface of one or both ovaries, or
cancer cells are found in fluid extracted from inside the abdomen during surgery, or the
ovary bursts during or before surgery.
 Stage 2 - the cancer has spread to the uterus, fallopian tubes or some other areas in the pelvis
(tummy area). This is subdivided into 3 groups:
• 2a - the cancer has spread into the uterus (womb) or the fallopian tubes.
• 2b - the cancer has spread into other tissues in the pelvis, such as the rectum or bladder.
• 2c - 2a and 2b, and there is cancer on the surface of one or both ovaries, or cancer cells are
identified in fluid extracted from inside the abdomen during surgery, or the ovary bursts
during or before surgery.
 Stage 3 - the cancer has spread into the peritoneum (the lining of the abdomen), or to the lymph
nodes in the upper abdomen, groin or behind the uterus. Most ovarian cancers are diagnosed at
this stage. This stage is divided into three subgroups:
• 3a - an examination with a microscope of tissue taken from the peritoneum (lining of the
abdomen) or the omentum (fatty layer over the top of the intestines) detects cancer cells.
• 3b - tumor growths are identified in the peritoneum 2cm or smaller.

89
• 3c - tumor growths larger than 2cm are identified in the peritoneum. Cancer is found in the
lymph nodes in the groin, behind the womb or the upper abdomen.
 Stage 4 - the cancer has spread beyond the abdomen to other parts of the body, including such
organs as the lungs or the liver. If cancer is just found on the surface of the liver, but not inside it,
it is still stage 3.
Recurrent or "refractory" ovarian cancer:
This means that the cancer has come back even though it has apparently been treated successfully.
Treatment: Surgery and chemotherapy are the key treatments for ovarian cancer. They may be used
alone or in combination. As with any treatment for cancer, each treatment has risks as well as
benefits.
Surgery: Surgery is the first line of treatment. An exploratory operation (laparotomy) allows the
surgeon to examine the internal organs and determine the stage of the disease. This provides
information about the best course of treatment. If cancer is found, as much of the tumour as possible is
removed during the operation. This is called "debunking". Debunking is important because chances of
survival are improved when as much as possible of the tumour is removed.
Surgery for ovarian cancer has risks, including damage to the Bowel, Bladder; Ureters (tube which
drain urine from the kidneys to the bladder) and large blood vessels and nerves in the area.
Fertility and sexuality after surgery: If the cancer has not spread, it may be possible to save one
ovary, one fallopian tube and the womb. If the patient has finished her childbearing, most doctors
favors removal of all ovarian tissue because it my be at risk of developing. If the removal of the
ovaries and womb is needed, periods stop, and child bearing is not possible. In younger women,
removal of the ovaries will cause symptoms of menopause, such as hot flushes, night sweats and mood
changes. These symptoms can be treated with hormone replacement therapy. After having their
ovaries and womb removed, younger women in particular can be very distressed because they are
not able to become pregnant. They may also fell they have lost part of their female identity.
Diet after surgery: After surgery for ovarian cancer, bowel function may be sluggish. In some women
it returns to normal slowly. Difficulties with poor bowel function can be improved by:
 Diet management, including a lot of fluids and foods high in fiber (advice from dietitian may be
needed)
 Stool softeners
 Mild laxatives
 Increased intake of fluids
Standard bowel function usually returns once the diet and daily activities are back to normal.
Chemotherapy: Chemotherapy may be given in one of 3 ways:
 Injection into a vein (the most usual method)
 Injection into the abdomen (peritoneum)
 Tablets taken by mouth
After the drugs gets into the blood, they are distributed throughout the body. The medicine kills
cancer cells by interfering with their growth or reproduction. While these medicines also affect normal
cells, they have an ability to recover.

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Normal cells which are usually affected the most are:
 Cells in the bone marrow, which make blood cells
 Cells in the lining of the mouth, stomach and intestines
 Cells which cause hair growth
Depending on the patient's reaction to the chemotherapy and her recovery between doses, the
doctors will decide how much medicine will be given and how often. During chemotherapy, regular
blood rests are performed to check for anemia and to see if the blood level of CA125 is falling.
Usually six chemotherapy treatments are given, and a CT scan is done after the third and sixth
treatments.
Each person reacts differently to chemotherapy. Some patients have minor side effects. Other
patients have side effects so unpleasant that they want to stop the treatment. The presence of
unpleasant side effects does not mean that the treatment is unsuccessful. The most common side effects
are:
 Nausea and vomiting
 Numbness or tingling in the hands and feet
 Reduced numbers of red cells in the blood (anemia)
 Reduced numbers of other blood cells called white cells (important in fighting infection) and
platelets (important in normal clotting)
Less common side effects include hair loss and partial loss of hearing. If any of these side effects
occur, the doctor should be told. Side effects which occur during chemotherapy and radiotherapy
should resolve when treatment is over. If side effects persist or come back, tell the doctor. Various
cytotoxic medicines are used in treating ovarian cancer. They may be used in different combination,
with surgery. Paclitaxel, carboplatin and cisplatin are among the cytotoxic medicines used in cancer
that is confined to the ovaries or has spread to other areas.
Read the Consumer Medicine Information: The Consumer Medicine Information (CMI) has more
complete details about the chemotherapy drug or drugs the patient is taking. The CMI has information
about side effects and other issues. It has been produced so patients can find out more about the
drugs they are taking. It is important to read and understand the CMI. If a patient has any questions
about the CMI or information in it, she should ask her doctor, cancer nurse or pharmacist. Most
chemotherapy drugs have a CMI.
Radiation Therapy (Radiotherapy): Radiation therapy is not often used to treat ovarian cancer. It is
used only in special situations. X-rays can be used to kill cancer cells and shrink tumours. The X-ray is
aimed only at the area which has the cancer. Cancer cells are more sensitive to X-rays and are killed
more easily than normal cells. Although normal cells are also damaged by X-rays, they have an
ability to repair themselves. Cancer cells do not have that ability. Side defects include nausea,
Diarrhoea, fewer cells in the blood, and skin irritation over the area being treated.
Check ups after treatment: After treatment has finished, the doctor will recommend regular check-
ups. At first, most check-ups are about six to eight weeks apart. The doctor may also do blood tests to
monitor CA125 levels. If there is no sign of the tumour coming back after two years, the check-ups will
become less frequent. If any symptoms return, however, the doctor should be told at once.

91
Diagnosis: Ovary Cancer
Protocol- paclitaxel + carboplatin: Regimens of Chemotherapy in Practice
Frequency: 3 weekly
Pre medication: Inj dexona 16 mg at 10 PM day before and 8 mg at 6 am of same day of
chemotherapy to be administered for paclitaxel premedicaton purpose.
S.N. Drug Day 1
1. Tab lorazepam 1 mg PO BD
2. Inj ondem 16 mg IV slow push before chemotherapy
3. Inj dexona 8 mg IV slow push before chemo
4. Inj ranitidine 50 mg IV push paclitaxel
5. Inj phenargon 12.5 mg IV slow push before paclitaxel
6. Inj paclitaxel 175 mg/ m2 IV in 500 ml
7. Inj carboplatin AUC 5 mg in 500 ml NS over 2 hours
Oral medications after chemo every cycle
 Tab dexamethasone 4 mg TDS for 3 days
 Tab metaclopromide 20 mg TDS for 3 days


Leukemia
92
Unit : 12
LEUKEMIA
Group of cancer that usually begins in the bone marrow and result in high numbers of abnormal white
blood cells. These white blood cells are not fully developed and are called blasts or leukemia cells.
Types: Leukemias are grouped by how quickly the disease develops (acute or chronic) as well as by
the type of blood cell that is affected (lymphocytes or myelocytes).
Acute leukemia
 Characterized by rapid increase in the numbers of immature blood cells
 Crowding due to such cells makes the bone marrow unable to produce healthy cells
 Immediate treatment is required
 Most common forms of leukemia in children
Chronic leukemia
 Characterized by the excessive build up of relatively mature but still abnormal white cells
 It takes months or years to progress
 The cells are produced at a much higher rate than normal resulting in many abnormal white cells
 Should be monitored for some time before treatment to ensure maximum effectiveness of
therapy
 Occurs in older people mostly
The four main types of leukemia on the basis of cells type involved include:
 Acute lymphoid leukemia (ALL)
 Chronic lymphoid leukemia (CLL)
 Acute myeloid leukemia (AML)
 Chronic myeloid leukemia (CML).
Acute lymphoid leukemia (ALL)
 ALL results from an uncontrolled proliferation of immature cells (lymphoblasts) derived from the
lymphoid stem cell.
 The cell of origin is the precursor to the B lymphocyte in approximately 75% of ALL cases;
 T-lymphocyte ALL occurs in approximately 25% of ALL cases.
 ALL is most common in young children, with boys affected more often than girls;
 The peak incidence is 4 years of age. After age 15 years, ALL is relatively uncommon.
Pathology:
 Immature lymphocytes proliferate in the marrow and crowd the development of normal myeloid
cells.

93
 As a result, normal hematopoiesis is inhibited, resulting in reduced numbers of leukocytes,
erythrocytes, and platelets.
 Leukocyte counts may be either low or high, but there is always a high proportion of immature
cells.
 Manifestations of leukemic cell infiltration into other organs are more common with ALL than with
other forms of leukemia
 Include pain from an enlarged liver or spleen, bone pain, and headache and vomiting (because
of meningeal involvement).
Chronic lymphoid leukemia (CLL)
It is a common type of leukemia. It occurs in children and adults. The incidence rate is 20%.
Pathophysiology
 CLL typically derives from a malignant clone of B lymphocytes (T-lymphocyte CLL is rare).
 In contrast to the acute forms of leukemia, most of the leukemia cells in CLL are fully mature.
 It appears that these cells can escape apoptosis (programmed cell death), with the result being
an excessive accumulation of the cells in the marrow and circulation.
 Lymphadenopathy occurs as the lymphocytes are trapped within the lymph nodes.
 The nodes can become very large and are sometimes painful.
 Hepatomegaly and splenomegaly then develop.
Signs and symptoms ALL
 Nonspecific symptoms that begin gradually or abruptly as a consequence of anemia,
leukocytosis, leukopenia or leukocyte dysfunction, or thrombocytopenia.
 Nearly half have had symptoms for ≤3 months before the leukemia is diagnosed.
 Fatigue as the first symptom
 Anorexia and weight loss
 Fever with or without an identifiable infection
 Signs of abnormal hemostasis (bleeding, easy bruising)
 Bone pain, nonspecific cough, headache
 Splenomegaly
 Hepatomegaly
 Leukostatic manifestations due to severe leukocytosis or thrombosis such as vasoocclusive disease,
cerebrovascular accidents, myocardial infarction, venous thrombosis, priapism, visual
disturbances,
 Histamine production secondary to basophilia causing pruritus, diarrhea, and flushing.
 Recurrent infections,
 Lymphadenopathy- nontender lymphadenopathy at diagnosis, most commonly involving the
cervical, supraclavicular, or axillary lymph nodes.
 Extranodal Involvement to other organs
 Oliguria, and anuria.

Leukemia
94
Diagnostic investigations
 History
 CBC and blood smear peripheral
• WBC count varies widely from 1,000 to 100,000/mm3 and may include significant numbers
of abnormal immature (blast) cells;
• Platelet counts <100,000/mm3 are found at diagnosis in ~75% of patients, and ~25%
have counts <25,000/mm3.
• The anemia due to decreased erythropoiesis and active blood loss is usually normocytic
normochromic.
 Bone marrow aspiration and biopsy cells to classify type of leukemia further.
 Lymph node biopsy to detect spread.
 Lumbar puncture and examination of cerebrospinal fluid for leukemic cells (especially in ALL).
 Liver dysfunction
 Immunologic Studies- the depression of IgG, IgA, and IgM that predisposes to infection.
Radiological diagnostic test
 Chest X-rays- to detect enlargement of the thymus or mediastinal nodes, with or without pleural
effusion
 Computed tomography (CT) scans: chest, abdomen,
 MRI/PET/ Bone Scan
 Ultrasounds
Supportive Care
 Early initiation of empirical broad-spectrum antibacterial and antifungal antibiotics
 Rational use of blood products - Transfusion should be given slowly in patients with profound but
chronic anemia to prevent development of congestive heart failure.
 Platelet transfusions should be given as needed to maintain a platelet count >10,000–
20,000/mm3 and RBC transfusions should be administered to keep the hemoglobin level 8 g/dL
 Administration of sedative Therapy
 Rational use of indwelling catheters,
 Prevention and treatment of nausea and vomiting,
 Pain control
 Continuous psychosocial support for the patient and family,
 Intravenous fluids
 Corticosteroid
 Allopurinol to treat hyperuricemia
 Phosphate binder, such as aluminum hydroxide, calcium carbonate (if the serum calcium
concentration is low), lanthanum carbonate, to treat hyperphosphatemia.
 I.V. immunoglobulins or gamma globulin to treat hypogammaglobulinemia.

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 Leukapheresis (or exchange transfusion in infants) may be used when abnormally high numbers
of white cells are present to reduce the risk of leukostasis and tumor burden before
chemotherapy.
 The agent G-CSF (Neupogen)
• To reestablish a normal white blood count
• Starting dosage 5 mcg/kg/day‚ subcutaneous injection OD,
• Stop if the ANC increases beyond 10‚000/mm3
• Administer NEUPOGEN at least 24 hours after cytotoxic chemotherapy.
• A transient increase in neutrophil count is typically seen 1 to 2 days after initiation of
NEUPOGEN therapy.
 Autologous or allogeneic bone marrow or stem cell transplantation.
 A protein-tyrosine kinase inhibitor- dasatinib, imitinib
 Patient with newly diagnosed CLL is generally observed and followed closely until symptoms
develop.
 Splenectomy
Medical Management of ALL
Treatment typically takes place in 3 phases:
 Induction (or remission induction)
 Consolidation (intensification)
 Maintenance
Induction (or remission induction) Phase
 The goal of induction chemo is a remission.
 This means that leukemia cells are no longer found in bone marrow samples, the normal marrow
cells return, and the blood counts become normal.
 But a remission is not necessarily a cure, as leukemia cells may still be hiding somewhere in the
body.
 Induction phase lasts 4-6 weeks.
Drugs used in induction phase are
 Inj. Vincristine
 Inj. Prednisone
 Inj. L- asparaginase
 Inj. Methotrexate
 Inj. Daunorubicin
Consolidation Phase
 Consolidation typically includes multiple cycles of intensive chemotherapy given over a six to
nine month period.
 Frequent hospitalizations are required and intensive supportive care is still needed, including red
blood cell and platelet transfusions.

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Drugs used in consolidation phase are
 Inj. 6 mercaptopurine
 Inj. Cyclophosphamade
 Inj. vincristine
 Inj. Cytosine arabinoside (cytarabine)
 Inj. Daunorubicin
Maintenance Phase
 This phase lasts for up to two years from diagnosis for girl and up to three years for boys.
 It involves the child needs to take oral chemotherapy tablets daily and weekly with
chemotherapy injection monthly.
 Patients need to have their blood tests checked once a month while taking chemotherapy tablets.
 Most patients with ALL can return to work during maintenance therapy.
Drugs used in maintenance phase are
 6 mercaptopurine
 Vincristine
 Inj. L- asparaginase
 Methotrexate
Central Nervous System (CNS) Prophylaxis
 ALL frequently can recur in the spinal fluid, to prevent relapse at this location, intrathecal
chemotherapy is done
 Patients are routinely given six or more injections of intrathecal chemotherapy to prevent
recurrence of ALL.
 Most people complete intrathecal therapy within two to four months of starting their treatment.
 Headaches and nausea are occasional side effects.
Drugs used for cranial prophylaxis
 6 mercaptopurine
 Cyclophosphamide
 Vincristine
 Intra Thecal Methotrexate(ITM)
Adjunctive Therapies
 Cranial radiation therapy
 Stem Cell Transplantation
Medical Management
 In early stages, CLL may require no treatment.
 When symptoms are severe or the disease progresses to later stages, chemotherapy with
corticosteroids and chlorambucil (Leukeran) is often used.

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Other useful agents include:
 Cyclophosphamide
 Vincristine
 Doxorubicin
Acute Myelocytic Leukemia (AML)
 AML results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells:
monocytes, granulocytes (neutrophils, basophils, eosinophils), erythrocytes, and platelets.
 AML is more common among adults than children, and affects males significantly more often than
females.
Subtypes of AML
FAB subtype Name
M0 Undifferentiated acute myeloblastic leukemia
M1 + Acute myeloblastic leukemia with minimal maturation
M2 Acute myeloblastic leukemia with maturation
M3 Acute promyelocytic leukemia (APL)
M4 Acute myelomonocytic leukemia
M4 eos Acute myelomonocytic leukemia with eosinophilia
M5 Acute monocytic leukemia
M6 Acute erythroid leukemia
M7 Acute megakaryoblastic leukemia
Figure: French-American-British classification of AML
Medical Management
 The overall objective of treatment is to achieve complete remission, in which there is no
detectable evidence of residual leukemia remaining in the bone marrow.
 Attempts are made to achieve remission by the aggressive administration of chemotherapy,
which is often carried out in 2 phases:
Induction phase
 The aim of this initial stage of treatment is to kill as many leukaemia cells in bone marrow and
blood as possible, restore blood to proper working order and treat any symptoms that patients
may have.

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 It involves high doses of Cytarabine, Daunorubicin and Etoposide.
 The treatment is repeated until the bone marrow shows no more blasts cells (complete remission).
It is usually done within 2-3 cycle once blood count remains normal.
Consolidation phase
 It begins once the leukemia is in remission.
 The goal of post remission therapy is to kill any remaining leukemia.
 The high dose of same chemo (Chytatabine) is given for this phase usually 2-4 cycle depending
on risk factors.
Maintenance phase
 Usually there is no maintenance phase in AML except in AML-M3 or APML. ATRA (all trans
retinoic acid- cell maturing agent) and 6 MP is used for 18 months.
Chronic Myelogenous Leukemia (CML)
 It arises from a mutation in the myeloid stem cell.
 Normal myeloid cells continue to be produced, but there is a preference for immature (blast)
forms.
 Therefore, a wide spectrum of cell types exists within the blood, from blast forms through mature
neutrophils.
 Because there is an uncontrolled proliferation of cells, the marrow expands into the cavities of
long bones (eg, the femur), and cells are also formed in the liver and spleen (extramedullary
hematopoiesis)
 It results in enlargement of these organs that is sometimes painful.
 The vast majority of patients are adults. 90% of treated patients survive for over 5 years.
Pathophysiology
 In CML, part of the DNA from one chromosome moves to another chromosome.
 This change is called the “Philadelphia chromosome.”
 It results in the bone marrow making an enzyme, called tyrosine kinase, which causes too many
stem cells to become white blood cells (granulocytes or blasts).
Philadelphia chromosome: A piece of chromosome 9 and a piece of chromosome 22 break off and
trade places. The BCR-ABL gene is formed on chromosome 22 where the piece of chromosome 9
attaches. The changed chromosome 22 is called the Philadelphia chromosome.

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Figure: Philadelphia Chromosome
Medical Management
 The goal of chronic myelogenous leukemia treatment is to eliminate the blood cells that contain
the abnormal BCR-ABL gene that causes the overabundance of diseased blood cells.
 For most people, it's not possible to eliminate all diseased cells, but treatment can help achieve a
long-term remission of the disease.
Targeted drugs
 Imatinib (Gleevec)
 Dasatinib (Sprycel)
 Nilotinib (Tasigna)
 Bosutinib (Bosulif)
 Omacetaxine (Synribo)
Stem cell transplant/ bone marrow transplant
 Medical procedure in which diseased bone marrow is replaced by highly specialized stem cells
that develop into healthy bone marrow.
 There are two main types of stem cell transplants: autologous and allogeneic
 Autologous transplantation (AUTO): Receives his or her own stem cells. During the AUTO
transplant process, the patient’s stem cells are collected and then stored in a special freezer that
can preserve them for decades. Usually the patient is treated the following week with powerful
doses ofchemotherapy and/or radiation therapy, after which the frozen stem cells are thawed
and infused into the patient's vein. The stem cells typically remain in the bloodstream for about
24 hours until they find their way to the marrow space, where they grow and multiply, beginning
the healing process.

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 Allogeneic transplantation (ALLO): Receives stem cells donated IV by another person after HLA
matching to avoid graft-versus-host disease (GVHD, a complication in which the immune cells in
the transplanted bone marrow recognize the recipient's body as foreign and attack it). Siblings
usually have the best chance of being a complete match.
Chemo regimen in leukemia
Diagnosis: Acute myeloid leukemia Non – M3
Protocol: 7+3 phase
Phase: Induction
S.N. Drug Day 1-3 Day 4-7
1. Inj. Ondem 8mg before chemo
2. Inj. Dexona 8 mg before chemo
3. Inj. Cytarabine 100mg/m2 + 500ml NS continuous 24 hrs
infusion IV for day 1-7
4. Inj. Daunorubicin 45mg/m2 IV bllus for day 1-3 XXX
Tab. Cotrimoxazole 960mg 1-0-1 BD for 2 weeks PO from day 1 for infection prophylaxis
Diagnosis: Acute myeloid leukemia M3
Protocol: Atra + Daunorubicin
Phase: Induction
S.N. Drug Days
1. Inj. Ondem 8mg before Daunorubicin
2. Inj. Dexona 8 mg before Daunorubicin
3. Inj. Dexona 8 mg IV BD as prophylaxis for retinoic acid syndrome Day 1-5
4. Cap Atra 45mg/m2 PO divided into 2 doses, 2nd dose to be given 6 hrs
after first dose
Day 1 - 90
5. Inj. Daunirubicin 60mg/m2 + 100 ml NS 30 ins IV infusion (induction) Day 6-8
6. Inj. Daunirubicin 60mg/m2 + 100 ml NS 30 ins IV infusion (!st consolidation) Day 34 - 36
7. Inj. Daunirubicin 60mg/m2 + 100 ml NS 30 ins IV infusion (2nd
consolidation)
Day 62 - 64
Tab. Cotrimoxazole 960mg 1-0-1 BD for 2 weeks PO from day 1 for infection prophylaxis
Maintenance regimen
 Cap Atra 45 mg /m2 PO in 2 divided doses Day 1-15, Repeat every 3 months for 2-3 years
Diagnosis: Acute lymphoblastic leukemia
Induction 1
 Tab. Prednisolone 40mg/m2 PO Day 1-28
 Inj. Vincristine (VCR) 1.4 mg /m2 IV push weekly (Day 1 , 8, 15, 22, 29)
 Inj. L – Asparaginase 6000 Unit /m2 IM 1o doses every alternate day ( Start from Day 2)
 Inj. Daunorubicin 30mg /m2 IV push on Day8, 15, 29
 Inj. ITM (Intra-Thecal Methotrexate) 12mg IT for more than 3 yrs of age weekly Day 1, 8, 15, 22

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 Evaluation: Blood count should be performed 3 weekly and bone marrow aspiration on recovery
 Begin next cycle when granulocytes more than 1000/m2 and platelets more than 1,00,000/m3
Induction 2
 Tab. 6-Mercaptopurine (6-MP) 75mg/m2 PO (From Day 1-8, 1 week gap, Day 15-21)
 Inj. Cyclophosphamide (CTX) 750mg/m2 IV 30 mins infusion (Fortnightly, Day 1, day 15)
 Inj. ITM (Intra-Thecal Methotrexate) 12mg IT for more than 3 yrs of age weekly Day 1, 8, 15, 22
 Intracranial radiation 200 Rads per dose ( 2 days break can be made at any point – Day 4-8,
2 days gap, Day 11 – 14)
 Evaluation: Blood count should be performed 3 weekly and bone marrow aspiration on
recovery
Consolidation phase
 Tab. 6-Mercaptopurine (6-MP) 75mg/m2 PO (From Day 1-8, 1 week gap, Day 15-21)
 Inj. Cyclophosphamide 750mg/m2 IV 30 mins infusion (Day 1)
 Inj. Vincristine (VCR) 1.4 mg /m2 IV push fortnightly (Day 1, 15)
 Inj. DAunorubicin 30mg /m2 IV push on Day 15
 Inj. ARAC (Cytosine Arabinoside/ Cytarabine) 100mg/m2 SC every 12 hrs 6 total doses (3
doses starting from Day 1 and next 3 doses starting from Day 15)
 Evaluation: Blood count should be performed 3 weekly and bone marrow aspiration on
recovery
Maintenance Phase
 Inj. Prednisolone 40 mg/m2 PO (Day 1 – 7)
 Tab. 6 –MP PO 75mg/m2 Day 15 – 35, Day 43 – 63, Day 71 – 91,
 Inj. VCR 1.4mg/m2 IV push (Day 1)
 Tab. Methotrexate PO 15mg/m2 (Day 15, 22, 29, 43, 50, 57, 71, 78, 85)
 Inj. Asparaginase IM 6000 Unit/m2 alternate (Day 1, 3, 5, 7)
 Bone marrow should be performed after every m cycle in low risk patient.
 In high risk patient after each m cycle bone marrow should be performed.
Complications
 Hemorrhage
 Weight loss and anemia are further complications of leukemia and its treatment.
 Relapse or a progression of the disease after a remission has been achieved with treatment.
 Tumor lysis syndrome
 Children who receive therapy for ALL may experience late adverse effects including central
nervous system (CNS) impairment, slowing of growth, infertility, cataracts, and an increased risk
for other cancers.
Prognosis
 Leukemic retinopathy usually is seen in patients who show a relapse
 Leukemic infiltration has a poor prognosis and usually associated with CNS involvement

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 Optic nerve head infiltration is associated with CNS disease and poor prognosis
 Prognosis of ALL is age dependent. Children have much better outlook than adults
Nursing Management
Assessment
 Weakness and fatigue
 Dry cough, mild dyspnea, and diminished breath sounds may indicate a pulmonary infection.
 The low platelet count and risk for significant bleeding.
 WBC count, ANC, hematocrit, platelet, and creatinine levels, hepatic function tests, and
electrolyte levels.
 Blood culture results
Nursing Diagnosis
 Impaired mucous membranes due to changes in epithelial lining of the gastrointestinal tract from
chemotherapy or prolonged use of antimicrobial medications.
 Acute pain and discomfort related to mucositis, WBC infiltration of systemic tissues, fever, and
infection.
 Imbalanced nutrition, less than body requirements, related to hypermetabolic state, anorexia,
mucositis, pain, and nausea
 Hyperthermia related to tumor lysis and infection
 Fatigue and activity intolerance related to anemia and infection
 Anxiety due to knowledge deficit and uncertain future
 Disturbed body image related to change in appearance, function, and role
 Grieving related to anticipatory loss and altered role functioning
 Potential for spiritual distress
 Risk for infection and bleeding
 Risk for excess fluid volume related to renal dysfunction, hypoproteinemia, need for multiple
intravenous medications and blood products
Easing pain and discomfort
 Acetaminophen is typically given to decrease fever
 Sponging with cool water.
 Bedclothes need frequent changing as well. Gentle back and shoulder massage may provide
comfort.
 Stomatitis can also cause significant discomfort so oral hygiene practices can be effective
 Implement creative strategies that permit uninterrupted sleep for at least a few hours while still
administering necessary medications on time.
 Listening to patients.
Improving nutritional intake
 Mouth care before and after meals and administration of analgesics before eating can help
increase intake.
 Small, frequent feedings of foods that are soft in texture and moderate in temperature may be
better tolerated.

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 Low-microbial diets are typically prescribed (avoiding uncooked fruits or vegetables and those
without a peelable skin).
 Nutritional supplements are frequently used.
 Daily body weights (as well as intake and output measurements) are useful in monitoring fluid
status.
 Parenteral nutrition is often required to maintain adequate nutrition.
 Nausea can result from antimicrobial therapy, so some antiemetic therapy may still be required
after the chemotherapy has been completed.
Managing anxiety and grief
 Providing emotional support and discussing the uncertain future are crucial.
 Assess how much information patients want to have regarding the illness, its treatment, and
potential complications.
 Priorities must be identified so that procedures, assessments, and self-care expectations are
adequately explained even to those who do not wish extensive information.
 Assist patients to identify the source of the grief and encourage them to allow time to adjust to
the major life changes produced by the illness.
Managing side effects of radiotherapy and chemotherapy
 Stomatitis
 Alopecia
 Nausea/ vomitting
 Diarrhoea
 Fatigue
 Infection
 Bleeding
Managing stomatitis
 Stomatitis commonly develops within 5 to 14 days after the patient receives certain
chemotherapeutic agents, such as doxorubicin and 5-fluorouracil, and BRMs, such as IL-2 and
IFN.
 Good oral hygiene that includes brushing, flossing, and rinsing
 Soft-bristled toothbrushes and nonabrasive toothpaste prevent or reduce trauma to the oral
mucosa.
 Oral swabs with sponge like applicators, Oral rinses with saline solution or tap water may be
used in place of a toothbrush
 Products that irritate oral tissues or impair healing, such as alcohol-based mouth rinses, are
avoided. Foods that are difficult to chew or are hot or spicy are avoided to minimize further
trauma.
 The patient’s lips are lubricated to keep them from becoming dry and cracked.
 Topical anti-inflammatory and anesthetic agents
 Systemic analgesics.
 Adequate fluid and food intake is encouraged.

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Coping with alopecia
 The temporary or permanent thinning or complete loss of hair caused by damaging stem cells
and hair follicles. The extent of alopecia depends on the dose and duration of therapy. As a
result, the hair is brittle and may fall out or break off at the surface of the scalp. Loss of other
body hair is less frequent.
 Hair loss usually begins within 2 to 3 weeks after the initiation of treatment; regrowth begins
within 8 weeks after the last treatment.
 The nurse’s role is to provide information about alopecia and to support the patient and family
in coping with disturbing effects of therapy, such as hair loss and changes in body image.
Decreasing fatigue
 Encouraged to maintain as normal a lifestyle as possible
 Prioritizing necessary and valued activities can assist patients in planning for each day.
 Maintain activity and rest balance
 Address factors that contribute to fatigue and implement pharmacologic and nonpharmacologic
strategies to manage pain.
 Nutrition counseling
 Monitored for alterations in oxygenation and electrolyte balances, hemoglobin and hematocrit
and administer blood product as prescribed
 Physical therapy and assistive devices
Preventing infection
 Antibiotics as prescribed after cultures
 Strict asepsis is essential when handling intravenous lines, catheters, and other invasive
equipment.
 Exposure of the patient to others with an active infection and to crowds is avoided.
 Patients with profound immunosuppression, such as BMT recipients, may need to be placed in a
protective environment where the room and its contents are sterilized and the air is filtered.
 Provide low-bacteria diets, avoiding fresh fruits and vegetables.
 Hand hygiene and appropriate general hygiene
 Invasive procedures, such as injections, vaginal or rectal examinations, rectal temperatures, and
surgery, are avoided.
 Coughing and deep-breathing exercises f to prevent atelectasis
 Prophylactic antimicrobial therapy
 Teaches the patient and family to recognize signs and symptoms of infection to report, perform
effective hand hygiene, use antipyretics, maintain skin integrity, and administer hematopoietic
growth factors when.


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Unit : 13
CERVICAL CANCER
Introduction: Cervical cancer is malignant neoplasm of the cervix uteri or cervical area. It begins in
the lining of the cervix.
Types of Cervical Carcinoma: The 2 main types of cells covering the cervix are squamous cells (on
the ectocervix) and glandular cells (on the endocervix). These 2 cell types meet at a place called the
transformation zone. Most cervical cancers begin in the cells in the transformation zone. The main
types of cervical cancers are: Squamous cell carcinoma and Adenocarcinoma.
Epidemiology:
 Second most common cancer in the world. It was responsible for 2,75,000 deaths, about 88% of
which occurred in developing countries in 2008 (International Agency for Research on Cancer
(IARC))
 In Nepal, It is the most common cancer in women.
 According to the WHO approximately 70% of all cases are found in low to middle income
countries. Worldwide, there were 528,000 new cases of cervical cancer and 266,00 deaths in
2012 (WHO 2012).
 Recently Worldwide, cervical cancer is the second most frequent cancer type and the third
greatest cause of death from cancer in women (WHO Fact Sheet, 2013).
Risk Factors
 Human Papiloma virus infection
 Smoking
 Immunosuppression
 Oral contraceptives
 Intrauterine device use
 Diet consumption: diet low in the antioxidants, carotenoids, flavonoids and folate
 Diethylstilbestrol (DES)- synthetic form of estrogen
 Multiple full-term pregnancies
 Multiple sex partners
 Sexual intercourse at young age
 Chlamydia infection
 Poverty
Stages of Cervical Carcinoma
 Stage 1
 Stage 2
 Stage 3
 Stage 4

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Stage Extent of disease 5-years survival
0 Carcinoma in situ (CIN) ~100%
I Limited to cervix
Ia1 Microscopic disease: Stromal invasion < 3mm, latral spread < 7
mm
> 95%
Ia2 Microscopic disease: Stromal invasion < 3mm and >5mm, lateral
spread < 7mm
Ib1 Macroscopic lesion < 4cm in gratest dimension ~90%
Ib2 Macroscopic lesion > 4cm in greatest dimension 80 – 85%
II Extension to uterus/parametria/vagina ~75 – 78%
IIa1 Involvement of upper two thirds of vagina without parametrial
invasion, > 4 cm greatest diameter
IIa2 Involvement of upper two thirds of vagina without parametrial
invasion, >4cm greatest diameter
IIb1 Involvemtn of upper two thirds of vagina with parametrial invasion
III Extension to pelvic side wall and/or lower third of vagina ~47 – 50%
IIIa Involvement of lower third of vagina
IIIb Extension to pelvic side wall and/or hydronephrosis
IV Extension to adjacent organs or beyond true pelvis ~20 – 30%
IVa Extension to adjacent organs e.g. bladder, bowel
IVb Distant metastases
Table: Stage of Cervical Cancer
Mode of spread
 Direct extension
 Lymphatic
 Hematogenous
 Direct implantation
Clinical features
 Abnormal cervical cell changes rarely cause symptoms.
 If cervical cell changes progress to cancer, symptoms may include:
• Vaginal bleeding between menstrual periods, after sex, or after menopause.
• Pain during sexual intercourse.
• Vaginal discharge that isn't normal.
• A significant unexplained change in menstrual cycle.
 The symptoms of advanced cervical cancer may include:
• Anemia because of abnormal vaginal bleeding.
• Ongoing pelvic, leg, or back pain.

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• Urinary problems because of blockage of a kidney or ureter.
• Leakage of urine or stool into the vagina.
• Weight loss
Diagnosis
1. Pap tests: standard method for cervical cancer screening.
2. Visual inspection with acetic acid: Application of 5% acetic acid is believed to cause a reversible
coagulation, or precipitation of the cellular proteins. The normal squamous epithelium appears
pink and the columnar epithelium red, due to the reflection of light from the underlying stroma,
which is rich in blood vessels. If the epithelium contains a lot of cellular proteins, acetic acid
coagulates these proteins, which may obliterate the colour of the stroma.
3. Cervicography: obtaining and evaluating a photographic image of the cervix.
4. HPV DNA testing
5. Colposcopy
6. Biopsy
7. Schiller’s test: Schiller's iodine solution is applied to the cervix under direct vision. Normal cervical
mucosa contains glycogen and stains brown, whereas abnormal areas, such as early cervical
cancer, do not take up the stain
8. Conization of cervix: excision of a cone-shaped sample of tissue from the mucous membrane of
the cervix. Conization may be used either for diagnostic purposes as part of a biopsy, or for
therapeutic purposes to remove pre-cancerous cells.
Other Investigations:
 Urine analysis.
 FBS, PPBS.
 Serum electrolytes.
 Blood ABO &Rh group.
 Descending pyelography.
 Cystoscopy, proctosigmoidoscopy
 ECG.
 Carcinoembryonic antigen (CEA)
 CBC, RFT, LFT
 Chest X ray
 CT, MRI, PET scan
Screening protocol
First Screening:
 Women should have a Pap test at least once every 3 years, beginning about 3 years after they
begin to have sexual intercourse, but no later than age 21.
 It is safe to wait 3 years, because cervical cancer usually develops slowly. Cervical cancer is
extremely rare in women under age 25.

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 Ages 19-29: Pap smears every three years unless ordered more frequently by physician.
 Age 30: women 30 and over should continue to be tested every 2-3 years unless ordered more
frequently by physician.
 Ages 65 to 70: Women who have had at least three normal Pap tests and no abnormal Pap
tests in the last 10 years may decide, after talking with their clinician, to stop having pap smears
performed.
Survival Rates
The overall 5- year survival is:
 Stage I > 90 %
 Stage II 60-80 %
 Stage III 50%
 Stage IV < 30%
Prevention
Primary prevention:
 It involves identifying or preventing the casual factors and eliminating or preventing those from
exerting their effects.
 Identifying high risk female
 Identifying high risk males
• Cancer consciousness
• Proper health education of the population
• Use of condom
• Removal of cervix during hysterectomy
• Prophylactic recombinant HPV vaccine
Secondary prevention
 It involves identifying and treating the disease earlier in the more treatable stage.
 This is done by screening procedures.
 The widespread introductions of cervical screening by the Papanicolaou test, or Pap
smear dramatically reduce the incidence and mortality in developed countries.
Down Staging Screening (WHO 1986)
 Down staging for cervical cancer is defined as the detection of the disease at an earlier stage
when it is still curable.
 Detection done by using simple speculum for visual inspection of cervix.
 A female primary health care worker is trained for 2-3 weeks to perform speculum examination.
 They are trained to distinguish normal cervix from abnormal one.
Management:
A. Surgical Management
1. Preinvasive Cervical Cancer Management
• Cryosurgery
• Laser surgery
• Conization

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2. Invasive Cervical Cancer Management
• Hysterectomy
• Trachelectomy (cervicectomy): surgical removal of the uterine cervix preserving the
uterine body; a fertility preserving surgical alternative to a radical hysterectomy and
applicable in selected younger women with early cervical cancer.
• Pelvic exenteration: radical surgical treatment that removes all organs from pelvic
cavity i.e. urinary bladder, urethra, rectum, anus. Requires permanent colostomy and
urinary diversion.
• Pelvic lymph node dissection
B. Radiation Therapy: External photo beam radiation and brachytherapy are the two main
methods. Wider applicability in all stages of carcinoma cervix, Survival rate 85%.
C. Chemotherapy: Drugs used are Cisplastin,5-Flurouracil, Ifosfamide, Paclitaxel or Vinorelbine.
Palliative Treatment
Bleeding: Palliative radiation therapy (180-200 Gy/day) or chemotherapy. Tight vaginal pack
soaked in Monsel’s solution (Ferric Subsulfate) against the cervix may control bleeding temporarily.
Pain: NSAIDs is first choice for pain. Palliative radiation with 2000 Gy over five treatment course
may be an alternative. Anxiolytics, antidepressants, opiods (oral morphine 3-10mg) with paracetamol
or aspirin can also be used. Regional and peduncal blocks are also helpful. A purulent vaginal
discharge is treated with antimicrobial vaginal creams and suppositories.
Preventive Measures: Although the cause of cancer of cervix is not known some of the preventive
measures that can be suggested against cancer of cervix are:
 Avoidance of early marriage and early and frequent sexual intercourse.
 Strict monogamous relationship.
 Restriction of the number of children.
 Improvement of genital hygiene.
 Prevention and better management of PID.
 Periodical clinical cytologic screening for those of age 25-45 years /menopausal women.
 Circumcision of male sexual partner has some beneficial effect in prevention of cervical cancer.
 Good obstetric care will reduce number of torn infected cervices and will minimize the incidence.
 Total hysterectomy for non-malignant conditions of uterus helps in prevention of cervical cancer.
Nursing management of the surgical client
Women undergoing cryosurgery and laser therapy
Nursing preparation:
1. Clarifying that this procedure is not actual surgery and an incision will not be made.
2. Explains that the procedure is performed with a vaginal speculum in place, as during routine PV
examination.
During procedure:
1. Provide psychological support by:
• Staying with client

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• Informing her of what is to be done
• Talking with her, listening to her
• Continuing to acknowledge her presence during the procedure
2. Assess the women/s discomfort during the procedure
3. A mild analgesic may be prescribed for the pain following the procedure.
4. Tell the client what to expect afterward – mild pain may continue for several days.
5. A clearly watery discharge occurs for about 14 days, which may be malodorous. If discharge
continues longer than 8 weeks, an infection is suspected.
After care:
1. Perineal hygiene minimized the risk of infection.
2. Showers of sponge baths should be taken during this time; avoid tub or sitz bath
3. Healing takes about 10 weeks.
A Patient undergoing a hysterectomy
Preoperative care: A women going to have hysterectomy, she needs to understand that her
reproductive capacity will be lost. If a woman is having her ovaries removed as well, a surgical
menopause should be discussed with her. It is particular important for the women to know that sexual
intercourse will be perfectly normal following hysterectomy. Answer honestly any questions the women
have and encourage her to express her feelings and concerns about sexuality. Physical preparation
also done.
Postoperative care:
1. Relieving anxiety: Anxiety stems from several factors like unfamiliar environment, effects of
surgery on body image, conflicts between medical treatment and religious beliefs. In such cases
nurse needs to determine – what the experiences means to the patient and how to assist her in
expressing her feelings to someone who can understand and help.
2. Improving body image: Patient needs assurance that she will have a vagina and that she can
experience sexual intercourse after a temporary postoperative abstinence while tissues heal.
• When hormonal balances are upset, the patient may experiences depression and heightened
emotional sensitivity to people and situations. The nurse needs to evaluate each patient
individually.
• The nurse who exhibits interest, concern and willingness to listen to patient's fears will assist
the patient's progress.
3. Relieving pain: Analgesics are administered as prescribed.
Discharge teaching:
 Perform prescribed abdominal strengthening exercises.
 Avoid heavy lifting for about 2 months, to prevent straining abdominal muscles that are healing.
 Avoid activities that increase pelvic congestion like dancing, prolonged standing.
 Early ambulation to prevent DVT.

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Chemotherapy:
Chemotherapy has defined role in two situations:
1. The management of advanced (stage IVB) or recurrent disease as primary therapy and
2. The management of advanced (stage IIB, III, or IV A) disease in combination with radiation.
Both single agent and combination chemotherapy has been used to treat patients with recurrent
cervical carcinoma in an attempt to improve survival. Cisplatin is considered the most active single
agent. Therapeutic synergism of cisplatin/doxorubicin and 5 – fluorouracil has been demonstrated.
The primary rationale for combining radiation with chemotherapy is – to increase local control,
decrease distant metastasis and improve survival.
Radiation therapy:
Radiation is usually the treatment of choice for squamous cell carcinoma of cervix, depending on the
stage of the cancer. A combination of external pelvic radiation and internal (intracavitary) irradiation
may be used. Only in the earliest micro-invasive carcinomas of the cervix the intracavitary irradiation
use alone. Cure rates exceeding 85% can be expected with cervical cancer limited to the cervix
alone.
1. External radiation therapy (tele therapy) given to patients.
2. Intra cavitary irradiation: Objective of internal treatment is to maintain the distribution of
internal radiation at a fixed dosage throughout the application. Such application usually last 24-
72 hrs, depending on dose calculations.
Intracavitary branchy therapy: Automated high dose rate intra canary branchy therapy systems
have been developed that allow outpatient radiation therapy. Treatment time is shorter, thereby
decreasing patient discomfort.
Nursing management during intracavitary radiation therapy
The radioactive elements used in intracavitary therapy are radium, cesium, iridium and cobalt, the
latter two being most frequently.
 The patient is carefully observed and care is provided however, the nursing staff must minimize
radiation exposure to themselves as much as possible by applying the principles of time,
distance and shielding as follows: minimize amount of time near a radioactive source, maximize
distance from radioactive source and use required shielding to minimize exposure.
 Nurses who are or may be pregnancy should not be involved in the immediate care of such
patient.
 Visits to the patient should have a specific purpose, nurse – patient contacts provide a good
opportunity for the patient to talk about her anxiety and fear.
 The nurse needs to explain that during the treatment, the patient must stay on absolute bed rest.
She may move from side to side with her back supported by a pillow, and the head of the bed
may be raised to 15o.
 She should be encouraged to practice deep breathing and coughing exercises and to flex and
extend the feet to stretch the calf muscles, promoting circulation and venous return.
 Back care, though appreciated by the patient, needs to be performed within the minimal time
allowed at the bedside.

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 Patient receives a low residue diet to prevent frequent bowel movements.
 Of the many nursing concerns, primary concerns involve not dislodging the applicator and
providing the patients with emotional support and physical comfort.
 A urinary catheter will be in place and must be inspected frequently to ensure that it drains
properly. The chief hazard of improper drainage is that the bladder many become distended
and its walls exposed to radiation.
 Although perineal care is not performed at this time, any profuse discharge should be reported
immediately to radiation oncologist.
 Additional nursing interventions include observing the patient for temperature elevation, nausea
and vomiting.
 Nurse should monitor from time to time to see that the applicator or the radioactive sources have
not been dislodged. Should this happen, the staff should avoid touching the radioactive object
and notify the radiation safety department at once.
 Patient teaching includes informing the patient that abdominal fullness, cramping, backache and
the urges to void are normal feelings during therapy. Severe pain should not be experienced.
Administering mild morphine may be helpful.
Applicator removal: The radiation oncologist calculates precisely the radiation dose. At the end of
the prescribed period, the nurse may be requested to assist the physician in removing the applicator
in the same manner as they were inserted.
Post treatment care:
 Progressive ambulation is recommended after any period of enforced bed rest.
 Diet may be offered as tolerated.
 Patient will be advised to take more liquids.
 Irradiation thins the vaginal epithelium and reduced vaginal lubrication. It may cause vaginal
stenosis. Such changes can make vaginal sexual activities uncomfortable or painful. Veginal
penetration during the course of irradiation and the subsequent months minimized the possibility
of vaginal stenosis. Vaginal penetration and dilation can be accomplished with the woman's own
fingers a vaginal dilator, or her sexual partner's fingers or penis.
 Encourage women who have treated for cervical cancer to have frequent health examinations to
diagnose a possible recurrence of the cancer early so it can be treated before it spreads too
far.
 Client should have a pelvic examination and pap smears scheduled at regular intervals as
advised by the physician.
Prognosis: In carcinoma cervix 5 years survival
Stage I – 70-80%
Stage II – 50-60%
Stage III – > 30%
Stage IV – 10-15%
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Unit : 14
UTERINE CANCER
Uterine cancer is also known as cancer of the womb, cancer of the uterus, endometrial cancer and
cancer of the lining of the womb. Account for almost 15% of all cancers in women, 4th most common
cancer following breast, lung and colorectal
Causes and Risk Factors:
 The exact cause of uterine cancer is not known.
 More common in women aged over 60
 Post menopause
 Endometrial hyperplasia
 Infertility
 Early menstruation (before age 12)
 Hypertension and diabetes
 Obesity
 A family history of ovarian, endometrial, breast or bowel cancer
 Previous pelvic radiation for cancer
 Ovarian tumours or polycystic ovary syndrome
 Taking oestrogen hormone replacement without progesterone
 Using the drug tamoxifen for the treatment of breast cancer.
Modes of spread
 Direct/ local spread
 Lymphatic- to pelvic, para aortic, inguinal lymph nodes
 Hematologic- to lungs, liver, bone, brain
 Peritoneal/ transtubal spread
Stages of uterine cancer
Stage Extent of disease 5-years survival
I Limited to body of uterus ~85%
Ia No myometrial invasion or <50% myometrial invasion
Ib >50% myometrial invasion
II Limited to body of uterus and cervix ~75%
III Extension to uterine serosa, peritoneal cavity and/or lymph
nodes
~45%

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IIIa Extension to uterine serosal, adnexe or peritoneal cavity (positive
peritoneal washings/ascites)
IIIb Extension to vagina or parametrium
IIIc1 Pelvic lymph node involvement
IIIc2 Para-aortic lymph node involvement
IV Extension to adjacent organs or beyond true pelvis ~25%
IVa Extension to adjacent organs e.g. bladder, bowel
IVb Distant metastases or positive inguinal lymph nodes
Table: Stages of Uterine Cancer
Symptoms
 The most common symptom unusual vaginal bleeding, particularly after menopause.
 In Some women watery discharge, this may have an offensive smell.
 Discomfort or pain in the abdomen
 Difficult or painful urination and change in bowel habits
 Dysparenea
 Weight loss
Diagnosis
 Physical examination: to check the abdomen for swelling
 Transvaginal ultrasound: to look at the size of the ovaries, uterus and thickness of the
endometrium
 Biopsy: done in several ways including having a dilatation and curettage (D&C)
 X-rays and other scans – such as computed tomography (CT) scan or magnetic resonance
imaging (MRI)
 Blood tests: to check general health
Treatment
Most cancers of the uterus are diagnosed early and treated before the cancer has spread.
Treatment options include:
Surgery: this is the first and most important treatment (hysterectomy), the fallopian tubes or the
ovaries (or both). If cancer has invaded the muscle walls of the uterus, the lymph nodes inside the
pelvis and abdomen will also be removed. If cancer has spread to the cervix, a small part of the
upper vagina and the cervix must be taken out as well.
Radiotherapy: external or internal. Radiotherapy may be given alone, or before or after surgery.
Hormone therapy: since cancer of the uterus is sensitive to hormones, oestrogen-blocking drugs may
be used as a treatment if the cancer comes back or has spread- different types of progesterone
treatment, including medroxyprogesterone acetate (Provera) and megestrol (Megace)
Chemotherapy: Anti-cancer drugs
Treatment Protocols

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General treatment recommendations for endometrial cancer
 Endometrial cancer is treated primarily with surgery, including hysterectomy, bilateral salpingo-
oophorectomy, abdominopelvic washings, lymph node evaluation; advanced disease patients
may be treated with maximal surgical cytoreduction
 There is no general agreement as to what constitutes the best chemotherapy
 Salvage agents such as paclitaxel may be an option for second-line therapy in patients who
have disease recurrence even after first-line chemotherapy
Treatment recommendations for limited disease
 Generally stage I endometrial cancer limited to the uterus, the recommended treatment is
surgery
 Radiation therapy has proven to be effective and tolerated for patients that are not candidates
for surgery whose disease is limited to the uterus
 Patients with suspected or gross cervical involvement who are candidates for surgery should be
recommended radical hysterectomy with bilateral salpingo-oophorectomy; cytology and
dissection of pelvic and para-aortic lymph nodes and inoperable patients should be treated with
radiation therapy
 Patients with suspected extra uterine disease should be evaluated through imaging studies (MRI
or CT) or lab tests (CA 125 levels); if negative results return, treat patients as for disease limited
to the uterus
 Patients with extrauterine pelvic disease should be treated with radiation therapy and
brachytherapy with or without surgery and chemotherapy
Risk classification for patients with endometrial cancer
 Low risk: endometrioid cancers that are confined to the endometrium
 Intermediate risk: disease confined to the uterus but invades the myometrium, includes some
patients with stage IA disease, stage IB disease, and a subset of patients with stage II disease
 High risk: includes gross involvement of the cervix; stage III or IV disease, regardless of grade
Postoperative adjuvant chemotherapy based on risk classification
 Low risk to low-intermediate risk: adjuvant therapy with chemotherapy or progestational agents
is not recommended
 High-intermediate risk: postoperative adjuvant radiation therapy
 High-risk: Adjuvant therapy is recommended for all patients including radiation therapy and
chemotherapy
Chemotherapy for metastatic, recurrent, or high-risk disease
Single-agent therapy
 Cisplatin 50-100 mg/m2 IV over 30min with vigorous hydration; repeat every 3wk or
 Carboplatin AUC 5-7 IV over 30min; repeat every 3wk or
 Paclitaxel 175 mg/m2 IV over 3h; repeat every 3wk or
 Doxorubicin 60-75 mg/m2 IV bolus; repeat every 3wk or
 Liposomal doxorubicin 50 mg/m2 IV; repeat every 3-4wk

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Combination therapy
 Doxorubicin 60 mg/m2 IV plus cisplatin 50 mg/m2 IV on day 1; repeat every 21d or
 Doxorubicin 45 mg/m2 IV plus cisplatin 50 mg/m2 IV on day 1 plus paclitaxel 160
mg/m2 over 3h on day 2; repeat every 21d or
 Cisplatin 50 mg/m2 IV plus doxorubicin 50 mg/m2 IV on day 1; repeat every 21 cycles or
 Doxorubicin 45 mg/m2 IV on day 2 plus cisplatin 50 mg/m2 IV on day 1 plus paclitaxel 160
mg/m2 IV over 3h on day 2 plus filgrastim 5 μg/kg SC on days 3-12; regimen repeated every
21d or
 Carboplatin AUC 5-7 IV plus paclitaxel 175 mg/m2 IV over 3h on day 1
Palliative treatment
 Chemotherapy, radiotherapy and surgery
 Medication to relieve pain, nausea and vomiting.
Nursing Management
Nursing Diagnosis:
1. Anxiety related to the diagnosis of cancer, fear of pain,perceived loss of feminity, or child
bearing potential.
2. Disturbed body image related to altered fertility, fears about sexuality, and relationship.
3. Pain related to surgery and other adjuvant therapy.
4. Knowledge deficient related to perioperative aspects of hysterectomy and self care.
Nursing Assessment for Chemotherapy and Radiotherapy
 Weight loss
 Frequent infection
 Skin problems
 Pain
 Hair Loss
 Fatigue
 Disturbance in body image/ depression
Nursing Intervention:
Maintain Tissue Integrity
 Handle skin gently
 DO NOT rub affected area
 Lotion may be applied
 Wash skin only with moisturizing soap and water
Management of Stomatitis
 Use soft-bristled toothbrush
 Oral rinses with saline gargles/ tap water
 Avoid ALCOHOL-based rinses

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Management of Alopecia:
 Alopecia begins within 2 weeks of therapy.
 Re-growth within 8 weeks of termination.
 Encourage to acquire wig before hair loss occurs.
 Encourage use of attractive scarves and hats.
 Provide information that hair loss is temporary but anticipate change in texture and color.
Promote Nutrition:
 Consider patient’s preferences.
 Provide small frequent meals.
 Avoid giving fluids while eating.
 Oral hygiene prior to mealtime.
Relieve Pain:
 Mild pain- NSAIDS
 Moderate pain- Weak opioids
 Severe pain- Morphine
 Administer analgesics round the clock with additional dose for breakthrough pain
Decrease Fatigue:
 Plan daily activities to allow alternating rest periods
 Light exercise is encouraged
 Small frequent meals should be given in between activity.
Improve Body Image
 Therapeutic communication is essential
 Encourage independence in self-care and decision making
 Offer cosmetic material like make-up and wigs
Assist in the Grieving Process
 Grieving can be due to loss of health, income, sexuality, and body image
 Answer and clarify information about cancer and treatment options
 Identify resource people
 Refer to support groups
Manage Complication:
Infection
 Fever is the most important sign
 Administer prescribed antibiotics for 2weeks
 Maintain aseptic technique
 Avoid exposure to crowds

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 Hand washing
 Avoid frequent invasive procedures
Septic Shock
 Monitor VS, BP, temp
 Administer IV antibiotics
 Administer supplemental oxygen
 Care as you care a patient in shock
Bleeding
 Thrombocytopenia (<100,000) is the most common cause, less than 20, 000 causes spontaneous
bleeding
 Use soft toothbrush
 Use electric razor
 Avoid frequent IM, IV, rectal and catheterization
 Soft foods and stool softeners.
Other nursing management includes:
 Pre-operative and post operative care:
• Maintaining fluid balance
• Preventing complications like bleeding, UTI, infections, pneumonia, DVT and so on.
Complication
 Hemorrhage
 Pyometra: specially with endocervical variety.
 Vesicovaginal fistula.
 Rectovaginal fistula
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Unit : 15
ENDOMETRIAL CANCER
Endometrial cancer, also known as womb cancer or uterine cancer is a type of cancer that begins in
the uterus (womb), specifically in the layer of cells that form the lining of the uterus, called the
endometrium. Endometrial cancer can also be called cancer of the womb or cancer of the uterus.
Nearly all uterine cancers are endometrial cancer. However, there is another much rarer type called
uterine sarcoma, in which the malignancy starts in the muscles surrounding the womb. Endometrial
cancer and uterine sarcoma are usually treated differently.
According to the National Cancer Institute, in the United States there are approximately 49,560 new
cases of endometrial cancer and 8,190 deaths caused by the disease each year.
Most newly-diagnosed patients are over 55 years of age.
Uterus: The uterus is a small, hollow, pear-shaped organ located in a woman's pelvis. It is part of a
woman's reproductive system. The fetus develops in the uterus.
The uterus is divided into three parts:
 The Fundus: the top part, shaped like a dome. The fallopian tubes extend from the top of the
uterus to the ovaries.
 The Corpus (body): the middle part. The fetus grows in this part.
 The Cervix: the bottom part. It is, in fact a canal that has an opening into the uterus and the
vagina.
The uterine wall has two layers of tissue:
 The Endometrium: The inner lining of the uterus. The lining of the uterus swells each month in
preparation for pregnancy in women of reproductive age. If pregnancy does not occur, the
swollen lining flows out of the body (menstrual period).
 The Myometrium: The outer layer, which consists of muscle tissue.
Figure: Parts of Uterus

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The majority of endometrial cancers start off in cells that make and release mucus and other liquids -
adenocarcinomas.
Signs and symptoms of endometrial cancer
A symptom is something the patient feels and describes, such as pain, while a sign can be detected by
others as well as, for example a skin rash.
The following are examples of signs and symptoms of endometrial cancer:
 Vaginal bleeding between menstrual periods
 Heavier-than-normal periods
 Vaginal bleeding in post-menopausal women
 Pain in the pelvic area (less common)
 Pain during sexual intercourse (less common)
 Abnormal vaginal discharge, usually watery or tinged with blood.
The following symptoms are possible in the more advanced stages of the disease:
 Pain in the legs and back
 Pain in the pelvic area
 Fatigue (tiredness)
 Nausea.
Some women also experience pain when urinating, while others have difficulties in emptying their
bladder. These signs and symptoms may be caused by endometrial cancer, or some other health
problem. Post-menopausal vaginal bleeding does not necessarily mean it is cancer. Irregular bleeding
could be caused by fibroids, endometriosis, endometrial hyperplasia or polyps in the womb lining.
Risk factors linked to endometrial cancer
A risk factor is something that increases the likelihood that something will happen, such as a disease.
For example, smoking raises the risk of developing lung cancer. Therefore smoking is a risk factor for
lung cancer.
The following are risk factors for endometrial cancer:
 Endometrial hyperplasia: abnormal overgrowth of the endometrium. The lining of the uterus
becomes abnormally thicker.
 Obesity: women who gain weight during adulthood have a higher risk of endometrial cancer
compared to those who maintain a stable body weight, researchers at the National Home Office
of the American Cancer Society found.
 Never having been pregnant.
 When a woman had her last baby may impact on endometrial cancer risk: researchers at the
University of Southern California found that women who last gave birth at age 40+ were 44%
less likely to develop the disease compared to women who last gave birth under the age of 25.
 Early menstruation: a woman who had her first menstrual period before twelve years of age.
 Late menopause: women who experienced the menopause after 55 years of age.

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 Hormone replacement therapy (HRT): estrogen only HRT should only be administered to women
who have undergone a hysterectomy (had their uterus surgically removed). Combination HRT,
where both estrogen and progesterone are used, is not associated with a higher risk of
endometrial cancer.
 Tamoxifen: a drug given to women to prevent or treat breast cancer. Women who took
Tamoxifen are at higher risk of cancer of the uterus. However, doctors say the benefit provided
by Tamoxifen in protecting from breast cancer outweighs the endometrial cancer risk.
 Age: women over the age of 55 have a much higher risk of developing the disease than
younger females.
 Radiation therapy: women who have received radiation therapy to the pelvis.
 A family history of uterine cancer: a woman whose mother, sister or daughter had/had uterine
cancer is at a higher risk herself of developing the disease. Women who have Lynch syndrome,
an inherited form of colorectal cancer are also at a higher risk.
 Low exposure to sunlight: a study carried out at the University of California, San Diego, found
a clear association between deficiency in sunlight exposure and endometrial cancer risk.
Specifically, low exposure to ultraviolet B.
 Diabetes: diabetes causes an increase in insulin body levels, which in turn raises estrogen levels.
Long-term high estrogen levels raise the probability of developing uterine cancer.
 Polycystic ovarian syndrome (PCOS): women with PCOS have higher estrogen levels, which
raises the risk of endometrial cancer.
 Other cancers: women who have or have had ovarian or breast cancer are at higher risk of
endometrial cancer.
Diagnosing endometrial cancer
The doctor will ask questions about the symptoms, the patient's medical history, and whether there is a
history of endometrial cancer in the family.
 Pelvic examination: after carefully inspecting the vulva (outer portion of the woman's genitals),
the doctor will insert two fingers of one hand into the vagina while pressing onto the abdomen
with the other hand to feel the uterus and ovaries. A speculum - a device that opens the vagina -
is inserted so that the doctor may look carefully at the vagina and cervix. The doctor will be
looking out for any lumps or changes in shape or size.
 Transvaginal ultrasound (TVU) scan: can determine the texture and thickness of the
endometrium. This allows the doctor to rule out other conditions. A transducer, a wand-like
device, is inserted into the vagina. Sound waves create a video image of the uterus on a
monitor.
 Blood test: some tumor markers can be detected in a blood test, which can help doctors in their
diagnosis. However, the test is not very reliable, says the National Health Service. It is possible
to have uterine cancer and not have the tumor markers show up in the blood test.
 Biopsy: a biopsy is the removal of a sample of tissue or cells so that a pathologist can examine
them, usually under a microscope for the presence of cancerous cells. A biopsy is usually
recommended if the TVU detected changes in the thickness of the endometrium. There are
several ways a biopsy can be carried out:

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• Hysteroscopy: the doctor uses a hysteroscope, a thin kind of telescope which is inserted
through the vagina and into the uterus. With hysteroscopy the doctor can look at the lining of
the uterus and take a tissue sample.
• Aspiration biopsy: a small flexible tube (cannula) is inserted into the uterus and attached via
tubing to a pump. The pump creates a vacuum, thus sucking up samples of cells from the lining
of the uterus.
Grading the tumor
If cancer is detected, the pathologist will need to learn the "grade" of the tumor. This can determine
how different the tumor tissue is from normal tissue in the uterus and can help suggest how fast it is
likely to grow. Higher grade tumors grow more rapidly than lower grade ones. A higher grade tumor
is more likely to metastasize - to spread to other parts of the body.
Staging endometrial cancer
The "stage" of the cancer refers to extend of the disease. Determining the stage, known as "staging",
helps the doctor chose the best treatment. Staging is based on whether the cancer is localized or has
spread to nearby tissue, or beyond. When endometrial cancer spreads from its original site to others
parts of the body and a new tumor is formed, that new tumor has the same type of abnormal cells as
the original endometrial cancer cells. Endometrial cancer that has spread to a lung is not lung cancer,
it is metastasized endometrial cancer.
Diagnostics:
 Pap test: to see whether the cancer has spread to the cervix.
 Blood tests: to measure levels of CA-125, which rise in the presence of cancer. Blood tests can
also show how well the kidneys and liver are functioning.
 Chest x-ray: to determine whether the cancer has spread to the lung(s).
 CT (computed tomography) scan: a medical imaging method that employs tomography, the
process of generating a two-dimensional image of a slice or section through a 3-dimensional
object (a tomogram), in this case of the pelvis, abdomen or chest. The patient may have contrast
material injected, to see whether the lymph nodes are affected. A CT scan can tell the doctor
whether there is cancer in the uterus, lungs, lymph nodes and other parts of the body.
 MRI (magnetic resonance imaging) scan: a large machine that uses a magnetic field and radio
waves to create detailed images of the body, in this case the uterus and lymph nodes.
Sometimes contrast material may be injected into the patient. MRI can reveal cancer in the
uterus, lymph nodes and elsewhere.
According to the National Cancer Institute, in the majority of cases the uterus is removed so that
staging can be done. The pathologist checks to see how deeply the tumor has grown and whether
other tissue samples from the uterus have cancer cells.
Endometrial cancer has five stages
 Stage 0 - referred to by doctors as carcinoma in situ, i.e. the cancerous cells remain in the place
where they first formed, on the surface of the inner lining of the uterus.
 Stage I - the cancer has spread through the inner lining of the uterus to the endometrium. There is
a possibility the myometrium may have been invaded too.

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 Stage II - the tumor has spread to the cervix.
 Stage III - the tumor has spread through the uterus to nearby tissue, including the vagina or a
lymph node.
 Stage IV - the cancer has spread to the bladder or intestine, and possibly to other parts of the
body, such as bones, liver, or lungs.
Treatment options for endometrial cancer
Treatment options depend on several factors, including the patient's age and general health, the
grade of the tumor, whether it has invaded the muscle layer of the uterus, spread to tissues outside
the uterus, or reached other parts of the body.
For patients with uterine cancer the current treatment options include surgery, radiation therapy,
chemotherapy, and hormone therapy.
A multidisciplinary team: Usually there will be a team of specialist health care professionals helping
to plan the patient's treatment. The doctor may refer the patient to a specialist, who may be a
gynecologist, gynecologic oncologist, medical oncologist and radiation oncologist. The team may also
include a registered dietitian and oncology nurse. The patient will be told what treatment choices and
the expected results for each one, plus their possible side effects. Although the aim of cancer therapy
is to destroy cancer cells, often healthy cells and tissues are also damaged. It is important to ask your
health care team about any possible side effects and how treatment may impact on your normal
everyday activities. It is important that the team and patient work together to make sure the
treatment plan takes into account the patient's needs.
Surgery:
Most doctors will recommend that women with endometrial cancer have their uterus surgically
removed (hysterectomy). The fallopian tubes and ovaries will usually be removed as well (salpingo-
oophorectomy). During the surgical procedure, the surgeon will look carefully around the uterus for
signs of cancer. Lymph nodes may also be removed and sent to the laboratory for testing. Removing
lymph nodes helps in the staging of the cancer. Most women spend a couple of days in hospital after
a hysterectomy before going home, but some may go home on the day of the operation. It takes from
4 to 8 weeks to be able to return to normal activities.
The doctor and patient should ideally discuss a plan for pain relief before the operation. Medicine
can help control pain and discomfort, which is usually present for a few days. It is not uncommon to
feel weak and tired for a few days, and also to experience nausea and vomiting. Temporary loss of
bladder control and constipation is also possible. If the patient is premenopausal, she will stop having
periods after the operation and will not be able to get pregnant. There may be symptoms of
menopause, such as hot flashes, night sweats and vaginal dryness. Lymphedema, swelling in one of
both legs, is possible after lymph nodes have been removed.
Radiation therapy
Radiation therapy works by damaging the cancer cell's DNA, thus destroying their ability to multiply.
Radiation therapy also kills cancer cells. This type of therapy uses powerful energy beams, such as x-
rays.
Two types of radiation therapy are used in the treatment of endometrial cancer:
 External radiation therapy: The patient lies on a table and a large machine directs radiation at
the pelvis and other areas with cancer. Treatment may occur for several weeks, with up to 5
sessions each week. A session lasts a few minutes.

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 Brachytherapy: Internal radiation therapy. Small devices filled with radiation, such as wires, a
cylinder or small seeds are placed inside the vagina for a few minutes, after which the patient
goes home. The therapy is repeated two or more times over a period of several weeks. The
radiation is gone from the patient's body as soon as the devices are removed.
Neo-adjuvant radiotherapy (before surgery): The doctor may recommend radiation to shrink the
tumor, making it easier to remove.
Adjuvant radiotherapy (after surgery): The aim is to eliminate any cancer cells that may have
remained. For some patients who may not be healthy enough for surgery, radiation therapy only is
an option. In more advanced endometrial cancer, radiation therapy may be used to alleviate
symptoms of pain.
Side effects: The skin in the treated area can become sore and red, there may be hair loss. The
bowel may be affected, causing sickness and diarrhea. During the radiation therapy course the
patient may feel progressively tired. When the treatment is completed these side-effects will usually
go away. According to the National Health Service, approximately 5% of patients carry on with
long-term treatment effects, including rectal bleeding and diarrhea.
Chemotherapy:
Chemotherapy involves the use of medication to destroy cancer cells. In overall cancer treatment,
chemotherapy can be used for the following goals:
 Total remission - to cure the patient. In some cases chemotherapy can achieve this.
 Combination therapy - alongside radiation therapy or surgery. For example, if the tumor
cannot be completely removed during surgery. In more advanced cancer chemotherapy may be
used in combination with radiation therapy.
 Prevent/delay recurrence - when used to prevent cancer recurrences it is used after surgery to
remove a tumor.
 Slow down cancer progression - for patients with advanced cancer.
 Symptom relief - for more advanced cancers.
Chemotherapy used for endometrial cancer is usually administered intravenously and in cycles. Each
treatment cycle is followed by a rest period.
Side effects
Chemotherapy, while killing fast-growing cancer cells, also harms some rapidly dividing healthy cells.
The following side effects are possible:
 Lower levels of healthy blood cells: Resulting in easier bruising and bleeding, as well as
fatigue. Patients who have these symptoms must tell the medical team immediately. The dosage
may have to be altered, or the treatment stopped for a while. There are drugs that help the
body make new blood cells.
 Hair loss: Cells in the hair roots are affected, resulting in possible hair loss. After the treatment
is over the hair grows back, but its texture may be permanently different.
 Gastrointestinal problems: Including nausea, vomiting, diarrhea and poor appetite. Some
patients also report lip and mouth sores. These problems typically go away after treatment is
completed.

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Less commonly, some patients may experience swollen legs and feet, joint pain, balance problems,
hearing difficulties, numbness and tingling in the hands and feet, and skin rash.
Hormone therapy
Hormone therapy is the use of hormones in medical treatment. Hormone therapy may be
recommended for patients with advanced endometrial cancer that has metastasized. Some women in
the early stages of cancer who wish to get pregnant may opt for hormone therapy rather than
surgery.
There are two main types of hormone therapy for people with endometrial cancer:
 Progesterone tablets: progestin can help shrink the tumor and control symtpoms.
 Hormone therapy to reduce estrogen levels: endometrial cancer cells need estrogen to thrive.
Hormone therapy medications to help reduce estrogen levels in the body or make it harder for
the estrogen to be used make it more difficult for the cancer cells to survive.
Side effects may include weight gain, mild muscle cramps, and mild nausea.
Complications of endometrial cancer: If the endometrial cancer is not detected early or is left
untreated it can metastasize - spread to other parts of the body, most commonly to the lungs.
Prognosis for endometrial cancer: The 5-year survival rate, when all endometrial cancer cases are
looked at together, is approximately 69%, according to the American Cancer Society. For patients
whose endometrial cancer is diagnosed at an early stage, the 5-year survival rate is more than 91%.
The earlier the cancer is detected and treated, the better the survival rate.
Prevention of endometrial cancer
Diet, exercise and coffee: a study carried out by the American Cancer Society found that
endometrial cancer risk can be reduced with physical exercise, following a healthy and balanced
diet, and drinking coffee. The researchers said that doing 30 minutes of exercise each day and
maintaining a healthy body weight can reduce the risk of developing endometrial cancer by almost
60%.
Contraception: long-term use of the combined contraceptive pill has been associated with a lower
risk of developing endometrial cancer, as have contraceptive implants and the IUD (intrauterine
device).


Vulval Cancer
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Unit : 16
VULVAL CANCER
Vulvar cancer, or vulval cancer is a cancer in the vulva and accounts for approximately 1 in every 25
female cancers - most health authorities worldwide say it is a rare type of cancer. The vulva refers to
the external genital organs of a female, and includes the labia majora, mons pubis, labia minora,
clitoris, bulb of the vestibule, vestibule of the vagina, greater and lesser vestibular glands, and
vaginal orifice.
Vulval cancer generally affects older women. According to the NIH (National Institutes of Health),
USA, approximately 3,740 new cases of vulvar cancer were diagnosed in 2006, in the same year
about 880 women died of the disease. The NHS (National Health Service), UK informs that about
1,000 patients are diagnosed with this type of cancer annually.
Typical symptoms include itching, bleeding and pain. If the cancer originated in the vulva it is called
primary vulvar cancer. If the cancer originated in another part of the body and then spread to the
vulva it is called secondary vulvar cancer.
Types of vulval cancer
 Squamous cell carcinoma: In medicine, the word squamous refers to flat cells that look like fish
scales - in this case it refers to the outer layers of skin (which are flat). About 90% of all vulvar
cancers are of this type. The cancer takes several years to develop into noticeable symptoms.
 Vulvar melanoma: This type makes up about 5% of all vulval cancers. The vulval melanoma
behaves like melanoma in other locations and may affect younger women. With this type of
cancer there is a high risk of metastasis (spreading into other parts of the body)
 Adenocarcinoma: This type of cancer originates in glandular tissues, which in this case are the
cells that line the glands in the vulva. A very small proportion of vulval cancers are of this type.
 Sarcoma: This type of cancer originates in the connective tissue. Most cancers of this type are
malignant. This is an extremely rare type of vulval cancer.
 Verrucous carcinoma: A subtype of the squamous cell cancer and tends to appear as a slowly
growing wart.
If the cancer is localized, has not metastasized (spread to other parts of the body) the prognosis is
generally good if the patient receives prompt and proper treatment.
Signs and symptoms of vulvar cancer: A symptom is something the patient feels and reports, while
a sign is something other people, such as the doctor detect. For example, pain may be a symptom
while a rash may be a sign. Usually there is some kind of lump or ulceration (open skin sore); the area
will typically itch, irritate and sometimes bleed. Sometimes, because of modesty or embarrassment the
patient may not seek medical help as soon as symptoms appear.
Most typical symptoms include:
 Dyspareunia - painful sexual intercourse
 Bleeding

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 Burning
 Dark discoloration in cases of melanoma
 Dysuria - painful urination
 Persistent itching
 The area may be sensitive and raw
 Wart-like growths
Causes vulvar cancer: Cancer is a class of diseases characterized by out-of-control cell growth.
Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue
called tumors (except in the case of leukemia where cancer prohibits normal blood function by
abnormal cell division in the blood stream). Tumors can grow and interfere with and alter body
function. Tumors that stay in one spot and demonstrate limited growth are generally considered to be
benign, dangerous cancer that spreads is malignant.
More dangerous, or malignant, tumors form when two things occur: a cancerous cell manages to move
throughout the body using the blood or lymph systems, destroying healthy tissue in a process called
invasion; and that cell manages to divide and grow, making new blood vessels to feed itself in a
process called angiogenesis.
If the patient with malignant cancer receives no treatment, it can grow and spread to other parts of
the body (metastasis). As soon as the cancer gets into the lymphatic system it can more effectively
reach other parts of the body, including vital organs.
Experts do not know exactly why the runaway growth of cancer cells starts. We do know, however,
that certain risk factors increase the probability of developing the disease. These include:
 Human papilloma virus (HPV): Women infected with HPV have a higher risk of developing
vulval cancer.
 Vulvar intraepithelial neoplasia (VIN): This is a general term for a precancerous state in which
certain cells within the vulvar epithelium have a range of low-grade carcinoma. Women with VIN
have a significantly higher risk of developing vulval cancer.
 Sexually transmitted infections: Women with antibodies to the herpes simplex virus type 2
have been linked to a higher increase of vulval cancer.
 Systemic lupus erythematosus: One study showed a three-fold increase in vulval cancer risk.
 Smoking: Studies have revealed an association between regular smoking and vulval cancer,
ranging from a three-fold to six-fold increase. If the regular smoker also has HPV infection, the
risk is much higher still.
 Kidney transplant: Women who have had a kidney transplant have a much higher risk of
developing vulval cancer. Doctors believe it is due to the immunosuppressant drugs (to stop
organ rejection by the body) the patient has to take for life.
 Human immunodeficiency virus (HIV): People with HIV/AIDS are more susceptible to HPV
infection.
 Psoriasis: Women with psoriasis have a significantly higher risk of developing vulval cancer.
Diagnosis of Vulvar cancer: The doctor will carry out a gynecologic evaluation, which includes
checking the vulva - this may reveal the presence of ulceration, lump, or a mass. If a lesion looks
suspicious a biopsy is required. The examination of the vulva should include the perineal area,
including areas around the clitoris and urethra, as well as the Bartholin's glands (palpation). If
necessary, anesthesia can be used for a more thorough examination.

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Depending on the results of the biopsy, the doctor may order further tests:
 Cystoscopy: The bladder is examined to determine whether the cancer has spread to that area.
 Proctoscopy: The rectum is examined to check whether the cancer has spread to the rectal wall.
 Imaging scans: Imaging scans can help the doctor determine whether the cancer has spread,
and if so, where to. An MRI or CT scan may be used. X-rays may be used to determine whether
the cancer has reached the lungs.
Staging of vulvar cancer: If a biopsy confirms the presence of vulval cancer, the doctor will stage it
with the help of imaging (CT or MRI). Staging guidelines used in the UK:
 Stage 0: Known as carcinoma in situ; the cancer only exists on the surface of the skin.
 Stage 1: The cancer is limited to the vulva or perineum and is up to 2cm in size.
 Stage 2: Same as 1, but the tumor is at least 2cm in size.
 Stage 3: The cancer has reached nearby tissue, such as the anus or vagina. It may also have
reached the lymph nodes.
 Stage 4: The cancer has reached lymph nodes on both sides (of the groin). It may also have
reached the urethra (where urine comes out of), the bowel or the bladder.
Treatment options for vulvar cancer: Surgery is the mainstay of therapy for vulval cancer and
includes the use of a radical vulvectomy, where the entire vulva is surgically removed, and possibly the
removal of lymph nodes as well. If the cancer has spread to adjacent organs, such as the urethra,
vagina or rectum, the surgery will be more extensive. In cases of early vulval cancer the procedure is
less radical and disfiguring.
 Laser surgery: an option during the early stages of the cancer.
 Excision: the surgeon attempts to remove all of the cancer and some healthy tissue around it.
 Skinning vulvectomy: the top layer of skin where the cancer is located is surgically removed.
Skin from another part of the body can be used to replace what was lost (skin graft)
 Radical vulvectomy: the whole vulva is surgically removed, including the clitoris, vaginal lips
and the opening to the vagina. Usually includes nearby lymph nodes as well.
 Radiation therapy: if lesions (tumors) are very deep, local radiotherapy may be used
before surgery to shrink them - this makes it easier for the surgeon to get them out
cleanly. Radiotherapy may also be used to treat lymph nodes.
Chemotherapy: often used with radiotherapy as part of palliative care.
Reconstructive surgery: sometimes the area can be reconstructed; this depends on how much tissue
was removed. Plastic surgery reconstruction involving skin-flaps can be performed. Skin can sometimes
be grafted from another part of the body.
Follow-up: in approximately 10% of cases, the cancer eventually comes back. The patient should
make sure she attends her follow-up visits according to her doctor’s instructions.
Prevention of Vulvar cancer be prevented
 Practice safe sex
 Go to your scheduled cervical smear tests
 Have the HPV vaccination
 Do not smoke
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Unit : 17
CARCINOMA OF PENIS
Introduction: Penile cancer is a malignant growth found on the skin or in the tissues of the penis. It
appears on the skin of penis as a painless, wart like growth or ulcer. It can involve the glans, the
coronal sulcus under the prepuce, the corporal bodies, the urethra, and regional or distant lymph
nodes.
Figure: Penile cancer
Incidence: Cancer of the penis is an uncommon malignancy in developed countries, but the incidence
is as high as 17% of all male cancers in some undeveloped countries. Higher incidence rates are seen
in Africa and Asia (10% to 20%).
Epidemiology: Penile carcinoma is typically a disease of middle-aged to older men, most commonly
affecting those between 50 and 70 years of age. Younger individuals are also affected;
approximately 22% of patients are less than 40 years of age. Penile cancer is rarely seen in Jewish
individuals, who are circumcised at birth.
Etiological risk factors:
1. HPV infection 2. Smoking
3. Smegma 4. Phimosis
5. Previous treatment of psoriasis 6. Age (55yrs and older)
7. AIDS

Carcinoma of Penis
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Pathological types:
 Cancer penis can develop in each of various types of the cells of penis.
 Its types are:
a. Cancer in situ:
- Bowen disease
- Bowenoid papulosis
b. Squamous cell carcinoma
Bowen disease:
 Bowen’s disease usually presents within the 5th to 6th decade as a solitary, thickened, gray-to-
white plaque with crusting and oozing.
 Microscopically, there is complete loss of normal epithelium but no invasion of underlying
epithelium.
Bowenoid papulosis:
 It presents as multiple, pigmented papular lesions on external genitalia.
 It is histologically indistinguishable from Bowen disease.
 Patients are generally younger than those with Bowen disease.
Squamous cell carcinoma:
 About 95% of penile cancer develops from the flat skin cells called squamous cells.
 It typically presents as epithelial thickening on the glans or inner surface of prepuce, progressing
to ulceroinfiltrative or exophytic growth eroding the penile tip, shaft or both.
Jackson Classification for Carcinoma of the Penis:
 Stage Description
I. Confined to glans of prepuce
II. Invasion into shaft or corpora
III. Operable inguinal lymph node metastasis
IV. Tumor invades adjacent structures; inoperable inguinal lymph node metastasis
Signs and symptoms:
 Redness
 Irritation
 Sore or lump on the penis
 Warts like lesions
 Metastatic lesions are often multiple, palpable, painless nodules that may mimic syphilitic
chancres.
Diagnosis:
 History
 Cell biopsy

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Management:
 Surgical management:
Surgery is the most common treatment of all forms of penile cancer. It includes
• Simple excision
• Electrodesiccation and curettage
• Cryosurgery
• Moh’s surgery
• Laser surgery
 Wide local excision
 Circumcision
 Surgical removal of part of the penis or the entire penis
Chemotherapy:
 The experience with cytotoxic drugs in penile and urethral carcinomas is limited to small series,
with inconclusive results.
 Some response has been observed with cisplatin, bleomycin, and methotrexate, as well as with
combinations of these agents.
 Topical chemotherapy with 5-fluorouracil cream.
Radiation therapy: It is used to treat small sq. cell carcinomas of the penis and for palliation in
advanced tumors or cases of lymph nodes metastasis.
HPV Vaccine: Infection with HPV is associated with some penile cancers. A quadri-valent vaccine
(Gardasil) to prevent infection by the four most common variants of HPV has been developed, for
females between the ages of 9 and 26, males between the ages of 16 and 26.
Nursing Care
Nursing diagnoses:
 Impaired skin integrity related to lesion formation secondary to carcinoma.
 Anxiety related to sexual dysfunction secondary to chronic disease process.
 Self image disturbance related to anatomical disfigurement, functions and roles.
 Risk for infection related to altered immunological response.
Nursing diagnoses for patients undergoing chemotherapy and radiation:
 Impaired oral mucous membranes (stomatitis), tissue integrity (alopecia) related to treatment
procedure.
 Imbalanced nutrition, less than body requirement related to anorexia, nausea and vomiting.
 Fatigue related to ongoing chemotherapy.
 Anticipatory grieving related to loss, altered role functioning.
 Risk for further complications (bleeding problems, recurrence of disease) related immunological
deficit secondary to treatment procedure.
Interventions:
 Care of affected area.
 Reducing anxiety
 Improve body image and self esteem
 Prevention of infection
 Maintenance of intact oral mucous membranes and prevention from further deterioration.
 Maintenance of nutritional status.
 Increase activity tolerance and reduce fatigue.
 Appropriate progression through grieving process.
 Preventing the complications.


Prostate Cancer
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Unit : 18
PROSTATE CANCER
Introduction: Carcinoma of prostate is common after the age of 65 years. It is the second most
common cause of cancer death in American men, exceeded only by lung cancer , and is responsible
for 10% cancer related deaths in men.
Epidemiology:
 Common in the USA and north western Europe but is rare in Asia, Africa, Central America and
South America.
 The highest incidence is in African American men.
 Prostate Cncer-180,400 cases/yr, 36% of new cases, 40,400 deaths
 Hormone dependence
Causes
 Exact cause is unknown
 Mutation of genes
• Especially BRCA2 may increase prostate cancer risk in some men.
• Lynch syndrome, a condition caused by inherited gene changes (DNA mismatch repair genes
such as MSH2 and MLH1), have an increased risk for prostate cancer.
• HOXB13 mutation
 Exposure to radiation
 Prostatitis
Risk factors
 Age: Prostate cancer is found most often in men older than age 65 and is rare in men younger
than age 40.
 Family history.
 Higher levels of testosterone
 Occupational exposure to cadmium (e.g., welding, electroplating, alkaline battery
manufacturing) has been identified as an added risk factor.
 Smoking
 Diet: Men who eat a lot of red meat or high-fat dairy products appear to have a slightly higher
chance
 Obesity
 Men with high blood pressure are more likely to develop prostate cancer.
Prostate Cancer Development
Develops from the epithelium: Possibly from the basal cell layer

133
Requires androgens to develop: Patients castrated before puberty do not develop BPH or Prostate
cancer, Increased cell proliferation and decreased apoptosis and BPH is not a risk factor
Pathophysiology
 When normal cells are damaged beyond repair, they are eliminated by apoptosis.
 Cancer cells avoid apoptosis and continue to multiply in an unregulated manner
 Prostate cancer is classified as an adenocarcinoma or glandular cancer that begins when normal
semen-secreting prostate gland cells mutate into cancer cells.
 The region of prostate gland where the adenocarcinoma is most common is the peripheral zone.
 Initially, small clumps of cancer cells remain confined to otherwise normal prostate glands, a
condition known as carcinoma in situ or prostatic intraepithelial.
 Over time, these cancer cells begin to multiply and spread to the surrounding prostate tissue (the
stroma) forming a tumor.
 Eventually, the tumor may grow large enough to invade nearby organs such as the seminal
vesicles or the rectum, or the tumor cells may develop the ability to travel in the bloodstream
and lymphatic system.
Spread
Local spread
 By local invasion, it will move into the bladder, seminal vesicles, or peritoneum.
 Further upward extension obstructs the lower end of one or both ureters, obstruction of both
resulting in anuria.
Spread by the bloodstream
 Spread by the bloodstream occurs particularly to bone, lung, and liver.
 The bones involved most frequently by carcinoma of the prostate are the pelvic bones and the
lower lumbar vertebrae. The femoral head, rib cage and skull are other common sites.
 Breast, kidney, and the thyroid gland may be involved.
Lymphatic spread
 The cancer may also spread through the lymph system to the pelvic nodes and may travel as far
as the supraclavicular nodes.
Histological appearances
 The prostate is a glandular structure consisting of ducts and acini; thus, the histological pattern is
one of an adenocarcinoma.
 The prostatic glands are surrounded by a layer of myoepithelial cells.
 The first change associated with carcinoma is the loss of the basement membrane.
 As the cell type becomes less differentiated, more solid sheets of carcinoma cells are seen.
TNM staging of prostatic cancer
 T1 tumour found incidentally during TURP
 T1a-<5% on TURP
 T1b>5% on TURP

Prostate Cancer
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 T1c-non palpable diagnosed by PSA
 T2 –confined to prostate
 T2a-palpable one lobe
 T2b-both lobes
 T3a-extraprostatic
 T3b-seminal vesicle involvement
 T4 adjacent structures
 N1-single node less than 2 cm
 N2-single or multiple nodes 2- 5cm in size
 N3- Nodes greater than 5 cm
 Mo- No metastasis
 M1-Distant metastasis
Symptoms: Prostate cancer may cause no signs or symptoms in its early stages. Prostate cancer that's
more advanced may cause signs and symptoms such as:
 Dysuria
 Frequent urination, nocturia,
 Urinary retention.
 Decreased force in the stream of urine
 Erectile dysfunction
 Discomfort in the pelvic area
 Bone pain often in the vertebrae (bones of the spine), pelvis, or ribs
Diagnosis
 Digital rectal exam (DRE): hard lump or hardened lobe
 Prostate-specific antigen (PSA) test or prostatic acid phosphatase (PAP): high
 Ultrasound: Transrectal ultrasonography creates a picture of the prostate using sound waves
from a probe in the rectum.
Biopsy
MRI
 Bone scans and other tests may be ordered to determine if the cancer has spread outside the
prostate gland.
Treatment of carcinoma of prostate
 Active surveillance (monitoring for tumor progress and symptoms)
 Hormone Therapy
 Surgery
 Radiation therapy
 Cryotherapy
Hormonal therapy

135
 LHRH agonists and antagonists
 Block production of testosterone
 Anti-androgens block the androgen receptor
 Hormonal therapy for advanced prostate cancer suppresses androgenic stimuli to the prostate.
 The effect is accomplished either by surgical castration orchidectomy (decreases the plasma
testosterone level) and result in prostatic atrophy.
 Other alternatives include –estrogen therapy usually in the form of diethylstilboestrol.
 Newer hormonal therapies include LNRH agonists(leuprolide and goserelin)
 Two medications which block the conversion of testosterone to dihydrotestosterone, finasteride
and dutasteride, have also shown some promise.
Surgery
 Radical prostatectomy- it is the complete surgical removal of the prostate, seminal vesicle, tips of
the vas deferens and often the surrounding fat, nerves and blood vessels.
 Laparascopic radical prostatectomy-is a new approach for the treatment of localised prostate
cancer.
Radiation therapy
 External beam radiotherapy: Dose escalation studies now pushing doses up into the 80-90Gy
range
 IMRT allows better targeting
 Side Effects
• Incontinence-rare
• Impotence-common
• Rectal irritation
• Hematuria, bladder/urethralirritation
 Brachytherapy: Outpatient, low morbidity
• Incontinence rare
• Impotence occurs over 2 year period
• Urethral irritation, worsening of BPH symptom
• Best for low grade, low stage tumors in older patients
Chemotherapy
 The cancer chemotherapic Docetaxel, has been used as treatment for (CRPC) with a median
survival benefit of 2 to 3 months. Docetaxel's FDA approval in 2004 was significant as it was the
first treatment proven to prolong survival in CRPC. In 2010, the FDA approved a second-line
chemotherapy treatment known as cabazitaxel.
 A combination of bevacizumab (Avastin), docetaxel (taxotere), thalidomide and prednisone
appears effective in the treatment of CRPC.
Cryotherapy: New generation of cyrotherapy units uses a template similar to brachytherapy. Allows
for more accurate probe placement
Prognosis: Prostate cancer rates are higher and prognosis poorer in developed countries than the
rest of the world. Many of the risk factors for prostate cancer are more prevalent in the developed
world, including longer life expectancy and diets high in red meat. (People who consume larger
amounts of meat and dairy also tend to consume fewer portions of fruits and vegetables. It is not
currently clear whether both of these factors, or just one of them, contribute to the occurrence of
prostate cancer.

Prostate Cancer
136
 In patients who undergo treatment, the most important clinical prognostic indicators of disease
outcome are stage, pre-therapy PSA level, and Gleason score.
 In general, the higher the grade and the stage, the poorer the prognosis.
 Many prostate cancers are not destined to be lethal, and most men will ultimately die from
causes other than of the disease.
Complications: Sexual dysfunction: each treatment for the prostate cancer further increases the
incidence of sexual problems.
Nursing management
Nursing diagnosis: Anxiety related to concern and lack of knowledge about the diagnosis, treatment
plan, and prognosis.
Interventions
 Obtain the history to determine patient’s level of understanding of health problem, his support
system and coping mechanisms.
 Educate the patient about diagnosis and treatment plan in simple terms.
 Assess his psychological reaction to his diagnosis/prognosis
 Provide information about institutional and community resources for coping with prostate cancer.
 Urinary retention related to urethral obstruction secondary to prostatic enlargement.
 Determine usual pattern of urinary function.
 Assess sign and symptoms of urinary retention; amount and frequency of urination, complaints of
urgency and discomfort.
 Catheterize patient to determine amount of residual volume.
 Initiate measures to treat retention; encourage assuming normal position for voiding, recommend
using Valvasa maneuver.
 Consult with physician regarding intermittent or indwelling catheterization.
 Monitor catheter function, maintain sterlity of closed system.
Nursing diagnosis: Imbalanced nutrition: less than body requirement related to decrease oral intake
because of anorexia, nausea, vomiting.
Interventions
 Assess the amount of food eaten
 Routinely weigh the patient.
 Elicit patient’s explanation of why he is unable to eat more.
 Recognise effect of medication or radiation therapy on apppetite.
 Inform patient that alterations in taste can occur.
 Administer prescribed anti emetic around the clock if necessary,
 Provide frequent small meals and a comfortable and pleasant environment.
Nursing diagnosis: Sexual dysfunction related to effects of therapy: chemotherapy, hormonal
therapy, radiation therapy, surgery.
Interventions
 Determine from history what effects patient medical condition is having on his sexual functioning.
 Inform patient of the effects of prostate surgery, orchidectomy, chemotherapy and hormonal
therapy.
 Include partner in developing, understanding, and in discovering allternative.


137
Unit : 19
CHILDHOOD CANCER
Crucial to the treatment of childhood cancer is the multidisciplinary team of medical professionals,
which focuses on the special needs of each child to offer support and administer therapy. Cancer is
the leading cause of death in children after congenital abnormalities and road traffic accidents. In
Singapore approximately 100 children are diagnosed with cancer each year.
Common Types of Child Cancer:
Acute lymphoblastic leukemia (ALL) is the most common cancer in children. It occurs in about 60 per
cent of all childhood cancers. This is followed by brain tumors, which occurs in approximately 20
percent of cases.
Other cancers seen in children are:
 Neuroblastoma –a cancer of specialized nerve cells
 Wilms’ tumour – a tumour of the kidneys
 Hepatoblastoma – a malignant liver tumour
 Lymphoma – a cancer related to the lymphatic system
 Retinoblasoma – a type of eye cancer
Survival in standard risk leukemia is close to 85 per cent, with almost 95 per cent of patients going
into remission. Stage I and II Wilms’ tumour has close to a 100 per cent survival rate. However, the
prognosis for brain stem gliomas continues to be dismal. Most children rarely survive beyond six
months from diagnosis. Only 30 per cent of Stage IV patients with Neuroblastoma will survive.
Multidisciplinary Support in Cancer Treatment:
The behavior of childhood cancer and its response to treatment is different from that of adult cancers.
Multidisciplinary support is critical in the management of childhood cancer. The team looking after a
child with cancer comprises the pediatric oncologist, surgeon, radiotherapist, nurse, medical social
worker, physiotherapist, pharmacist and play therapist, to name a few. Everyone in this team is
focused on the unique requirements of a child with cancer and the family. The mainstay of treatment
in a child with cancer is maximum cure with minimal morbidity. Paying close attention to potential
problems that can cause late effects is paramount in childhood cancer treatment. The favorable
outcomes obtained in the treatment of a child with cancer have resulted from the progress made in
several areas.
These include the following:
 A team of dedicated pediatric-orientated professionals, including surgeons, neurosurgeons,
orthopedic surgeons, oncologists, radiotherapists and specialist nurses
 Improved radio imaging modalities such as the three-dimensional computed tomography (3DCT)
Scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) scans.

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 New and improved treatment regimes that are carefully selected so that the most appropriate
treatment is given with the least morbidity
 Intensive and improved antibiotic regimes to threat infection aggressively
 Better supportive care in terms of blood and platelet products
 The development of colony-stimulating factors, which are synthetic versions of natural substances
that help bone marrow make new white blood cells, red blood cells and platelets. Colony-
stimulating factors such as GCSF stimulate the bone marrow to produce white blood cells, hence
reducing periods of profound neutropenia (a blood disorder) and thus the risk of infection.
 New and improved anti-emetics, drugs that reduce or prevent nausea and vomiting, which
enable treatment to be more acceptable
 Central venous access devices like the portacath, a plastic or metal container placed surgically
under the skin. Such devices reduce anxiety and pain from the frequent venous access required
for treatment and blood sampling.
 Play therapy and emotional support to help the child and the family live as normal a lifestyle as
possible during treatment. The Children’s Cancer Foundation and the Assisi Hospice day care
and palliative facility provide services specially designed for the critical support for children
with cancer and their family.
The Molecular Biology of Childhood Cancer:
The molecular analysis of the biology of pediatric cancers continues to be the mainstay of research in
the treatment of childhood cancer. Only with improved understanding of the underlying behavior of
the cancer can oncologists accurately select the most precise therapy thus allowing for the most
appropriate treatment with minimal side effects. This practice is clearly exemplified in patients with
Neuroblastoma where treatment is selected both by the stage of the tumour as well as the biological
characteristics of the tumour.
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139
sUnit : 20
SKIN CANCER
Introduction: Skin cancers are cancers that arise from the skin. Because the skin is easily inspected,
skin cancer is readily seen and detected and is the most successfully treated type of cancer.
Epidemiology
 Skin cancer is the most common cancer in the United States.
 Exposure to the sun is the leading cause of skin cancer; incidence is related to the total amount
of exposure to the sun.
 Sun damage is cumulative, and harmful effects may be severe by age 20 years.
 The increase in skin cancer probably reflects changing lifestyles and the emphasis on sunbathing
and related activities in light of changes in the environment, such as holes in the Earth’s ozone
layer.
Risk factors
 Changes in the ozone layer from the effects of worldwide industrial air pollutants, such as
chlorofluorocarbons
 Fair-skinned, fair-haired, blue-eyed people
 People who sustain sunburn and who do not tan
 Long-time sun exposure (farmers, fishermen, construction workers)
 Exposure to chemical pollutants (industrial workers in arsenic, nitrates, coal, tar and pitch, oils
and paraffins)
 Sun-damaged skin (elderly people)
 History of x-ray therapy for acne or benign lesions
 Scars from severe burns
 Chronic skin irritations
 Immunosuppression
 Genetic factors
Classification
 There are three main types: basal-cell cancer (BCC), squamous-cell cancer (SCC) and melanoma.
 The first two together along with a number of less common skin cancers are known as
nonmelanoma skin cancer (NMSC).
 Basal and squamous cell are common and treatment is very effective. Malignant melanoma can
be difficult to treat.
Basal Cell Carcinoma
 Most common type of skin cancer.

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 Generally appears on sun-exposed areas of the body and is more prevalent in regions where
the population is subjected to intense and extensive exposure to the sun.
 The incidence is proportional to the age of the patient (average age of 60 years) and the total
amount of sun exposure, and it is inversely proportional to the amount of melanin in the skin.
Malignant Melanoma
 A malignant melanoma is a cancerous neoplasm in which atypical melanocytes (ie, pigment cells)
are present in the epidermis and the dermis (and sometimes the subcutaneous cells).
 It is the most lethal of all the skin cancers and is responsible for about 2% of all cancer deaths
(Odom et al., 2000).
 It can occur in one of several forms: superficial spreading melanoma, lentigo-maligna melanoma,
nodular melanoma, and acral-lentiginous melanoma.
Figure: Malignant Melanoma
 Most melanomas arise from cutaneous epidermal melanocytes, but some appear in preexisting
nevi (ie, moles) in the skin or develop in the uveal tract of the eye.
 Melanomas occasionally appear simultaneously with cancer of other organs.
 The worldwide incidence of melanoma doubles every 10 years, a rise that is probably related
to increased recreational sun exposure and better methods of early detection.
 Peak incidence occurs between ages 20 and 45.
 Superficial spreading melanoma occurs anywhere on the body and is the most common form of
melanoma.
 Usually affects middle-aged people and occurs most frequently on the trunk and lower
extremities.

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 The lesion tends to be circular, with irregular outer portions. The margins of the lesion may be
flat or elevated and palpable.
 This type of melanoma may appear in a combination of colors, with hues of tan, brown, and
black mixed with gray, blue-black, or white. Sometimes a dull pink rose color can be seen in a
small area within the lesion.
Causes
 Ultraviolet radiation - primary cause
 Other factors that play a role include:
 Smoking tobacco
 HPV infections increase the risk of squamous-cell carcinoma.
 Some genetic syndromes including congenital melanocytic nevi syndrome which is characterized
by the presence of nevi (birthmarks or moles) of varying size which are either present at birth, or
appear within 6 months of birth. Nevi larger than 20 mm (3/4") in size are at higher risk for
becoming cancerous.
 Chronic non-healing scars
 Ionizing radiation, environmental carcinogens, artificial UV radiation (e.g. tanning beds), aging,
and light skin color.
 The use of many immunosuppressive medications e.g. Cyclosporin A
Prevention
 Sunscreen is effective and thus recommended to prevent melanoma and squamous-cell
carcinoma. There is little evidence that it is effective in preventing basal-cell carcinoma.
 Studies show that regular daily use of a sunscreen with a solar protection factor (SPF) of at least
15 can reduce the recurrence of skin cancer by as much as 40%.
 Avoid sun burn, wear protective clothing, sunglasses and hats, and attempt to avoid sun
exposure or periods of peak exposure.
 Decrease indoor tanning and mid day sun exposure, increasing the use of sunscreen, and
avoiding the use of tobacco products.
 Vitamin supplements and antioxidant supplements have not been found to have an effect in
prevention. Evidence for a benefit from dietary measures is tentative.
 Zinc oxide and titanium oxide are often used in sun screen to provide board protection from
UVA and UVB ranges.
Medical Management
 The goal of treatment is to eradicate the tumor.
 The treatment method depends on the tumor location; the cell type, location, and depth; the
cosmetic desires of the patient; the history of previous treatment; whether the tumor is invasive,
and whether metastatic nodes are present.
 Topical chemotherapy with imiquimod or 5-fluorouracil
 The management of BCC and SCC includes surgical excision, Mohs’ micrographic surgery,
electrosurgery, cryosurgery, and radiation therapy.
 Treatments for metastatic melanoma include biologic immunotherapy agents ipilimumab,
pembrolizumab, and nivolumab

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Surgical Management
 The primary goal is to remove the tumor entirely.
 The best way to maintain cosmetic appearance is to place the incision properly along natural
skin tension lines and natural anatomic body lines.
 In this way, scars are less noticeable.
 The size of the incision depends on the tumor size and location but usually involves a length-to-
width ratio of 3:1.
 The adequacy of the surgical excision is verified by microscopic evaluation of sections of the
specimen.
 When the tumor is large, reconstructive surgery with use of a skin flap or skin grafting may be
required.
 The incision is closed in layers to enhance cosmetic effect.
 A pressure dressing applied over the wound provides support.
 Infection after a simple excision is uncommon if proper surgical asepsis is maintained.
Mohs Surgery
 Mohs surgery, also known as chemosurgery, developed in 1938 by a general
surgeon, Frederic E. Mohs, is microscopically controlled surgery used to treat common types
of skin cancer.
 During the surgery, after each removal of tissue and while the patient waits, the tissue is
examined for cancer cells and informs the decision for additional tissue removal.
 One of the many methods of obtaining complete margin control during removal of skin cancer
(CCPDMA – complete circumferential peripheral and deep margin assessment) using frozen
section histology.
 Allows for the removal of a skin cancer with very narrow surgical margin and a high cure rate.
 The cure rate with Mohs surgery cited by most studies is between 97% and 99.8%[
Electrosurgery
 Electrosurgery is the destruction or removal of tissue by electrical energy. The current is
converted to heat, which then passes to the tissue from a cold electrode.
 May be preceded by curettage (ie, excising the skin tumor by scraping its surface with a
curette).
 Electrodesiccation is then implemented to achieve hemostasis and to destroy any viable
malignant cells at the base of the wound or along its edges.
 Electrodesiccation is useful for lesions smaller than 1 to 2 cm (0.4 to 0.8 in) in diameter.
 The tumor is removed and the base cauterized. The process is repeated twice.
 Usually, healing occurs within a month.
Reconstruction
 The goal of reconstructive surgery is restoration of normal appearance and function.
 The choice of technique depends on the size and location of the defect.
 If the repair is made along a natural skin fold or wrinkle line, the scar will be hardly visible.
Larger defects may require repair with a skin graft, local skin flap, pedicled skin flap, or a
microvascular free flap.

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 Skin grafting is patching of a defect with skin that is removed from another site in the body.
There are two forms: split thickness and full thickness.
 In a split thickness skin graft, a shaver is used to shave a layer of skin from the abdomen or
thigh. The donor site regenerates skin and heals over a period of two weeks.
 In a full thickness skin graft, a segment of skin is totally removed and the donor site needs to be
sutured closed.
Cryosurgery
 Cryosurgery destroys the tumor by deep freezing the tissue.
 A thermocouple needle apparatus is inserted into the skin, and liquid nitrogen is directed to the
center of the tumor until the tumor base is −40°C to −60°C.
 Liquid nitrogen has the lowest boiling point of all cryogens tried, is inexpensive, and is easy to
obtain.
 The tumor tissue is frozen, allowed to thaw (soften), and then refrozen. The site thaws naturally
and then becomes gelatinous and heals spontaneously.
 Swelling and edema follow the freezing. The appearance of the lesion varies.
 Normal healing, which may take 4 to 6 weeks, occurs faster in areas with a good blood supply.
Radiation Therapy
 Radiation therapy is frequently performed for cancer of the eyelid, the tip of the nose, and
areas in or near vital structures (e.g, facial nerve).
 It is reserved for older patients, because x-ray changes may be seen after 5 to 10 years, and
malignant changes in scars may be induced by irradiation 15 to 30 years later.
 The patient should be informed that the skin may become red and blistered.
 A bland skin ointment prescribed by the physician may be applied to relieve discomfort.
 The patient should also be cautioned to avoid exposure to the sun.
Follow Up
 Follow-up examinations should be at regular intervals, usually every 3 months for a year, and
should include palpation of the adjacent lymph nodes.
 The patient should also be instructed to seek treatment for any moles that are subject to
repeated friction and irritation, and to watch for indications of potential malignancy in moles as
described previously.
 The importance of lifelong follow- up evaluations should be emphasized.
Prognosis
 The mortality rates of basal-cell and squamous-cell carcinoma are around 0.3%, causing 2000
deaths per year in the US.
 The prognosis for BCC is usually good. The prognosis for SCC depends on the incidence of
metastases, which is related to the histologic type and the level or depth of invasion.
 In comparison, the mortality rate of melanoma is 15–20% and it causes 6500 deaths per year.
 Even though it is much less common, malignant melanoma is responsible for 75% of all skin
cancer-related deaths

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Nursing Management (for BCC and SCC)
 Because many skin cancers are removed by excision, patients are usually treated in outpatient
surgical units.
 The role of the nurse is to teach the patient about prevention of skin cancer and about self-care
after treatment
Teaching Patients Self-Care
 The patient is advised when to report for a dressing change or is given written and verbal
information on how to change dressings, including the type of dressing to purchase, how to
remove dressings and apply fresh ones, and the importance of hand washing before and after
the procedure.
 The patient is advised to watch for excessive bleeding and tight dressings that compromise
circulation.
 If the lesion is in the perioral area, the patient is instructed to drink liquids through a straw and
limit talking and facial movement.
 Dental work should be avoided until the area is completely healed.
 After the sutures are removed, an emollient cream may be used to help reduce dryness.
 Applying a sunscreen over the wound is advised to prevent postoperative hyperpigmentation if
the patient spends time outdoors.
Nursing management (for malignant melanoma)
Nursing diagnoses
 Acute pain related to surgical excision and grafting
 Anxiety and depression related to possible life-threatening consequences of melanoma and
disfigurement
 Deficient knowledge about early signs of melanoma
Facts about skin cancer
 About 1.3 million Americans are diagnosed with skin cancer each year.
 There are three kinds of skin cancer. The rarest, malignant is the most serious.
 Almost half of all Americans will have some type of skin cancer at least once by the time they
reach age 65.
 Most cases of skin cancer occur in people age 50 and over.
 Childhood sun exposure may decide an individual's risk of skin cancer.
 People with certain skin types have the highest risk of skin cancer.
 Some individuals may inherit a defective gene that increases the risk of malignant melanoma.
 The risk of skin cancer may be rising because of damage to Earth's protective ozone layer.
 Routine skin self-examination is important in early detection of skin cancer. .
 The cure rate for skin cancer would be almost 100 per cent if all were detected early and
treated.

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Need To Know
Practical measures to prevent skin cancer include:
 Staying out of the sun, especially between 11 a.m. and 3 p.m., when the strongest UV rays reach
Earth's surface.
 Avoiding both direct sunlight and sunlight reflected from water, sand and snow. It also can
damage the skin.
 Shielding the skin with tightly knit clothing. Long-sleeved garments made from light fabric can
protect the skin in summer and yet be cool and comfortable. Hats with broad brims can shield
the face.
 Using sunscreen. Pick a sunscreen that provides "broad spectrum" protection against both kinds
of UV radiation in sunlight, UVA and UVB.
People with close relatives who developed malignant melanoma may have inherited a damaged
gene that increases their risk. For them, preventive measures and regular skin exams can be
especially important. They also can check with the doctor about the advantages and disadvantages
of genetic testing. It can show whether an individual did inherit the abnormal gene.
Skin self-exam
Your chances of finding skin cancer can be improved by performing a regular simple skin test.
 A good time for doing this self-exam would be right after a bath or shower.
 The room should be well lighted, with a full length mirror and a hand held mirror.
 Learn where your birthmarks, blemishes and moles are and what they look like.
 Be aware of anything new, such as a change in size, color, texture or a sore that does not heal.
 If you see any unusual changes, contact your dermatologist. These changes don't necessarily
mean skin cancer, but get them checked out just to ease your mind.
Check your entire body, not just the readily visible areas. This check should include the back, the
scalp, between the buttocks, and the genital area. This should take no more than 15 minutes.
1. Look at the front and back of your body in the mirror, then raise your arms and look at the left
and right sides.
2. Bend your elbows and look carefully at your palms; forearms, including the undersides; and the
upper arms.
3. Examine the back and front of your legs. Also look between your buttocks and around your
genital area.
4. Sit and closely examine your feet, including the soles and the spaces between the toes.
5. Look at your face, neck and scalp. You may want to use a comb or a blow dryer to move hair so
that you can see better.
By checking your skin regularly, you will become familiar with what is normal. If you find anything
unusual, see your doctor right away. Remember, the earlier skin cancer is found, the better the chance
for cure.


Gland Cancer
146
Unit : 21
GLAND CANCER
Introduction: Sebaceous glands are part of epidermal appendages. Neoplasms of the sebaceous
glands may be benign, such as sebaceous hyperplasia or sebaceous gland adenomas. The malignant
sebaceous gland carcinoma most commonly arises in the periocular area. The most common site of
origin is the meibomian glands of the eyelids, leading to the term meibomian gland carcinoma. Error
or delay in diagnosis is common, and this tumor carries a significant mortality rate with metastasis.
Epidemiology: The incidence of sebaceous cell carcinoma is 3.2% among malignant tumors and 0.8%
of all eyelid tumors. The mortality rate is 22%. Sebaceous cell carcinomas are typically found in
women, more often in the seventh decade of life, and they usually are on the upper eyelid margin.
Although sebaceous cell carcinomas are more common in elderly patients, they may be seen in
younger patients with a history of radiation to the face.
Clinical manifestations
 The clinical appearance of sebaceous gland carcinoma is highly variable. They simulate such
benign conditions as chalazion, blepharoconjunctivitis, keratitis, and other malignant or benign
skin lesions.
 Many of the skin tumors have a predilection for the upper eyelid and have a yellowish
appearance. Tumors at the eyelid margin commonly cause loss of eyelashes.
 Classically, this lesion is a firm, painless, indurated mass or ulceration associated with the loss of
cilia, in an area that has been treated for recurrent chalazia.
Diagnosis
 Biopsy specimen of the lesion
 Formalin fixation, if the laboratory staff knows to avoid alcohol and xylene histoprocessing
methods.
 Evaluate lymph nodes to rule out distant spread.
Surgical Therapy
 Treatment aims to remove the malignant lesion to prevent local or systemic spread.
 The treatment of sebaceous gland carcinoma is adequate surgical excision, with wide surgical
margins and fresh frozen section controls to delineate the tumor edges.
 Lymph node evaluation is necessary to evaluate metastasis.
 If diffuse involvement of the upper and lower eyelids is present, exenteration is required.

147
 Obtain a biopsy specimen of the areas of reddening of the conjunctiva that are suggestive of
sebaceous gland carcinoma at the time of surgery.
Follow Up: Monitoring for additional malignancies or metastatic sites is warranted. A marked
increase in head and neck basal cell lesions is found in patients with previous eyelid malignancies. As
many as 40% of patients also may have had or may develop other visceral malignancies.
Prognosis
 With wide excision and no evidence of metastasis, surgery results in a cure for the malignancies.
However, sebaceous lesions have a high incidence of recurrence and metastasis.
 The Mohs chemosurgery method is commonly used in facial and periocular nonmelanocytic
malignancies. This method allows the focal and complete removal of a tumor with histologically
verified margins.
 However, in diffuse tumors with high recurrence rates, such as sclerosing sweat duct carcinoma,
recurrence rates may high.


Anal Cancer
148
Unit : 22
ANAL CANCER
Anal cancer occurs in the anus, the end of the gastrointestinal tract. Anal cancer is very different from
colorectal cancer, which is much more common. Anal cancer's causes, risk factors, clinical progression,
staging and treatment are all very different from colorectal cancer. Anal cancer is a lump which is
created by the abnormal and uncontrolled growth of cells in the anus.
Anal cancer is very rare. According to the American Cancer Society, there were an estimated 7,270
new cases of anal cancer in the USA in 2014 (a rise from 5,070 in 2008). Of these, 4,630 were
women and 2,640 were men. Approximately 1,010 people died from anal cancer in the USA in
2014.1
Reports suggest that the incidence of this type of cancer is rising. The number of anal cancer cases is
increasing in both sexes, particularly among American men, and changing trends in sexual behavior -
combined with current tobacco use and infection by a specific strain of the human papillomavirus -
may help explain the increase, as this article explains.
Most anal cancer patients are diagnosed in their early 60s. Anal cancer is more common among
women, men who receive anal intercourse, and people with weakened immune systems. Experts say
that anal cancer is closely associated with some HPV (human papilloma virus) strains.
Figure: The anus, the anal canal and squamous cell carcinomas

149
The anus is right at the end of the gastrointestinal tract, the area right at the end. The anal canal is
surrounded by the sphincter muscle. The sphincter controls bowel movements by contracting and
relaxing. In short, the anus is the outside area while the anal canal is the tube.
The anal canal is lined with squamous cells - flat cells that look like fish scales under the microscope.
The majority of anal cancers develop from these squamous cells. Such cancers are known as squamous
cell carcinomas.
The point at which the anal canal meets the rectum is called the transitional zone. The transitional zone
has squamous cells and glandular cells, these produce mucus which helps the stool (feces) pass through
the anus smoothly. Adenocarcinoma (type of cancer) of the anus can develop from these glandular
cells. However, squamous cell carcinomas make up the vast majority of anal cancers.
Symptoms of anal cancer
Common symptoms of anal cancer may include:
 Rectal bleeding - the patient may notice blood on feces or toilet paper.
 Pain in the anal area.
 Lumps around the anus. These are frequently mistaken for piles (hemorrhoids).
 Mucus discharge from the anus.
 Jelly-like discharge from the anus.
 Anal itching.
 Change in bowel movements. This may include diarrhea, constipation, or thinning of stools.
 Fecal incontinence (problems controlling bowel movements).
 Bloating.
 Women may experience lower back pain as the tumor exerts pressure on the vagina.
 Women may experience vaginal dryness.
Causes of anal cancer
Experts cannot comprehensively say what causes anal cancer. However, the following are considered
as possible risk factors:
 HPV (human papilloma virus): some types of HPV are closely linked to anal cancer.
Approximately 80% of patients with anal cancer are infected in the anal area with a HPV.
 Sexual partner numbers: this is also linked to HPV. The more sexual partners somebody has (or
has had) the higher are the chances of being infected with HPV, which is closely linked to anal
cancer risk.
 Receptive anal intercourse: both men and women who receive anal intercourse have a higher
risk of developing anal cancer. HIV-positive men who have sex with men are up to 90 times
more likely than the general population to develop anal cancer, this study revealed.
 Other cancers: women who have had vaginal or cervical cancer and men who have had penile
cancer are at higher risk of developing anal cancer. This is also linked to HPV infection.
 Age: the older somebody is the higher is his/her risk of developing anal cancer. In fact, this is
the case with most cancers.
 A weak immune system: people with a weakened immune system have a higher risk of
developing anal cancer. This may include people with HIV/AIDS, patients who have had
transplants and are taking immunosuppressant medications.

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 Smoking: smokers are significantly more likely to develop anal cancer compared to non-
smokers. In fact, smoking raises the risk of developing several cancers.
 Benign anal lesions: IBD (irritable bowel disease), hemorrhoids, fistulae or cicatrices.
Inflammation resulting from benign anal lesions may increase a person's risk of developing anal
cancer.
Diagnosis of anal cancer:
The first person to see will probably be a GP (general practitioner, primary care physician). The GP
will ask the patient about his/her symptoms and carry out an examination. The doctor will also need
to know about the patient's medical history. Then the patient will be referred to a colorectal surgeon -
this is a doctor who specializes in bowel conditions. Colorectal surgeons are sometimes called
proctologists. The specialist may carry out the following tests:
A rectal examination: This may be a bit uncomfortable, but is not painful. A proctoscope or
sigmoidoscope may be used - an instrument that allows the doctor to examine the area in more
detail. In some countries this device is called an anoscope, and the procedure 'anoscopy'. The
examination will determine whether the patient needs a biopsy.
A biopsy: A small sample of tissue is taken from the anal area and sent to the lab for testing. Tissue
will be examined under a microscope.
If cancerous tissue is detected after the biopsy the patient will need further tests to find out how
advanced (big) the cancer is and whether or not it has spread. The following tests may be done:
 CT (computerized tomography) scans: X-rays are used to create a 3-dimensional picture of the
target area.
 MRI (magnetic resonance imaging) scan: magnets and radio waves produce 2-dimensional
and 3-dimensional pictures of the target area.
 Ultrasound scan: sound waves are used to create an image of the target area. This could be
done internally with a rectal ultrasound - the instrument is inserted into the anus before the
scanning begins.
Treatments for anal cancer:
Treatment for anal cancer will depend on various factors, including how big the tumor is, whether or
not it has spread, where it is, and the general health of the patient. If the tumor is small it can be
removed surgically, and that's it.
Surgery:
The type of surgery a patient will require depends on the size and position of the tumor.
Resection: This removes a small tumor and some surrounding tissue. This type of surgery can only be
carried out if the anal sphincter is not sacrificed. Patients who undergo a resection do not have their
ability to pass a bowel movement affected.
Abdominoperineal resection: The anus, rectum and a section of the bowel are surgically removed.
The patient will need a colostomy - the end of the bowel is brought out onto the skin on the surface of
the abdomen. A bag is placed over the stoma - the opening of the bowel - and collects the stools
(feces) outside the patient's body. Although this sounds shocking, people with colostomies can lead
normal lives, play sports and have active sex lives.

151
Chemotherapy and radiotherapy: In most cases, the patient will probably have to undergo
chemotherapy and/or radiotherapy. Radiotherapy combined with chemotherapy treatments
(chemoradiation) are commonly used to destroy the anal cancer cells. Treatments are either given
simultaneously or consecutively. This combined therapy approach has led to a much higher
percentage of patients with an intact anal sphincter, survival and cure rates are good. Chemotherapy
uses cytotoxic drugs (antineoplastics): cytotoxic drugs prevent the cancer cells from dividing. They are
administered either by injection or orally.
Radiotherapy uses high-energy rays that destroy the cancer cells. This can be given by an external
beam or internally (brachytherapy). Radiotherapy has side effects, as doe’s chemotherapy. When the
treatment is combined the side effects may be more acute.
Side effects may include:
 Diarrhea
 Constipation
 Soreness and blistering around the target area (anus)
 A higher susceptibility to infections during treatment
 Low white blood cell count (which raises infection risk)
 Fatigue
 Nausea or vomiting
 Mouth ulcers
 Sore mouth
 Loss of hair
 Narrowing and dryness of the vagina
 Anemia (low red blood cell count)
 Low platelet count which raises risk of bruising or bleeding
 Dry skin
 Rashes
 Muscle and nerve problems
 Excessive coughing, sometimes breathing difficulties
 Fertility problems.
Prevention of anal cancer:
Although anal cancer is already very rare, there are some recommendations that can help reduce
your risk further. These include:
 Reduce your chances of being infected with HPV
 Use condoms when having sex
 Limit the numbers of sexual partners
 Abstain from anal intercourse
 Quit smoking


Urinary Bladder Cancer
152
Unit : 23
URINARY BLADDER CANCER
The bladder is a hollow organ in the lower abdomen that stores urine. Cancer occurs when cells in the
bladder begin to grow uncontrollably affecting the normal function of the organ, and, sometimes
surrounding organs. When detected and treated early, bladder cancer can be cured the majority of
the time.
Risk Factors: People with a history of smoking, a family history of bladder cancer, or who have had
regular exposure to industrial chemical may be at increased risk for bladder cancer.
Cancer Symptoms: The most common symptoms of bladder cancer are
 Blood in the urine
 Increased frequency of urination
 Pain or burning with urination
 Incomplete emptying of bladder
Signs and Symptoms of Bladder Cancer: Bladder cancer can often be found early because it causes
blood in the urine or other urinary symptoms.
Blood in the urine: In most cases, blood in the urine (called hematuria) is the first sign of bladder
cancer. Sometimes, there is enough blood to change the color of the urine to orange, pink, or, less
often, darker red. Sometimes, the color of the urine is normal but small amounts of blood are found
when a urine test (urinalysis) is done because of other symptoms or as part of a general medical
checkup.
Blood may be present one day and absent the next, with the urine remaining clear for weeks or
months. If a person has bladder cancer, blood eventually reappears. Usually, the early stages of
bladder cancer cause bleeding but little or no pain or other symptoms. Blood in the urine does not
always mean due to bladder cancer. More often it is caused by other things like an infection, benign
(non-cancerous) tumors, stones in the kidney or bladder, or other benign kidney diseases.
Changes in bladder habits or symptoms of irritation: Bladder cancer can sometimes cause changes
in urination, such as:
 Having to urinate more often than usual
 Pain or burning during urination
 Feeling as if you need to go right away, even when the bladder is not full
 Having trouble urinating or having a weak urine stream
Symptoms of advanced bladder cancer: Bladder cancers that have grown large enough or have
spread to other parts of the body can sometimes cause other symptoms, such as:
 Being unable to urinate
 Lower back pain on one side
 Loss of appetite and weight loss
 Feeling tired or weak
 Swelling in the feet
 Bone pain

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Again, many of these symptoms are more likely to be caused by something other than bladder
cancer, but it’s important to have them checked so that the cause can be found and treated, if
needed.
Diagnostic Tests: There are several different laboratory and clinical tests used to diagnose bladder
cancer. They are all relatively simple and painless, though some do require the use of local
anesthetics and, in some patients, can cause mild discomfort.
 Urinalysis: A small sample of urine is examined under the microscope to check for the presence
of blood.
 Intravenous Pyelogram or IVP: Patients receive an injection of a liquid dye though a vein in
their arm followed by several x-rays. The dye travels to the kidneys, ureters and bladder and
allows the doctors see if there are any suspicious lumps or lesions. Some patients report feeling
warm or tingly during this procedure.
 Cystoscopy: A thin, lighted tube is inserted through the urethra and into the bladder under local
anesthesia to allow the doctor to visualize the bladder. If the doctor sees any suspicious areas, a
sample of the tissue will be removed and examined under a microscope for cancer cells.
 Biopsy: A surgical procedure in which a piece of tissue is removed from the bladder and
examined for the presence of cancer cells. It is the only definitive way to diagnose bladder
cancer.
Pathological classification: 90% of bladder cancers are transitional cell carcinoma. The other 10%
are squamous cell carcinoma, adenocarcinoma, sarcoma, small cell carcinoma, and secondary
deposits from cancers elsewhere in the body.
TNM Classification for Bladder Cancer: The TNM classification for staging of bladder cancer is
provided below.
Primary tumour (T)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Ta Non-invasive papillary carcinoma
Tis Carcinoma in situ: “flat tumour”
T1 Tumour invades sub-epithelial connective tissue
T2 Tumour invades muscularis propria
pT2a Tumour invades superficial muscularis propria (inner half)
pT2b Tumour invades deep muscularis propria (outer half)
T3 Tumour invades perivesical tissue
pT3a Microscopically
pT3b Macroscopically (extravesical mass)
T4
Tumour invades any of the following: prostatic stroma, seminal vesicles, uterus,
vagina, pelvic wall, abdominal wall
T4a Tumour invades prostatic stroma, uterus, vagina
T4b Tumour invades pelvic wall, abdominal wall

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Regional lymph nodes (N)
Regional lymph nodes include both primary and secondary drainage regions. All other nodes above
the aortic bifurcation are considered distant lymph nodes.
NX Lymph nodes cannot be assessed
N0 No lymph node metastasis
N1
Single regional lymph node metastasis in the true pelvis (hypogastric, obturator,
external iliac, or presacral lymph node)
N2
Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator,
external iliac, or presacral lymph node metastasis)
N3 Lymph node metastasis to the common iliac lymph nodes
Distant metastasis (M)
MO No distant metastasis
M1 Distant metastasis
Table: Staging of tumour
Stage T N M
Stage 0a Ta N0 M0
Stage 0is Tis N0 M0
Stage I T1 N0 M0
Stage II T2a N0 M0
T2b N0 M0
Stage III T3a N0 M0
T3b N0 M0
T4a N0 M0
Stage IV T4b N0 M0
Any T N1-3 M0
Any T Any N M1
Table: Staging of tumours

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Figure: Stages of Urinary Bladder Cancer
Current Treatments: There are a wide variety of methods used to treat bladder cancer, including
surgery, radiation treatment and drug therapy. At Johns Hopkins, bladder cancer experts develop a
personalized treatment plan for each patient based upon the specific characteristics of the tumor.
Treatment may involve a single therapy or a combination of therapies.
Early or superficial bladder cancer: At this stage, the cancer is confined to the inside lining of the
bladder. Cancerous cells can often be removed using surgical tools inserted through a cystoscope into
the bladder. More than 70 percent of bladder cancers diagnosed are of this type.
Invasive bladder cancer: In these more advanced cases, cancer cells have spread from the lining of
bladder into the muscle and possibly surrounding organs, and a radical cystectomy is usually needed.
In this treatment, a surgeon removes the diseased bladder and possibly other surrounding organs,
including the uterus, fallopian tubes, and ovaries in women, and the prostate and seminal vesicles in
men.
In addition to surgery, radiation therapy or chemotherapy may be recommended to kill cancer cells
doctors were unable to remove during surgery or to safeguard against recurrence of the disease.
Radiation therapy is a localized treatment that uses targeted beams of x-rays to destroy cancer cells
in a specific part of the body. Chemotherapy refers to the use of anticancer drugs administered
orally and/or intravenously and travels through the bloodstream to destroy cancer cells that have
broken away from the original tumor. Cisplatin is the drug most commonly used in the treatment of
bladder cancer.

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Treatment Approaches:
By Stage
Most of the time, initial treatment of bladder cancer is based on the tumor’s clinical stage, which is
how deep it is thought to have grown into the bladder wall and whether it has spread beyond the
bladder. Other factors, such as the size and grade of the tumor and a person’s overall health can
also affect treatment option.
Treatment of stage 0 cancer
Stage 0 bladder cancer includes non-invasive papillary carcinoma and flat non-invasive carcinoma
(Tis). In either case, the cancer has not invaded the bladder wall beyond the inner layer. This early
stage of bladder cancer is most often treated with transurethral resection (TURBT). Of the intravesical
treatments, immunotherapy with Bacille-Calmette Guerin (BCG) seems to be better than
chemotherapy at both keeping cancers from coming back and from getting worse.
Stage 0a
For low-grade non-invasive papillary (Ta) tumors, the options after TURBT include observation, a
single dose of intravesical chemotherapy (usually with mitomycin) within a day of surgery, or weekly
intravesical chemo, starting a few weeks after surgery. If the cancer comes back, the treatments can
be repeated.
High-grade non-invasive papillary (Ta) tumors are more likely to come back after treatment, so
intravesical Bacille-Calmette Guerin (BCG) is often recommended after surgery.
Stage 0is
For flat non-invasive (Tis) tumors, BCG is the treatment of choice after surgery. Patients with these
tumors often get 6 weekly treatments of intravesical BCG, starting a few weeks after TUR. Some
doctors recommend repeating BCG treatment every 3 to 6 months.
Follow-up and outlook after treatment: After treatment for any stage 0 cancer, close follow-up is
recommended, with cystoscopy about every 3 to 6 months for a least a couple of years to look for
signs of the cancer coming back or for new bladder tumors.
Treating stage I bladder cancer
Stage I bladder cancers have grown into the connective tissue layer of the bladder wall but have not
reached the muscle layer. Transurethral resection (TURBT) is typically the first treatment for these
cancers. if the cancer is found to be low grade, a second TURBT is often recommended several weeks
later. If the doctor then feels that all of the cancer has been removed, intravesical BCG or mitomycin
is usually given. If the cancer is high grade, if many tumors are present, or if the tumor is very large
when it is first found, radical cystectomy may be recommended. For people who aren’t healthy
enough for a cystectomy, radiation therapy (often along with chemo) might be an option for
treatment, although the chances for cure might not be as good.
Treating stage II bladder cancer
These cancers have invaded the muscle layer of the bladder wall. Transurethral resection (TURBT) is
typically the first treatment for these cancers, but it is done to help determine the extent of the cancer
rather than to try to cure it.
When the cancer has invaded the muscle, radical cystectomy (removal of the bladder) is the standard
treatment. Lymph nodes near the bladder are often removed as well.

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If cancer is in only one part of the bladder, some patients can be treated with a partial cystectomy
instead. There may already be tiny deposits of cancer growing elsewhere in the body. For this
reason, chemotherapy is often given either before surgery (neoadjuvant chemo) or after surgery
(adjuvant chemo) to lower the chance the cancer will come back. Another option for some patients
may be a second (and more extensive) transurethral resection (TURBT), followed by radiation and
chemotherapy.
Treating stage III bladder cancer
These cancers have reached the outside of the bladder and might have grown into nearby tissues or
organs. Transurethral resection (TURBT) is typically done first to help determine how far the cancer
has grown. Radical cystectomy (removal of the bladder and nearby lymph nodes) is then the
standard treatment. Partial cystectomy is seldom an option for stage III cancers. An option for some
patients with single, small tumors might be treatment with a second (and more extensive) transurethral
resection (TURBT) followed by a combination of chemotherapy and radiation. If this isn’t successful
and cancer is found when cystoscopy is repeated, the patient might need cystectomy.
Treating stage IV bladder cancer
These cancers have reached the abdominal or pelvic wall (T4b tumors) or have spread to nearby
lymph nodes or distant parts of the body. Stage IV cancers are very hard to get rid of completely.
In most cases surgery (even radical cystectomy) can’t remove all of the cancer, so treatment is usually
aimed at slowing the cancer’s growth and spread to help you live longer and feel better
For stage IV bladder cancers that have not spread to distant sites, chemotherapy (with or without
radiation) is usually the first treatment. If the cancer shrinks in response to treatment, a cystectomy
might be an option. Patients who can’t tolerate chemo (because of other health problems) are often
treated with radiation therapy.
For stage IV bladder cancers that have spread to distant areas, chemo is usually the first treatment,
sometimes along with radiation therapy. Urinary diversion without cystectomy is sometimes done to
prevent or relieve a blockage of urine that could otherwise cause severe kidney damage.
Bladder Cancer Survivorship:
The five-year survival rate after treatment for bladder cancer is the percentage of patients who live
at least five years after diagnosis. Many people live much longer.
Stage 0 -- 98%.
For stage I -- 88%.
For stage II -- 63%.
For stage III -- 46%, depending on the size of the cancer deposits present in the tissues next to
the bladder and whether the cancer has spread to nearby organs.
For stage IV -- 15%
These numbers provide an overall picture, but keep in mind that every person's situation is unique.
Statistics cannot predict exactly.
Nursing Management: Managing the effects of chemotherapy and radiationtherapy is the most for
person undergoing treatment of cancer.
Side Effects of Chemotherapy/Radiationtherapy
 Alopecia

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 Anorexia
 Fatigue
 Mucositis
 Anemia
 Neutropenia
 Thrombocytopenia
Nursing Assessment for patient undergoing chemotherapy/radiationtherapy
 Weight loss
 Frequent infection
 Skin problems
 Pain
 Hair Loss
 Fatigue
 Disturbance in body image/ depression
Managing Side Effects
Maintain Tissue Integrity
 Handle skin gentle
 DO NOT rub affected area
 Lotion may be applied
 Wash skin only with moisturizing soap and water
Management of Stomatitis
 Use soft-bristled toothbrush
 Oral rinses with saline gargles/ tap water
 Avoid ALCOHOL-based rinses
Management of Alopecia: Alopecia begins within 2 weeks of therapy.
 Re-growth within 8 weeks of termination.
 Encourage to acquire wig before hair loss occurs.
 Encourage use of attractive scarves and hats.
 Provide information that hair loss is temporary BUT anticipate change in texture and color.
Promote Nutrition:
 Consider patient’s preferences.
 Provide small frequent meals.
 Avoid giving fluids while eating.
 Oral hygiene PRIOR to mealtime.
Relieve Pain:
 Mild pain- NSAIDS

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 Moderate pain- Weak opioids
 Severe pain- Morphine
 Administer analgesics round the clock with additional dose for breakthrough pain
Decrease Fatigue:
 Plan daily activities to allow alternating rest periods
 Light exercise is encouraged
 Small frequent meals should be given in between activity
Improve Body Image
 Therapeutic communication is essential
 Encourage independence in self-care and decision making
 Offer cosmetic material like make-up and wigs
Assist in the Grieving Process
 Grieving can be due to loss of health, income, sexuality, and body image
 Answer and clarify information about cancer and treatment options
 Identify resource people
 Refer to support groups
Manage Complication: Infection
 Fever is the most important sign
 Administer prescribed antibiotics X 2weeks
 Maintain aseptic technique
 Avoid exposure to crowds
 Hand washing
 Avoid frequent invasive procedures
Manage Complication: Septic Shock
 Monitor VS, BP, temp
 Administer IV antibiotics
 Administer supplemental O2
 Care as you care a patient in shock
Manage Complications: Bleeding
 Thrombocytopenia (<100,000) is the most common cause < 20,000 → spontaneous bleeding).
 Use soft toothbrush
 Use electric razor
 Avoid frequent IM, IV, rectal and catheterization
 Soft foods and stool softeners.
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Bone Cancer
160
Unit : 24
BONE CANCER
Bone cancer can be primary or secondary. Primary bone cancer starts in the bone; the cancer initially
forms in the cells of the bone, while secondary cancer starts elsewhere in the body and spreads to the
bone. Examples of primary bone cancer include steosarcoma, Ewing sarcoma, malignant fibrous
histiocytoma, and chondrosarcoma.
According to the National Cancer Institute, USA, it is estimated that by the end of 2015 there will
have been 2,970 new cases and 1,490 deaths from cancer of the bones and joints. They suggest that
approximately 0.1 percent of men and women will be diagnosed with bone and joint cancer at some
point during their lifetime1.
Primary bone cancer (tumor): These can be divided into benign tumors, which can have neoplastic,
developmental, traumatic, infectious, or inflammatory cause cancers.
Examples of benign bone tumors include: Osteoma, osteoid osteoma, osteochondroma,
osteoblastoma, enchondroma, giant cell tumor of bone, aneurysmal bone cyst, and fibrous dysplasia
of bone.
Examples of malignant primary bone tumors include: Osteosarcoma, chondrosarcoma, Ewing's
sarcoma, malignant fibrous histiocytoma, fibrosarcoma, and other sarcomas. Multiple myeloma is a
blood cancer which may include one or more bone tumors. Teratomas and germ cell tumors are
frequently located in the tailbone.
Osteosarcoma is the most common type of bone cancer. It usually develops in children and young
adults. After leukemia and Brian tumors, osteosarcoma is the third most common cancer among for
children in the UK and the USA.
Ewing sarcoma usually develops in the pelvis, shin bone or thigh bone. 90% of patients develop this
type of cancer when they are less than 20 years of age. Chrondrosacroma usually develops in adults.
It starts in the cartilage cells and moves on to the bone.
The outlook for a patient with malignant bone cancer depends mainly on whether it has metastasized
(spread to other parts of the body). If the cancer is localized (has not spread), prognosis is usually
good.
Symptoms of bone cancer: A symptom is something the patient feels and reports, while a sign is
something other people, such as the doctor notice. For example, pain may be a symptom while a rash
may be a sign.
The patient initially experiences pain in the affected area. Over time the pain gets worse and
continuous. In some cases the pain is subtle and the patient may not see a doctor for several months.
The progression of pain with Ewing sarcoma tends to be faster than in most other bone cancers.
Typically, bone cancer pain is deep, nagging and has a permanent character.
 There may also be swelling in the affected area.
 Often the bone will weaken, resulting in a significantly higher risk of fracture.
 The patient may find he/she loses weight unintentionally.
 A mass (lump) may be felt in the affected area.
 Although much less common, the patient may also experience fever, chills and/or night sweats.

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Causes of bone cancer: Nobody knows in general what the causes of bone cancer are. Patients with
chronic inflammatory diseases, such as Paget's disease are at a significantly higher risk of developing
bone cancer later on in life. It is not contagious.
The following groups of people may be at a higher risk of developing bone cancer (risk factors):
 Being a child or very young adult: most cases of bone cancer occurs in children or young adults
aged up to 20.
 Patients who have received radiation therapy.
 People with a history of Paget's disease.
 People with a close relative (parent or sibling) who has/had bone cancer.
 Individuals with hereditary renoblastoma: a type of eye cancer that most commonly affects very
young children.
 People with Li-Fraumeni syndrome: a rare genetic condition.
 Babies born with an umbilical hernia.
Diagnosis of bone cancer: The following diagnostic tests may be ordered
 Bone scan: a liquid which contains radioactive material is injected into a vein. This material
collects in the bone, especially in abnormal areas, and is detected by a scanner. The image is
recorded on a special film.
 Computerized tomography (CT): the CT scanner uses digital geometry processing to generate a
3-dimensional (3-D) image of the inside of an object. The 3-D image is made after many 2-
dimensional (2-D) X-ray images are taken around a single axis of rotation - in other words,
many pictures of the same area are taken from many angles and then placed together to
produce a 3-D image. It is a painless procedure. CT scans are commonly used to see whether the
bone cancer has spread and where it has spread to.
 Magnetic resonance imaging (MRI): the device uses a magnetic field and radio waves to
create detailed images of the body, which in this case would be a specific bone or part of a
bone. Most MRI machines look like a long tube, with a large magnet present in the circular area.
When beginning the process of taking an MRI, the patient is laid down on a table. Then
depending on where the MRI needs to be taken, the technician slides a coil to the specific area
being imaged. The coil is the part of the machine that receives the MR signal.
 Positron emission tomography (PET): a PET scan uses radiation, or nuclear medicine imaging,
to produce 3-dimensional, color images of the functional processes within the human body. The
machine detects pairs of gamma rays which are emitted indirectly by a tracer (positron-emitting
radionuclide) which is placed in the body on a biologically active molecule. The images are
reconstructed by computer analysis.
 X-rays: this type of scan can detect damage the cancer may have caused to the bone. It may
also detect new (bone) cells that have started to form around the tumor. An x-ray does not
provide enough data for a definitive diagnosis, but can help the surgeon decide whether further
tests are recommended.
 Bone biopsy - a sample of bone tissue is extracted and examined for cancer cells. This is the
most reliable way to diagnose bone cancer. A core needle biopsy involves inserting a long, thin
needle into the bone and removing a sample, while an open biopsy involves making an incision
in the target bone area and surgically removing a sample of tissue.
Staging the bone cancer
Bone cancer is has different stages which describe its level of advancement.
 Stage I: The cancer has not spread out of the bone. The cancer is not an aggressive one.
 Stage II: Same as Stage I, but it is an aggressive cancer.
 Stage III: Tumors exist in multiple places of the same bone (at least two).
 Stage IV: The cancer has spread to other parts of the body.

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Treatments for bone cancer
The type of treatment for bone cancer depends on several factors, including what type of bone
cancer it is, where it is located, how aggressive it is, and whether it is localized or has spread. There
are three approaches to bone cancer are: Surgery, Chemotherapy and Radiotherapy (radiation
therapy)
Surgery: The aim of surgery is to remove the tumor, all of it if possible, and some of the bone tissue
that surrounds it. If some of the cancer is left behind after surgically removing the tumor it may
continue to grow and eventually spread.
Limb sparing surgery, also known as limb salvage surgery means that surgical intervention occurs
without having to amputate the limb. The surgeon may take some bone from another part of the body
to replace lost bone (bone graft), or an artificial bone may be put in. In some cases, however,
amputation of a limb may be necessary.
Radiation therapy:
Radiation therapy is also known as radiotherapy, radiation oncology and XRT. Approximately 40%
of patients of all types of cancer undergo some kind of radiotherapy. It involves the use of beams of
high-energy X-rays or particles (radiation) to destroy cancer cells. Radiotherapy works by damaging
the DNA inside the tumor cells, destroying their ability to reproduce. Radiotherapy can be used for
different reasons:
 Total Cure: to cure the patient by completely destroying the tumor.
 To alleviate symptoms: radiotherapy is often used to relieve pain in more advanced cancers.
 Neo-adjuvant radiotherapy (before surgery): if a tumor is large, radiotherapy can shrink it,
making it easier and less harmful to then surgically remove it.
 Adjuvant radiotherapy: given after surgery. The aim is to eliminate the cancer cells that
remained behind.
 Combination therapy (radiotherapy combined with another type of therapy): in some cases,
chemoradiation - radiotherapy combined with chemotherapy, is more effective.
Chemotherapy
Chemotherapy involves use of chemicals (medication) to treat disease. More specifically, it usually
refers to the destruction of cancer cells. Cytotoxic medication prevents cancer cells from dividing and
growing. In general, chemotherapy has 5 possible goals:
 Total remission - to cure the patient completely. In some cases chemotherapy alone can get rid
of the cancer completely.
 Combination therapy - chemotherapy can help other therapies, such as radiotherapy or surgery
have more effective results.
 Delay/Prevent recurrence - chemotherapy, when used to prevent the return of a cancer, is most
often used after a tumor is removed surgically.
 Slow down cancer progression - used mainly when the cancer is in its advanced stages and a
cure is unlikely. Chemotherapy can slow down the advancement of the cancer.
 To relieve symptoms - also more frequently used for patients with advanced cancer.
Phantom limb pain: Also known as phantom limb syndrome - the patient feels sensations, often of
pain, in a limb that has been amputated; the limb is no longer there. The brain still receives messages
from the nerves that originally carried impulses from the missing arm or leg.


163
Unit : 25
SPINAL CORD TUMORS
Introduction:
 A spinal cord tumor is a noncancerous (benign) or cancerous (malignant) growth in or around the
spinal cord.
 Spinal cord tumors are much less common than brain tumors. It affects 0.5% to 1% of all
neoplasms
 Spinal cord tumors may be primary (arising from some components of cord, dura, nerves or
vessels) or secondary (from primary growth in breast, thyroid, lung, kidney, and other sites) .
 Primary spinal cord tumors may be cancerous or noncancerous.
 They may originate in the cells within or next to the spinal cord.
 Only about 10% of primary spinal cord tumors originate in the cells within the spinal cord. These
tumors can extend within the cord and cause a fluid-filled cavity (syrinx) to form.
Primary spinal Cord Tumor
 About 90% of primary spinal cord tumors originate in cells next to the spinal cord, such as those
of the spinal nerve roots—the parts of spinal nerves that emerge from the spinal cord
 Meningiomas and neurofibromas are most common benign primary spinal tumors which originate
in cells next to the cord
Secondary spinal cord tumors
 Secondary spinal cord tumors, which are more common, are metastases of cancer originating in
another part of the body and thus are always cancerous.
 Metastases most commonly spread to the vertebrae from cancers that originate in the lungs,
breasts, prostate gland, kidneys, or thyroid gland.
 Metastases compress the spinal cord or nerve roots from the outside.
 Lymphomas may also spread to the spine and compress the spinal cord.
Types of Spinal Tumors:
 Astrocytoma: Cells of the tissue that supports nerve cells
 Ependymoma: Cells lining the canal in the center of the spinal cord
 Meningioma: Cells of the layers of tissue covering the spinal cord (meninges)
 Neurofibroma: Cells that support peripheral nerves
 Sarcoma: Cells of connective tissue in the spine
 Schwannoma: Cells that form the myelin sheath around peripheral nerve fibers (Schwann cells)
Symptoms
 Symptoms are caused by pressure on the spinal cord and nerve roots.

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164
 Pressure on the spinal cord may cause the following:
• Back pain that progressively worsens, is unrelated to activity, and is worse when people lie
down
• Decreased sensation, progressive weakness, or paralysis in areas controlled by the parts of
the spinal cord below the part that is compressed
• Erectile dysfunction
• Loss of bladder and bowel control
 Pressure on the spinal cord may also block the blood supply to the cord, resulting in death of
tissue, fluid accumulation, and swelling.
 Fluid accumulation may block more of the blood supply, leading to a vicious circle of damage.
 Symptoms due to pressure on the spinal cord can worsen quickly.
 Pressure on spinal nerve roots can cause:
• Pain, numbness, tingling, weakness in areas supplied by the compressed nerve root.
• Pain may radiate along the nerve whose root is compressed.
• If compression continues, the affected muscles may waste away.
• Walking may become difficult.
Diagnosis
 Magnetic resonance imaging (MRI) is considered the best procedure for examining all the
structures of the spinal cord and spine. When MRI is unavailable, myelography with computed
tomography (CT) may be done instead.
 X-rays of the spine can show only changes in the bones, and many tumors do not affect the bone
when they are in an early stage.
 A biopsy is usually needed to diagnose the precise type of tumor, especially primary spinal
cord tumors. However, a biopsy is not needed for spinal cord tumors that result from metastases
if cancer has been diagnosed elsewhere in the body
Treatment
1. Corticosteroids: If symptoms suggest that the tumor is compressing the spinal cord,
corticosteroids (such as dexamethasone) are immediately given in high doses to reduce the
swelling.
2. Surgery: Many tumors of the spinal cord and spine can be removed surgically. Tumor
compressing the spinal cord needs immediate surgery
3. Radiotherapy: If tumors cannot be removed, radiation therapy is used, sometimes after surgery
to relieve the pressure on the spinal cord is done.
Recovery: Recovery generally depends on how quickly treatment begins and how much damage was
done. Removal of meningiomas, neurofibromas, and some other primary spinal cord tumors may be
curative.


165
Unit : 26
PANCREATIC CANCER
Introduction: In the United States each year, over 30,000 people are diagnosed with pancreatic
cancer. Europe sees more than 60,000 diagnoses each year. Because pancreatic cancer is usually
diagnosed late into its development, the five-year survival rate after diagnosis is less than 5%.
Classification of pancreatic cancer:
Pancreatic cancer is categorized depending on whether it affects the exocrine or endocrine functions
of the pancreas. There is an important distinction between the two broad types of pancreatic cancer
because they have different risk factors, causes, symptoms, diagnostic tests, treatments, and
prognoses.
Tumors that affect the exocrine functions are the most common type of pancreatic cancer. Sometimes
these tumors or cysts are benign, called cystadenomas. However, it is more likely to find malignant
tumors called adenocarcinomas, which account for 95% of exocrine pancreatic cancers.
Adenocarcinomas typically start in gland cells in the ducts of the pancreas, but they can also arise
from pancreatic enzyme cells (acinar cell carcinoma).
Other types of pancreatic cancers that are associated with exocrine functions include adenosquamous
carcinomas, squamous cell carcinomas, and giant cell carcinomas, named for their appearances
underneath a microscope. There is also a disease called ampullary cancer (carcinoma of the ampulla
of Vater) that starts where the bile duct and pancreatic duct meet the duodenum of the small
intestine.
Tumors that affect the endocrine functions of the pancreas are called neuroendocrine or islet cell
tumors, but these are fairly uncommon. These tumors are named for the type of hormone-producing
cell that is initially affected. For example: insulinomas (insulin), glucagonomas (glucagon), gastrinomas
(gastrin), somatostatinomas (somatostatin), and VIPomas (vasoactive intestinal peptide or VIP).
Functioning islet cell tumors still make hormones, while non-functioning ones do not. Most of these
tumors are benign, but non-functioning tumors are more likely to be malignant, islet cell carcinomas.
Causes of pancreatic cancer: Cancer is ultimately the result of cells that uncontrollably grow and do
not die. Normal cells in the body follow an orderly path of growth, division, and death. Programmed
cell death is called apoptosis, and when this process breaks down, cancer results. Pancreatic cancer
cells do not experience programmatic death, but instead continue to grow and divide. Although
scientists do not know exactly what causes these cells to behave this way, they have identified several
potential risk factors.
Genes - the DNA type: Cells can experience uncontrolled growth if there is damage or mutations in
the DNA, and therefore, damage to the genes involved in cell division. Four key types of genes are
responsible for the cell division process: oncogenes tell cells when to divide, tumor suppressor genes
tell cells when not to divide, suicide genes control apoptosis and tell cells to kill themselves if
something goes wrong, and DNA-repair genes instruct cells to repair damaged DNA.

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Cancer occurs when a cell's gene mutations make the cell unable to correct DNA damage and unable
to commit suicide. Similarly, cancer is a result of mutations that inhibit oncogene and tumor suppressor
gene functions, leading to uncontrollable cell growth. If you have DNA mutations of oncogenes or
tumor suppressor genes that lead to pancreatic cancer, it is likely that the mutation was a result of
factors that affected DNA after you were born rather than a result of inheritance from parents.
Genes - the family type: Cancer can be the result of a genetic predisposition that is inherited from
family members. It is possible to be born with certain genetic mutations or a fault in a gene that
makes one statistically more likely to develop cancer later in life. About 10% of pancreatic cancers
are though to be caused by inherited gene mutations. Genetic syndromes that are associated with
pancreatic cancer include hereditary breast and ovarian cancer syndrome, melanoma, pancreatitis,
and non-polyposis colorectal cancer (Lynch syndrome).
Carcinogens: Carcinogens are a class of substances that are directly responsible for damaging DNA,
promoting or aiding cancer. Certain pesticides, dyes, and chemicals used in metal refining are thought
to be carcinogenic, increasing the risk of developing pancreatic cancer. When our bodies are
exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in
the body. Theses free radicals damage cells, affecting their ability to function normally, and the result
can be cancerous growths.
Other medical factors: As we age, there is an increase in the number of possible cancer-causing
mutations in our DNA. This makes age an important risk factor for pancreatic cancer, especially for
those over the age of 60. There are several other diseases that have been associated with an
increased risk of cancer of the pancreas. These include cirrhosis or scarring of the liver, helicobacter
pylori infection (infection of the stomach with the ulcer-causing bacteria H. pylori), diabetes mellitus,
chronic pancreatitis (inflammation of the pancreas), and gingivitis or periodontal disease.
Traits, habits, and diet: Pancreatic cancers are more likely to exist in men than in women, and among
African-Americans than among whites. Smoking cigarettes increases one's risk of pancreatic cancer by
a factor of 2 or 3. Even smokeless tobacco has been noted as a risk factor. Diet and obesity have
also been linked to cancers of the pancreas. People who do not exercise much and who are obese
are more likely to develop pancreatic cancer. In addition, those who eat diets low in vegetables and
fruits and high in red meat and fat are more likely to be diagnosed with the disease. Alcohol
consumption is also considered a risk factor for pancreatic cancer. Long term, heavy drinking leads to
chronic pancreatitis, which is a known risk factor for pancreatic cancer.
Symptoms of pancreatic cancer: Cancer symptoms are quite varied and depend on where the
cancer is located, where it has spread, and how big the tumor is. Pancreatic cancer is often called a
"silent" disease because it rarely shows early symptoms and presents non-specific later symptoms.
Tumors of the pancreas cancers are usually too small to cause symptoms. However, when the cancer
grows, symptoms include:
 Pain in the upper abdomen from the tumor pushing against nerves
 A painless yellowing of the skin and eyes and darkening of the urine called jaundice, created
when the cancer interferes with the bile duct and the liver.
 Loss of appetite, nausea, and vomiting
 Significant weight loss and weakness
 Acholic stool (pale or grey stool) and steatorrhea (excess fat in stool)

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These symptoms of pancreatic cancer have numerous other causes, making it difficult to diagnose the
disease before it is in an advanced stage. Cancers of the pancreas are also associated with
Trousseau's sign - spontaneous blood clots formed in the portal blood vessels, deep veins of the arms
and legs, or other superficial veins. Clinical depression is another symptom that is sometimes reported
before the cancer is diagnosed.
If the cancer spreads, or metastasizes, additional symptoms can present themselves in the newly
affected area. Symptoms of metastasis ultimately depend on the location to which the cancer has
spread. Islet cell or neuroendocrine cancers of the pancreas may cause the organ to produce too
much insulin or hormones. This may lead to weak or dizzy feelings, chills, muscle spasms, or diarrhea.
Diagnosis of Pancreatic Cancer: In general, when making a pancreatic cancer diagnosis, common
symptoms such as abdominal or back pain, weight loss, poor appetite, tiredness, irritability, digestive
problems, gallbladder enlargement, blood clots (deep venous thrombosis or pulmonary embolism),
fatty tissue abnormalities, diabetes, swelling of lymph nodes, diarrhea, steatorrhea, and jaundice.
It is also common for doctors to administer blood, urine, and stool tests. Blood tests can detect a
chemical called carcinoembryonic antigen (CEA) as well as CA 19-9 - a chemical released into the
blood by pancreatic cancer cells. Liver function tests check for bile duct blockage. Several imaging
techniques are employed in order to see if cancer exists and to find out how far it has spread.
Common imaging tests include:
 Ultrasound: to visualize tumor
 Endoscopic ultrasound (EUS): thin tube with a camera and light on one end
 Abdominal computerized tomography (CT) scans: to visualize tumor
 Endoscopic retrograde cholangiopancreatography (ERCP): to x-ray the common bile duct
 Angiogram: to x-ray blood vessels
 Barium swallows to x-ray the upper gastrointestinal tract
 Magnetic resonance imaging (MRI) - to visualize tumor
 Positron emission tomography (PET) scans - useful to detect if disease has spread
The only absolute way to make a cancer diagnosis is to remove a small sample of the tumor and look
at it under the microscope in a procedure called a biopsy. A fine needle aspiration (FNA) biopsy is
the most commonly used method. Another type is the brush biopsy performed during ERCP to gather
cells. A laparotomy is sometimes ordered to determine the stage, or extent, of the disease because it
provides access to a large part of the abdominal cavity.
Pancreatic cancer staging (TNM classification): The standard pancreatic cancer staging method is
called the TNM (Tumor - Node - Metastasis) system. T indicates the size and direct extent of the
primary tumor, N indicates the degree to which the cancer has spread to nearby lymph nodes, and M
indicates whether the cancer has metastasized to other organs in the body. A small tumor that has not
spread to lymph nodes or distant organs may be staged as (T1, N0, M0).

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Pancreatic cancer staging (TNM classification)
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor limited to the pancreas, ≤ 2 cm in greatest dimension
T2 Tumor limited to the pancreas, > 2 cm in greatest dimension
T3 Tumor extends beyond the pancreas but without involvement of the
celiac axis or the superior mesenteric artery
T4 Tumor involves the celiac axis or the superior mesenteric artery
(unresectable primary tumor)
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
M0 No distant metastasis
M1 Distant metastasis
Stage
0
IA
IB
IIA
IIB
T N M
Tis N0 M0
T1 N0 M0
T2 N0 M0
T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
III T4 Any N M0
IV Any T Any N M1

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Treatments for pancreatic cancer: Cancer treatment depends on the type of cancer, the stage of the
cancer (how much it has spread), age, health status, and additional personal characteristics. There is
no single treatment for cancer, and pancreatic cancer is usually only curable when found in its earliest
stages. Surgery, radiation, and chemotherapy are the most common treatment types. Treatments seek
to remove the cancer and/or relieve painful symptoms that the cancer is causing.
Surgery: Surgery may be used to remove all or part of the pancreas. If a cancer has not
metastasized, it is possible to completely cure a patient by surgically removing the cancer from the
body. After the disease has spread, however, it is nearly impossible to remove all of the cancer cells.
There are three main surgical procedures that are used when it seems possible to remove all of the
cancer:
1. Whipple procedure (most common in cancers of the head of the pancreas): the pancreas head,
and sometimes the entire organ, is removed along with a portion of the stomach, duodenum,
lymph nodes, and other tissue. The procedure is complex and risky with complications such as
leaking, infections, bleeding, and stomach problems.
2. Distal pancreatectomy: the pancreas tail is removed, and sometimes part of the body, along
with the spleen. This procedure is usually used to treat islet cell or neuroendocrine tumors.
3. Total pancreatectomy: The entire pancreas and spleen are removed. Although you can live
without a pancreas, diabetes often results because your body no longer produces insulin cells.
Palliative surgery is also an option when the cancer in the pancreas cannot be removed. Often, a
surgeon will create a bypass around the common bile duct or the duodenum if either is blocked so
that bile can still flow from the liver and pain or digestive problems can be kept at a minimum. Bile
duct blockage can also be relieved by inserting a small stent in the duct to keep it open, a less
invasive procedure using an endoscope.
Chemotherapy:
Chemotherapy utilizes chemicals that interfere with the cell division process - damaging proteins or
DNA - so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not
necessarily just cancer cells), but normal cells can usually recover from any chemical-induced damage
while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or
metastasized because the medicines travel throughout the entire body. Treatment occurs in cycles so
the body has time to heal between doses. However, there are still common side effects such as hair
loss, nausea, fatigue, and vomiting. Combination therapies often include multiple types of
chemotherapy or chemotherapy combined with other treatment options.
Gemcitabine (Gemzar) is the chemotherapy drug used most often to treat pancreatic cancer, and it is
usually administered intravenously on a weekly basis. Another commonly used drug is 5-fluorouracil
(5-FU). Chemotherapy is not always administered with the intent to cure the cancer. Some patients
receive treatments after surgery (adjuvant therapy) to kill any cancer cells that were missed, and
others receive it as palliative chemotherapy to improve their quality of life if the cancer cannot be
cured.
Newer drugs that target specific parts of cancer cells are now being studied. These drugs work
differently from standard chemotherapy drugs, and they often have fewer side effects. One such
drug, erlotinib (Tarceva), has helped some patients with advanced pancreatic cancer and is taken
orally in pill form. This drug has been used in combination with gemcitabine to show modest benefits.

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Radiation:
Radiation treatments for pancreatic cancer are usually given 5 days a week for 5 to 6 weeks.
Patients may receive radiation treatment in addition to surgery, chemotherapy, or other treatments. In
addition, radiation therapy can be palliative, serving to relieve pain or digestive problems when the
common bile duct or duodenum is blocked.
Using radioactive bacteria to stop the spread of pancreatic cancer: Used bacteria to carry
radioisotopes commonly used in cancer treatment directly into pancreatic cancer cells. They found in
animal experiments that the incidence of secondary tumors went down dramatically; i.e. the cancer
was much less likely to spread (metastasize).
Prevention of pancreatic cancer:
There are no established guidelines or recommendations for preventing pancreatic cancer, according
to the American Cancer Society. However, it is advisable to quit smoking because cigarette use is
thought to be a main factor in 20-30% of pancreatic cancers. In general, physicians recommend
standard preventive measures such as keeping a healthy weight, exercising, and increasing
consumption of fruits, vegetables, and whole grains while decreasing red meat intake. There is no
evidence, however, that following these dietary guidelines will prevent or reduce pancreatic cancer.
Some studies suggest that certain vitamins can reduce the risk of pancreatic cancer. Vitamin D has
been associated with reducing the risk of several types of cancer, including pancreatic cancer. B
vitamins such as B12, B6, and folate that are consumed in food (not in pill or tablet form) have also
been suggested to reduce pancreatic cancer risk.


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Unit : 27
KIDNEY TUMORS
Benign Kidney Tumors
1. Renal Adenoma
• Most common form
• Solid kidney tumor
• Typically small, low-grade growths.
• Cause unknown
• Asymptomatic, hence incidence is unknown
• One study found them present in 7% to 22% of autopsy cadavers.
2. Renal Oncocytoma
• Usually asymptomatic tumor that can grow quite large.
• Can develop throughout the body and are not unique to the kidneys.
• Cause unknown, and they appear with greater frequency in men than in women.
• Typically discovered incidentally by ultrasound, IVP, CT, or MRI scan for an unrelated health
problem.
3. Angiomyolipoma
• Rare tumour of the kidney often associated with tuberous sclerosis
• Malignant elements present in about one-quarter of them and may lead to metastasis.
• Most often occur in middle-aged women.
• Management of the condition depends on the size of the tumors and the severity of the
symptoms they produce.
• Asymptomatic patients and those with small tumors are observed periodically with an eye
toward surgery if the tumors grow or produce symptoms.
• Patients with large tumors are considered for surgical treatment (partial nephrectomy to
arterial embolization)
4. Fibroma
• Tumors of the fibrous tissue on, in, or surrounding the kidney.
• Rare and are more common in women.
• Cause unknown and most do not cause symptoms.
• No special characteristics to differentiate them from malignant tumors of the kidney.
• Partial or radical nephrectomy is the standard treatment.

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5. Lipoma
• Rare renal tumors that originate in the fat cells within the renal capsule or surrounding tissue.
• Typically occur in middle-aged women, can grow very large, and produce pain and
hematuria.
• May become cancerous and usually are treated with total nephrectomy.
Malignant kidney tumors
 There are two main types of primary kidney tumors
• Renal cortical tumors (about 90 percent of tumors)
• Transitional cell (also called urothelial) tumors.
 Each of these tumor types arises from different parts of the kidney and requires different
approaches for treatment.
Renal cell carcinoma
 Also known as renal cell cancer or renal cell adenocarcinoma
 By far the most common type of kidney cancer.
 About 9 out of 10 kidney cancers are renal cell carcinomas.
 Although RCC usually grows as a single tumor within a kidney, sometimes there are 2 or more
tumors in one kidney or even tumors in both kidneys at the same time.
Epidemiology
 13th most common malignancy in the world
 The American Cancer Society’s most recent estimates for kidney cancer in the United States are
for 2014:
 About 63,920 new cases of kidney cancer (39,140 in men and 24,780 in women) will occur.
 1.7% acccording to Hospital records of 7 different hospitals of Nepal (2007)
 Overall, the lifetime risk for developing kidney cancer is about 1 in 63 (1.6%). This risk is higher
in men than in women.
Types
There are several subtypes of RCC, based mainly on how the cancer cells look under a microscope.
The 2004 World Health Organization (WHO) classification of genitourinary tumours recognizes over
40 subtypes of renal neoplasms. Some of them are as follows:
Clear cell papillary renal cell carcinoma and Clear cell renal cell carcinoma with smooth muscle
stroma: Most common form of renal cell carcinoma.
 Mucinous tubular and spindle cell carcinoma (MTSCC)
 Multilocular cystic clear cell renal cell carcinoma
 Tubulocystic renal cell carcinoma
 Thyroid-like follicular renal cell carcinoma
 Acquired cystic kidney disease-associated renal cell carcinoma
 Renal cell carcinoma with t(6;11) translocation (TFEB)
 Hybrid oncocytoma/chromophobe renal cell carcinoma
 Hereditary leiomyomatosis and renal cell carcinoma (HLRCC)

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Transitional Cell Carcinoma
 Malignant tumor arising from the transitional (urothelial) epithelial cells lining the urinary tract
from the renal calyces to the ureteral orifice.
 Most common tumor of the renal pelvis.
 Upper urinary tract TCC in 5% of all urothelial cancers
 Surgical intervention is the main form of radical treatment for localized disease.
 Medical therapy administered as an adjuvant to surgical therapy or to patients in whom surgical
treatment is contraindicated
 The role of radiation therapy is not well defined.
Risk Factors and causes
Lifestyle-related and job-related risk factors
 Smoking
 Obesity: Obesity may cause changes in certain hormones that can lead to RCC.
 Workplace exposures: Substances like cadmium (a type of metal), some herbicides, and organic
solvents, particularly trichloroethylene.
 Genetic and hereditary risk factors:
• Von Hippel-Lindau disease: Mutations (changes) in the VHL gene.
• Hereditary papillary renal cell carcinoma: Changes in the MET (Mesenchymal Epithelial
Transition) gene.
• Hereditary leiomyoma-renal cell carcinoma: Changes in the FH (Fumarate Hydratase) gene.
• Birt-Hogg-Dube (BHD) syndrome: Chnages in the FLCN (Folliculin) gene.
• Familial renal cancer: Defects in the genes SDHB (Succinate Dehydrogenase subunit B) and
SDHD (Succinate Dehydrogenase subunit D).
• Hereditary renal oncocytoma
Other risk factors
 Family history of kidney cancer: This risk is highest in brothers or sisters of those with the cancer
 High blood pressure
 Certain medicines
• Phenacetin: Once a popular non-prescription analgesic and antipyretic, this drug has been
linked to RCC in the past.
• Diuretics: It is not clear whether the cause is the drugs or the high blood pressure they treat.
 Advanced kidney disease: People with advanced kidney disease, especially those needing
dialysis, have a higher risk of RCC.
 Gender: Twice as common in men as in women.
 Race: African Americans and American Indians/Alaska
Signs and symptoms of kidney cancer
 Early kidney cancers: asymptomatic
 Blood in the urine (hematuria)

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 Low back pain on one side (not caused by injury)
 A mass (lump) on the side or lower back
 Fatigue (tiredness)
 Weight loss
 Fever that is not caused by an infection and that doesn’t go away
 Anemia
 Hypertension
 Hypercalcemia manifestations (nausea, vomiting, constipation, flank pain, etc)
 Night sweats
 Malaise
 Varicocele (2% of males): Usually left sided, due to obstruction of the testicular vein
Diagnosis
Medical history and physical examination
 A complete medical history for risk factors and to learn more about the symptoms.
 A physical exam can provide information about signs of kidney cancer and other health
problems. For example, the doctor may be able to feel an abnormal mass when he or she
examines the abdomen.
 If symptoms or the results of the physical exam suggest kidney cancer, lab tests and imaging
tests are done.
Lab tests
 Urinalysis: About half of all patients with renal cell cancer will have blood in their urine. If the
patient has transitional cell carcinoma (in the renal pelvis, the ureter, or the bladder), urine
cytology will show actual cancer cells in the urine.
 Complete blood count: Anemia is very common. Less often, a person may have polycythemia
because of excessive erythropoietin production.
 Blood chemistry tests: Elevated liver enzymes are sometimes found. High blood calcium levels
may indicate that cancer has spread to the bones, and may therefore prompt a doctor to order
a bone scan.
TNM classification
Primary tumors (T)
 TX: Primary tumor cannot be assessed
 T0: No evidence of primary tumor
 T1: Tumor ≤7 cm in greatest dimension, limited to the kidney
 T1a:Tumor ≤4 cm in greatest dimension, limited to the kidney
 T1b: Tumor >4 cm but ≤7 cm in greatest dimension, limited to the kidney
 T2: Tumor >7 cm in greatest dimension, limited to the kidney
 T2a: Tumor >7 cm but ≤10 cm in greatest dimension, limited to the kidney

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 T2b: Tumor >10 cm, limited to the kidney
 T3: Tumor extends into major veins or perinephric tissues but not into the ipsilateral adrenal
gland and not beyond the Gerota fascia
 T3a: Tumor grossly extends into the renal vein or its segmental (muscle-containing) branches, or
tumor invades perirenal and/or renal sinus fat but not beyond the Gerota fascia
 T3b: Tumor grossly extends into the vena cava below the diaphragm
 T3c: Tumor grossly extends into the vena cava above the diaphragm or invades the wall of the
vena cava
 T4: Tumor invades beyond the Gerota fascia (including contiguous extension into the ipsilateral
adrenal gland)
Regional lymph node (N)
 NX: Regional lymph nodes cannot be assessed
 N0: No regional lymph node metastasis
 N1: Metastasis in regional lymph node(s)
 M0: No distant metastasis
 M1: Distant metastasis
Staging
 Stage I: T1 N0 M0
 Stage II: T2 N0 M0
 Stage III: T1-2 N1 M0 or T3 N0-1 M0
 Stage IV: T4 N2 M0 or Any T Any N M1
Treatment: The treatment options for kidney cancer may include
 Surgery
 Ablation and other local therapies
 Active surveillance
 Targeted therapy
 Immunotherapy (biologic therapy)
 Chemotherapy
Surgery for kidney cancer
Radical nephrectomy: The whole kidney, the attached adrenal gland, and the fatty tissue around the
kidney are removed. The most common sites of incision are the middle of the abdomen (belly), under
the ribs on the same side as the cancer, or in the back, just behind the kidney.
Laparoscopic nephrectomy and robotic-assisted laparoscopic nephrectomy: For a laparoscopic
nephrectomy, special long instruments are inserted through the incisions, each of which is about 1/2-
inch long, to remove the kidney. A newer approach is to do the laparoscopic surgery remotely using a
robotic interface (called the da Vinci system). The surgeon sits at a panel near the operating table

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and controls robotic arms to perform the operation.
Partial nephrectomy (nephron-sparing surgery): Only the part of the kidney that contains cancer is
removed, leaving the rest of the organ behind. Preferred treatment for many people with early stage
kidney cancer. The obvious benefit is that the patient keeps more of their kidney function.
Regional lymphadenectomy (lymph node dissection): This procedure removes nearby lymph nodes
to see if they contain cancer.
Removal of metastases: The metastasis may be removed at the same time as a radical nephrectomy
or at a later time if the cancer recurs (comes back).
Surgery to relieve symptoms (palliative surgery) : When other treatments aren’t helpful, surgically
removing the metastases can sometimes relieve pain and other symptoms.
Risks and side effects of surgery: The short-term risks include reactions to anesthesia, pain, excess
bleeding (which might require blood transfusions), blood clots, and infections.
Other possible risks of surgery include:
 Damage to internal organs and blood vessels (such as the spleen, pancreas, aorta, vena cava,
large or small bowel) during surgery
 Pneumothorax
 Incisional hernia (bulging of internal organs near the surgical incision due to problems with
wound healing)
 Leakage of urine into the abdomen (after partial nephrectomy)
 Kidney failure (if the remaining kidney fails to function well)
Ablation and other local therapy for kidney cancer
 Cryotherapy (cryoablation): This approach uses extreme cold to destroy the tumor.
 Radiofrequency ablation (RFA): This technique uses high-energy radio waves to heat the tumor.
 Arterial embolization: This technique is used to block the artery that feeds the kidney that has
the tumor.
Active surveillance for kidney cancer
 For some patients with small kidney tumors, watch the tumor carefully to see if it grows.
 The tumor is removed (or treated another way) if it grows quickly or gets larger than 4 cm.
 This approach is most often used in elderly or frail patients as it avoids the risks of treatment.
Radiation therapy
 Uses high-energy radiation to kill cancer cells.
 External beam therapy focuses radiation from a source outside the body on the cancer.
Possible side effects
 Skin changes (similar to sunburn)
 Hair loss where the radiation passes through the skin
 Nausea
 Diarrhea
 Tiredness
 Shortness of breath (when chest is exposed)

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Targeted therapies for kidney cancer
 Drugs different from standard chemotherapy drugs.
 Often used as the first line of treatment against advanced kidney cancers.
 These drugs block angiogenesis or important proteins in cancer cells (called tyrosine kinases) that
help them grow and survive.
 Some targeted drugs affect both of these.
 Some examples are Sorafenib, Sunitinib, Temsirolimus, Everolimus, Bevacizumab, Pazopanib,
Axitinib, etc.
Biologic therapy (immunotherapy) for kidney cancer
 The goal is to boost the body’s immune system to help fight off or destroy cancer cells.
 Main drugs used are cytokines (man-made versions of natural proteins that activate the immune
system).
 Most often used cytokines are interleukin-2 (IL-2) and interferon-alpha. Both cytokines can cause
kidney cancers to shrink in a small percentage of patients.
Chemotherapy for kidney cancer
 Useful for cancer that has spread (metastasized) to organs beyond the kidney.
 Not standard treatment for kidney cancer as kidney cancer cells resistant to chemo.
 Some chemo drugs, such as vinblastine, floxuridine, 5-fluorouracil (5-FU), capecitabine, and
gemcitabine have been shown to help a small number of patients.
Possible side effects of chemotherapy
 The side effects of chemo depend on the type of drugs, the amount taken, and the length of
treatment. Possible side effects can include:
• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea or constipation
• Increased chance of infections
• Easy bruising or bleeding
• Fatigue
Lifestyle changes after treatment for kidney cancer
 Making healthier choices: Try to eat better, get more exercise, cut down on alcohol or give up
tobacco. Even things like keeping the stress level under control may help.
 Eating better: Eat small, frequent meals to avoid nausea and vomiting. An expert in nutrition be
sought through a dietician. Maintain a healthy weight.
 Rest, fatigue, and exercise: Studies have shown that patients who follow an exercise program
tailored to their personal needs feel better physically and emotionally and can cope better, too.
Balance activity with rest.

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Nursing Management
Nursing Assessment
 Assess for clinical manifestations of systemic diseases like fatigue, anorexia, weight loss, pallor,
fever as well as evidence of metastasis.
 Assess cardiopulmonary and nutritional status before surgery.
 Monitor for adverse effects and complications of diagnostic tests and treatment.
 Assess pain control and coping ability.
Nursing Diagnoses
 Anxiety related to diagnosis of cancer and possibility of metastatic disease
 Acute Pain and hyperthermia related to postinfarction syndrome
Reducing Anxiety
 Explain each diagnostic test, its purpose, and possible adverse reactions. Ensure that informed
consent has been obtained as indicated.
 Assess patient's understanding about diagnosis and treatment options. Answer questions, and
encourage more thorough discussion with health care provider as needed.
 Encourage patient to discuss fears and feelings; involve family and significant others in teaching.
Controlling Symptoms of Postinfarction Syndrome
 Administer analgesics as prescribed to control flank and abdominal pain.
 Encourage rest, and assist with positioning for 2 to 3 days until syndrome subsides.
 Obtain temperature every 4 hours, and administer antipyretics as indicated.
 Restrict oral intake and provide I.V. fluids while patient is nauseated.
 Administer antiemetics as ordered.
Pre-op teaching
 Includes the following teaching points before the patient is sent for surgery:
 1 week before surgery, instruct the patient not to take anticlotting medications.
 Teach the patient about the post-op use of incentive spirometry and splinting of his incision.
 Explain the position of the patient's wound and the limitations he may experience:
 Offer emotional support and explain to the patient that his body will adapt to having only one
functioning kidney.
Post-op care
 After the patient has undergone a nephrectomy, the post-op nursing care must be marked by
astute assessment for potential complications with bleeding, breathing, and elimination. The plan
of care for the duration of the patient's hospital stay should focus on the following areas that will
require frequent monitoring and assessment.
 Assess the patient's wound regularly for redness, inflammation, or swelling and approximation of
the suture line.
 Assess his dressing frequently.

179
 Reinforce and change his dressing as needed.
 Measure and record output from all drains (possible chest tube care for radical nephrectomy).
 Instruct the patient concerning his pain control with patient-controlled analgesia or epidural or
I.V. pain medication.
 Encourage and assist him with turning and deep breathing while splinting the incision.
 Encourage him to perform incentive spirometry.
 Measure the patient's urine output.
 Monitor his chemistry, especially serum creatinine levels.
 Assist the patient to begin walking immediately post-op.
Discharge teaching
 When the patient is ready to go home, the following points must be included:
 Teach the patient proper hand-washing techniques.
 Explain wound care and that bruising around the incision site and bilateral swelling of
extremities is common.
 Instruct the patient not to drive, lift anything, or engage in strenuous or sexual activity until his 2-
week follow-up appointment.
 Encourage him to consume 2 L of water per day to maintain hydration.
 Instruct him to take a stool softener as ordered to avoid straining during bowel movements.
 Explain the need for regular lab work to monitor the remaining kidney's function.
• Teach the patient when he should contact his healthcare provider:
• The wound is painful, red, or inflamed
• Fever, pain in the back, or chills are present
• Urine is foul smelling or cloudy
• One leg is painful and swollen.
Patient Education and Health Maintenance
 Ensure that patient understands where and when to go for follow-up (surgeon, primary care
provider, oncologist, and radiologist for metastatic workup and treatment).
 Explain the importance of follow-up for hypertension and renal function, even if patient feels
well.
 Advise patient with one kidney to wear a Medic Alert bracelet and notify all health care
providers because potentially nephrotoxic medications and procedures must be avoided.
 Asks questions and verbalizes fears
 Afebrile; states reduced pain
Prognosis
Survival predictors
 High blood lactate dehydrogenase (LDH) level
 High blood calcium level

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 Anemia (low red blood cell count)
 Cancer spread to 2 or more distant sites
 Less than a year from diagnosis to the need for systemic treatment (targeted therapy,
immunotherapy, or chemotherapy)
 Poor performance status (a measure of how well a person can do normal daily activities)
People with none of the above factors are considered to have a good prognosis; 1 or 2 factors are
considered intermediate prognosis, and 3 or more of these factors are considered to have a poor
prognosis and may be more or less likely to benefit from certain treatments.
Survival rates by AJCC TNM stage
People with kidney cancer tend to be older and may have other serious health conditions. Therefore,
the percentage of people surviving the cancer itself is likely to be higher.
Stage 5-Year Survival Rate
• I 81%
• II 74%
• III 53%
• IV 8%
Recent Advacnes
 New approaches to local treatment: High-intensity focused ultrasound (HIFU)
 Targeted therapies: Many new targeted therapies drugs are now being tested, with including
cediranib and trebananib.
 Immunotherapy: Clinical trials of many new immunotherapy methods are being tested.
 Drugs that block PD-1 and PD-L1: Several drugs that block PD – L1 proteins are now in
development.
 Vaccines: Several types of vaccines are being tested in clinical trials.
 Bone marrow or peripheral blood stem cell transplant: First, very early forms of immune
system cells (called stem cells) are collected from a compatible donor, either from their bone
marrow or their blood. The person with cancer is then treated with chemotherapy drugs, either in
lower doses (called a mini or nonmyeloablative stem cell transplant) to suppress the immune
system or in higher doses to cause more severe damage to the immune cells and other
components of the bone marrow. They are then given the donor stem cells to try to build a new
immune system that will be more likely to attack the cancer cells.


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Unit : 28
THYROID CANCER
Introduction: Thyroid cancer is a disease in which the cells of the thyroid gland become abnormal
grow uncontrollabl form a mass of cells called a tumor. Thyroid tumors are either benign (non-
cancerous) or malignant (cancerous) growths. Examples of benign tumors are adenomas, which may
secrete thyroid hormone. Malignant tumors are rare and are more common in women than in men.
Incidence and Mortality
 Most common malignancy of the endocrine system.
 Differentiated tumors (papillary or follicular) are highly treatable and usually curable.
 Poorly differentiated tumors (medullary or anaplastic) are much less common, are aggressive,
metastasize early, and have a much poorer prognosis.
 Thyroid cancer affects women more often than men and usually occurs in people between the
ages of 25 and 65 years.
Risk Factors
 Patients with a history of radiation administered in infancy and childhood for benign conditions
of the head and neck
 A history of goiter.
 Family history of thyroid disease.
 Female gender.
 Asian race.
Classification of Thyroid Cancer
 Benign thyroid enlargement and nodules
 Malignant (cancerous) thyroid tumors
There are four main varieties of thyroid cancer
1. Papillary carcinoma
2. Follicular carcinoma: Hürthle cell carcinoma, a variant of follicular carcinoma with a poorer
prognosis.
3. Medullary carcinoma
4. Anaplastic carcinoma: Small cell carcinoma and Giant cell carcinoma
5. Others : Lymphoma, Sarcoma, Carcinosarcoma
1. Papillary Carcinoma
• Most common cancer of the thyroid, about 8 out of 10 thyroid cancers are papillary
carcinomas
• Tend to grow very slowly and usually develop in only one lobe of the thyroid gland.
• Often spread to the lymph nodes in the neck.

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Aetiology
• Irradiation to the neck during childhood.
• It can be a complication of Hashimoto’s thyroiditis.
Pathology
• It is made up of colloid-filled follicles with palillary projections.
• In some cases, calcified lesions are found which are called psammoma bodies. These are
diagnostic of papillary carcinoma of thyroid.
• Characteristic pale, empty, nuclei are present in a few cases which are described as Orphan
Annie eyed nuclei.
• Papillary carcinoma can be unifocal or multifocal.
Clinical presentation
• Young females are commonly affected (in the age of 20-40 years).
• It can present as a solitary nodule.
• Very often, the lymph nodes in the lower deep cervical region are involved and thyroid may
or may not be palpable.
• A few patients present late to the hospital with fixed nodes in the neck, and fixed thyroid to
the trachea with or without recurrent laryngeal nerve paralysis.
Investigations
• All routine investigations such as blood examination, chest X-Ray, laryngoscopy have to be
done.
• Thyroid scan may demonstrate a cold nodule.
• FNAC can demonstrate colloid filled follicles with papillary process.
Treatment
• Near-total thyroidectomy
• Total lobectomy on the side of the lesion and a subtotal on the opposite side
• If FNAC is inconclusive, hemithyroidectomy specimen or a good portion of the diseased lobe
is sent for frozen section.
• If frozen section is reported as malignant, near total thyroidectomy is completed.
Types of Thyroidectomy
• Thyroid lobectomy - removing half of the butterfly shaped gland.
• Thyroid lobectomy and isthmusectomy - removing half of the gland and the middle part of
the gland.
• Near-total or total thyroidectomy - removing the entire gland.
• Subtotal thyroidectomy - leaves behind a part of the thyroid gland.
• Minimally invasive thyroidectomy – thyroidectomy performed through a very small incision.
• Endoscopic video-assisted thyroidectomy – thyroidectomy performed through several very
small incisions, aided by a small camera inserted into the neck.

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Treatment of secondaries in the lymph nodes
• Lymph node secondaries are treated by functional block dissection.
• Other strucutres such as internal jugular vein, sternocleidomastoid muscle etc are not removed
because lymph nodes are slow growing and they rarely spread outside the capsule of the
lymph node.
Suppression of TSH
• Papillary carcinoma is TSH dependent tumour.
• To prevent the patient developing hypothyroidism in the postoperative period and to
suppress TSH, thyroxine 0.3mg/day is given.
2. Follicular Carcinoma
• Incidence: Constitutes 17% of cases
• Follicular adenoma: 20% are malignant and 80% are benign
• Well-differentiated tumor resembles the normal microscopic pattern of the thyroid.
• Originates in follicular cells and is the second most common cancer of the thyroid, after
papillary carcinoma.
Aetiology
• Follicular carcinoma usually arises in a multinodular goitre, especially in cases of endemic
goitre.
• It should be suspected when MNG starts growing rapidly.
Pathology
• Depending upon the property of invasion, it is classified into:
 Non-invasive which means minimal invasion.
 Invasive refers to angio-invasion and capsular invasion, necessary for the diagnosis of
follicular carcinoma of thyroid.
Clinical presentation
• It can be present as a solitary nodule.
• In cases of long-standing multinodular goitres, if the goitre is rapidly growing, if it is hard
or it is present with restricted mobility, follicular carcinoma can be considered.
• Metastasis in the flat bones: Pathological fractures or pulsatile swelling.
Routine investigations
• Thyroid scan is done to demonstrate cold nodule.
• FNAC of the cold nodule.
• Alkaline phosphatase – if increased, bone scan should be done.
• Plain X-Ray of the involved bone can reveal osteolytic lesions.
• When primary is not found, bone biopsies from the secondaries.
Treatment
• Near-total thyroidectomy
• After near-total thyroidectomy, a whole body bone scan is done to see for metastasis in the
bone.
• In the postoperative period, patients should receive thyroxine 0.3mg/day.

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3. Medullary Carcinoma
• Arise from parafollicular ‘C’ cells.
• Often release too much calcitonin and a protein called carcinoembryonic antigen (CEA) into
the blood.
• Because MTC does not absorb or take up radioactive iodine (used for treatment and to find
metastases of differentiated thyroid cancer), the prognosis (outlook) is not quite as good as
that for differentiated thyroid cancers.
These tumors present in two different ways:
• Sporadic is common, seen in about 80-90% of cases.
• Familial variety presents as a part of Multiple Endocrine Neoplasia (MEN).
• MEN is when two or more endocrine tumor types, known to occur as a part of one of the
defined MEN syndromes, occurs in a single patient and there is evidence for either a
causative mutation or hereditary transmission.
Treatment
• Before proceeding with surgery, look for an associated pheochromocytoma.
• Near-total thyroidectomy or total thyroidectomy
• The lymph nodes are treated by radical block dissection because they are fast growing,
when compared to papillary carcinoma.
4. Anaplastic Carcinoma
• Rare form of thyroid cancer.
• Cancer cells do not look very much like normal thyroid cells under the microscope
(undifferentiated).
• Spreads quickly into the neck and to other parts of the body, and is very hard to treat.
• Incidence 10-12% of cases
Clinical features
• Common in elderly women around 60-70 years of age
• Surface of the swelling is regular and consistency is hard.
• Early infiltration of the trachea results in stridor.
• Infiltration of carotid sheath results in absent carotid artery pulsation known as Berry sign
positive.
• Early fixity is characterisitc. Thus, the resectability rate is almost nil.
• Diagnosis is established by FNAC.
Treatment
• Excision of isthmus so as to relieve compression of the trachea.
• Postoperative radiation as a palliative treatment.
5. Hurthle Cell Carcinoma
• Variant of follicular carcinoma.
• These tumors are defined by the presence of more than 75% follicular cells having oncocytic
features.

185
• Does not take up I131.
• Secretes thyroglobulin.
Criteria to diagnose Hurthle cell carcinoma
• Capsular/vascular invasion, distant metastasis
• Higher chance of spread to lymph nodes
Treatment
• Total thyroidectomy
• TSH suppression
Malignant Lymphoma
• It is rare.
• Hashimoto’s thyroiditis can predispose to malignant lymphoma.
• Older patients are commonly affected.
• The tumor can present as rapidly growing, large thyroid swelling (primary lymphoma).
• FNAC can give the diagnosis.
• It responds very well to chemotherapy or radiotherapy.
Papillary
Thyroid
Cancer
Follicular
Thyroid
Cancer
Medullary
Thyroid
Cancer
Anaplastic
Thyroid
Cancer
80% of
thyroid
cancers
Begins in
follicular
cells
Grows
slowly
treatment
rate if
found early
15% of
thyroid
cancers
Begins in
follicular
cells
Grows
slowly
treatment
rate if
found early
3% of
thyroid
cancers
Begins in C
cells
Grows
slowly
Easier to
control if
found early
2% of
thyroid
cancers
Begins in
follicular
cells
Grows
quickly
Very hard
to control
Flow Chart: Thyroid Cancer Overview
Clinical criteria for the diagnosis of carcinoma of thyroid s
 Presence of a single nodule rather than multiple nodules
 Thyroid scan reveals the nodule is not functioning
 Nodule is solid instead of filled with fluid (cyst)

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 Rapidly growing
 Swelling with lower deep cervical lymph nodes
 Hard gland, fixed to the trachea
 Rapidly growing, vascular pulsatile swelling
 Hoarseness of the voice
 Difficulty swallowing as the cancer presses on the throat
 Throat or neck pain that does not go away
 Breathing problems
 A cough that does not go away
TNM Classification
 TX - Primary tumor cannot be assessed.
 T0 - No evidence of primary tumor.
 T1 - Tumor ≤2 cm in greatest dimension limited to the thyroid.
 T1a - Tumor ≤1 cm, limited to the thyroid.
 T1b - Tumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.
 T2 - Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.
 T3 - Tumor >4 cm in greatest dimension limited to the thyroid or any tumor with minimal
extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).
 T4a - Moderately advanced disease.
 Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues,
larynx, trachea, esophagus, or recurrent laryngeal nerve.
 T4b - Very advanced disease.
 Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.
 cT4a - Intrathyroidal anaplastic carcinoma.
 cT4b - Anaplastic carcinoma with gross extrathyroid extension.
 NX - Regional lymph nodes cannot be assessed.
 N0 - No regional lymph node metastasis.
 N1 - Regional lymph node metastasis.
 N1a - Metastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph
nodes).
 N1b - Metastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or
retropharyngeal or superior mediastinal lymph nodes (Level VII).
 M0 - No distant metastasis.
 M1 - Distant metastasis.
General management
Radioactive iodine ablation
 Postoperative whole-body scintigraphy scan may identify previously unrecognized disease and
influence staging. If residual disease is found, adjuvant therapy with radioactive iodine (RAI)
may be considered.

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RAI ablation is indicated for patients with any of the following:
 Large (>4 cm) tumors
 Known distant metastasis
 Gross extrathyroid extension
RAI ablation may be considered for tumors with the following characteristics:
 Moderate-size (1-4 cm) and node positive
 Grossly multifocal
 Aggressive, based on histology
 High risk, based on patient factors (age >45 y, history of head and neck radiation, family
history of thyroid cancer)
Thyroid-stimulating hormone (TSH) suppression therapy (levothyroxine)
 TSH suppression to < 0.1 mU/L is indicated in intermediate and high-risk disease.
 TSH maintenance at or slightly below the lower-normal limit (0.3-2 mU/L) may be considered for
low-risk disease
For unresectable disease or metastases
 Unresectable gross residual/recurrent disease/metastases may be treated with external beam
radiation therapy (EBRT)
 Consider systemic treatment for persistent metastatic disease
 Tyrosine kinase inhibitors (TKIs) such as sorafenib 400 mg PO BID or sunitinib 50 mg PO daily
for 4wk of a 6-wk cycle
 Pazopanib 800 mg PO daily for progressive or symptomatic metastatic differentiated (Hürthle
cell, papillary, and follicular) thyroid carcinoma
 Doxorubicin 60 mg/m2 as monotherapy or in combination with cisplatin 40 mg/m2 for patients
who cannot tolerate TKIs or in whom TKIs have failed; however, efficacy very limited
For differentiated thyroid cancer (DTC)
 Consider scintigraphy especially in the setting of thyroid-stimulating hormone (TSH) in the low-
normal range
 Hyperfunctioning nodules may be observed; however, if a concordant hyperfunctioning nodule is
not identified, lobectomy or total thyroidectomy should be considered
For hurthle cell neoplasm
 Surgery based on patient factors and surgeon expertise (scintigraphy not required)
 Hemithyroidectomy for patients with an isolated, indeterminate, solitary nodule
Papillary and follicular thyroid cancer stages I-IV (confirmed by cytology)
 Total thyroidectomy is recommended for tumors >1 cm
 Hemithyroidectomy may be considered for small (< 1 cm), low risk, unifocal, intrathyroid tumors
in the absence of prior head and neck radiation and cervical nodal metastasis
 Therapeutic central neck dissection when cervical lymph nodes are involved
 When lateral cervical lymph nodes have biopsy-proven disease, therapeutic central and lateral
compartment neck dissection should be performed

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 Prophylactic unilateral or bilateral central neck dissection may be considered in clinically N0
disease, especially for advanced primary tumors (T3 or T4)
 Current National Comprehensive Cancer Network (NCCN) guidelines recommend lobectomy plus
isthmusectomy as the initial surgery for patients with follicular neoplasms, with prompt completion
of thyroidectomy if invasive FTC is found on the final histologic section.
For medullary cancer
 Total thyroidectomy with prophylactic or therapeutic central neck dissection (level VI)
 For patients with minimal or no distant metastasis - therapeutic compartmental lateral neck
dissection
 Palliative debulking surgery may be considered to relieve tracheal compression and local pain
 Thyroxine replacement therapy postoperatively to maintain euthyroidism.
NURSING MANAGEMENT
Pre-operative Nursing Management
Nursing Assessment
 Assess level of anxiety and ability to cope with symptoms.
 Explore patient's feelings and concerns regarding the diagnosis, treatment and prognosis.
 Assess nutritional status and drug history.
 Monitor weight and bowel function.
 Note degree of muscle weakness.
 Monitor vital signs and note any changes such as increased pulse rate and blood pressure.
 Assess the effect of the goiter on breathing and swallowing. Stridor, a whistling sound, may be
heard if the airway is obstructed.
Nursing Diagnosis
 Anxiety related to concern about cancer, upcoming surgery
 Activity intolerance related to fatigue
 Constipation related to slowed gastrointestinal motility
 Impaired skin integrity related to dry skin, inactivity
 Altered nutrition, more than requirements, related to decreased metabolic rate
 Deficient knowledge related to lack of exposure to information about surgery
 Risk for injury related to forthcoming surgery
Alleviating Anxiety
 Reassure the patient that symptoms will be relieved after surgery.
 Allow the patient time to express fears and ask questions.
 Provide all explanations in a simple, concise manner and repeat important information as
necessary because anxiety may interfere with patient's processing of information.
 Stress the positive aspects of treatment, high cure rate as outlined by health care provider.
 Encourage support by significant other, social worker, nursing staff as available

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Managing Activity Intolerance
 Assist patient with self-care activities.
 Allow for rest between activities.
 Slowly increase patient’s activities as medication begins to be effective.
Relieving Constipation
 Monitor and record bowel movements.
 Help patient follow usual preillnesspattern (e.g., after morning coffee).
 Increase fluids to eight 8-ounce glasses of water daily if cardiovascular status stable.
 Add fiber to diet: fresh fruit, vegetables, bran.
 Encourage regular ambulation.
 Use bedside commode or bathroom rather than bedpan.
 Obtain physician order for stool softener if needed.
 If stool is impacted, break up stool digitally and gently remove.
 Avoid use of enemas
Maintaining Skin Integrity
 Assess skin daily for breakdown.
 Avoid use of soap on dry areas. Try bath oil.
 Use nondrying lotion following bath.
 Encourage/assist with position changes at least every 2 hours.
Maintaining Optimum Nutrition
 Weigh weekly and record.
 Consult dietitian for therapeutic diet until hypothyroidism is controlled.
 Encourage regular exercise within limits of fatigue.
 Counsel patient that weight should normalize once hypothyroidism is controlled.
Enhancing knowledge
 Assess the patient’s level of understanding
 Provide accurate, concrete information about what is being done and what will be the possible
outcomes.
 Provide/review information regarding disease process, treatment regimen, prognosis and also
encourage for questions.
 Refer to concern physician or surgeon for more accurate information regarding disease process
and need of surgery.
Post-Operative Nursing Management
Nursing Assessment
 Monitor vital signs and dressings every 15 minutes initially, progressing to every 4 hours as
ordered.

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 Decreased blood pressure with increased pulse is possibility of shock related to blood loss.
 Tachycardia and fever, along with mental status changes, may indicate thyrotoxic crisis.
 Check the back of the neck for pooling of blood.
 Observe for signs of respiratory distress, including an increase in respiratory rate, dyspnea, or
stridor.
 Ask the patient to speak to detect hoarseness of the voice, which may indicate trauma to the
recurrent laryngeal nerve.
 Monitor the patient for evidence of tetany (tetany can occur if the parathyroid glands are
accidentally removed during thyroid surgery).
Nursing Diagnoses
 Acute pain related to surgical interruption/manipulation of tissues/muscles, postoperative edema
 Risk for complications (hemorrhage, tetany, edema) related to invasive procedure of the neck,
possible removal of parathyroid gland.
 Risk for infection related to invasive procedure, anasthesia.
Relieving Pain
 Assess verbal/nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.
 Place in semi-Fowler’s position and support head/neck in neutral position with sandbags or small
pillows as required in immediate postoperative phase.
 Instruct client to use hands to support neck during movement and to avoid hyperextension of
neck.
 Keep call light and frequently needed items within easy reach.
 Give cool liquids or soft foods, such as ice cream or popsicles.
 Encourage client to use relaxation techniques; e.g., guided imagery, soft music, progressive
relaxation.
 Administer analgesics and throat sprays/lozenges as necessary.
 Provide ice collar if indicated.
Minimizing Hemorrhage and Airway Edema
 Administer humidified oxygen as prescribed to reduce irritation of airway and to prevent
edema.
 Move the patient carefully; provide adequate support to the head so that no tension is placed
on the sutures.
 Place the patient in semi-Fowler's position, with the head elevated and supported by pillows;
avoid flexion of neck.
 Monitor vital signs frequently, watching for tachycardia and hypotension that indicates
hemorrhage (most likely between 12 and 24 hours postoperatively).
 Observe for bleeding at sides and back of the neck, and anteriorly, when the patient is in dorsal
position.
 Watch for repeated clearing of the throat or for complaint of smothering or difficulty
swallowing, which may be early signs of hemorrhage.

191
 Watch for irregular breathing, swelling of the neck, and choking
 Reinforce dressing if indicated.
 Keep a tracheostomy set in the patient's room for 48 hours for emergency use.
Preventing Tetany
 Watch for the development of tetany caused by removal or disturbance of parathyroid glands
through a progression of signs:
 Tingling of toes and fingers and around the mouth; apprehension.
 Positive Chvostek's sign tapping on the cheek over the facial nerve causes a twitch of the lip or
facial muscles.
 Positive Trousseau's sign carpopedal spasm induced by occluding circulation in the arm with a BP
cuff.
 Be prepared to treat hypocalcemic tetany.
 Position the patient for optimal ventilation; pillow removed to prevent head from bending
forward and compressing trachea.
 Keep side rails padded and elevated and position the patient to prevent injury if a seizure
occurs; do not use restraints because they only aggravate the patient and may result in muscle
strain or fractures.
 Have equipment available to treat respiratory difficulties that includes airway suction
equipment, tracheostomy, and cardiac arrest equipment.
 Administer I.V. calcium as directed.
Minimizing Infection
 Make sure that instruments are maintained in sterile condition before use.
 Check IV line site for thrombophlebitis.
 Administer antibiotic as per prescription.
 Encourage the patient to use the incentive spirometer to assist with deep breathing
 Encourage patient to do coughing and deep breathing exercises
 Teach the patient or significant other how to change the dressing and to report bleeding or signs
of infection at the site.
Patient Education and Health Maintenance
 Instruct the patient about thyroid hormone replacement and follow-up blood tests.
 Stress the need for periodic evaluation for recurrence of malignancy.
 Supply additional information or suggest community resources dealing with cancer prevention
and treatment.
 Assist patient in identifying sources of information and support available in the community
 Teach patient about complications to look for if discharge occurs within a day or two of surgery
(hypothyroidism occurs in 5% of patients in first postoperative year and hypoparathyroidism
occurs in about 4% of patients and is usually mild and transient; requires calcium supplements
I.V. and orally when more severe).
 Advise patient to rest at home and to prevent any strain on suture line as directed by surgeon.
 Advise nutritious diet; report difficulty swallowing.
 Encourage follow-up for monitoring and thyroid hormone replacement after surgery.


Hepatocellular (Liver) Carcinoma
192
Unit : 29
HEPATOCELLULAR (LIVER) CARCINOMA
Introduction: Hepatocellular carcinoma (HCC, also called malignant hepatoma) is the most common
type of liver cancer.The cell(s) of origin are believed to be the hepatic stem cells, although this
remains the subject of investigation.Tumors progress with local expansion, intrahepatic spread, and
distant metastases.Most cases of HCC are secondary to either a viral hepatitis infection (hepatitis B or
C) or cirrhosis (alcoholism being the most common cause of liver cirrhosis)
Incidence: HCC is now the third leading cause of cancer deaths worldwide, with over 500,000
people affected. The incidence of HCC is highest in Asia and Africa, where the endemic high
prevalence of hepatitis B and hepatitis C strongly predisposes to the development of chronic liver
disease and subsequent development of HCC.HCC- most commonly appears in a person with chronic
viral hepatitis (hepatitis B or hepatitis C, 20%) or/and with cirrhosis (about 80%).The annual global
incidence is approximately 1 million cases, with a male to female ratio of approximately 4:1 (1:1
without cirrhosis to 9:1 in many high-incidence countries).
Types of Liver Cancer
 Primary (originating in the liver): Primary liver tumors may be further divided into those that are
benign or malignant
 Metastatic (spread from another body organ to the liver): Metastatic tumors of the liver
commonly originate in the lung, colon, melanoma, gallbladder, breast, pancreas, or stomach.
Primary tumors can be further classified by the tissue of origin; either Mesenchymal (undifferentiated
tissue that arise form connective tissue) or Epithelial (membranous tissue that lines a tube or cavity).
Benign epithelial tumors include:
 Focal nodular hyperplasia: abnormal increase in the number of cells concentrated in a
particular location on an organ
 Hepatocellular adenoma: often associated with the use of birth control pills or hormones
Benign mesenchymal tumors include:
 Hamartoma: tumor-like but non-neoplastic overgrowth with a disordered structure
 Cavernous hemangioma—tumor that involves blood vessels and soft tissue; may enlarge in
women taking hormones; discontinuation of birth control pills hormone replacement therapy often
recommended
 Lipoma: tumor of fatty tissue
Primary malignant epithelial tumors include:
 Hepatocellular carcinoma (HCC): most common type of liver cancer; encompasses various forms
of adenocarcinoma (cancer that originates in epithelial tissue).
 Hepatoblastoma: type of liver tumor that occurs mostly in infants and children before age 3;
thought to be caused by an abnormal gene

193
Primary malignant mesenchymal tumors include:
 Angiosarcoma: begins in the lining of blood vessels
 Leiomyosarcoma: rare soft tissue cancer of smooth muscle tissue, usually in the uterus or wall of
the stomach, abdomen, and pelvic region
 Lymphoma: arises in cells of the lymphatic system
 Cholangiocarcinoma: tumor of the connective tissues of the bile ducts
 Hepatic cystadenocarcinoma: malignant neoplasm of glandular epithelium, characterized by
fluid-filled cysts
Symptoms
 Abdominal pain
 Weight loss
 Weakness
 Vomiting, and
 Jaundice (yellowing of the skin and eyes).
Physical signs include:
 Abdominal distention caused by hepatomegaly
 Ascites
 Splenomegaly and
 Wasting and fever.
Diagnosis
 Medical history and physical examination
 Hepatitis serology tests: Hepatitis B and C.
 Elevated Liver function tests
 Complete blood counts (CBC)
 Coagulation profile: A damaged liver might not make enough of these clotting factors, which
could increase your risk of bleeding. So a prothrombin time (PT) to help assess this risk.
Alpha-fetoprotein blood (AFP) test
 AFP is normally present at high levels in the blood of fetuses but drops to low levels shortly after
birth. Levels in adults can go up from liver disease, liver cancer, or other cancers.
Increased AFP
 During treatment, the test can be used to help give an idea of how well it is working, as the AFP
level should go down if treatment is effective.
Imaging studies
 Magnetic resonance imaging (MRI scan)
 Computed tomography (CT scan) with angiophotography (to differentiate benign and malignant
tumors)
 Diagnosis is confirmed by either needle or open biopsy

194
TNM Classification
 TX: The primary tumor cannot be evaluated.
 T0: There is no evidence of a primary tumor.
 T1: The tumor is 2 cm or smaller. It does not involve nearby blood vessels.
 T2: Either of these
Any tumor that involves nearby blood vessels, More than 1 tumor, but none larger than 5 cm.
 T3a: There is more than 1 tumor, and at least 1 is larger than 5 cm.
 T3b: A tumor of any size involves the major veins around the liver.
 T4: Either of these:
 The tumor has spread to the organs near the liver, except the gallbladder.
 The tumor has broken through the visceral peritoneum, which is the layer of tissue that lines the
abdomen.
Regional Lymph Node
 NX: Regional lymph nodes cannot be assessed.
 N0: No regional lymph node metastasis present.
 N1: Regional lymph node metastasis present.
Distant Metastasis
 MX: Presence of distant metastasis cannot be assessed.
 M0: No distant metastasis present.
 M1: Distant metastasis present.
Stage of the HCC by Combining the T, N, and M Classifications
 Stage I: This is the earliest stage of HCC. The tumor has not spread to the blood vessels, lymph
nodes, or other parts of the body (T1, N0, M0).
 Stage II: The tumor involves nearby blood vessels, but it has not spread to the regional lymph
nodes or other parts of the body (T2, N0, M0).
 Stage IIIA: The cancer has not spread beyond the liver, but the area of the cancer is larger than
stage I or II (T3a, N0, M0).
 Stage IIIB: The cancer involves a major vein around the liver, but it has not spread to nearby
lymph nodes or other parts of the body (T3b, N0, M0).
 Stage IIIC: Any tumor that has spread to the organs near the liver (except the gallbladder), or if
the tumor has broken through the visceral peritoneum. There is no spread to nearby lymph nodes
or other parts of the body (T4, N0, M0).
 Stage IVA: Any tumor that has spread to the regional lymph nodes but not to other parts of the
body (any T, N1, M0).
 Stage IVB: Any tumor that has spread to other parts of the body (any T, any N, M1).
Treatment
 Surgery (partial hepatectomy or liver transplant)
 Tumor ablation

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 Tumor embolization
 Targeted therapy
 Chemotherapy
 Surgery: Conventional resection- either lobar or wedge resection, liver transplantation, and
either pre-operative chemotherapy (neoadjuvant) followed by resection, or post-operative
chemotherapy (adjuvant).
 Chemotherapy: The drugs that have been most effective as systemic chemo in liver cancer are
• 5-fluorouracil
• Cisplatin
• Dxorubicin (Adriamycin)
Embolization therapy: A procedure that injects substances to try to block or reduce the blood flow to
cancer cells in the liver. The liver is unusual in that it has 2 blood supplies. Most normal liver cells are
fed by branches of the portal vein, whereas cancer cells in the liver are usually fed by branches of
the hepatic artery. Blocking the branch of the hepatic artery feeding the tumor helps kill off the
cancer cells. It may be
 Chemoembolization
 Radiation embolization
Radiofrequency ablation (RFA): This procedure uses high-energy radio waves for treatment. The
doctor inserts a thin, needle-like probe into the tumor. A high-frequency current is then passed through
the tip of the probe, which heats the tumor and destroys the cancer cells. This is a common treatment
method for small tumors.
Ethanol (alcohol) ablation: This is also known as percutaneous ethanol injection (PEI). In this
procedure, concentrated alcohol is injected directly into the tumor to kill cancer cells.
Targeted therapy
Sorafenib: Sorafenib is a targeted drug that works in 2 ways. It helps block tumors from forming new
blood vessels, which they need to grow. It also targets some of the proteins on cancer cells that
normally help them grow.
Other nonsurgical measures:
 For most patients, treatment options other than palliative care are limited.
 For patients with Child class C cirrhosis and contraindications for transplantation, any intervention
has the potential to result in progressive hepatic decompensation.
 In these patients, treatment focuses on pain control, ascites, edema, and portosystemic
encephalopathy management.
 Pain control may provoke worsening of portosystemic encephalopathy, in that some patients are
sensitive to narcotics and sometimes benzodiazepines.
 Insomnia (depression and fear, or result ofportosystemic encephalopathy) may also worsened by
(narcotic-induced) constipation that should be prevented.
 Lactulose can be helpful, and the ideal dosage should lead to not more than and not fewer than
two or three bowel movements daily.

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 Aspirin and aspirinlike products, as a rule, are contraindicated in the patient with fluid retention
because prostaglandin inhibition can strongly enhance retention of water and salt. In addition,
consequences of platelet dysfunction may occur.
 Fluid overload is best managed with a combination of spironolactone (50-400 mg/day),
replaced by amiloride (10-20 mg/day) in case of painful gynecomastia, and furosemide (40-
160 mg/day)
 Large-volume paracentesis in excess of 5-7 L, even accompanied by intravenous albumin, can
result in renal decompensation and worsening of portosystemic encephalopathy.
 In terminal patients, hypoglycemia can be confused with hepatic coma and can be managed
with glucose infusions.
 Patients with large tumors have a short life expectancy, and every effort should be made to
preserve and enhance quality of life. Early referral to palliative care practitioners should be
considered.
Surgical management: Surgical Excision
 To remove a tumor together with surrounding liver tissue while preserving enough liver remnant
for normal body function.
 This treatment offers the best prognosis for long-term survival, but only 10-15% of patients are
suitable for surgical resection.
 After liver resection, as many as 75% of patients will develop intrahepatic recurrence within 5
years.
 Pathologic characteristics associated with a higher rate of recurrence include the following:
• Tumor at the resection margin
• Presence of cirrhosis
• Vascular invasion
• Advanced tumor grade
• Number of tumor nodules
• Microvascular portal vein thrombosis
 Other clinical factors associated with a higher rate of HCC recurrence include the following:
• Preresection serum alpha-fetoprotein (AFP) level higher than 10,000 ng/mL
• Large intraoperative transfusion requirements
• Preoperative aspartate aminotransferase (AST) level greater than twice normal
• Diagnosis of hepatitis C
Ablative therapies:
 Curative treatment of patients with HCC who are not candidates for resection or OLT is limited.
 However, local ablative therapies can be used either as a bridge to transplant by reducing the
risk of tumor progression or as a palliative procedure to extend disease-free survival.
 Ablative procedures, including ethanol injection, RFA, and cryotherapy, can be performed
percutaneously, laparoscopically, or via an open surgical approach.
 Percutaneous ethanol injection (PEI) was the first ablative technique used for HCC.

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 PEI involves the injection of alcohol directly into the tumor leading to complete ablation of up to
70% of lesions, which are less than or equal to 3 cm.
 It is generally performed with ultrasound guidance and requires 4-6 sessions to complete the
ablation.
 Cryoablation of tumors using a liquid nitrogen filled probe had been used historically for
ablation. However, as a result of higher complication rates and lower efficacy rates, it has
largely fallen out of the clinical armamentarium.
 Radiofrequency ablation (RFA) uses high frequency radio-waves to destroy tumor by local
heating.
 The electrodes are inserted into the liver tumor under ultrasound image guidance using
percutaneous, laparoscopic or open surgical approach.
 It is suitable for small tumors (<5 cm). RFA has the best outcomes in patients with a solitary tumor
less than 4 mm.
Liver transplantation: Liver transplantation to replace the diseased liver with a cadaveric liver or a
living donor graft has historically low survival rates (20%-36%).A viable option for stages I and II
tumors in the setting of cirrhosis is OLTX (orthotopic liver transplantation), with survival approaching
that for noncancer cases.OLTX for patients with a single lesion 5 cm or three or fewer nodules, each 3
cm (Milan criteria), resulted in excellent tumor-free survival (70% at 5 years). For advanced HCC,
OLTX has been abandoned due to high tumor recurrence rates.
Prognosis: The usual outcome is poor, because only 10–20% of HCC can be removed completely
using surgery. If the cancer cannot be completely removed, the disease is usually deadly within 3 to 6
months.This is partially due to late presentation with large tumours, but also the lack of medical
expertise and facilities in the regions with high HCC prevalence. However, survival can vary, and
occasionally people will survive much longer than 6 months. The prognosis for metastatic or
unresectable hepatocellular carcinoma has recently improved due to the approval of sorafenib
(Nexavar) for advanced hepatocellular carcinoma.
Nursing Assessment:
 Obtain history of hepatitis, alcoholic liver disease and cirrhosis, exposure to toxins, or other
potential causes.
 Assess for signs and symptoms of malnutrition, including recent weight loss, loss of strength,
anorexia, and anemia.
 Assess for abdominal pain, any right shoulder pain, and enlargement of the liver.
 Assess for fever, jaundice, ascites, or bleeding.
 Note any change in mental status as precipitating hepatic encephalopathy.
Nursing Diagnoses:
 Acute and Chronic Pain related to growth of tumor
 Imbalanced Nutrition: Less Than Body Requirements related to anorexia
 Excess Fluid Volume related to ascites and edema

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i. Controlling Pain:
• Administer pharmacologic agents, as ordered, to control pain, considering metabolism
through a liver with decreased function.
 Use caution not to administer doses more frequently than prescribed.
 Monitor for signs of drug toxicity.
• Provide nonpharmacologic methods of pain relief, such as massage and guided imagery.
• Position patient for comfort, usually in semi-Fowler's position.
• Assess patient's response to pain control measures.
ii. Improving Nutritional Status:
• Encourage patient to eat small meals and to take supplementary feedings such as Ensure.
• Assess and report changes in factors affecting nutritional needs: increased body
temperature, pain, signs of infection, stress level. Encourage additional calories as tolerated.
• Monitor daily weight.
iii. Relieving Excess Fluid Volume:
• Monitor vital signs and record accurate fluid intake and output.
• Restrict sodium and fluid intake as prescribed.
• Administer diuretics and replacement potassium as prescribed.
• Administer albumin and protein supplements as prescribed to draw fluid from interstitial to
intravascular space.
• Measure and record abdominal girth daily.
• Weigh daily, watching for increases that indicate increased fluid retention.
• Monitor laboratory values pertinent to liver function.
iv. Patient Education and Health Maintenance:
• Instruct patient and family on preparation for surgery reinforce and clarify surgical
procedure proposed, and review postoperative instructions.
• Instruct patient and family on nonsurgical treatment, if appropriate.
• Explore pain management options.
• Inform patient of signs and symptoms of complications.
• Instruct patient in continued surveillance for recurrence.
• Instruct patient and family in care of tubes or drains.
 Verbalizes reduced pain
 Tolerates small feedings; no weight loss
 Abdominal girth decreased; urine output greater than intake
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Unit : 30
GALL-BALDDER CANCER
Epidemiology: Fifth most common GI malignancy, more common in women, High incidence in S
America (Chile), about 1% of pt’s undergoing cholecystectomy for symptomatic gallstones.
Risk Factors
 Gallstones
 Gallbladder Polyps
 Chronic Salmonella infection
 Abnormal Pancreaticobiliary duct junction
 Porcelain gallbladder
 Age
Presentation/Diagnostic Imaging
 Presentation is non-specific
 Diagnositic Imaging
• Sono
• CT
• MR/MRCP
• EUS
Histology/Pathology
Progression to Ca may take up to 15 yrs
 Adenocarcinoma 80-90%
 Anaplastic 7%
 Squamus 6%
Staging
TABLE I
TNM Staging System for Gall-blader Carcinoma
Primary tumor
T1 Tumor invades the lamina propria or muscular layer
T2 Tumor invades the perimuscular connective tissue but not through serosa
T3 Tumor perforates the serosa but <2 cm into liver
T4 Tumor extends >2 cm into liver or invades >2 adjacent organs
Regional lymph nodes
N1 Tumor in cystic, peridochal or hilar lymph nodes
N2 Tumor in peripancreatic, periduodenal, celiac or superior mesenteric lymph nodes
Distant metastases
M1 Distant metastases

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Stage
1 T1, N0, M0
2 T2, N0, M0
3 T1, T2 or T3: N1, M0
T3, N0, M0
4A T4
4B N2 or M1
Table: TNM Staging of Gall blader Cancer
Surgical Management
 Only 10-30% resectable at the time of diagnosis
 Three Presentations:
• GB CA discovered during or after lap/open chole for assumed benign dz
• GB CA suspected after diagnostic evaluation
• GB CA advanced stage at presentation
Surgical Options
 Simple cholecystectomy
 Radical cholecystectomy
 Radical chole w/ anatomic liver resection
 Radical chole w/ Whipple
What to do during elective lap chole if GB Ca is suspected intraoperatively?
 ~ 0.5 % of asx cases found to have GB CA in lap chole
 Convert to OPEN
 Resect PORTS
 No place for laparoscopic resection
Management of T1 lesions
 5Yr survival rates have improved for T1a dz following simple cholecystectomy  75-100%
 T1b (muscularis) is controversial
• Simple v radical chole
• Wakai (2001) – 10 yr survival for T1b tumors after simple chole was 87%
Management of T2 lesions
 Incidentally detected GB Ca in specimen → Re-exploration with radical chole for T2 lesions or
greater
Management of locally advanced T3/T4 lesions
 High morbidity & mortality rates (~50% & 15%)
 Reluctance to operate because of poor prognosis
 Extensive surgery for stage IV pt’s showed significant improvement in 5Yr survival when
compared to palliative operation/unresectable
Contraindications to resection
 Mets to liver, peritoneum, or encasement of major vessels
 Direct involvement of adjacent organs is NOT absolute contraindication.
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Unit : 31
LYMPHOMA
Lymphoma is a form of cancer that affects the immune system specifically; it is a cancer of immune
cells called lymphocytes, a type of white blood cell. There are two broad types of lymphoma and
many subtypes.
The two types of lymphoma are described as: Hodgkin's or Non-Hodgkin's. Lymphoma can occur at
any age but is the most common cancer in young people. It is often very treatable, and most people
live for a long time after being diagnosed. Use this page for comprehensive and easy-to-follow
information about lymphoma - both non-Hodgkin's and Hodgkin's lymphoma.
Fast facts on lymphoma
Here are some key points about lymphoma:
 Lymphoma is cancer that develops in the lymph nodes and lymphatic system.
 The two main types of lymphoma are non-Hodgkin's (about 90% of cases) and Hodgkin's (about
10%).
 The main symptom is usually enlargement of lymph nodes that does not go away (as it does
after infection).
 There are an estimated 761,659 people living with, or in remission from, lymphoma in the US.3
 For Hodgkin's lymphoma, an estimated 177,526 people are living with the disease or are in
remission.
 For non-Hodgkin's lymphoma, an estimated 584,133 people are living with the disease or are in
remission.
 There are around 79,990 new cases of lymphoma diagnosed in the US each year (9,190 cases
of Hodgkin's lymphoma, 70,800 cases of non-Hodgkin's lymphoma).
 Lymphoma cannot be prevented, but survival rates after treatment are good.
Lymphoma is cancer of the lymph system (or lymphatic system), which is part of our immunity. It is
characterized by the formation of solid tumors in the immune system. The cancer affects immune cells
called lymphocytes, which are white blood cells.

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Figure: The lymphatic system
About 90% of lymphomas are the non-Hodgkin's type while about 10% are Hodgkin's. Lymphatic
cancers are classified by the type of immune cells affected. In non-Hodgkin's lymphoma, B-cells and
T-cells are affected - both being types of lymphocyte white blood cell with special roles in immunity.
In the US, B-cell lymphomas are much more common than T-cell ones. In Hodgkin's lymphoma, the
cancer cells are usually an abnormal type of B lymphocyte, named Reed-Sternberg cells. There are
many subtypes of Hodgkin's lymphoma, typed by differences seen under the microscope - but a very
high percentage of cases are classed as "classic" Hodgkin's.
Types of lymphoma: There are many different types of lymphoma depending on the type of
lymphatic cells affected. Hodgkin's lymphoma can occur at any age, affects more men that women
and the majority will be completely cured. Hodgkin's lymphoma is diagnosed when a special type of
cell, the Reed-Sternberg cell, is seen under the microscope. Non-Hodgkin's lymphoma accounts for all
the other types of lymphoma. These can be high grade or low grade and the treatment and
prognosis varies.
Causes of lymphoma: For most cancers, researchers are still trying to understand how they are
caused. The same is true for lymphoma - doctors do not know what causes it, although it is more likely
to occur in certain people.
Non-Hodgkin's lymphoma
 Age - most non-Hodgkin lymphomas are in people 60 years of age and over

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 Sex - there are different rates of different types of non-Hodgkin's lymphoma across the sexes
 Ethnicity and location - in the US, African-Americans and Asian-Americans are less prone than
white Americans, and the disease is more common in developed nations of the world
 Chemicals and radiation - some chemicals used in agriculture have been linked, as has nuclear
radiation exposure
 Immune deficiency - for example, caused by HIV infection or in organ transplantation
 Autoimmune disease, in which the immune system attacks the body's own cells
 Infection - certain viral and bacterial infections increase the risk. The Helicobacter Infection has
been implicated, as has the Epstein Barr Virus (the virus that causes glandular fever)13
 See the American Cancer Society's page for more detail on risk factors for non-Hodgkin's
lymphoma.
Hodgkin's lymphoma
 Infectious mononucleosis - infection with Epstein-Barr virus
 Age - two specific groups are most affected: typically people in their 20s, and people over the
age of 55 years
 Sex - slightly more common in men
 Location - most common in the US, Canada and northern Europe; least common in Asia
 Family - if a sibling has the condition, the risk is slightly higher, and very high if there is an
identical twin
 Affluence - people from higher socioeconomic status are at greater risk
 HIV infection
 See the American Cancer Society's page for more detail on risk factors for Hodgkin's lymphoma.
Symptoms of lymphoma: The symptoms and signs of lymphoma are very similar to those of simple
illnesses such as viral illnesses and the common cold, and this can cause problems with delayed
diagnosis. The difference is that the symptoms of lymphoma persist long after the usual run of a viral
infection.
The symptoms typically involve painless swelling of the lymph nodes (glands), often in the neck or
armpits where these nodes are concentrated. Swelling may also occur in the groin and abdomen,
although some people do not experience any detectable swelling in any part of the body.
The enlarged glands can press on organs, bones and other structures causing pain, but this pain can
be similar to that of other less serious causes (such as simple backache), again making lymphoma an
easy diagnosis to miss. Anyone who has swelling of the glands, and does not get better after a short
time, should see their doctor. The lymph nodes, part of the immunity's lymphatic system, are found all
around the body, but their swelling in lymphoma is noticeable.
Other symptoms that can be experienced by people with lymphoma include the following:
 Swelling in the legs or ankles
 Cramping and bloating of the abdomen
 Night sweats and fever
 Weight loss and loss of appetite

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 Chills
 Unusual itching
 Fatigue
 Pain or altered sensation
 Unusual tiredness/lack of energy
 Persistent coughing
 Breathlessness
 Enlarged tonsils
 Headache.
Painful symptoms are not normally seen in the early stages of lymphoma. In fact, swollen and painful
lymph nodes accompanied by other signs of infection are usually a sign of active infection.
Painless swelling of the lymph nodes is much more common in lymphoma, with pain, weakness,
paralysis, or otherwise altered sensation typically occurring only when an enlarged lymph node is
pressing against spinal nerves or the spinal cord.
Anyone experiencing any of these symptoms should seek immediate medical attention: Some
people may also experience lymph node pain after drinking alcohol. Lymphoma is a type of cancer
that originates in the lymph nodes, but it can spread rapidly to other parts of the body through the
lymphatic system. As cancerous lymphocytes spread into other tissues this can decrease the body's
ability to fight infection. Lymphoma can result in a number of different symptoms, many of which
could signal numerous other conditions. It is always worthwhile presenting any symptoms to a doctor.
Spread of lymphoma: Hodgkin's lymphoma is a cancer of the lymphocytes, a type of white blood
cell. This type of cancer affects the lymph nodes and, as lymphatic tissue is connected throughout the
body, this gives the cancer cells an easy way of traveling from their original location to spread to
other tissues, including those outside of the lymphatic system.
In Hodgkin's lymphoma, this spread usually occurs in a sequential fashion, affecting one lymph node
after another in order. In non-Hodgkin's lymphoma, tumors may arise in disparate lymph nodes,
skipping some nodes.
Tests and diagnosis: There is currently no active screening program for lymphoma, so it is only
diagnosed when the person goes to their doctor with something that is concerning them. Because of
the vagueness of the symptoms, doctors often reassure early cases of lymphoma, thinking that they
are simple infections. If symptoms persist, patients should go back to their doctor. Doctors may
investigate lymphoma when a patient presents the signs and symptoms. They will start investigating
lymphoma by "taking a history" - asking questions to help rule out other explanations for the
symptoms. This will narrow down:
 Possible risk factors
 Family history
 Other medical conditions.
A physical examination will follow for all cases of suspected lymphoma - palpating areas of the
body where any swollen lymph nodes may be felt. The doctor may also feel around the abdomen to
examine the spleen and liver. During the physical examination, the doctor will look out for signs of
infection near lymph nodes, since most cases of swelling can be explained by this.

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The doctor will look for swollen lymph nodes in a number of areas, including the:
 Chin
 Neck
 Tonsils
 Groin
 Axillae (armpit)
 Shoulders
 Elbows.
Classifying lymphoma: Classification is a complicated process, but it helps surgeons and physicians
to determine the best course of action for treating (or not treating) the cancer. A number of different
classification systems have been proposed over recent years, with the most commonly used system
devised by the World Health Organization (WHO). This lymphoma classification system helps
physicians to standardize how they discuss lymphoma.
Grading lymphoma: After classification, the clinical grade of the lymphoma also needs to be
determined. This describes how aggressive the tumor is and predicts how the tumor will behave.
The pathologist will take into account:
 The type of cells present in the biopsy
 The function and growth rate of those cells
 Any unique characteristics observed in the cells, and other factors
 A low-grade lymphoma is one that is slow growing (sometimes referred to as indolent), while an
intermediate or high-grade lymphoma is fast growing and aggressive.
Types of indolent lymphoma include:
 Follicular lymphoma
 Small lymphocytic lymphoma
 MALT lymphoma
 Nodal marginal zone B-cell lymphoma
 Lymphoplasmacytic lymphoma
 Anaplastic large cell lymphoma, primary cutaneous type (this can also be an aggressive
lymphoma).
The most common type of aggressive lymphoma is diffuse large B-cell lymphoma (DLBC). Other forms
of aggressive lymphoma include:
 Burkitt lymphoma
 Lymphoblastic lymphoma
 Hepatosplenic gamma/delta T-cell lymphoma
 Subcutaneous panniculitis-like T-cell lymphoma
 Enteropathy-type intestinal T-cell lymphoma
 Adult T-cell lymphoma/leukemia (HTLV 1+)

Lymphoma
206
 Anaplastic large cell lymphoma, primary systemic type
 Aggressive NK-cell leukemia.
Biopsy laboratory tests
If lymphoma is suspected - because, for example, the swelling has persisted after infection has been
ruled out - the diagnosis can be definitively confirmed by biopsy, which involves laboratory
examination of lymph tissue under a microscope.
Biopsy testing can also confirm the particular type of lymphoma, and so provide a guide to prognosis
and treatment. The most common forms of biopsy procedure are: Excisional biopsy - the surgeon cuts
through the skin to remove an entire lymph node for analysis and Incisional biopsy - the surgeon
removes only part of a large suspected lymph tumor.
The operations, depending on the location, will involve using local anesthetic, sedative or general
anesthetic. Less often, invasive biopsy procedure using needles - known as fine needle biopsy or core
needle biopsy is used to test. Other tests that may be ordered are blood tests to check the number of
white blood cells, for example, and chest X-rays to pick out swollen lymph nodes.
If a lymphoma diagnosis has already been confirmed by biopsy, further testing is carried out to
determine the stage of the cancer, to see whether it has spread (metastasized) to other parts of the
body.
Staging tests include a choice from the following, depending on the case:
 Blood tests - including complete blood count (CBC), white blood count, protein levels, liver
function tests, kidney function tests, uric acid level, inflammatory markers and lactate
dehydrogenase (LDH) level.
 Biopsy - a sample of cells is taken from the blood and looked at under a microscope. The results
of a biopsy are key to the diagnosis and classification of lymphoma. A biopsy can reveal
whether a tumor originated from B-cells or T-cells, with the former being much more common. The
biopsy will also help a pathologist determine the classification, or type, of non-Hodgkin's
lymphoma that is present
 CT (computed tomography X-ray imaging) scans of the chest, abdomen, and pelvis, sometimes
using a contrast, to check for tumors
 MRI for detailed images of tissues
 Ultrasound scanning for tumors
 PET (positron emission tomography) scan, in which radioactive tracers pick out cancer
 Bone marrow biopsy in some cases, to check for lymphoma cells in the sample
 Spinal tap - a long, thin needle is used under local anesthetic to remove some spinal fluid, which
is tested for lymphoma.
The testing regime enables the cancer team to understand the type and stage of cancer. Oncologists
use staging systems for all types of cancer. In lymphoma, four stages are described - from I to IV,
with each corresponding to the cancer's spread.
The following are basic descriptions of each stage:
 Stage I - the tumor is localized, confined to one area
 Stage II - there is limited spread of the lymphoma, remaining on one side of the diaphragm

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 Stage III - there is regional spread of the cancer to either side of the diaphragm, or to an area
or an organ near the primary lymph node tumor
 Stage IV - the lymphoma has spread beyond the lymphatic system to distant parts of the body.
The stage is given a further description according to the particular symptoms displayed, with either A
or B added to the number. The B-denoted cancer is usually more advanced than A and is
characterized by the following symptoms (without these symptoms, the lymphoma is denoted A):
 Unexplained weight loss of more than 10% over the previous 6 months
 Unexplained fever of at least 100.4°F (38°C)
 Drenching night sweats.
Treatments and prevention
A number of treatment options are used against lymphoma, many of which are common to other types
of cancer. While statistics cannot predict the success of an individual person's treatment plan, which
depends on numerous factors, including the stage of the cancer, the figures do show good overall
success rates in beating lymphoma:
 More than two-thirds of people diagnosed with non-Hodgkin's lymphoma will survive for five
years
 The five-year survival rate is even higher for the rarer Hodgkin's lymphoma, at just over 85%.
Non-Hodgkin's lymphoma
An indolent non-Hodgkin's lymphoma often causes few, if any, symptoms until quite late in the
disease, when it has already become widespread. This means that treatment typically takes the form
of watchful waiting, followed by medical intervention to help shrink the tumors
 Treatment is usually effective and leads to a period of remission, where the patient is free from
the disease
 Indolent (low-grade) lymphoma may relapse though, requiring further treatment. In some cases,
an indolent lymphoma can become aggressive, which necessitates more aggressive treatment
 Typically people with indolent lymphoma live for a long time and have a good quality of life
 Some people may not require any treatment
 In contrast, patients diagnosed with a high-grade or intermediate lymphoma will typically
require immediate and intensive treatment to help slow down tumor growth and, eventually, to
shrink the tumor
 Where indolent lymphoma turns into aggressive lymphoma this can be especially difficult as the
tumors may be widespread, whereas an aggressive lymphoma may be caught earlier and still
be somewhat localized.
Hodgkin's lymphoma
 Treatment for Hodgkin's lymphoma also depends on the grade of the cancer
 Unlike non-Hodgkin's lymphoma, however, treatment for early stage Hodgkin's lymphoma
usually takes the form of a short course of chemotherapy followed by field radiation to treat the
affected lymph nodes
 This offers systemic and localized cancer treatment, but helps minimize damage to healthy tissue
 Treatment for later-stage Hodgkin's lymphoma typically comprises combination chemotherapy to
shrink widespread tumors.

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208
In addition to watchful waiting, chemotherapy, and radiation therapy, lymphoma treatment may also
take the form of:
 Biologic therapy
 Antibody therapy
 Stem-cell transplantation
 Splenectomy
 Steroid treatment
 Radioimmunotherapy
Radiotherapy, or radiation therapy, involves directing a carefully focused beam of high-energy X-
rays onto lymphomas, thereby destroying the cancerous cells.
Immunotherapy is the use of biological drug therapies that boost the immune system or provide
artificial versions of normal parts of the immune system. Again, the aim is to kill cancer cells or slow
their growth. Some drugs are monoclonal antibodies - manmade immune proteins - and several of
these drugs are available against lymphoma. For non-Hodgkin's lymphoma, other biological drugs
may be tried in some cases, or after other treatments have failed. These include interferon, and the
immunomodulating agents thalidomide and lenalidomide.
A small number of lymphoma cases are treated by stem cell transplantation. This is a process that
allows high-dose chemotherapy, and sometimes high-dose radiotherapy, to be given in cases that
have not responded to standard treatment. High-dose treatment would usually cause unacceptable
bone-marrow side-effects, but the stem cell transplant given after treatment restores damaged bone
marrow. Infusion of blood-forming stem cells means that this function is not lost, and new blood cells
can still be created.
Prognosis for lymphoma
When diagnosing Hodgkin's lymphoma, physicians will not only classify and grade the cancer, they
also assign either "A" or "B" to the stage of the disease.
 "B" means that at least one of the following symptoms is present: unintentional weight loss, night
sweats, or fevers
 "A" grade means that these symptoms are not present.
Based on the classification, aggressiveness, and stage of the lymphoma, a physician will calculate the
"International Prognostic Score for Hodgkin's lymphoma". This score also takes into account the
patient's age and other information. Patients can ask for their prognosis based on these calculations.
The Leukemia and Lymphoma Society note that Hodgkin's lymphoma is considered to be one of the
most curable forms of cancer.
 The five-year relative survival rate for people with Hodgkin's lymphoma has more than doubled,
from 40% in whites from 1960 to 1963 (only data available) to 87.7% for all races from 2004
to 2010
 The five-year relative survival rate is 93.7% for all people with Hodgkin's lymphoma who were
less than 45 years old at diagnosis
 The five-year relative survival rate for people with non-Hodgkin's lymphoma has risen from 31%
in whites from 1960 to 1963 (only data available) to 71.4% for all races from 2004 to 2010
 Early diagnosis and appropriate treatment has helped to improve survival rates for lymphoma.
An estimated 20,170 members of the US population die from lymphoma (18,990 non-Hodgkin's
lymphoma and 1,180 Hodgkin's lymphoma) each year. Overall, death rates have been declining for
people with Hodgkin's lymphoma since 1975.
All cancer treatments produce side-effects, many of which are serious. Treatment plans always involve
weighing up the balance of treatment aims against potential adverse events. The benefits of
treatment should outweigh any risks.
Diagnosis: Hodgkin’s lymphoma

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Regimen- ABVD: Regimens of Chemotherapy in Practice
Drugs: Adriamycin, bleomycin, vinblastine, dacarbazine
Frequency: 4 weekly for max 6 cycles
S.N. Drugs Day 1, Day 15
1. Inj Ondem 16 mg IV before chemotherapy
Inj dexamethasone (….) 8 mg IV before chemotherapy
Inj doxorubicin (…) 25 mg/m2 IV slowly push
Tab PCM 500 mg PO stat before bleomycin
Inj bleomycin 10 mg/ m2 IV slow push
Inj vinblastine 6 mg/ m2 IV slow push
Inj dacarbazine 375 mg/ m2 + 500 ml NS 2 hour infusion
Medications on discharge
 Tab ondem 8 mg PO BD for 3 days
 Inj filgastim (neupogen) 300 mcg SC OD from day 8-10 and day 22-24
Cycle is repeated every 28 days for maximum 6 cycles
Oral medications on discharge
 Tab. Ranitidine 150mg PO BD for 5 days
 Tab. Ondem 8 mg PO BD for 3 days
 Tab. Domperidone 10mg TDS PO for 5 days
 Hexidine mouth gargle TDS
Diagnosis: Non Hodgkin’s lymphoma
Protocol- CHOP: Regimens of Chemotherapy in Practice
Frequency- 3 weeks
Type of treatment- curative/ neoadjuvant/ adjuvant/ aggressive/ palliative/ salvage
S.N. Drugs Day 1
1. Inj Ondem 16 mg IV before chemotherapy
2. Inj dexamethasone (….) 16 mg IV before chemotherapy
3. Inj cyclophosphamide 750mg/m2 plus 500 ml NS over 1 hour IV
4. Inj Doxorubicin (…) 50 mg / m2 (…) IV slow push
5. Inj vincristine 1.4mg/m2 IV slow push
6. Tab prednisolone 100 mg PO PC Day 1-5
Medications on discharge
 Tab ranitidine 150 mg BD PO for day 1-5
 Tab ondem 8 mg PO BD for 3 days
 Tab domperidone 10 mg PO TDS for 5 days
 Hexidine mouth gargle TDS


Lung Cancer
210
Unit : 32
LUNG CANCER
The term “lung cancer” is used for tumors arising from the respiratory epithelium (bronchi, bronchioles,
and alveoli). Lung cancer is the uncontrolled growth of abnormal cells that start off in one or
both lungs; usually in the cells that line the air passages. Lung cancer is a malignant lung
tumor characterized by uncontrolled cell growth in tissues of the lung.
A variety of benign and malignant tumors may arise in the lung, but 90% to 95% are carcinomas, about
5% are bronchial carcinoids, and 2% to 5% are mesenchymal and other miscellaneous neoplasms.Lung
cancer is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung.
Any type of lung carcinoma may extend on to the pleural surface and then within the pleural cavity
or into the pericardium. Metastases to the bronchial, tracheal, and mediastinal nodes can be found in
most cases. The frequency of nodal involvement varies slightly with the histologic pattern but
averages greater than 50%. Distant spread of lung carcinoma occurs through both lymphatic and
hematogenous pathways. These tumors often spread early throughout the body except for squamous
cell carcinoma, which metastasizes outside the thorax late. Metastasis may be the rst manifestation
of an underlying occult pulmonary lesion. No organ or tissue is spared in the spread of these lesions,
but the adrenals, for obscure reasons, are involved in more than half the cases. The liver (30% to
50%), brain (20%), and bone (20%) are additional favored sites of metastases.
Epidemiology
Lung cancer is currently the most frequently diagnosed major cancer in the world (estimated 1.6
million new cases in 2008) and the most common cause of cancer mortality worldwide (1,380,000
deaths in 2008). This is largely due to the carcinogenic effects of cigarette smoke. Over the coming
decades, changes in smoking habits will greatly inuence lung cancer incidence and mortality as well
as the prevalence of various histologic types of lung cancer.
Lung Cancer in Never Smokers: The WHO estimates that 25% of lung cancer worldwide occurs in
never smokers. This percentage is probably closer to 10% to 15% in Western countries. These cancers
occur more commonly in women and most are adenocarcinomas. Cancers in nonsmokers are more
likely to have EGFR mutations, and almost never have KRAS mutations; TP53 mutations are not
uncommon, but occur less frequently than in smoking related cancers.
Etiology and Pathogenesis
Most lung cancers are associated with a well-known carcinogen i.e. cigarette smoke. In addition there
are other genetic and environmental factors.
1. Tobacco Smoking: About 80% of lung cancers occur in active smokers or those who stopped
recently. There is a nearly linear correlation between the frequency of lung cancer and pack-
years of cigarette smoking. The increased risk becomes 60 times greater among habitual heavy
smokers (two packs a day for 20 years) compared with nonsmokers. However, since lung cancer
develops in only 11% of heavy smokers, there are other factors that predispose individuals to
this deadly disease. For reasons not entirely clear, women have a higher susceptibility to
carcinogens in tobacco than men.

211
Passive smoking increases the risk for lung cancer development to approximately twice that of
nonsmokers. The smoking of pipes and cigars also increases the risk, but only modestly.
2. Industrial Hazards: Certain industrial exposures, such as asbestos, arsenic, chromium, uranium,
nickel, vinyl chloride and mustard gas, increase the risk of developing lung cancer. High-dose
ionizing radiation is carcinogenic.
3. Air Pollution: It is uncertain whether air pollution, by itself, increases the risk of lung cancer, but
it likely adds to the risk in those who smoke or are exposed to secondhand smoke. It may do so
through several different mechanisms. Chronic exposure to air particulates in smog may cause
lung irritation, inammation and repair, and chronic inammation and repair increases the risk of
a variety of cancers.
4. Genetics: As with other cancers, smoking-related carcinomas of the lung arise by a stepwise
accumulation of oncogenic “driver” mutations that result in the neoplastic transformation of
pulmonary epithelial cells. Some of the genetic changes associated with cancers can be found in
the “benign” bronchial epithelium of smokers without lung cancers, suggesting that large areas of
the respiratory mucosa are mutagenized by exposure to carcinogens in tobacco smoke those
few cells that accumulate a sufcient panoply of complementary driver mutations to acquire all
of the hallmarks of cancer develop into invasive carcinomas.
Histologic Classification
Lung carcinomas may arise in the peripheral lung (more often adenocarcinomas) or in the
central/hilar region (more often squamous cell carcinomas), sometimes in association with
recognizable precursor lesions.
1. Adenocarcinoma (38%): Adenocarcinoma is an invasive malignant epithelial tumor with
glandular differentiation or mucin production by the tumor cells. Adenocarcinomas grow in
various patterns, including acinar, lepidic, papillary, micropapillary, and solid with mucin
formation. Compared with squamous cell cancers, the lesions are usually more peripherally
located and tend to be smaller.
2. Squamous cell carcinoma (20%): It is most commonly found in men and is strongly associated
with smoking. Precursors lesions that give rise to invasive squamous cell carcinoma are well
characterized.
3. Small cell carcinoma (14%): Small cell carcinoma is a highly malignant tumor with a strong
relationship to cigarette smoking; only about 1% occurs in nonsmokers. They may arise in major
bronchi or in the periphery of the lung. They are the most aggressive of lung tumors,
metastasizing widely and virtually always proving to be fatal.
4. Large cell carcinoma (3%): Large cell carcinoma is an undifferentiated malignant epithelial
tumor that lacks the cytologic features of other forms of lung cancer. The cells typically have
large nuclei, prominent nucleoli, and a moderate amount of cytoplasm. Large cell carcinoma is a
diagnosis of exclusion since is expresses none of the markers associated with adenocarcinoma
(TTF-1, napsin A) and squamous cell carcinoma.
5. Other (25%)
Types of Lung Cancer:
Based on the size and appearance of the cancer cells, lung cancer is classifies as:
 Small Cell Lung cancer (SCLC)

Lung Cancer
212
 Non Small Cell Lung cancer (NSCLC)
 Secondary or Metastatic lung cancers
Small Cell Lung cancer (SCLC)
 Also called oat-cell carcinoma because of the packed nature of small dense cells, begins in the
larger airways and becomes sizeable.
 The oat cells contain dense neurosecretory granules vesicles containing neuroendocrine hormones.
 These cancers grow quickly and spread early in the course of the disease. Sixty to seventy
percent have metastatic disease at presentation.
 Most small cell cancers arise in the major bronchi and spread by infiltration along the bronchial
wall
 This type of lung cancer is strongly associated with smoking.
 These represent about 20% of all lung cancer.
 The tumours are very responsive to chemotherapy but carries a worse prognosis as they tend to
metastasize early to lymph nodes and by blood-borne spread
Non Small Cell Lung Cancer (NSCLC)
 Non–small cell lung carcinoma (NSCLC) represents approximately 80% of tumors
 The three main subtypes of NSCLC are:
• Adenocarcinoma: Nearly 40% of lung cancers are adenocarcinoma, which begin in the
alveolus
• Squamous cell carcinoma: Accounts for about 20 - 30% of lung cancers which typically occur
close to bronchi.
• Large-cell carcinoma: About 15% of lung cancers are large-cell carcinoma. These are so
named because the cancer cells are large, with excess cytoplasm, large nuclei and
noticeable nucleoli.
Secondary or Metastatic lung cancers
 Secondary lung cancers (or lung metastases) are tumors which have spread to the lung from
another cancer somewhere else in the body.
 The lung is a common site for metastasis from other cancers. This is because all blood flows
through the lungs and may contain tumour cells from any other part of the body.
 Tumors of the breast, prostate, colon and bladder commonly metastasize to the lung.
Pathogenesis
 Similar to many other cancers, lung cancer is initiated by activation of oncogenes or inactivation
of tumor suppressor genes.
 Carcinogens cause mutations in these genes which induce the development of cancer
 Mutations in the K-ras proto-oncogene are responsible for 10–30% of lung adenocarcinomas
 The epidermal growth factor receptor (EGFR) regulates cell proliferation, apoptosis,
angiogenesis, and tumor invasion..
 Mutations and amplification of EGFR are common in non-small-cell lung carcinoma.
 Lung cancers arise from a single transformed epithelial cell, in which the carcinogen binds to and
damages the cell’s DNA.

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 This damage results in cellular changes, abnormal cell growth, and eventually a malignant cell.
 As the damaged DNA is passed on to daughter cells, the DNA undergoes further changes and
becomes unstable.
 With the accumulation of genetic changes, the pulmonary epithelium undergoes malignant
transformation from normal epithelium eventually to invasive carcinoma.
 Carcinoma tends to arise at sites of previous scarring (TB, fibrosis) in the lung
Clinical Manifestation:
Lung cancer is one of the most insidious and aggressive neoplasms in the realm of oncology. In the
usual case it is discovered in patients in their 50s or older whose symptoms are of several months’
duration. The major presenting complaints are cough (75%), weight loss (40%), chest pain (40%), and
dyspnea (20%).
Clinical Feature:
 Cough (50%-75%): Involvement of central airways
 Hemoptysis (25%-50%): Hemorrhage from tumor in airway
 Chest pain (20%): Extension of tumor into mediastinum, pleura or chest wall
 Pneumonia, abscess, lobar collapse: Airway obstruction by tumor
 Lipoid pneumonia: Tumor obstruction; accumulation of cellular lipid in foamy macrophages
 Pleural effusion: Tumor spread into pleura
 Hoarseness: Recurrent laryngeal nerve invasion
 Dysphagia: Esophageal invasion
 Diaphragm paralysis: Phrenic nerve invasion
 Rib destruction: Chest wall invasion
 SVC syndrome: SVC compression by tumor
 Horner syndrome: Sympathetic ganglia invasion
 Pericarditis, tamponade: Pericardial involvement
TNM Staging
Tumor
Tis: Carcinoma in Situ
T1: Tumor ≤ 3 cm without pleural or mainstem bronchus involvement (T1a, <2 cm; T1b, 2-3 cm)
T2: Tumor 3-7 cm or involvement of mainstem bronchus 2 cm from carina, visceral pleural
involvement, or lobar atelectasis (T2a, 3-5 cm; T2b, 5-7 cm)
T3: Tumor >7 cm or one with involvement of parietal pleura, chest wall (including superior sulcus
tumors), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium, mainstem
bronchus < 2 cm from carina but without involvement of carina, or entire lung atelectasis, or
separate tumor nodules in the same lobe
T4: Any tumor with invasion of mediastinum, heart, great vessels, trachea, recurrent laryngeal
nerve, esophagus, vertebral body, or carina or separate tumor nodules in a different
ipsilateral lobe

Lung Cancer
214
Lymph node
N0: No metastasis to regional lymph nodes
N1: hilar or peribronchial nodal involvement
N2: Metastasis to ipsilateral mediastinal or subcarinal lymph nodes
N3: Metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral
scalene, or supraclavicular lymph nodes
Metastasis
M0: No distant metastasis
M1: Distant metastasis (M1a, separate tumor nodule in contralateral lobe or pleural nodules or
malignant pleural effusion; M1b, distant metastasis)
Stage Grouping
Stage IA T1a, T1b N0 M0
Stage IB T2a N0 M0
Stage IIA T2b
T1a, T1b, T2a
N0
N1
M0
M0
Stage IIB T2b
T3
N1
N0
M0
M0
Stage IIIA T1, T2
T3
T4
N2
N1, N2
N0, N1
M0
M0
M0
Stage IIIB Any T
T4
N3
N2, N3
M0
M0
Stage IV Any T Any N M1a, M1b
Diagnosis: Medical History and Physical Examination for Lung Cancer
Investigation
1. Chest radiography 2. PET, CT
3. Sputum cytology 4. Biopsy
5. Broncoscopy 6. Mediastinoscopy
7. Mediastinotomy
Mediastinoscopy: This procedure is performed under general anaesthesia with the patient supine
and his or her neck extended. A transverse incision is made 2 cm above the sternal notch and
deepened until the strap muscles are reached. These are retracted laterally and the thyroid isthmus is
retracted superiorly to reveal the pretracheal fascia. Careful blunt dissection in this plane allows
access to the paratracheal and subcarinal nodes. A mediastinoscope is introduced for direct
visualisation and biopsy. Great caution should be used in the presence of superior vena caval
obstruction. Complications include pneumothorax and haemorrhage.
Mediastinotomy: An incision is made through the second intercostal space to gain access to some of
the mediastinal lymph nodes on the affected side. Damage to the internal mammary artery and the
phrenic nerve must be avoided. Mediastinal extension of tumor can also be assessed.
Management:

215
A. Medical management
1. Radiation Therapy
2. Chemotherapy: Commonly used regimen:
• EP: cisplatin and etoposide
• Carboplatin and etoposide
• GemCarbo (gemcitabine and carboplatin)
For relapse
• CAV (Cyclophosphamide, Doxorubicin and Vincristine)
• CAVE (CAV plus Etoposide)
• ACE (doxorubicin, cyclophosphamide and etoposide)
B. Surgical Management
• Wedge resection to remove a small section of lung that contains the tumor along with a
margin of healthy tissue.
• Segmental resection to remove a larger portion of lung, but not an entire lobe (bronchioles
and its alveoli).
• Lobectomy- to remove the entire lobe of one lung.
• Pneumonectomy
• Thoracoscopic lung resection
• Chest tube insertion
• Lung Transplantation: A lung transplant removes a person's diseased lung and replaces it
with a healthy one. The healthy lung comes from a donor who has died. Some people get
one lung during a transplant. Other people get two. Lung transplants are used for people
who are likely to die from lung disease within 1 to 2 years. Their conditions are so severe
that other treatments, such as medicines or breathing devices, no longer work.
Complication:
 Pleural effusion
 Superior vena cava syndrome
 Atelectasis and pneumonia
 Metastasis
Prognosis:
The outlook is still poor for most patients with lung carcinoma. Even with many incremental
improvements in thoracic surgery, radiation therapy, and chemotherapy, the overall 5-year survival
rate is only 16%. The 5-year survival rate is 52% for cases detected when the disease is still
localized, 22% when there is regional metastasis and only 4% with distant metastases. In general,
adenocarcinoma and squamous cell carcinoma tend to remain localized longer and have a slightly
better prognosis than do the undifferentiated cancers, which are usually advanced by the time they
are discovered.
Untreated, the survival time for patients with small-cell carcinoma is 6 to 17 weeks. This cancer is
particularly sensitive to radiation therapy and chemotherapy, and cure rates of 15% to 25% for
limited disease have been reported in some centers. However, most patients with small cell carcinoma
have distant metastases at diagnosis. Thus, even with treatment, the mean survival after diagnosis is
only about 1 year.
Nursing Management
Assessment
 Assess and document respiratory rate and depth, skin and mucous membrane color, lung sounds,
cough and sputum amount and character.
 Ask the patient to rate the degree of pain and dyspnea on appropriate scales.

Lung Cancer
216
 Ask about appetite and weight loss, as well as symptoms of other complications.
 Note activity tolerance and fatigue.
 In addition, the patient may be grieving about his or her illness and impending death.
 Assessment of the patient’s coping strategies and support systems
Nursing Diagnosis
 Impaired gas exchange related to advanced disease condition.
 Ineffective airway clearance related to pain, fatigue and shortness of breath.
 Pain related to cancer mass pressing on adjacent structures
 Imbalanced nutrition less than body requirements related to low appetite
 Altered bowel habit(constipation) related to opioid use, side effects of chemotherapy.
 Anxiety/grief related to disease condition.
 Activity intolerance related to surgery, shortness of breaths.
For optimal breathing
 Oxygen therapy may be necessary to relieve dyspnea.
 Positioning, relaxation and breathing exercises can help reduce dyspnea and feelings of panic.
 Anti anxiety drugs or morphine may also be helpful to reduce pain and discomfort.
 Resting between activities reduces the demand for oxygen.
 Encourage the patient to avoid smoking and exposure to secondary smoke.
For effective airway clearance
 Room humidifier and oral fluids to reduce viscosity of secretions, as well as regular coughing and
deep breathing exercises.
 Nonproductive cough can be treated with an antitussive (suppress coughing) as ordered by the
physician.
 Instruct the patient to notify the physician if hemoptysis is persistent.
 Exposure to powders, tobacco smoke, and aerosols increases airway irritation and should be
eliminated.
 Suctioning may be necessary if the patient becomes too weak to cough effectively.
For nutritional balance
 Nutrition can be maintained by eating frequent small meals. Nutritional supplements that are
high in calories but easy to eat or drink may be used.
 A dietitian consultation is helpful.
 Antiemetics before meals may help control nausea.
 Mints may help reduce the metallic taste left in the mouth by some chemotherapeutic
medications.
 Good mouth care is essential and should be encouraged to patient.
 Total parenteral nutrition may be necessary late in the disease.
Relieving pain
 Pain is controlled by opioids and supportive noninvasive therapies.

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Promoting activity tolerance
 Fatigue is prevented with frequent rest periods and assistance with activities of daily living.
 Encourage the patient to identify and engage in those activities that are most important to him
or her and to avoid unnecessary or undesirable activities.
For relieving anxiety/grief
 The patient who is grieving should be allowed the opportunity to talk about his or her life and
impending death and to express anger or sadness.
 As a nurse you should be physically present but should not force verbalization unless the patient
wishes to talk.
 Encourage the family to stay with the patient as much as the patient wishes.
 Contact a spiritual counselor if the patient desires a referral.
 Hospice care
Diagnosis: Non Small Cell Lung Carcinonoma
Protocol- cisplatin+ etoposide: Regimens of Chemotherapy in Practice
Frequency: 3 weekly
S.N. Drug Day 1 Day 2-3
1. Inj NS 2000 ml with each 500 ml add inj KCL 10 meq/L +
Mgso4 250 mg over total 8-10 hours injection prehydration
Xxx
2. Tab lorazepam 1 mg PO BD Xxx
3. Inj ondem 16 mg IV before chemo
5. Inj ranitidine 50 mg IV push
6. Inj etoposide 100 mg/m2 + 500 ml NS over 2 hours
7. Inj cisplatin 100 mg/m2 + 500 ml NS IV over 2 hours Xxx
8. Inj mannitol 20% 350 ml IV over 1 hour infusion Xxx
9. Inj ondem 8 mg IV push stat Xxx
10. Inj dexona 8 mg IV push stat Xxx
11. Inj NS 2000 ml with each 500 ml add inj KCl 10 meq/L +
MgSO4 250 mg over total 8-10 hours injection
posthydration
xxx
* Note- hydration amount and rate can be adjusted if necessary
* Cycle is repeated every 3 weeks for a maximum of 6 cycles


Nutrition Therapy for Cancer Patients
218
Unit : 33
NUTRITION THERAPY FOR CANCER PATIENTS
Finding and treating nutrition problems early may improve the patient's prognosis. Early nutrition
screening and assessment can identify problems that affect the success of anticancer therapy. Patients
who are underweight or malnourished may not respond well to cancer treatments. Malnutrition may
be caused by the cancer or made worse as the cancer progresses. Finding and treating nutrition
problems early may help the patient gain or maintain weight, improve the patient's response to
therapy, and reduce complications of treatment. Screening and assessment are done before
beginning anticancer therapy, and assessment continues throughout treatment. Because the ability to
tolerate treatment is better for the well-nourished patient, screening and assessment are done before
beginning anticancer therapy. Appropriate nutrition management is begun early, and nutritional
status is checked often during treatment. Screening is used to identify patients who may be at
nutritional risk. Assessment determines the complete nutritional status of the patient and identifies if
nutrition therapy is needed. The patient or caregiver may be asked for the following information:
Weight changes over the past 6 months: Changes in the amount and type of food eaten compared
to what is usual for the patient. Problems that have affected eating, such as nausea, vomiting,
diarrhea, constipation, dry mouth, changes in taste and smell, mouth sores, pain, or loss of appetite.
Ability to walk and perform the activities of daily living: A physical exam is part of the assessment.
The physical exam will check the body for general health and signs of disease, such as lumps or
growths. The physician will look for loss of weight, fat and muscle, and fluid buildup in the body. A
healthcare team completes ongoing assessment with expertise in nutritional management. A nutrition
support team will monitor the patient's nutritional status during cancer treatment and recovery. The
team may include the following specialists: Physician, Nurse, Registered dietitian, Social worker, and
Psychologist.
Goals of Nutrition Therapy: The goals of nutrition therapy for cancer patients in active treatment
and recovery are designed to restore nutrient shortages, maintain nutritional health, and prevent
complications. The following are the goals of nutrition therapy for patients in active treatment and
recovery:
 Prevent or correct malnutrition.
 Prevent wasting of muscle, bone, blood, organs, and other lean body mass.
 Help the patient tolerate treatment.
 Reduce nutrition-related side effects and complications.
 Maintain strength and energy.
 Protect ability to fight infection.
 Help recovery and healing.
 Maintain or improve quality of life.

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A patient whose religion forbids eating certain foods may consider speaking with a religious leader
about waiving the restriction during cancer treatment and recovery. Good nutrition continues to be
important for patients who are in remission or whose cancer has been cured. The goals of nutrition
therapy for patients who have advanced cancer are designed to improve the quality of life.
The following are the goals of nutrition therapy for patients who have advanced cancer:
 Reduce side effects.
 Reduce risk of infection.
 Maintain strength and energy.
 Improve quality of life.
 Methods of Nutrition Care
 Nutrition support provides nutrition to patients who cannot eat normally.
Nutritional support of cancer patients
 Cancer can change the way the body uses food and may affect nutrition.
 Good nutrition is important for cancer patients.
 Healthy eating habits are important during cancer treatment.
 Good nutrition is important for good health. Eating the right kinds of foods before, during, and
after cancer treatment can help the patient feel better and stay stronger.
 A healthy diet includes eating and drinking enough of the foods and liquids that have the
important nutrients (vitamins, minerals, protein, carbohydrates, fat, and water)
 Having enough protein and calories is important for healing, fighting infection, and having
enough energy
Nutritional Assessment
 Nutritional assessment provides an estimate of body composition, such as fat, skeletal muscle
protein.
 These assessment techniques include a thorough patient history and physical examination and
specific laboratory tests.
 The history should reveal usual body weight, any recent weight change, or incorporation of new
or special diets.
 It is important to treat weight loss caused by cancer and its treatment
 Unintentional weight loss of 10% or more of body weight within the previous 6 months signifies a
substantial nutritional deficit and is a good prognostic indicator of clinical outcome.
 Concentrations of serum proteins such as transferrin, and albumin can be used to estimate the
degree of visceral protein depletion.
 Decreases in the serum concentration of these proteins are related to longer periods of
nutritional deficiency.
 Several studies have shown that a low serum albumin concentration predicts a poor prognosis in
cancer patients.

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Nutritional Supplement: Nutrients can be delivered by the oral, enteral or parenteral route.
Oral Nutrition
 Oral supplementation is the preferred modality in patients who are able to eat but require
special diets because of impairments in the gastrointestinal tract.
 The oral diet is modified based on the physiologic and anatomic constraints of the disease
process.
 Examples include multiple small meals that are low in carbohydrates in patients after gastric
resections and the use of soft foods with an emphasis on high-calorie liquid nutritional
supplements in patients with esophageal strictures.
 Small & Frequent Meals
 Eat slowly
 Cold and non-odorous food
 Light & low fat food
 Avoid Very sweet or spicy food
 Avoid smoked food.
 Avoid fried, greasy or fatty foods.
 Rest & sit up after eating
 Provide soft and bland diet
 Water: 2 liters of hydrating fluid daily
Avoid risky foods
 These include: Inorganic salad greens – some retain dirt even when washed (instead eat cooked
organic greens)
 Raw or lightly cooked eggs
 Shellfish
 Soft cheeses
Macro nutrients
 Complex carbohydrates: Whole meal bread, Whole meal pasta, Brown rice, Oats, Beans , Root
vegetables
 Protein: protein intake should be above 1 g/kg/day and, if possible up to 1.5 g/kg/day. Eggs,
Fish, Poultry, Meat, Beans and lentils, Nuts and seeds
 Essential fats: Oily fish, Nuts and seeds, Avocados, Olives
 Encourage the intake of energy-enriched foods and fluids that are better tolerated
High levels of micro nutrients
 Avoid dehydrating fluids: tea/coffee, Alcohol, fizzy drinks
 Avoid anti-nutrients: Refined carbohydrate, Processed foods, Sugar
 The main drawback with use of these oral supplements is taste fatigue.
 They avoid more complex and costly methods of enteral or parenteral feeding.

221
Enteral Nutrition
 Enteral feeding is preferred to parenteral feeding because it preserves the gastrointestinal
architecture and prevents bacterial translocation from the gut.
 This method has fewer complications and is less expensive than TPN.
 Carbohydrates usually represent the major source of calories.
 Addition of specific nutrients to enteral feeding solutions may provide immunologic and
metabolic benefits.
 Increase prealbumin by 1mg/dL per day
EN should be considered in patients
 Who are unable to attain oral intake
 Small bowel resection and mucosal injury
 In case of diarrhea and mal-absorption, use low osmolar nutrient supplements, hydrolized
carbohydrates and proteins.
Total Parenteral Nutrition
In patients unsuitable for oral or enteral nutritional support, TPN remains an important option. It
delivers nutrients directly into the circulation, avoiding the problems with poor oral intake and
gastrointestinal dysfunction seen in patients with cancer-induced cachexia.
PN is recommended in patients who need nutritional support when:
 Tube feeding is unsuccessful
 GI Tract is not appropriate (e.g. Obstruction, High output Fistula)
 In Cachectic patients, the goal may be to minimize wasting rather than to nutritionally replete
patient
Some of the serious complications that may occur with parenteral feeding include the following:
 Placement of the tip of the catheter into the wrong place.
 Blood clots.
 A collapsed lung.
 A high or low sugar level in the blood.
 A low potassium level in the blood.
 Elevated liver enzymes.
 Parenteral nutrition support may continue after a patient leaves the hospital.
If parenteral nutrition is to be part of the patient's care after leaving the hospital, the patient and
caregiver will be trained in the procedures and in care of the patient. The home must be clean and
the nutrition support team must monitor the patient often. Experienced medical staff should manage
the patient's removal from parenteral nutrition support. Going off parenteral nutrition support needs
to be done gradually and under medical supervision. The parenteral feedings are reduced by small
amounts over time as the patient is changed to enteral or oral feeding.
Before Treatment Begins: When cancer was first diagnosed, treatment plan must be discussed. This
may have involved surgery, radiation therapy, chemotherapy, hormone therapy, and biologic
immunotherapy or some combination of those treatments.

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All of these methods of treating cancer kill cells. In the process of killing the cancer cells, some healthy
cells are also damaged. That is what causes the side effects of cancer treatment. Side effects that can
affect your ability to eat include:
 Changes in weight (either losing or gaining weight)
 Sore mouth or throat
 Dry mouth
 Dental and gum problems
 Changes in sense of taste or smell
 Nausea/vomiting
 Diarrhea
 Lactose intolerance
 Constipation
 Fatigue and/or depression
Patients may or may not have any of these side effects. Many factors determine whether patient will
have any and how severe they will be. Managing side effects of the drugs:
Eat a Healthy Diet
 A healthy diet is vital for a person's body to work its best. This is even more important for cancer
patients.
 If you've been eating a healthy diet, you'll go into treatment with reserves to help keep up your
strength, prevent body tissue from breaking down, rebuild tissue, and maintain your defenses
against infection.
 People who eat well are better able to cope with side effects. You may even be able to handle
higher doses of certain treatments. For example, we know that some cancer treatments are
actually much more effective if the patient is well nourished and getting enough calories and
protein in his or her diet.
 Don't be afraid to try new foods. Some things you may never have liked before may taste good
to you during treatment.
Plan Ahead
 Stock the pantry and freezer with favorite foods so that you won't need to shop as often. Include
foods you know you can eat even when you are sick.
 Keep foods handy that need little or no preparation, for example, pudding, peanut butter, tuna
fish, cheese, and eggs.
 Do some cooking in advance and freeze in meal-sized portions.
 Talk to friends or family members about helping with shopping and cooking. Or, ask a friend or
family member to manage that job for you.
 Talk to a registered dietitian about your concerns and what you might expect. She or he can
give you ideas and help you plan meals. Ask for help in developing a grocery list with foods
that might help with potential side effects, such as constipation or nausea. Ask about what has
worked for other patients.

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Ways to Get Back into Eating: Even if treatment is over and patient may feel much better, still may
not feel completely back to old self. Here are some ways to help ease back to regular meals and
mealtimes, without overdoing it:
 Make simple meals using familiar, easy-to-prepare recipes.
 Cook enough for two or three meals, and then freeze the remainder for a later meal.
 Take advantage of the supermarket's salad bar and prepared foods to make cooking easier.
 Think about ways you used to make mealtime special and try them again.
 Don't be afraid to ask a friend or family member for help with cooking or shopping.
Foods you can eat: Foods you can eat on a bland diet include
 Milk and other dairy products, low-fat only
 Cooked, canned, or frozen vegetables
 Fruit juices and vegetable juices
 Cooked or canned fruit with the skin and seeds removed, such as applesauce or canned peaches
 Breads, crackers, and pasta made with refined white flour
 Refined, hot cereals, such as Cream of Wheat (farina cereal)
 Lean, tender meats, such as poultry, whitefish, and shellfish that are steamed, baked, or grilled
with no added fat
 Creamy peanut butter
 Pudding and custard
 Eggs
 Tofu
 Soup, especially broth
 Weak tea
Foods to avoid: Some foods you should not eat when you are on a bland diet are
 Fatty dairy foods, such as whipped cream or high-fat ice cream
 Strong cheeses, such as bleu or Roquefort cheese
 Raw vegetables
 Vegetables that make you gassy, such as broccoli, cabbage, cauliflower, cucumber, green
peppers, and corn
 Fresh berries and other fresh fruits
 Dried fruits
 Whole-grain or bran cereals
 Whole-grain breads, crackers, or pasta
 Pickles, sauerkraut, and similar foods
 Spices, such as hot pepper and garlic
 Foods with a lot of sugar or honey in them
 Seeds and nuts

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 Highly seasoned, cured or smoked meats and fish
 Fried foods
Patients should also avoid medicine that contains aspirin or ibuprofen.
Other diet tips
 Eat small meals, and eat more often during the day
 Chew your food slowly, and chew it well
 Stop smoking cigarettes, if you smoke
 Do not eat within 2 hours of your bedtime.
Table: How Cancer Treatments Can Affect Eating
Cancer Treatment How it Can Affect Eating
What Sometimes Happens:
Side Effects
Surgery Increases the need for good
nutrition. May slow digestion.
May lessen the ability of the
mouth, throat, and stomach to
work properly. Adequate
nutrition helps wound healing
and recovery.
Before surgery, a high-protein,
high-calorie diet may be
prescribed if a patient is
underweight or weak. After
surgery, some patients may not
be able to eat normally at
first. They may receive nutrients
through a needle in their vein
(such as in total parenteral
nutrition), or through a tube in
their nose or stomach.
Radiation Therapy As it damages cancer cells, it
also may affect healthy cells
and healthy parts of the body.
Treatment of head, neck, chest,
or breast may cause:
• Dry mouth
• Sore mouth
• Sore throat
• Difficulty swallowing
(dysphagia)
• Change in taste of food
• Dental problems
• Increased phlegm Treatment
of stomach or pelvis may
cause:
• Diarrhea
• Cramps, bloating

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Chemotherapy As it destroys cancer cells, it
also may affect the digestive
system and the desire or
ability to eat.
• Loss of appetite
• Diarrhea
• Constipation
• Sore mouth or throat
• Weight gain or loss
Biological Therapy
(Immunotherapy)
As it stimulates your immune
system to fight cancer cells, it
can affect the desire or ability
to eat.
• Diarrhea
• Sore mouth
• Severe weight loss
• Dry mouth
• Muscle aches, fatigue, fever
Hormonal Therapy Some types can increase
appetite and change how the
body handles fluids.
• Changes in appetite
• Fluid retention
Helpful Hint for Cancer Patients:
To Manage Common Health Problems at Home
Taste Problems:
 Try cold foods like lassi or milkshakes, cheese or egg salad.
 Adding sugar can mask the flavor of salty foods.
  Adding salt can decrease the sweetness of sugary food.
 If you can’t taste anything, try stronger seasonings.
 If meat tastes unusual, substitute chicken, dairy products, ham, eggs and fish for your protein
needs.
 Try chewing gum, elaichi or cloves to eliminate bad taste. Fresh fruits also leave a pleasant taste
in the mouth. Avoid pan masalas though.
 Drink your milk and other nutritional supplements cold if the aroma brothers you.
 Check with your doctor if the condition persists
Dry Mouth
 Sip on juices and other fluids throughout the say.
 Use extra butter, gravies, sauces, yogurt and mayonnaise to moisten foods.
 Drink or soak dry foods in hot liquids.
 Chewing gum. Toffees or ice chips can be effective.

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 A room humidifier helps alleviate dry lips and mouth. Boil water in an open vessel in the room
and allow steam to circulate freely.
Sore mouth
 Try blended, smooth and creamy foods such as eggs, soup Dalia khichri, kheer well cooked dal,
ice cream and puddings.
 Avoid hot foods. Cols or room temperature foods are generally less irritating.
 Avoid acidic (Oranges, Lemons, Tomatoes, Maltas), spicy, rough (toast, potato wafers) and salty
foods.
 After meals, rinse with tap water to freshen mouth.
 Sore throat and Swallowing difficulty
 Choose soft-textured foods, such as soups, mashed potatoes, custard, kheer, scrambled eggs,
etc. and use a food grinder or blender when necessary.
 Avoid hot or cold extremes. Room temperature foods may be soothing.
 Use straws for drinks, and a cup or glass instead of a bowl and spoon for soups. Tilt your head
backward and forward to make swallowing easier. You can sip water every few minutes to help
swallow easily.
Loss of Appetite
 Eat well during your” up” times.
 Make mealtimes as relaxed and pleasurable as possible.
 Include a relaxing walk before mealtime. Fresh air often helps.
 Keep a variety of nutritious snack foods on hand, such as biscuits, cheese, nuts, paneer and other
such nutritional supplements.
 Try a glass of thin lassi to help stimulate your appetite. Be flexible. If not hungry at dinner time
make breakfast, mid-morning snack and lunch at main meal.
 Try a variety of new tastes and textures to find those that appeal to most.
 Try to get plenty of sleep every night.
 Chew slowly, and take breaks during mealtime.
 Maintaining your weight is important. Make an effort to eat regularly, even if it’s only a few
bites.
 If you are losing weight, high calorie liquids such as milkshakes and kheer (with milkmaid), and
nutrional supplements such as Proteinex, Syu granules, Threptin biscuits may be recommended.
 Check with your doctor if the condition persists.
Nausea /Vomiting
 Eat slowly and chew food well.
 Eat frequent small meals and snacks instead of large meals.
 Have 8-10 cups of fluid daily to counter dehydration.
 Try cool foods without a storng aroma, such as watered-down juices, Limca, Colas, Frooti, Jelly,
Custard, Biscuits, Mashed Potatoes, Toast, Dal, Khichri etc.

227
 Do not eat or drink until you have the vomiting under control. Once this occurs, slowly sip chilled
liquids. You may suck chip of ice made from boiled water.
 After eating, relax in an upright position to ease digestion.
 Avoid lying down for atleast two hours.
 Avoid mixing hot and cold foods at the same meal.
 Try your meals cold or at room temperature, since they have fewer odours that way.
 Avoid fried, heavily spiced, high-fat foods. Try to avoid cooking odours.
 Loose clothing may be mare comfortable at mealtime.
 Fresh air can also help.
 It is essential to replace body fluid lost by vomiting with clear liquids such as nimboo-pani and
weak tea. When you are able to keep down clear liquids, try a full liquid diet-fruit juices, lassi,
skimmed milk etc. Once you can keep these down, only then begin regular food.
 If nausea / vomiting persist’s, medications may help. Consult your physician.
Constipation
 For meals and snacks, eat high-fibre foods like chappatis, bread, rice, dals, khichri plus fruits
and vegetable.
 Drink plenty of liquids, at least 8-10 glasses a day; especially in combination with high-fibre
foods.
 Take a walk or exercise as part of your daily routine.
 May try 3-4 teaspoons of lsabgol in a cup of milk at bedtime; 3-4 teaspoons of Cremaffin at
bedtime.
 Check with doctor about other medications to relieve constipation.
Diarrhoea
 Eat small meals throughout the day.
 Drink 10 or more large glasses of liquid (water, tea, nimboo-pani, soups) a day to replace lost
fluids. Instead of having plain water, have Electral diluted in boiled water-about a litre per day.
 Try non-irritating foods such as khichri, soups, Dalia, idles, mashed potatoes, rice, bread,
bananas etc. Avoid raw fruits and vegetables and whole grain cereals and nuts.
 Avoid fatty and fried foods, rich sauces and gravies, alcohol and cigarettes.
 Keep activity to a minimum after meals.
 Be careful with extremely hot or cold foods. Try to drink your liquids slowly at room
temperature.
 Avoid milk products until the diarrhea stops. Substitute your milk portion by dahlia and lassi.
 If you have problems with gas and cramps, chew slowly with your mouth closed to eliminate air
swallowing. Sit for a while in an upright position after a meal. Avoid carbonated drinks and
spicy foods.
 Check with your doctor if the condition persists.


Pain Management
228
Unit : 34
PAIN MANAGEMENT
Pain is an unpleasant sensation signaling that the body is damaged or threatened with injury. People
can suffer from different types of pain, including: Back pain, Menstrual cramps, Pain following
surgery, Arthritis, Headache, Dental pain and Cancer pain. Not all people with cancer experience
pain; however, if you do, it is comforting to know that you can take control of your pain.
The causes of pain experience by cancer patients may include the following:
 The cancer itself: May be cancer is pressing on a nerve, an organ or a bone.
 The cancer treatment: Although radiation and chemotherapy are there to help, they may cause
some discomfort.
 Factors totally unrelated to the cancer: Perhaps have been sitting or lying awkwardly, causing
muscles to become stiff and painful; may even have pulled a muscle as a result.
Treatment of Pain: Pain- relieving medicine may pricribe according to the severity of pain. For mild
pain, may be given aspirin or Paracetamol. These drugs directly reduce pain and fever. For
moderate to severe pain, may need a stronger medicine. While many drug treatments for mild pain
are available over the counter, others require a prescription.
Table showing the Details of Pain medication
Mode of
administration
How does it work Advantages Disadvantages
Oral (tablet,capsule or
solution )
• Medicine taken
orally in the form of
capsule, tablet or
suspension.
• Easy & convenient
• Can be given 4,12
or 24 hourly
• Slow-release
formulations
provide continuous
pain relief.
• Not suitable for
patients unable to
swallow and / or
where vomiting is a
problem
• Administration could
be frequent with
short acing
formulations.
Skin Patch • Drug is absorbed
through the skin into
the bloodstream.
• Easy to administer
• Provide continuous
pain relief for 3
days
• Convenient for
patients who have
difficulties in
swallowing and /
or where vomiting
is a problem
• Non- invasive
• Discreet form of
treatment.
• Gradual onset of
action with the first
application
• Can be used only
for stabilized
chronic pain.

229
Injection • Medicine injected
into the muscle, vein
or underneath the
skin and then
absorbed into the
bloodstream.
• Useful when oral
route is not possible
• Provides fast pain
relief
• Inconvenient to
administer
• Only appropriate
in certain conditions
• Only lasts for a
short period
• Multiple doses
• Invasive
Rectal suppository • Medicine delivered
via the rectal route.
• Suitable for
patients who can
not swallow or
suffer from
vomiting.
• Multiple doses
• Not a normal route
of delivery.
The WHO basic rules for the management of cancer pain
1. Cancer pain can, and should, be treated.
2. Evaluation and treatment of cancer pain is vest achieved by a team approach.
3. The first steps are to take a detailed history and to examine the patient carefully, to determine
if the pain is:
• Caused by the cancer, related to the cancer, caused by anticancer treatment, or caused by
another disorder;
• Part of a specific syndrome;
• Nociceptive, neuropathic, or mixed nociceptive and neuropathic;
4. Treatment begins with an explanation and combines physical and psychological approaches,
using both non- drug treatment.
5. It is useful to have a sequence of specific aims, such as:
• To increase the hours of pain- free sleep;
• Ro relieve the pain when the patient is at rest.
• To relieve pain when the patient is standing or active.
6. Drugs alone usually give adequate relief from pain caused by cancer, provided that the right
drug is administered in the right dose at the right time intervals.
7. By mouth: the oral route is the preferred route for analgesics, including morphine.
8. By the clock: for persistent pain, drugs should be taken at regular time intervals and not "as
needed".
9. By the ladder:
• Unless the patient is in severe pain, begin by prescribing a non- opioid drug and adjust the
dose, if necessary, tot he maximum recommended dose.
• If or when the non- opioid no longer adequately relieves the pain, an opioid drug should be
prescribed in addition to the non- opioid.
• If or when an opioid for mild to moderate pain no longer adequately relieves the pain, it
should be replaced by an opioid for moderate to severe pain (e.g. morphine).
10. For the individual: the right dose of an analgesic is the dose that relieves the pain. The dose of
oral morphine may range from as little as 5 mg to more than 1000 mg.
11. Adjuvant drugs should be prescribed as indicated.
12. For naturopathic pain, a tricyclic antidepressant or an anticonvulsant is the analgesic of choice.
13. Attention to detail: it is essential to monitor the patient's response to the treatment to ensure that
the patient obtains maximum benefit with as few adverse effects as possible.

Pain Management
230
Commonly used pain scales
 Numerical rating scale 0–10, 0 signifying no pain, 1-3-mild pain, 4-6 moderate pain, 7-10
severe pain
 Simple descriptive pain intensity scale
 Visual analog scale
Pain management
WHO analgesic ladder stepwise approach established in 1986
 Mild pain- non opoid (paracetamol and or NSAID +/- adjuvant
 Moderate pain- weak opoid +/- NSAID +/-adjuvant
 Severe pain- strong opoid +/- NSAID +/-adjuvant
Adjuvants
 Steroids like dexamethasone 8-16 mg / day. Give before mid afternoon
 Antidepressents amitriptyline 10- 75 mg/day
 Anticonvulsants (carbamazemine 100-400 mg/day)
Morphine in chronic cancer pain
Oral morphine
 Tablet
 Quick release 10mg
 Control release -10 mg, 30mg
 Syrup morphine- 120mg/ 60 ml
Injection morphine-Injection- 15 mg/ 1ml, 10 mg/ 1 ml
Usually given subcutaneous route for severe cancer pain in palliative setting
Prescribing guidelines of morphine
 Start with low dose 2.5-5 mg 4 hourly
 Titrate according to pain relief and toxicity
 When two or more breakthrough doses are needed in 24 hours, increases the dosage by 30-
50% every 2-3 days
 Double dose can be given at bed time that patient do not need to wake up in middle of the
night to take the medicine
 For break through pain is treated with extra dose of morphine but do not omit the next regular
dose
 Always prescribe a stimulant laxative prophylactically


231
Unit : 35
CHEMOTHERAPY
Introduction: The use of chemicals to treat cancer first began in the early 1940's. The era of modern
chemotherapy can be considered to have begun in 1948 with the introduction of nitrogen mustard.
Since that time, scientists have continued to search for medications to treat neoplasm. It is only in the
last 10 to 15 years, however, that chemotherapy has become a major cancer treatment modality.
Chemotherapy: Chemotherapy refers to cytotoxic agent(s) used to systematically kill cancer cells.
Chemo means chemical and therapy means treatment. Cytotoxic means toxic to cells / cell death. It is
a major treatment modality used for cancer treatment. It includes the use of various chemotherapeutic
agents and hormones, and targeted therapy.
Goals of chemotherapy treatment
 Cure: To achieve prolonged absence of detectable disease (Complete Remission)
 Control: When cure is not an option, to prevent the growth of cancer cells without complete
remission of the disease.
 Palliation: When cure or control is not possible, to reduce tumor burden in order to provide
relief of symptoms and side effects.
 Prevention: Used to reduce cancer risk in individuals who are highly susceptible for certain
cancer types (e.g., Tamoxifen is given to certain women who are at risk for developing breast
cancer).
Therapeutic Strategies of Chemotherapy
 Adjuvant chemotherapy: The use of chemotherapy following with other primary therapy, such
as surgery or radiation. The aim is to reduce risk for disease recurrence by eliminating micro-
metastasis. (e.g.; colon cancer)
 Neo-adjuvant therapy: The use of chemotherapy prior to surgery or other treatment 
modalities. The aim is to reduce tumor’s size in order to aid in surgical removal of tumor and to
decrease likelohood for local and distant metastasis of the disease.
 Concurrent therapy: The use of chemotherapy administered concurrently with radiation therapy.
The aim is to maximize cell destruction that may not be so effective if only one modality is used.
 Salvage therapy: Chemotherapy treatment is given to patient who has failed or recurred
following a different regimen.
 Myeloblastive therapy: The use of high dose chemotherapy. The aim is to obliterate the bone
marrow in preparation for peripheral stem cell or bone marrow transplantation.
Primary therapy: Chemotherapy is given to patient who has localized cancer, for which an
alternative but less than completely effective treatment is available. Primary therapy consists of:
 Induction phase: Chemotherapy is given as the primary treatment to patients with advanced
disease for which no alternative treatment exists. The term induction therapy in haematological
cancer treatment is initial course of chemotherapy with a goal of achieving a ‘remission’ of
cancer.

Chemotherapy
232
 Consolidation or Intensification phase: In haematological cancers, chemotherapy is often given
in repetitive cycles to patients who are in ‘remission’ to prevent recurrence of the cancer.
 Maintenance Phase: It refers to the continued use of chemotherapy medications for months or
years after cancer has gone into remission to reduce recurrence
Classification of Chemotherapy Drugs
They can be classified as:
 Alkylating agents: Cisplatin, Carboplatin, Cyclophosphamide, dacarbazine
 Antimetabolites: Methotrexate, 5-FU, Gemcitabine
 Anti-tumor antibiotics: Doxorubicin, Bleomycin, Mitomycin C
 Vinca-alkaloids (Plant alkaloids): Vincristine, Vinblastine, Etoposide
 Hormonal: Dexamethasone, Tamoxifen, and Prednisolone
 Targeted therapy: Imatinib, Sunitib, Bevacizumab
Objective of chemotherapy: The main objective in treating patients with chemotherapy is to
maximize the death of malignant tumour cells while sparing those normal cells with a high mitotic
index e.g. bone marrow cells, oral mucosal cells, hair follicles.
 To cure the client with cancer.
 To control the tumour growth when cure is not possible.
 To extend the life span and improve the quality of life of client with cancer.
How chemotherapy works: Reproduction of both healthy and malignant cells follows the cell cycle
pattern. The cell cycle time is the time required for one tissue cell to divide and reproduce into
identical daughter cells. The cell cycle of any cell has four distinct phases, each with a vital underlying
function.
G1 phase – RNA and protein synthesis occurs.
S phase – DNA synthesis occurs.
G2 phase – premitotic phase, DNA synthesis is complete, mitotic spindle occurs.
M phase – cell division occurs.
The G0 phase, the resting or dormant phase of cells can occur after mitosis and during the G1phase.
In the G0 phase are those dangerous cells that are not actively dividing but have the future potential
for replication.

233
Figure: Cell Cycle Pattern
Chemotherapy Drugs ACT through a variety of mechanism but, essentially, kill cells by Limiting DNA
synthesis and expression – by interfering with synthesis of building blocks for nucleic acid Cross linking
polymer DNA – Damaging the DNA template and cross link the two strands of the double helix,
preventing replication. DNA double strand breaks – bind selectively with DNA, producing complexes
that block DNA replication and formation of DNA dependent RNA. Preventing formation of mitotic
apparatus – prevent chromosome segregation at mitosis by producing metaphase arrest.
Classification of Chemotherapy: Chemotherapeutic agents are broadly classified as,
Cell Cycle-specific Drugs: Those chemotherapeutic agents that destroy cells in specific phases of the
cell cycle. Most affect cells in the S-phase by interfering with DNA and RNA synthesis. Other are
specific to M phase, where they halt mitotic spindle formation.
Cell Cycle Non-specific: Those chemotherapeutic agents that act independently of the cell cycle
phases are termed cell cycle non-specific drugs. These drugs usually have a prolonged effect on cells,
leading to cellular damage or death.

Chemotherapy
234
Chemotherapeutic agents are also classified according to various chemical groups each with a
different mechanism of action. These include: Alkyl ting agents, Antimetabolites, Antitumor antibiotics,
Nitrosuereas, Plant alkaloids, Hormonal agents, Miscellaneous agents.
Intravenous routes
Peripheral Access: Large veins in the fleshy part of the forearm are the preferred access sites. Avoid
areas of impaired lymphatic drainage, phlebitis, invading neoplasm, haematoma, inflamed or
Sclerosing agents, areas of impaired venous circulation, the lower extremities and sites distal to a
recent venipuncture site. Avoid veins that are on the dorsal aspect of the hand or over an area of
flexion such as the wrist or elbow.
Vascular Access: Vascular access devices (VADs) are being used during treatment of clients requiring
continuous chemotherapy. VADs are usually inserted into one of the major veins of the upper chest.
The brachial or cephalic vein in the forearm is used for peripherally inserted central catheters
(PICCS). The distal catheter tip is advanced to the level of the superior venacava at or above the
junction of the right atrium.
Figure: Central Catheters
Alternative routes: Intracavitary therapy: It involved administration of cytotoxic drugs directly into
areas such as pleura (Intrapleural), peritoneum (intraperitoneal) or bladder.
With this method, a high concentration of a chemotherapeutic agent is delivered to the actual tumour
site with minimal exposure of healthy tissues therapy decreasing toxic effects.
Intra-arterial therapy: The basic principle of arterial infusion is to administer chemotherapy into a
localized region containing the tumour through the artery supplying that area. Although intra-arterial
infusions involve some risk, major organs or tumour sites do receive maximal exposure with limited
serum levels of medications.

235
Hepatic arterial infusion: (HAI) is one of the recent innovative modes of chemotherapy being used in
the treatment of hepatic metastases from colorectal cancer. Flouridine is the commonest therapeutic
agent delivered using HAI.
Ommaya reservoir: Most medications given systematically are not effective against central nervous
system (CNS) tumors because they cannot cross the blood brain barrier. Chemotherapeutic agents can
be instilled into the CNS through a reservoir placed in the ventricle or via a lumbar puncture.
Figure: Ommaya reservoir
Continuous infusions of chemotherapy: Recent modification in the administration of chemotherapy is
the use of continuous infusions administered through a surgically implanted port and small external
infusion pump. The port is usually placed in the subcutaneous tissue of the anterior chest and the
attached catheter in tunneled into the region of the clavicle and inserted into subclavian vein. After
the part is accessed using a specially designated 90o angle needle the tubing attached to the needle
is connected to a small ambulatory infusion pump that delivers a continuous pre-set dose of
chemotherapy.

Chemotherapy
236
Figure: Continuous infusions
This mode of therapy has been used to administer 5 – FU to patients with metastatic colorectal
cancer.
Safe preparation, handling and disposal: The safe administration and disposal of chemotherapeutic
agents is controversial. Although evidence suggests that these agents may be carcinogenic, no valid
and reliable studies have determined the risks of exposure to the health care provider. Undue
exposure to antineoplastic drugs can occur from three major routs: Inhalation of aerosols, Absorption
through the skin, and Ingestion of contaminated materials. Several organizations including the
occupational safety and Health Administration, the National Study commission on Cytotoxic Exposure,
and the Oncology Nursing Society, has prepared guidelines for the safe preparation.
Extravasations
Vesicant drugs: These are those agents that if deposited into the subcutaneous tissue, cause tissue
necrosis and damage to the underlying tendons, nerves, and blood vessels.
Irritarit drugs: These can produce venous pain at the site and along the vein, with or without an
inflammatory reaction.
Extravasations are infiltration of cytotoxic drugs into the subcutaneous tissue. Although the complete
mechanism of tissue destruction is unclear, it is known that the pH of many antineoplastic drugs and
the binding ability of drugs to tissue DNA is responsible for the severe inflammatory reaction.
Extravasations occur due to: Absence of blood return from the intravenous catheter, Resistance to
flow of intravenous fluid & Swelling, pan or redness at the site.
General recommendations for the management of extravagation are:
 Stop drug administration
 Leave the needle in place and attempt to aspirate any residual drug from the tubing, needle,
and site.
 Administer and antidote if appropriate.
 Remove the needle and do not apply direct manual pressure to the site.
 Apply warm (for vinca alkaloid) or cold compresses as indicated.

237
 Observe the site regularly for pain, erythema, swelling, Induration, and necrosis.
 The appearance of the site before and after chemotherapy should be carefully documented in
the client's record.
Hypersensitivity reactions: Hypersensitivity reactions to chemotherapy, although rare, can be serious
and life threatening. The antineoplastic agents most commonly implicated in the development of
hypersensitivity reactions are: L-asparagines, Carboplatin, Bleomycin, Cisplatin and Teniposide. When
administering a drug with anaphylactic potential, take the following precautions to ensure client
safety:
 Obtain an allergy history from the client.
 Administer a test dose
 Stay with the client the entire time the drug is being administered.
 Have emergency equipment and drugs readily available.
 Obtain baseline vital signs.
 Establish a free flowing intravenous line for the administration of fluids and emergency drugs
should the need arise.
Clinical manifestations of hypersentivity reactions are: Dyspnea, tachycardia, Chest tightness or
pain, dizziness, Pruritis, Anxiety, Inability to speak, nausea, abdominal pain, hypotension, Cloudy
sensorium, fused appearance and Cyanosis.
 Management hypersentivity reactions
 Immediately stop drug administration
 Maintain IV access with 0.9% saline.
 Notify physician
 Maintain airway, and place the client in the supine position with the feet elevated (unless
contraindicated).
 Monitor the client’s vital signs every 2 minutes.
 Administer epinephrine, aminophylline, diphenhydramine, and corticosteroids based on the
physician's orders.
Toxic effects of chemotherapy: Toxicity associated with chemotherapy can be acute or chronic. Cells
with rapid growth rates (e.g. epithelium, bone marrow, hair follicles, and sperm) are very susceptible
to damage from these agents. Various body systems may also be affected by these drugs. The
details of the toxic effects are described below:
Gastrointestinal system:
Nausea and vomiting are the most common side effects and may persist for up to 24 hrs after drug
administration. Other are anorexia, taste alteration, weight loss, oral mucositis, Diarrhoea and
constipation. Research indicated that the vomiting center, located in the medulla oblongata is
responsible for coordinating the act of vomiting. Stimulation of vomiting center occurs via a variety of
pathways and is mediated by a variety of neurotransmitters. Antiemetics – are usually prescribed 6
to 12 hours prior to the administration of chemotherapy and are continued every 4 to 6 hours of at
least 12 to 24 hrs, or for as long as manifestations persist. Commonly used drugs include serotonin
blockers such as ondansetron (which flock serotonin receptions of CTZ), dopaminergic blockers such as
metoclopramde (Reglan), phenthiazines, sedatives, steroid, and histamines, alone or in combination.

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Nonpharmacologic interventions include adjusting oral and fluid intake, relaxation, exercise, hypnosis,
biofeedback, guided imagery and systemic desensitization.
Anorexia and weight loss: occur as a result of the disease process as well as the treatment. Common
problems that interfere with oral intake include anorexia, nausea and vomiting, early satiety, taste
alterations, dry mouth, stomatitis, esophagitis, viscous saliva, lactose intolerance, pain Diarrhoea, and
constipation. Assess the nutritional status of the client. When medically appropriate, oral nutrition can
be enhanced. It nutritional requirements cannot be met orally, enteral and intravenous feedings can
be considered.
Stomatitis or oral mucositis is the term used to describe inflammation and ulceration of the mucosal
lining of the mouth. What is seen in the mouth is present throughout the gastrointestinal tract.
Consequences of stomatitis include pain, decreased nutritional and fluid intake, oral infections,
malabsorption, and Diarrhoea.
 An oral hygiene program should start before therapy and continue throughout treatment.
 Dental examination prior to and during therapy.
 Thorough and gentle cleaning to avoid further trauma.
 Moisturization if saliva is scanty or absent.
 Avoidance of alcohol and smoking.
 Culture and antimicrobial therapy for infections, and topical anesthetics and analgesics for pain
or discomfort.
 Dietary modification: avoiding extremely hot or cold foods, spices and citrus fruits and juices,
eating soft foods; and taking nutritional supplements.
Diarrhoea: is most often the result of Antimetabolites drugs – A low residue or liquid diet is usually
advised. Electrolytes and intake and output should be carefully monitored. Scrupulous perineal
hygiene is encouraged, especially in the neutropenic client. Antidiarrhoeals
Constipation: is frequently the effect of vinca alkaloids (vinblastine, Vincristine) on bowel peristalsis.
Other causes of constipation include narcotic use, immobility, decreased fluid and bulk intake, tumour
invasion of the GI tract and depression. Preventive measures include increasing fluid and bulk intake,
administering stool softeners. Prophylactically, increasing activity, and administering laxatives.
Hematopoietic system: Most chemotherapeutic agents depress bone marrow function
(Myelosuppression) resulting in decreased production of blood cells. Myelosuppression decreases the
number of white blood cells or leucocytes (Leucopoenia), red blood cells (anemia), and platelets or
thromocytes (thrombocytopenia) and increases the risk of infection and bleeding. The time after
chemotherapy administration, when the white blood cell or platelet count is at the lowest point is
referred to as the nadir. For most myelosuppressive agents, the nadir occurs within 7 to 14 days after
drug administration.
Neutropenia: The absolute neutrophil count (ANC) is calculated by ANC = WBC X % gametocytes
neutropenia is defined as ANC of less than 1000/mm3, and the longer the client remains
neutrophenic. Gametocyte colony- stimulating factor (G-CSF) or gametocyte – macrophage colony
stimulating factor (GM-CSF) are given following chemotherapy as they stimulate bone marrow to
produce while blood cells at an accelerated rate, thus decreasing the duration of neutropenia. Teach
clients measures to protect against infection e.g. Maintain adequate nutrition and fluid intake. Avoid
raw or uncooked foods. Avoid crowds, people with infections, and children who have been recently

239
vaccinated with live or attenuated vaccines. Avoid contact with animal excreta (e.g. bird, cat and dog
faeces). Immediately report any manifestations of infection such as fever over 38Oc (100Of), cough,
sore throat, chills or sweating, or frequent or painful urination. Maintain personal hygiene, especially
hand washing. Get adequate rest and exercise. Avoid indiscriminate use of antipyretics (e.g.,
acetaminophen, aspirin) because they may mask fever.
Thrombocytopenia: increases the client's risk of bleeding. A high risk of hemorrhage exists when the
platelet count is less than 20,000/mm3. Fatal CNS hemorrhage or massive GI hemorrhage can occur
when the platelet count is less than 10,000/mm3. Assess for change in level of intracranial
hemorrhage.
Instruct clients to report any of the following
 Bleeding gums
 Increased bruising, petechiae, or purpura, especially on the lower extremities.
 Tarry stools, blood in urine, coffee ground vomitus.
 Headaches blurred vision.
 Visual changes (thrombocytopenia clients may have retinal bleeding)
 Hemoptysis
 Nose bleed
 Platelet transfusion may be given to keep the platelet count above 20,000/mm3.
Anemia: may cause fatigue, headache, dizziness, fainting, pallor, dyspnea, palpitations and
tachycardia. Packed red blood cell transfusions may be required to relieve anemia. Erythropoietin
may be prescribed to maintain the erythrocyte level and decrease the need for transfusions.
Integumentary system: Alopecia: is the common side effect of many antineoplastic agents. The
extent of hair loss depends on the specific drug, dosage, and method of administration. Alopecia is
temporary, with regrowth often occurring before chemotherapy ends, although hair Colour and
texture may change. Approaches to lessen or prevent chemotherapy induced Alopecia remain
controversial.
Skin reactions: Red patches (Erythema) or hives (urticaria) at the drug injection site or on the other
body parts: These reactions generally disappear within several hours. Darkening of the skin (hyper
pigmentation) in the nail beds, mouth, on gums or teeth, and along the veins used for intravenous
chemotherapy, or generalized' hyper pigmentation usually occurs 2 to 3 weeks after administration
of chemotherapy and continues for 10 to 12 weeks after the end of therapy.
Sensitivity to Sunlight (photosensitivity): This may result in acute sunburn after just a short exposure
to the sun. The sensitivity disappears once treatment stops. Clients must be taught to use sunscreen or
protective clothing before sun exposure.
Radiation Recall: This skin reaction may occurs in clients who received radiation therapy. When
chemotherapy is given several weeks or moths later, a recall, reaction occurs in the previously
irradiated skin area. Skin effects range from redness, shedding, or peeling, to blisters and oozing.
After the skin heals, it is permanently darkened. It is important to maintain meticulous hygiene to
avoid a superimposed infection. Antibiotic therapy should be initiated at the first manifestation of
infection.

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Reproductive system: Testicular and ovarian function can be affected by chemotherapeutic agents,
resulting in possible sterility. Azoospermia, oligospermia, and sterility have been documented in
males. Amenorrhea, menopausal manifestations, and sterility have been noted in females.
Administration of antineoplastic agents during the first trimester of pregnancy increases the risk of
spontaneous abortion and fetal malformations. Second and third trimester chemotherapy exposure
may result in low birth weight or prematurely. So clients and their partners are advised to use
reliable methods of birth control while receiving chemotherapy.
CLASSIFICATION, ACTION AND SIDE EFFECTS OF ANTINEOPLASTIC AGENTS
Category Mechanism of action Common drugs Cell cycle specificity Common side effects
Alkylating agents Alter DNA structure
by
Misreading of DNA
code
Breaks in DNA
molecule
Cross linking of DNA
strands
Buzulfan (myleran)
Carboplatin (CBDCA,
Paraplatin)
Chlorambucil
(leukeran)
Cyclophosphamide
(cytoxan)
Ifosfamide (Ifex)
Dacarbazine (DTIC)
Mechorethamine
hydrochloride
(Mustargen, nitrogen
mustard)
Cell cycle
non specific
Bone marrow
suppression, nausea,
vomiting, cystitis
(cyclophosphamide
and ifosamid),
stomatitis, alopecia,
gonadal suppression,
renal toxicity.
Antimetabolites Interfere with the
biosynthesis of
metabolities / nucleic
acids necessary for
RNA and DNA
synthesis
Cladribine (leustain)
Cytarabine (ara-C1
Cytosar – U)
Floxuridine (FUDR)
Fludarabine (Fludara)
5- fluorouracil
(Adrucil, 5-FU)
Mercaptopurine
(Purinethol, 6 MP
Methotrexate sodium
(Folex)
Cell cycle specific (S
phase)
Nausea, vomiting,
diarrhoea,
myelosuppression,
proctitis, inflammation
of anus and rectum,
stomatitis, renal
toxicity (MTX),
hepatotoxicity.
Antitumour antibiotis Intercalate with DNA
to prevent DNA
replication and / or
messenger RAN
production
Bleomycin sulfate
(blenoxane)
Dactinomycin
(actinomycin
Department of
Surgery)
Daunorubiun
(daunonycin)
Doxorubicin(adriamy
cin, rubex)
Epirubicin
(pharmorubicin)
Idarubicin
(Iadamycin)
Cell cycle non-specific Bone marrow
suppression, nausea,
vomiting, alopecia,
anorexia, cardia
toxicity (Daunorubicin,
Doxorubicin)

241
Mitomycin (Mitomycin
C)
Mitoxantrone
(Novantrone)
Plicamycin
(Mithramycin)
Nitrosureas Similar to alkylating
agents, cross blood
brain barrier
Carmustine (Bi CNU)
Lomustine (CCNU)
Semustine (methyl –
CCNU)
Streptozocin
(Zanosar)
Cell cycle non –
specific
Delayed and
cumulative
myclosuppression,
especially
thrombocytopenia,
nausea, vomiting.
Plant
alkaloids/Natural
products
Cause metaphase
arrest by inhibiting
mitotic tubular
formation (mitotic
spindle inhibitors);
inhibit DNA and
protein synthesis
Docetaxel (Taxotere)
Etoposide (vepesid,
VP -16-213)
Pactitaxel (Taxol)
Teniposide (Vumon,
VM-26)
Vinblastine sulfate
(Velban)
Vincristine sulfate
(Onorin)
Vindesine sulfate
(eldisine)
Vinorelbine tartrate
(Navelbine)
Cell cycle specific (M
phase)
Bone marrow
suppression, (Mild with
VCR)
neuropathies (VCR),
stomatitis,
Bradycardia,
hypersensitivity
reactions (taxol).
Hormonal Agents Bind to hormone
receptor sites that
alter cellular growth;
block binding of
estrogens to receptor
sites (antiestrogens);
inhibit RNA synthesis
Androgens –
Dromostanolone
proprionate
(Drolban)
Fluoxymesterone
(Halotestin)
Antiandrogen –
Flutamide (Eulexin,
Euflex)
Estrogens –
Chlorotrianisene
(Tace)
Conjugated estrogens
(Premarin)
Estradiol (Estrace)
Diethylstilbestro (DES)
Cell cycle non –
specific
Hypercalcemia,
jaundice, increased
apetite,
masculinization,
sodium and flid
retention, nausea,
vomiting hot flashes.

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Antiestrogen –
Taxoxifen
(Nolvadex)
Progestational agents
– Megestrol
(Megace)
Medroxyprogrestero
ne (Depo-proveara,
provera)
Adrenal cortical
compounds
Corticose acetate
(cortone acetate)
Denmethasone
(decadron)
Predinisone
(Deltasone)
Prenisolone
(Cortalone, Delta
cortef)
Adrenal cortical
steroid inhibitor
Miscellaneous Agents Unknown, too
complex to
categorize
Altretamine
(Hexalen), Amsacrine
(m-AMSA),
Asparaginase
(Elspar, L-ASP),
Extramustine (Emcyt),
Hydroxyurea
(Hydrea), Levamisole
(Ergamisol, Mesna
(Mesnex), Mitotane
(Lysodren),
Procarbazine
(Matulane)
Anorexia, nausea,
vomiting,
myelosuppression,
hepatotoxicity,
anaphylaxis,
hyptension, altered
glucose metabolism.

243
Commonly Used Cytotoxic Drugs
CISPLATIN METHOTREXATE
CLASS – Alkylating Agent
Indications – Metastatic tesicular and ovarian
cancer, advanced bladder, head and neck cancer.
Contraindications- Hypersensitivity, pregnancy,
lactation, renal impairment.
Dosage – Testicular tumours – 20mg/m2/day
I.V. for 5 days (day 1-5) 3 weeks, for 3
courses.
Ovarian tumour – 50mg/m2/IV once every 3
weeks (day 1)
Bladder cancer – 50-70mg/m2/IV once every 3-
4 weeks.
Special Precautions – Not to use needles and I.V.
sets containing aluminium components.
Maintain good hydration
Monitor neurological status, renal status and
hematological function
CLASS – Antimetabolites
Indications – Lymphoblastic leukemia.
Choricarcinoma
Contraindications – Severe leucopenia or
thrombocytopenia, anemia.
Dosage – Lymphoblastic leukemia 20-40mg/m2
BSA twice weekly I.V. or I.M.
Choriocarcinoma – 1530 mg daily for 5 days.
Special precautions - Monitor hepatic, renal and
haematological function.
Children, GI disorders, CNS disturbance, hepatic
and renal impairment, bone marrow depression.
DOXORUBICIN VINCRISTINE
CLASS – Cytotoxic Antibiotic
Indications – GI tract carcinoma. Actue
myeloblastic leukemia, bronchogenic, breast
and ovarian carcinoma, soft tissue and bone
sarcoma
Contraindications – Cardia disease. Hepatic
dysfunction.
Dosage – 1.2-2.4 mg/kg body wt. Or 60-75
mg/m2 BSA given as a single dose every 3
weeks by slow I.V.
Special precaution- Haematological and cardiac
monitoring
Observe for hyperuricaemia.
Use with care in cardiac or hepatic dysfunction
CLASS – Plant Alkaloid
Indications – Acute leukemia, lymphomas,
neuroblastoma, Hodgkin's disease, inoperable
malignant neoplasms of breast, bladder and
cervix, kaposi's sarcoma.
Contraindications – Severe granulocytopenia,
systemic infections, hyper sensitivity.
Dosage – Adults – 1.4 mg/sq.m BSA / weekly.
Children – 2 mg/sq.m. BSA weekly.
Special precautions – Avoid eye contact.
Hepatic clearance of vincristine is reduced if L-
asparanginase is administered first.
Observe for peripheral neuropathy.
Nursing Care: Nursing Diagnosis and therie care Plan
1. Fear related to disease process and /or treatment
Goal: Patient will verbalize fears and begin to deal with them effectively.
• Assess previous experience with chemotherapy.

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• Assist patient and/or significant others with recognizing and clarifying fears and with
developing coping strategies for those fears.
• May be helpful to role-play and/or coach patient by using examples of coping skills used by
others.
2. Alteration in comfort: Pain related to disease process.
Goal: Patients pain will be minimized and comfort will be maintained.
• Monitor and documents pain characteristics, as well as associated factors such as anxiety.
• Establish a trusting relationship with patient.
• Administer prescribed analgesic q3h to q4h at regular intervals to control pain.
• Provide environment conductive to rest.
• Evaluate patient’s fears and perceptions regarding pain and pain therapy.
• Evaluate level of consciousness and note changes in sensorium.
• Involve significant other in care planning as much as possible.
3. Alteration in nutrition: Less than body requirements related to nausea and vomiting, anorexia,
Stomatitis, disease process and/or treatment
• Goal: Patient will maintain adequate nutritional intake and control of nausea and vomiting,
weight loss and other side effects of stomatitis and chemotherapy will be minimized.
• Evaluate nutritional status: Ht. Wt., serum albumin, history of food preference, oral
assessment, and evaluation of fatigue, depression, anxiety and pain.
• Frequent oral hygiene.
• Avoidance of extreme temperature of foods and spicy food.
• Include basic food group in diet.
• Maintain fluid intake 3000mL daily unless contraindicated.
• Increasing calories and protein diet.
• Weighting patient weekly.
• Explain measures to prevent abdominal feeling of fullness or bloating: limit fluid intake at
meals, avoid gas-producing food, encourage small frequent meals, and avoid greasy or
spicy food.
• Explain measures to control Diarrhoea: reduce amount of fiber in diet, identity food or
medication that cause Diarrhoea, explain use of antidiarrhoeals medication.
• Evaluate hydration status and skin turgor.
• Monitor intake and output.
• Administer antiemetics before, during and after chemotherapy as needed.
• Administer chemotherapy in late after noon or at night when possible.
• Check for oral burning, pain and changes in tolerance to foods.

245
4. Disturbance in self-concept related to disease process and / or treatment.
Goal: Patient will verbalize concerns and develop coping mechanisms to deal effectively with
problems.
• Assess patient’s level of knowledge related to disease process and treatment.
• Evaluate how diagnosis and treatment are affecting patient’s life style.
• Evaluate support system.
• Determine patient and / or significant other's coping strategies.
• Provide opportunity for discussion of concerns regarding physical self (feelings: physically,
feelings about owns body), role function (wife, mother, wage earner) and dependence/
independence.
• Professional counseling if support system detorating.
• Individualized care of patient.
5. Knowledge deficient regarding chemotherapy
Goal: Patient, and/or significant others will demonstrate knowledge of disease process,
treatment and potential side effects of chemotherapy.
• Assess ability and desire to learn
• Assess knowledge and level of understanding related to the disease process and treatment
(factual, misconceptions).
• Ascertain expectations of outcome of treatment.
• With the help of A.V. aids, explain how drugs work and expected therapeutic effects of
chemotherapy treatment.
• Provide patient and/or significant other with written material regarding name of drug, action
of drug, and potential side effects.
• Explain method, frequency and duration of administration of each drug.
• Provide verbal and written material regarding management of side effects / toxicity.
• Instruct patient about early side effects such as, nausea and vomiting.
• Disease side effects those are reversible.
• Information about emergency contact given.
6. Risk for infection related to altered immunologic response
Goal: Prevention of infection
• Assess patient for evidence of infection: Check vital signs every 4hrs, monitor WBC count,
inspect all sites for entry ports for pathogens (IV site, wound, oral cavity).
• Report fever > 101of (38.3oc), chills, diaphoreses, swelling, heat, pain, erythema.
• Report change in respiratory or mental status, urinary frequency or burning, malaise,
arthrelgia, rash or Diarrhoea.
• Obtain culture sensitivity report before initiation of microbial therapy (exudates, sputum,
urine, stool, blood.

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• Initiate measures ot minimize infection.
• Isolate patient if WBC count <1000/mm3.
• Control visitors and use barrier methods, hand washing encourage.
• Meticulous personal hygiene maintained.
• Instruct client to use electric razor.
• Encourage patient to ambulate in room unless contraindicated.
• Avoid fresh fruits, raw meat, fish and vegetables if absolute WBC count <1000/mm3. (It
harbor bacteria not remove by ordinary washing)
• Assess IV site every day for evidence of infection.
• Change IV site every other day
• Clean skin with Betadine before arterial or venipuncture.
• Change CVP catheter dressing every other day.
• Change all solutions and infusion sets every 48 hrs.
• Avoid IM injections.
• Avoid urinary catheter if possible. Use strict aseptic technique.
• Administration of chemotherapeutic drugs
• Verify patient’s identification.
• Review patient’s allergy history.
• Assess learning needs and concerns, and answers questions appropriately.
• Review educational materials with patients and family (pamphlets, direction).
• Check physicians order for drug dose, route, rate, and time of administration.
• Verify that informed consent has been given.
• Review laboratory data with knowledge of acceptable parameters.
• Review immediate and long-term side effects of drugs.
• Calculate dose, double check calculation, and ascertain if dose is within normal administration
range.
• Know amount and type of diluents to use for reconstitution (mix in biologic safety hood and
observe safety precautions): -
• Only pharmacists, physicians and nurse with special training should prepare
chemotherapeutic agents for administration.
• All equipments and unused drugs should be treated as hazardous waste.
• Pregnant women should not handle these drugs.
• Transport parental drugs in plastic cover to prevent spillage and contamination.
• Wear disposable cover gowns with closed front and cuffed, long sleeves and latex gloves
throughout preparation, administration, and disposable period.
• Wear protective garment and gloves when handling patients’ excreta during administration
and for 48 hrs flowing administration.
• Syringes and IV sets with leur-lok fitting should be used whenever possible to prevent
spillage.

247
• When priming IV line ad removing needle from injection port, place alcohol swab and 4 x 4
beneath site to collect small spills; discord in hazardous waste container.
• Wipe up spills immediately; contain spills by gently covering them with disposable absorbent
material, be care full to prevent gerosolization, and discard as "hazardous waste".
• Verify drug dose with another nurse, a pharmacists, or physician.
• Correctly label drug with patients name, dose, and route of administration.
• Select site for venipuncture with regard to previous trauma to gram and drug to be given,
begin at distal portion of extremity.
• Avoid use of pre-existing IV for vesicant drugs.
• Avoid use of lower extremities.
• Wash hands.
• If use scalp vein size will be 23 or 26 No.
• Avoid multiple sticks. (Adhesive tape).
• Stabilize arm or hand; use pillow or board if necessary.
• Ensure patient's comfort.
• Instruct patient to notify nurse immediately of adverse effects.
• Administer antiemetics 30min, prior to administration of chemotherapy if indicated.
• Have emergency medications and antidote readily available for adverse reaction.
Complications in chemotherapy
Myelosuppression: Inhibition of bone marrow activity resulting in decreased production of blood
cells and platelets due to the effects of chemotherapy, the disease state of radiation therapy.
1. Leucopoenia: Temporary reduction in the total number of circulating white blood cells; since the
life span of leukocytes is very brief (12 hrs), leucopoenia occurs frequently in patient receiving
chemotherapy, placing them at risk for infections; a good indication of a patients ability to fight
infection is the absolute granulocyte count (AGC), which is calculated by multiplying the total
WBC count by the percent of granulocytes in the differential. AGC – WBC x % granulocytes.
When AGC is below 1000 cells/mm3, patient is at risk of infection; opportunistic endogenous
organisms can cause systemic and severe infections.
2. Thrombocytopenia: Reduction in the number of circulating platelets caused by destruction of
bone marrow during chemotherapy, platelets circulate for about 10 days before removal from
circulation.
Observe For: Petechiae, easy brushing, bleeding gum or nose, purpura, hypermenorrhea, tarry
stool, blood in urine and/or emesis, abdominal pain, distention, prolong bleeding from invasive
procedures, vaginal or rectal bleeding, blurred vision, headache, disorientation, decreased
platelet counts.
Discharge criteria
Prior to discharge, the client will:
 Identify ways to prevent infection during periods of lowered immunity.
 Demonstrate the ability to correctly take an oral and axillary temperature.

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 Demonstrate appropriate oral hygiene technique.
 Identity technique to control nausea and vomiting.
 Verbalize ways to improve appetite and nutritional status.
 Verbalize ways to manage and cope with persistent fatigue.
 Verbalize ways to prevent urinary calculi.
 Verbalize ways to prevent bleeding when platelet counts are low.
 Demonstrate the ability to care for a central-venous catheter, a peritoneal catheter or an
implanted infusion device if in place.
 Verbalize an understanding of the care and precautions necessary if an "ommaya" reservoir is
in place.
 Verbalize an understanding of an implanted infusion pump and precautions necessary if one is in
place.
 State signs and symptoms of complications to report to the health care provider.
 Share thoughts and feelings about changes in body image resulting from chemotherapy.
 Identify community resources that can assist with home management and adjustment to the
diagnosis of cancer and chemotherapy and its effects.
 Verbalize and understanding of and a plan for adhering to recommended follow up care
including schedule for chemotherapy, laboratory studies, and future appointments with health
care provide and medications prescribed.


249
Unit : 36
RADIOTHERAPY
Introduction: More than 60% of all clients with cancer receive radiation therapy (RT) at some point
during the course of their disease. RT may be used as a primary, adjuvant, or palliative treatment
modality. As the primary modality, RT is the only treatment used and aims to achieve local cure of the
cancer, e.g., early stage Hodgkin's disease, skin cancer, and carcinoma of cervix. As the adjuvant, RT
can be used either preoperatively or postoperatively to aid in the destruction of cancer cells e.g.
colorectal cancer, early breast cancer.
In addition, it can be used in conjunction with chemotherapy to treat disease in sites not readily
accessible to systemic chemotherapy, such as brain. Chemotherapy also can be combined with RT and
is administered before the RT dose in order to potentiate the effects of RT. As a palliative treatment
modality, to relieve pain caused by obstruction, pathologic fractures, spinal cord compression, and
metastasis.
In radiation therapy high- energy radiation such as X-ray or gamma rays are used to destroy cancer
cells and stop them from growing and multiplying. Most of cancer patient require radiation therapy
at some point during their illness.
Purposes of Radiation Therapy
 Curative: To cure cancer.
 Palliation: To relieve pain, pressure symptoms
 Combination therapy: Radiation can be combined with chemotherapy and also with surgery
when tumor is too large to be operated.
 Sterilization: Example- blood
Types of Radiation Therapy: Tele-therapy and Brachy therapy
 Tele-therapy: It is most commonly used method also known as external radiation therapy where
tumor is placed at a known distance from an external source.
 Brachy Therapy: Brachy therapy is temporary or permanent placement of a radioactive source
either near to or within tumor.
Types of brachy therapy
 Intracavitory: It can be given into cavity such as cervical cancer, vaginal cancer
 Intraluminal: It can be given into lumen as esophagus cancer
 Interstitial: It can be given into tissue such as cancer of tongue, lips, eye, and breast.
 Surface mould: It can be given into skin
 Intra-arterial: It can be given into artery to treat benign as well as malignant tumor.
Radiation dose
Radiation doses for cancer treatment are measured in a unit called a gray (gy), which measures
amount of radiation energy absorbed by 1 kilogram of tissue. Different doses are needed to kill
different types of cancer cells. Radiation dose is calculated by using the unit c Gray. Usually dose is
calculated on the basis of types of cell of origin of tumor and its location.

Radiotherapy
250
Radiation is given usually in fraction
 Purpose of giving fractionated
 To minimize the damage to normal tissue
 To increase the likelihood that cancer cell are exposed to radiation at points in the cell cycle
when they are most vulnerable to DNA damage.
Type of Fraction
 Accelerated fraction: It gives larger daily dose/ weekly dose to reduce the no of treatment.
 Hypo fraction: Larger dose given once a day and less often to reduce the no of treatment.
 Hyper fraction: Smaller dose of radiation given more than once a day
Common Side effects of Radiation Therapy
 Regardless of site of radiation therapy, some effects occur systematically and are common in
patients receiving radiotherapy to any sites. They are:
 Nausea, vomiting
 Anorexia
 Skin reaction
 Bone marrow suppression
 Fatigue
Types of Radiation:
Radiation of concern is those with the capacity to produce ionizations and excitations during the
absorption of energy in biological material. The raising of an electron in an atom or molecule to
higher energy level, without the actual ejection of that electron from the atom or molecule, is called
excitation.
Electromagnetic Radiation: These are indirectly ionizing. They do not themselves produce chemical
and biological damage, but when absorbed in the medium through which they pass, they give up
their energy to produce fast moving electrons by either the Compton, photoelectric or pair production
processes.
Particulate Radiation: Other forms of radiation used experimentally and that are used or
contemplate for radiotherapy include electrons, protons, alpha particles, neutrons, negative pi-
mesons, and high energy heavy ions.
Electrons: These are light, negatively charged particles that can be accelerated to high energy and
to a speed close to that of light, by means of electrical device such as a betatron or linear
accelerator. These are the same as beta-rays. The term beta ray is used when referring to the
electrons emitted from radioactive substances, when they are accelerated in machines they are simply
called electrons. Owing to their small mass, The LET value is much smaller than the alpha particles of
the same energy.
Protons: These are positively charged particles and are relatively massive, having the mass nearly
2000 times greater than electron.
Alpha particles: There are nuclei of helium atoms, each consisting of two protons and two neutrons in
close association, Alpha particles are also emitted during the decay of some radioactive isotope.
These are manly obtained from natural radioactive sources, although beams of alpha particles from
accelerators can also be produce.

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Owing to their large mass and double charge, these particles lose energy very rapidly. For the same
reason they produce a very large no of ions per unit path, which on the whole means a greater
biological effect.
Neutrons: These are the particles having a mass similar to that of protons, but they carry no electrical
charge. Neutrons are indirectly ionizing, since the first step in their absorption is for them to collide
with nuclei of the atoms of the atoms of the absorbing material and produce recoil protons, alpha
particles, or heavier nuclear fragments. It is these charged particles that are responsible for the
biological effects. These are produced in nuclear reactors or in particle accelerators.
Negative pi-mesons: These are negatively charged particles with a mass 273 times larger than
electron.
Heavy ions: These are nuclei of elements such as nitrogen, carbon, neon, argon, or silicon that are
positively changed, because all of their planetary electrons are stripped away from them.
Photons: These are the X-rays, electromagnetic waves of very short wave lengths. Photons do ionize
directly and they interact with matter by three distinct processes: Photoelectric absorption, Compton
scattering and pair production, all of which result in the production of fast electrons.
How does radiation therapy kill cancer cells?
 Energy or source from radiation beam
 It strikes the body surface of the patient
 Ionization occurs which helps in electron production
 High energy electron penetrate through the skin
 Secondary electron beam produce below the skin surface
 Secondary electron beam also reacts with the water molecules
 Secondary electron dissociates water molecules and forms H20= H+ 0H-
 This process continuously going on and finally forms fast moving, active radical and penetrates
the nucleus of cancer cells
 Damage to the DNA
 Disturb the mitotic activity and repopulation
Frequency of radiation therapy
Radiation can come from a machine outside the body (external-beam radiation therapy) or from
radioactive material placed in the body near cancer cells (internal radiation therapy, more commonly
called brachytherapy). Systemic radiation therapy uses a radioactive substance, given by mouth or
into a vein that travels in the blood to tissues throughout the body.
The type of radiation therapy prescribed by a radiation oncologist depends on many factors,
including:
 The type of cancer.
 The size of the cancer.
 The cancer’s location in the body.
 How close the cancer is to normal tissues that are sensitive to radiation.
 How far into the body the radiation needs to travel.
 The patient’s general health and medical history.
 Whether the patient will have other types of cancer treatment.
 Other factors, such as the patient’s age and other medical conditions.

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External-beam radiation therapy
External-beam radiation therapy is most often delivered in the form of photon beams (either x-rays
or gamma rays) (1). A photon is the basic unit of light and other forms of electromagnetic radiation. It
can be thought of as a bundle of energy. The amount of energy in a photon can vary. For example,
the photons in gamma rays have the highest energy, followed by the photons in x-rays.
Figure: Linear Accelerator Used for External-beam Radiation Therapy
Many types of external-beam radiation therapy are delivered using a machine called a linear
accelerator (also called a LINAC). A LINAC uses electricity to form a stream of fast-moving subatomic
particles. This creates high-energy radiation that may be used to treat cancer.
Many types of external-beam radiation therapy are delivered using a machine called a linear
accelerator (also called a LINAC). A LINAC uses electricity to form a stream of fast-moving subatomic
particles. This creates high-energy radiation that may be used to treat cancer.
Patients usually receive external-beam radiation therapy in daily treatment sessions over the course
of several weeks. The number of treatment sessions depends on many factors, including the total
radiation dose that will be given.
One of the most common types of external-beam radiation therapy is called 3-dimensional conformal
radiation therapy (3D-CRT). 3D-CRT uses very sophisticated computer software and advanced
treatment machines to deliver radiation to very precisely shaped target areas.
Many other methods of external-beam radiation therapy are currently being tested and used in
cancer treatment. These methods include:
Intensity-modulated radiation therapy (IMRT): IMRT uses hundreds of tiny radiation beam-shaping
devices, called collimators, to deliver a single dose of radiation (2). The collimators can be stationary
or can move during treatment, allowing the intensity of the radiation beams to change during
treatment sessions. This kind of dose modulation allows different areas of a tumor or nearby tissues to
receive different doses of radiation.

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Unlike other types of radiation therapy, IMRT is planned in reverse (called inverse treatment
planning). In inverse treatment planning, the radiation oncologist chooses the radiation doses to
different areas of the tumor and surrounding tissue, and then a high-powered computer program
calculates the required number of beams and angles of the radiation treatment (3). In contrast, during
traditional (forward) treatment planning, the radiation oncologist chooses the number and angles of
the radiation beams in advance and computers calculate how much dose will be delivered from each
of the planned beams.
The goal of IMRT is to increase the radiation dose to the areas that need it and reduce radiation
exposure to specific sensitive areas of surrounding normal tissue. Compared with 3D-CRT, IMRT can
reduce the risk of some side effects, such as damage to the salivary glands (which can cause dry
mouth, or xerostomia), when the head and neck are treated with radiation therapy (4). However, with
IMRT, a larger volume of normal tissue overall is exposed to radiation. Whether IMRT leads to
improved control of tumor growth and better survival compared with 3D-CRT is not yet known.
Image-guided radiation therapy (IGRT): In IGRT, repeated imaging scans (CT, MRI, or PET) are
performed during treatment. These imaging scans are processed by computers to identify changes in
a tumor’s size and location due to treatment and to allow the position of the patient or the planned
radiation dose to be adjusted during treatment as needed. Repeated imaging can increase the
accuracy of radiation treatment and may allow reductions in the planned volume of tissue to be
treated, thereby decreasing the total radiation dose to normal tissue.
Tomotherapy: Tomotherapy is a type of image-guided IMRT. A tomotherapy machine is a hybrid
between a CT imaging scanner and an external-beam radiation therapy machine. The part of the
tomotherapy machine that delivers radiation for both imaging and treatment can rotate completely
around the patient in the same manner as a normal CT scanner. Tomotherapy machines can capture
CT images of the patient’s tumor immediately before treatment sessions, to allow for very precise
tumor targeting and sparing of normal tissue. Like standard IMRT, tomotherapy may be better than
3D-CRT at sparing normal tissue from high radiation doses. However, clinical trials comparing 3D-CRT
with tomotherapy have not been conducted.
Stereotactic radiosurgery: Stereotactic radiosurgery (SRS) can deliver one or more high doses of
radiation to a small tumor (5, 8). SRS uses extremely accurate image-guided tumor targeting and
patient positioning. Therefore, a high dose of radiation can be given without excess damage to
normal tissue.
SRS can be used to treat only small tumors with well-defined edges. It is most commonly used in the
treatment of brain or spinal tumors and brain metastases from other cancer types. For the treatment
of some brain metastases, patients may receive radiation therapy to the entire brain (called whole-
brain radiation therapy) in addition to SRS.
SRS requires the use of a head frame or other device to immobilize the patient during treatment to
ensure that the high dose of radiation is delivered accurately.
Stereotactic body radiation therapy: Stereotactic body radiation therapy (SBRT) delivers radiation
therapy in fewer sessions, using smaller radiation fields and higher doses than 3D-CRT in most cases.
By definition, SBRT treats tumors that lie outside the brain and spinal cord. Because these tumors are
more likely to move with the normal motion of the body, and therefore cannot be targeted as
accurately as tumors within the brain or spine, SBRT is usually given in more than one dose. SBRT can
be used to treat only small, isolated tumors, including cancers in the lung and liver. Many doctors
refer to SBRT systems by their brand names, such as the CyberKnife.

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Proton therapy: External-beam radiation therapy can be delivered by proton beams as well as the
photon beams described above. Protons are a type of charged particle.
Proton beams differ from photon beams mainly in the way they deposit energy in living tissue.
Whereas photons deposit energy in small packets all along their path through tissue, protons deposit
much of their energy at the end of their path (called the Bragg peak) and deposit less energy along
the way.
In theory, use of protons should reduce the exposure of normal tissue to radiation, possibly allowing
the delivery of higher doses of radiation to a tumor. Proton therapy has not yet been compared with
standard external-beam radiation therapy in clinical trials.
Other charged particle beams: Electron beams are used to irradiate superficial tumors, such as skin
cancer or tumors near the surface of the body, but they cannot travel very far through tissue.
Therefore, they cannot treat tumors deep within the body.
Patients can discuss these different methods of radiation therapy with their doctors to see if any is
appropriate for their type of cancer and if it is available in their community or through a clinical trial.
Internal radiation therapy
Internal radiation therapy (brachytherapy) is radiation delivered from radiation sources (radioactive
materials) placed inside or on the body. Several brachytherapy techniques are used in cancer
treatment. Interstitial brachytherapy uses a radiation source placed within tumor tissue, such as within
a prostate tumor. Intracavitary brachytherapy uses a source placed within a surgical cavity or a body
cavity, such as the chest cavity, near a tumor. Episcleral brachytherapy, which is used to treat
melanoma inside the eye, uses a source that is attached to the eye.
In brachytherapy, radioactive isotopes are sealed in tiny pellets or “seeds.” These seeds are placed
in patients using delivery devices, such as needles, catheters, or some other type of carrier. As the
isotopes decay naturally, they give off radiation that damage nearby cancer cells.
If left in place, after a few weeks or months, the isotopes decay completely and no longer give off
radiation. The seeds will not cause harm if they are left in the body (see permanent brachytherapy,
described below).
Brachytherapy may be able to deliver higher doses of radiation to some cancers than external-beam
radiation therapy while causing less damage to normal tissue. Brachytherapy can be given as a low-
dose-rate or a high-dose-rate treatment:
 In low-dose-rate treatment, cancer cells receive continuous low-dose radiation from the source
over a period of several days.
 In high-dose-rate treatment, a robotic machine attached to delivery tubes placed inside the
body guides one or more radioactive sources into or near a tumor, and then removes the sources
at the end of each treatment session. High-dose-rate treatment can be given in one or more
treatment sessions.
An example of a high-dose-rate treatment is the MammoSite system, which is being studied to treat
patients with breast cancer who have undergone breast-conserving surgery.
The placement of brachytherapy sources can be temporary or permanent:
 For permament brachytherapy, the sources are surgically sealed within the body and left there,
even after all of the radiation has been given off. The remaining material (in which the
radioactive isotopes were sealed) does not cause any discomfort or harm to the patient.
Permanent brachytherapy is a type of low-dose-rate brachytherapy.

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 For temporary brachytherapy, tubes (catheters) or other carriers are used to deliver the
radiation sources, and both the carriers and the radiation sources are removed after treatment.
Temporary brachytherapy can be either low-dose-rate or high-dose-rate treatment.
Brachytherapy alone or in addition to external-beam radiation therapy can be used to provide a
“boost” of radiation to a tumor while sparing surrounding normal tissue.
Systemic radiation therapy
In systemic radiation therapy, a patient swallows or receives an injection of a radioactive substance,
such as radioactive iodine or a radioactive substance bound to a monoclonal antibody.
Radioactive iodine (131I) is a type of systemic radiation therapy commonly used to help treat some
types of thyroid cancer. Thyroid cells naturally take up radioactive iodine.
For systemic radiation therapy for some other types of cancer, a monoclonal antibody helps target
the radioactive substance to the right place. The antibody joined to the radioactive substance travels
through the blood, locating and killing tumor cells. For example:
 The drug ibritumomab tiuxetan (Zevalin) has been approved by the Food and Drug
Administration (FDA) for the treatment of certain types of B-cell non-Hodgkin lymphoma (NHL).
The antibody part of this drug recognizes and binds to a protein found on the surface of B
lymphocytes.
 The combination drug regimen of tositumomab and iodine I 131 tositumomab (Bexxar) has been
approved for the treatment of certain types of NHL. In this regimen, nonradioactive tositumomab
antibodies are given to patients first, followed by treatment with tositumomab antibodies that
have 131I attached. Tositumomab recognizes and binds to the same protein on B lymphocytes as
ibritumomab. The nonradioactive form of the antibody helps protect normal B lymphocytes from
being damaged by radiation from 131I.
Many other systemic radiation therapy drugs are in clinical trials for different cancer types.
Some systemic radiation therapy drugs relieve pain from cancer that has spread to the bone (bone
metastases). This is a type of palliative radiation therapy. The radioactive drugs samarium-153-
lexidronam (Quadramet) and strontium-89 chloride (Metastron) are examples of
radiopharmaceuticals used to treat pain from bone metastases.
Types of radiation therapy given in many small doses: Patients who receive most types of
external-beam radiation therapy usually have to travel to the hospital or an outpatient facility up to
5 days a week for several weeks. One dose (a single fraction) of the total planned dose of radiation
is given each day. Occasionally, two treatments a day are given.
Most types of external-beam radiation therapy are given in once-daily fractions. There are two main
reasons for once-daily treatment:
 To minimize the damage to normal tissue.
 To increase the likelihood that cancer cells are exposed to radiation at the points in the cell cycle
when they are most vulnerable to DNA damage.
In recent decades, doctors have tested whether other fractionation schedules are helpful, including:
 Accelerated fractionation: treatment given in larger daily or weekly doses to reduce the
number of weeks of treatment.
 Hyperfractionation: smaller doses of radiation given more than once a day.

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 Hypofractionation: larger doses given once a day or less often to reduce the number of
treatments.
Researchers hope that different types of treatment fractionation may either be more effective than
traditional fractionation or be as effective but more convenient.
Potential side effects of radiation therapy: Radiation therapy can cause both early (acute) and late
(chronic) side effects. Acute side effects occur during treatment, and chronic side effects occur months
or even years after treatment ends (1). The side effects that develop depend on the area of the
body being treated, the dose given per day, the total dose given, the patient’s general medical
condition, and other treatments given at the same time.
Fatigue is a common side effect of radiation therapy regardless of which part of the body is treated.
Nausea with or without vomiting is common when the abdomen is treated and occurs sometimes when
the brain is treated. Medications are available to help prevent or treat nausea and vomiting during
treatment.
Late side effects of radiation therapy may or may not occur. Depending on the area of the body
treated, late side effects can include:
 Fibrosis (the replacement of normal tissue with scar tissue, leading to restricted movement of the
affected area).
 Damage to the bowels, causing diarrhea and bleeding.
 Memory loss.
 Infertility (inability to have a child).
 Rarely, a second cancer caused by radiation exposure.
Radiotherapy Nursing Care:
1. Anxiety related to prescribed radiations therapy and insufficient knowledge of treatments
and self care measures Expected outcome:
The client is relieved of anxiety and has sufficient knowledge regarding treatment and self care
practices as evidenced by: Client verbalizing fear, doubts, misconceptions and concerns, Client
identifies the expected side effects and management and Client describes self care measures
and shows interest in self care activities.
Plan of action
• Encourage the client to share fears and beliefs regarding radiation. Delay teaching if the
client is experiencing severe anxiety.
• Review general principles of RT as necessary. Provide written materials such as client
education booklets.
• Reinforce the treatment plan, covering the following items-area to be administered, marking
and tattoos, shielding of vital organs.
• Explain the fatigue that accompanies RT.
• Explain skin reactions and precautions.
• Explain site specific radiation side effects.
• Encourage family to share concerns.

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2. High risk for altered oral mucous membrane related to dry mouth or inadequate oral
hygiene or radiation tooth decay:
Expected Outcome
The client has healthy oral mucous membrane and understands the possible effect of radiation
on the oral cavity. Also demonstrates proper techniques of oral care.
Plan of Action
• Explain the signs and symptoms of mucositis and stomatitis.
• Stress the need to have caries filled and bad or loose teeth extracted before initiation of RT
to head and neck.
• Emphasize the need for regular oral hygiene during and after therapy.
• Brush with fluoridated toothpaste after meals.
• Use a soft bristle tooth brush.
• Rinse mouth with topical fluoride solutions after brushing
• Encourage oral fluid intake, and moistening lips.
• If gingival tissue becomes inflamed, suggest an oral rinse.
• Teach to avoid the following: Commercial mouth washes, very spicy or hot drinks, alcoholic
beverages, tobacco, highly seasoned food and acidic foods like oranges, grapes and
tomatoes.
• Offer topical relief of pain with Lidocaine ointment or ice chips.
• Explain the need for dental examinations during and after the course of treatment.
3. Impaired skin integrity related to effects of radiation on the epithelial and basal cells:
Expected Outcomes: The client has intact skin integrity as evidenced by the healthy skin in the
irradiated areas, and verbalizes understanding of the relationship of nutritional status with skin
integrity and relate strategies to reduce skin damage
Plan of Action:
• Explain the effects of radiation of skin (redness, tanning, peeling, and itching, hairless,
decreased perspiration) and monitor skin in the irradiated areas.
• For Alopecia: Help patient plan for a wig or scarf or hat before hair loss, Have patient
gently was and comb remaining hair, reassure that hair will grow back after therapy.
• For dermatitis: Observe irradiated area daily, Teach them not to was the treated area until
therapist tells, If tattoos are used for making, wash with mild soap and tepid water do not
remove the marking, Avoid harsh soap, ointments, creams, cosmetics and deodorants on
treated skin unless approved by therapist; keep reddened area dry and aerated, use a thin
layer of vit A and Department of Surgery ointment to relieve dryness and itching.
• For Moist Desquamation: Shower or irradiate the area frequently, use moist wound healing
dressing, Avoid use of adhesive tapes, assist patient with bathing to maintain marking, have
patient avoid excessive head, sunlight, tight restrictive clothing and soap. Provide special skin
care to tissue folds such as buttocks, perineum, groin and axilla. Avoid application of
deodorant/after shave lotion to treated area.
• Use an electric razor only- no blades- to shave the irradiate area.

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• Instruct the client to report any skin changes promptly.
• After the skin is completely healed, teach precautions in sun
• Use a sun screen lotion
• Increase exposure time very slowly
• Discontinue sum exposure if redness occurs
• Protect treated skin with hats etc
4. Altered comfort related to stimulation of vomiting center and damage to the GIT mucosa
cells secondary to radiation:
Expected outcome: The clients comfort is enhanced as evidenced by decreased nausea and
vomiting and increased ability to tolerate food and fluids
Plan of Action:
• Promote a positive attitude about radiotherapy and reinforce its cancer killing effects.
• Explain the possible reasons of nausea and vomiting.
• Encourage to have small, frequent meals. Cool, bland foods and fluids are will tolerated.
• Instruct to avoid hot/cold liquids, high fat-high fiber diet, spicy food and caffeine.
• Teach stress reduction techniques like relaxation techniques and guided imagery.
5. Impaired mobility related to fatigue and altered motor function
Expected outcome
The client demonstrated adequate mobility pattern and is free of complications of immobility.
Plan of Action
• Plan frequent rest periods.
• Avoid injury
• Use assistive devices for ambulation as required
• Assess reflexes, tactile sensation, and movement in extremities and report abnormal findings.
• Observe for Lhermittes sign (sensation of electric shock-running down back and over
extremities), which shows cervical cord compression.
6. Altered nutrition, less than body requirements related to decreased oral intake, reduced
salivation, dysphagia, nausea, vomiting and Diarrhoea:
Expected Outcome: The client maintains adequate nutritive status as evidenced by maintaining
ideal body weight with minimal further weight loss, normal BUN, S. albumin and protein values.
Plan of Action
• Help the client identify reasons for inadequate nutrition and explain possible causes.
• Stress the need to increase calorie intake,
• Encourage resting before meals
• Offer small frequent meals
• Restrict fluids with meals and avoid fluids one hour before and after meals.
• Maintain good oral hygiene before and after eating

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• Ensure greatest protein and calorie intake when client most feels like eating.
• Teach techniques to reduce nausea like avoiding the smell of food preparation, loosen
clothing before eating, sit in fresh air. Avoid lying down immediately after food intake.
• Instruct to avoid food and fluids high in fat.
• Consider client likes and dislikes pertaining food intake.
7. Self-concept disturbance related to Alopecia and skin changes, weight loss, sterility and
changes in role, relationships and life style
Expected Outcome: Client maintains high self esteem and communicate feeling about changes.
Plan of Action
• Encourage client to verbalize his feelings.
• Provide reliable information and clarity misconceptions.
• Help to identify positive attributes and possible new opportunities.
• Encourage visitors.
• Encourage self care activities.
• Assess the signs of negative response like refusal to discuss loss, denial to changes, decreased
self care ability, social isolation and refusal to discuss future.
• Refer at risk client for professional counseling.
8. Grieving related to changes in life style, role, finances, functional, capacity, body image and
health losses
Expected Outcome: The client and significant others go through the grieving process with
professional support as evidenced by expression of grief, showing interest in getting
professional help as and when required.
Plan of Action
• Provide opportunity to ventilate feelings, discuss loss openly and explore personal meaning
of loss. Explain grief is a common and healthy reaction.
• Encourage to use positive coping strategies.
• Encourage to express feeling of worth.
• Promote grief at each stage.
a. Denial
• Do not reinforce denial by giving false reassurance
• Promote hope through giving care, comfort and support
• Do not push a person to move past denial before he is emotionally ready
b. Isolation
• Convey acceptance, promote open, honest communication
• Reinforce clients self-worth, encourage feasible socialization
c. Depression
• Employ empathetic sharing and acknowledge grief, identify degree of depression and
develop appropriate strategies.
d. Anger
• Encourage verbalization of anger, explain family members the reason behind anger.

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e. Guilt
• Acknowledge client's expressed self image
• Avoid arguing with client, help to identity positive aspects
f. Fear: Maintain safe and secure environment
• Explore reason for and meaning of fears
g. Rejection: Provide reassurance; involve family in giving care,
h. Hysteria: Reduce environmental stimuli and provide safe environment
Act as a guide through the client's grieving experience by understanding need and providing
helps where needed.
9. Altered family process related to imposed changes in family roles, relationship and
responsibilities
Expected outcome: The client and family members verbalize fears and concerns; identify
appropriate resources to seek help whenever needed.
Plan of Action
• Convey an understanding of the situation and its impact on the family.
• Explore the family's perception of the situation.
• Try to promote family bonding by involving family in client's care, encouraging humor,
encouraging communication, acknowledging the assistance provided by them.
• Assist in reorganizing roles at home, setting new priorities and redistributing responsibilities.
• Prepare family for signs of stress, depression, anxiety, anger and dependency in the client.
• Encourage family to call on its social network (relatives, friends, church members) for
emotional and other support.
• Direct to community agencies and other sources of assistance as needed.
10. Collaborative Problems
Potential complication: Myelosuppression, malabsorption, Pleural effusion, cerebral edema,
cystitis, urethritis and Tenesmus, Myelitis / parotitis, renal calculi etc.
Expected Outcome
The client doesn't develop complications or if any develops, they are promptly identified and
managed.
• Monitor signs of Myelo suppression (decrease WBC, and RBC count, decrease platelet count)
• Monitor for signs of spontaneous / excessive bleeding.
• Instruct client to use soft tooth brush, avoid injections intramuscularly, avoid venipuncture,
straining during defecation blowing nose etc.
• Monitor for signs and symptoms of infection.
• Explain the risk of bleeding and infection.
• Monitor signs and symptoms of malabsorption (Diarrhoea, steatorrhea, abdominal pain) easy
bruising and bleeding, paresthesias, skin/vision changes, fluid – electrolyte imbalances,
weight loss, abnormal Hb, Vit. B12, PT, electrolytes etc.
• Monitor signs and symptoms of pleural effusion, cerebral edema, pneumonitis, oesophagitis,
urethritis etc.
• Educate the patient so that they can report these at the earliest


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Unit : 37
ONCOLOGIC EMERGENCIES
It is acute life threatening oncologic complications which may results due to malignancy and/or its
treatment. Clinical situations which are secondary to a malignancy or its treatment, and which may
result immediate catastrophic consequences in the absence of successful interventions
Classification of oncologic emergency:
Structural Metabolic
• Cardiac tamponade - D.I.C.
• Increased I.C.P - Hyperecalcemia
• Spinal cord compression - M.pleural Effusion
• Superior venacava Syndrome - Sepsis
- Tumor Lysis.s
- Anaphylaxis
- SIADH
Superior Vena-Cava Synadrome
SVCS is the compression of SVC from direct tumour invasion, enlarged lymphnode or thrombus within
the Vessels.
 Venous return to the heart from the head, neck, thorax and U .extremities is impaired.
 Venous Pressure
 Cardiac output
Cancers which cause SVCS
 Lung cancer (75%)
 Lymphoma (15%)
 Ca breast, colon, esophagus, testes
Signs and symptoms
 Engorged conjunctiva  Periorbital edema
 Swelling of the neck and arms  Dyspnea, SOB, discomfort l pain
 Headache, Visual changes  Dizziness, change in mental status
Management of S.V.C syndrome
 RT  Surgery - stent placement or S.V.C bypass
 Chemotherapy  CT in conjunction with RT
 Diuretics  Thrombolytic therapy
Nursing Intervention for S.V.C.S
 Position pt. in upright position to decrease dyspnea
 Reassurance.
 Provide oxygen inhalation.

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 Observe respiratory and neurological.
 Avoid veni puncture, I/v fluid administration or measurement of BP in the upper extremities.
 Analgesics as ordered.
Spinal Cord Compression (SCC)
SCC occurs in 3-5% of pt. with ca10% of pt. with spinal cord metastasis.
Cancer in which SCC is more common
 Multiple myeloma  Prostate
 Lung  Breast
Site of compression
 Thoracic (70%)
 Lumbosacral (20%)
 Cervical (10%)
Sign and symptoms of SCC
 Back pain (90%)  Weakness of extremities
 Decreased sensory level  Impaired urinary/ bowel function
Treatment and management
 RT (within 24 hrs)
 Decompressive surgery (Posterior Decompression Laminectomy)
 CT
 Assess for pain and give analgesics
 Assess level of mobility, motor weakness and establish activity regimen
 Care of bladder and bowel
 Psychological support
 Teaching to caregivers on how to correctly undertake handing activities to maximize patient
function and safety (precaution while taking hot and cold application, assist in mobility, maintain
proper body alignment, support joint etc)
 Prevent from complications of immobility
Increased intracranial pressure
 Increased intracranial pressure result when the volume of any of the three components (Brain
tissue, vascular tissue and CSF) increases .
 The most common oncologic etiology for IICP is brain metastases 20 to 40% of cancer patients
develop brain mets.
High risk client
 Client with ca of the lung, breast thyroid, stomach or kidney
 Primary tumour of brain or spinal cord.
 Leukemia or neuroblastoma.
Sign and symptoms
 Headache  Nausea
 Vomiting  Altered level of consciousness

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 Blurred vision  Confusion / restlessness
 Cushing’s traid  Hemiplegia, seizure,pupillary changes
 Slow, shallow respiration, tachycardia
Treatment and management
 Corticosteroids  Osmotic diuretics
 Loop diuretics  Anticonvulsant therapy
 Surgery: insertion of VP shunt  Radiation and chemotherapy
Nursing management
 Ensure adequate oxygenation, patent airway
 Maintain rest
 Instruct to avoid exertion
 Decrease stress
 Monitor activities and positioning to minimized increased ICP.
 Monitor for S/S of Increased ICP.
Hypercalcemia
 It is an elevated serum calcium level above 11.0mg/d/l – occurs in 10-20% of pt
 Cancer in which hypercalcemia occurs
Breast cancer (most common)
• Prostate cancer • Lung cancer
• Renal cancer • Bladder cancer
• Head and neck cancer
Sign and symptoms of hypercalcemia
 Fatigue, weakness  Confusion
 Drowsiness  Anorexia
 Constipation  Nausea, vomiting
 Polydipsia/polyuria  Dehydration
 Bone pain
Malignant Pleural Effusion: The abnormal accumulation of fluid in the pleural cavity caused by
malignancy
Life threatening: Increased pleural fluid affects respiratory function by restricting lung expansion –
decreases lung volume – alters gas exchange.
Cancer in which MPE is more common
 Lung cancer  Lymphoma
 Breast  Leukemia
 Ovary  Ca Stomach
Clinical manifestation:
 Dyspnea  Tachyphnea
 Restricted chest wall expansion  Chest tenderness
 Dry cough  SOB
 Chest pain  Malaise

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Tumor Lysis Syndrome: A metabolic imbalance that occurs with the rapid release of intracellular
potassium, phosphorus and nucleic acid in to the blood as a result of tumor cell kill.
Client at risk for TLS
 Pt. with leukemia, lymphoma, lung cancer
 Recent chemotherapy or RT
 Concurrent renal or cardiac disease
Clinical manifestation of TLS
 Hyperkalemia
 Hyperuricemia
 Hyperphosphatemia
 Hypocalcemia
• Early signs may include: Nausea, vomiting, diarrhoea anorexia,muscle weakness and
cramping
• Late signs: tetany paresthesia, convulsion, anuria and cardiac arrest.
DIC (Disseminated Intravascular Coagulation): It is one of the acquired bleeding disorders.DIC is an
alteration in the blood clotting mechanism, with abnormal acceleration of the coagulation cascade,
resulting in thrombosis and subsequently hemorrhage due to depletion of clotting factor.
Cardiac Tamponade
 Cardiac tamponade is the compression of the cardiac muscle by pathogenic fluid collection
under the pressure within the pericardial sac.
 As intrapericardiac pressure increases
• Left ventricular filling decreases.
• Ability of the heart to pump decreases.
• Cardiac output decreases.
• Impaired systemic perfusion.
Anaphylaxis
 It is an immediate hypersensitivity reaction that usually occurs within sec-min.
 It is a life threatening immunologic response to a foreign substance or antigen.
 High risk: Paclitaxel,Teniposide Procarbazine
 Moderate risk: Bleomycin, carboplatin, Cisplatin, Etoposide, Methotrexate.
 Low risk: 5 FU, Ifosphamide, Mitomycin.
Sepsis
 Sepsis is a systemic inflammatory response to pathologic micro-organisms and associated
indotoxins in the blood.
 It is the systemic response to infection, manifested by two or more of the following conditions
• Temperature > 38 degree centigrade or <36
• Pulse rate > 90 per minute
• Respiration > 20 per minute
• WBC count > 12000/cu mm < 4000/cu mm or 10% band


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Unit : 38
NURSING MANAGEMENT OF PATIENT WITH
CANCER
Nursing process approach: As a result of the underlying disease process and various treatment
modalities, the patient with cancer may experience a variety of secondary problems. An important
role of the nurse in the oncology team is to assess the patient for these problems and complications.
Nursing assessment: Nurse should obtain base line data in relation to the cancer patient’s health
and health habits, since the treatment of cancer often involves complex changes in the patient’s ability
to meet psychologic, physiologic, and sociologic health care.
Subjective data
Knowledge of Diagnosis
 The first important question to be answered is whether the patient knows the diagnosis.
 The nurse should elicit from both the patient and the physician what the patient has been told.
The patient may have only heard part of the information given by the physician or have
misinterpreted the information.
 The nurse can identify any discrepancies to plan care on the basis of the patient’s perceptions of
the illness.
 Determine how long the patient has known the diagnosis.
Coping skills
 Coping skills should be identified, because the diagnosis of cancer is an enormous test of the
person’s inner resources, as well as those of the friends & family.
 Some persons cope by directly verbalizing fears and seeking support from others, whereas
other persons are less direct.
 Some deal with problems with a problem solving approach, others try to avoid dealing with the
problem.
 Assess the patient’s family’s interpersonal, physical & financial resources.
Psychosocial Status: Assess patient’s emotional reaction to the results of diagnostic testing and
prognosis.
Body Image: Assess the patient’s ability to cope with many assaults to body image throughout the
course of disease & treatment.
Objective data
1. Infection
• Assess the factors that can promote infection.
• Common sites of infection, such as the pharynx, skin, perianal area, urinary tract, and
respiratory tract are assessed frequently.
• Monitor patient for sepsis particularly if invasive catheters or infusion lines are in place.

Nursing Management of Patient with Cancer
266
2. White blood cell count
• Assess WBC & ANC (absolute neutrophil count).
3. Bleeding
• Monitor for factors that may contribute to bleeding.
• Assess skin and mucous membranes, the intestinal, urinary, and respiratory tracts, and the
brain for bleeding.
• Gross hemorrhage as well as blood in the stools, urine, sputum or vomitus, oozing at infection
sites, bruising, petechiae, and changes in mental status are monitored and reported.
4. Skin problems
• Assess for erythema, urticaria, hyper pigmentation, photosensitivity (other side effects of
chemotherapy and radiotherapy).
• Assess for risk factors like nutritional deficits, bowel and bladder incontinence, immobility,
immunosuppression, and changes related to ageing.
5. Hair loss
• Assess for Alopecia and its psychological impact.
6. Nutritional concerns
• Assess the patient’s nutritional status: anthropometrics measurement (triceps skin fold & middle
upper arm circumference), serum protein levels, lymphocyte count, hemoglobin levels,
haematorit, urinary Creatinine levels and weight.
• Assess any alteration in nutritional status and weight loss.
• Assess difficulty in chewing or swallowing, nausea, vomiting, or diarrhea.
7. Pain
• Assess the source and site of pain
• Determine those factors that increase the patient’s perception of pain, such as fear and
apprehension, fatigue, anger and social isolation.
• Assess the patient’s pain level using pain assessment scales.
8. Fatigue
• Assess fro fears of weariness, weakness, lack of energy and inability to carry out necessary
daily activities.
• Assess physiologic and psychologic stresses that can contribute to fatigue.
Nursing diagnosis
1. Anxiety related to uncertainty about cancer treatment outcomes, feelings of helplessness and
insufficient knowledge about cancer and treatments.
2. Grieving related to illness and impending death, functional losses, changes in self concept.
3. High risk for self-concept disturbance related to changes in lifestyle, role responsibilities and
appearance.
4. Risk for infection related to altered immunologic response.
5. Pain and discomfort related to disease process.
6. Fatigue and activity intolerance related to illness.
7. Impaired skin integrity related to radiation therapy.

267
8. Alteration of oral mucous membranes related to chemotherapy.
9. Alopecia related to radiotherapy.
10. Alteration in nutrition, less than body requirements, related to nausea/vomiting.
11. Altered family processes related to fears associated with recent cancer diagnosis, financial
problems and uncertain future.
Potential complication. Risk for bleeding related to thrombocytopenia secondary to chemotherapy.
Nursing Diagnosis Planning and Implementation
NURSING DIAGNOSIS EXPECTED OUTCOME INTERVENTIONS
1. Anxiety related to uncertainty
about cancer treatment
outcomes, feelings of
helplessness, and insufficient
knowledge about cancer and
treatment.
The client and family will share
concerns regarding the cancer
diagnosis.
• Provide opportunities for client
and family.
• Convey a nonjudgmental
attitude and listen attentively.
• Encourage an open discussion
of cancer, experience of others,
and its potential for cure of
control.
• Explain hospital routines,
diagnostic tests and treatment
plans.
• Convey a sense of hope and
promote physical activity and
exercise.
2. Grieving related to illness and
impending death, functional
losses, changes in self
concept.
The client and family will
• Progress through the phases of
grief as evidenced by
increased verbalization and
expression of grief
• Identify resources available to
aid coping strategies during
grieving
• Use resources and supports
appropriately
• Discuss concerns and feelings
openly with each other.
• Encourage verbalization of
fears, concerns and questions
regarding disease, treatment,
and future implications.
• Encourage active participation
of patient or family in care and
treatment decisions.
• Visit family frequently to
establish and maintain
relationships and physical
closeness.
• Encourage ventilation of
negative feelings (projected
anger and hostility within
acceptable limits).
• Allow for periods of crying and
expression of sadness.
• Involve clergy as desired by
the client and family.
• Advise professional counseling
to alleviate pathologic grieving.
• Allow for progression through
the grieving process at the
individual pace of the client
and family.

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3. High risk for self- concept
disturbance related to changes
in life style, role
responsibilities and
appearance.
The client will
1. Communicate feelings about
changes
2. Participate in self-care
• Assess client’s fellings about
body image and level of self-
esteem.
• Identify potential threats to
client’s self-esteem (altered
appearance, hair loss.
Decreased energy, role
changes).
• Validate concerns with patient.
• Encourage continued
participation in activities and
decision making.
• Encourage client to verbalize
concerns.
• Individualized care for the
client.
• Assist client in selecting and
using cosmetics, scarves, hair
pieces and clothing that
increase his or her sense of
attractiveness..
4. Risk for infection related to
altered immunologic response
The client will
• Demonstrate normal
temperature and vital signs.
• Exhibits absence of signs of
inflammation.
• Assess client for evidence of
infection.
• Report fever > 1010
F, chills,
diaphoresis, swelling, heat,
pain, crythema, exudates on
any body surfaces.
• Report change in respiratory or
mental status, urinary
frequency or burning, malaise,
myalgias, arrhralagias, rash or
diarrhea.
• Obtain culture & sensitivity
before starting antimicrobial
treatment.
• Instruct all personnel in careful
hand washing.
• Avoid rectal & vaginal
procedures.
• Use stool softness to prevent
constipation & straining.
• Assist client in practice of
meticulous personal hygiene.
• Avoid fresh flowers and potted
plants.
• Change drinking water, denture
cleaning fluids, and respiratory
equipment containing water
daily.

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• Assess IV sites everyday for
evidence of infection.
• Avoid intramuscular injections.
• Avoid insertion of urinary
chatheters, if necessary use
aseptic technique.
Pain and discomfort related to
disease process.
The client reports decreased level
of pain and discomfort.
• Assess pain and discomfort
characteristics: location,
quality, frequency, duration
etc.
• Assure client that you know
that pain is real and will help
him or her in reducing it.
• Assess other factors
contributing to pain.
• Administer analgesics as
prescribed.
• Encourage strategies of pain
relief that patient has used
successfully in previous pain
experience.
• Teach client new strategies to
relieve pain and discomfort,
distraction, distraction,
imagery, relaxation.
5. Fatigue and activity
intolerance related to illness.
The client will
• Report decreasing levels of
fatigue
• Increases participation in
activities gradually
• Rests when fatigued
• Reports restful sleep.
• Encourage several rest periods
during the day.
• Increase total hours of night
time sleep.
• Organise daily schedule to
conserve energy.
• Encourage adequate protein &
calorie intake.
• Allow/ask for others assistance
with necessary works such as
house work, child care,
shopping, cooking.
• Encourage use of relaxation
techniques, mental imagery.
• Assess for fluid and electrolyte
disturbances.
• Assess for sources of
discomfort.

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6. Altered family process related
to fears associated with recent
cancer diagnosis, financial
problems & uncertain future.
The client and family members
will
• Verbalize feelings regarding
the diagnosis and prognosis
• Identify signs of family
dysfunction
• Identify appropriate recourses
to seek shen needed.
• Convey an understanding of
the situation and its impact on
the family.
• Explore family members
perception of the situation.
Encourage verbalization of
feelings.
• Determine whether present
coping mechanisms are
effective.
• Promote family strengths by
encouraging communication.
• Assist to recognize roles at
home, set new priorities and
redistribute responsibilities.
• Direct to community agencies
and other sources of assistance
as needed.
Rehabilitation
 Nurses play an important role in the rehabilitation of the cancer patient. Cancer rehabilitation
needs to begin early in the treatment of the disease to maximize outcome.
 Assessment of body image change as a result of disfiguring treatments is necessary to facilitate
the patient’s adjustments to changes in appearance or functional abilities.
 The nurse can refer the patient and family to a variety of support groups.
 She can collaborate with physical and occupational therapist in improving the patient’s abilities
and use of prosthetic devices.
 Nurses can collaborate with dieticians to help patients plan meals that will be acceptable and
meet nutritional requirements.
 She should assess the existence of problems associated with treatment modalities and assist the
patient in identifying strategies for coping with them.
 She can participate in efforts to educate employers and the public in general to ensure that the
rights of patients with cancer are maintained.
 Nurses can encourage patients to regain the highest level of independence possible.
Client education and home care consideration: Nurses need to provide support and education for
clients and caregivers as they make the transition from hospital to home.
 Teaching focuses on providing information regarding nutrition, fluid intake, medication & follow
up.
 Side effects of treatments and changes in the client’s status that should be reported are clearly
spelled out.
 Stress the necessity of avoiding sick people, have the client take his or her temperature twice a
day, teach good hand-washing, suggest avoiding bumping or cutting the skin, avoiding fresh
fruits, and practicing meticulous personal hygiene.
 Instruct the client to adhere to medical regimen and follow up.

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Family support
 Nursing interventions for family members in crisis may parallel nursing interventions for the
patients with cancer.
 Education of the disease process, treatment modalities, rehabilitation and the patients’ prognosis
may serve as a beginning point.
 The ultimate goal of nursing interventions for the patient’s family should be optimum quality of
life throughout the disease process.
 Support to family members should include recognition and acceptance of their feelings,
acknowledgement that the situation is stressful for the family, provision of explanation of events
to decrease fears: identification and affirmation of previous coping strategies used by family
members; recognition that family anxiety is reduced when they are permitted to participate in
patient care; encouragement of verbalization without judgment discussion of expectations: and
making referrals to appropriate consultants when indicated.
The terminally ill and hospice care
 More than 50 percent of clients with cancer die from their disease. The time from diagnosis to
death ranges from weeks to years. The goals of treatment are directed towards supportive care
of the client and family until death occurs.
 The philosophy of hospice care emphasizes symptom control and paid management, providing
comfort and dignity for the client during the dying process.
 The hospice can be connected with a hospital, community home care agency, or skilled nursing
facility.
The basic characteristics of a hospice program include:
 Control of client symptoms and pain relief.
 Treatment of client and family as a unit.
 Provision of care by a physician directed interdisciplinary team.
 24 hours, 7 day coverage.
 An autonomous hospice administration providing coordinated home care with back up inpatient
services.
 Use of trained volunteers to augment staff services.
 Structured systems of staff support.
 Bereavement follow up and
 Services given based on need and not ability to pay.
 Masterful use of ordinary nursing skills, combined with creative symptom management and
compassion for he client and family suffering, is the essence of hospice nursing care.
 When all else has failed, nursing care remains to ameliorate the suffering of the dying.
Rehabilitation of Cancer Patients
Cancer Rehabilitation is a process to restore mental and/or physical abilities lost to injury or disease,
in order to function in a normal or near normal way. Cancer rehabilitation is available before, during
and after cancer treatment. It helps build strength and endurance, regain independence, reduce stress
and maintain the energy needed to participate in daily activities. It mainly focuses in:

272
1. Physical Therapy: It helps patients to move and function better, and to improve their general
fitness and health. We develop individualized programs for each patient, using exercises to
improve balance, strength, and endurance. It wil helps in decreased strength, decreased range
of motion, pain, difficulty walking, decreased balance, tingling, numbness, pain, or weakness due
to nerve damage, fatigue etc
2. Occupational Therapy: It helps you to regain and build skills that are important to functioning
independently. It helps with daily living activities and quality of life, such as dressing, showering
and eating etc.
3. Manual Therapy: It help reduce cancer-related pain and improve quality of life during cancer
treatment through different kind of massage like; traditional massage, acupressure, stone
therapy, myofacial release, friction etc.
4. Speech and language pathology: Patient might experience dry mouth, difficulty swallowing,
loss of voice and cognitive changes that can result from cancer treatment. So, this therapy helps
to regain speech, language etc.
5. Recreational Therapy: This therapy uses games, exercise, arts, crafts, and music to help a
person with cancer reduces stress, anxiety, and depression. These activities can also help people
build confidence and strengthen personal skills.
6. Vocational Therapy: This therapy helps people recovering from cancer find and keeps a
satisfying job. This is an important for those who may no longer be able to return to their
previous position because of physical or emotional changes.
Nurses Role in Cancer Patients
As patients with cancer has greatly improved because of technologic and scientific advances.
However, as a result of the underlying disease or various treatment modalities, patients with cancer
may experience a variety of secondary problems such as infection, reduced WBCs counts, bleeding,
skin problems, nutritional problems, pain, fatigue and psychological stress.
The major roles of nurse of these patients with cancer are:
1. Maintaining Tissue Integrity:
Most of the frequently encountered disturbances of tissue integrity are: Stomatitis, Radiation
associated skin impairment, Alopecia and malignant lesions. The nursing care includes are:
• Cleansing the skin and reducing superficial bacteria
• Controlling bleeding
• Reducing odor.
• Protecting the skin from further trauma.
• Educate patient and family members about skin care and address about comfort measures at
home.
2. Promoting Nutrition:
Different nutritional problems are common in the cancer patients like; Anorexia, Mal-absorption
and Cachexia. The nursing care includes are:
• Monitoring nutritional assessment, weight and calorie intake.
• Monitoring different clinical and laboratory reports like; serum protein levels, lymphocyte
counts, hemoglobin, hematocrit, urine creatine, etc.
• Diet therapy; Nutritional support via oral or enteral or parenteral.

273
3. Relieving Pain:
• Assessment of pain source, site and intensity.
• Management of pain by pharmacologic or non-pharmacological approaches.
4. Decreasing Fatigue:
• Assessing levels of fatigue.
• Assessing physiologic or psychological stressors.
• Management by pharmacologic or non-pharmacological measures.
5. Improving Body Image and Self-Esteem:
• Acting as good listener and counselor to patients along with family members.
6. Assisting in the Grieving Process:
• Assessing patient’s psychological and mental status.
• Appropriate counseling about diagnosis and its prognosis.
• Addressing anticipatory grieving.
7. Monitoring and Managing Potential Complications:
Most common potential complications are Infection, Septic Shock, Bleeding and Hemorrhage.
• Monitoring WBC count, Platelet counts frequently during intervention.
8. Promoting Home and Community-Based Care:
• Teaching and coordinating in outpatient setting.
• Continuing the care.
9. Advanced Care: Hospice and Palliative Care
Patients with advanced care are likely to experience many problems in greater degree or
seriously ill. Hospice and Palliative Care is the best that describes the advanced care. It can be
provided in several settings; free standing, hospital based, and community or home based
settings. Hospice nurses are actively involved in bereavement counseling.


Warning Signs & Prevention of Cancer
274
Unit : 39
WARNING SIGNS & PREVENTION OF CANCER
Warning Signs of Cancer: The awareness of early signs and symptoms for cancer types such as skin,
cervical, breast, colorectal and oral in order to get them diagnosed and treated at early stage is
important. Some warning signs of cancer are below:
Warning signs What to look for
Unusual bleeding/discharge • Blood in urine or stool
• Discharge from any parts of your body, for example
nipples, penis, etc.
A sore which does not heal Sores that:
• Don't seem to be getting better over time
• Are getting bigger
• Getting more painful
• Are starting to bleed
Change in bowel or bladder
habits
• Changes in the colour, consistency, size, or shape of stools.
(diarrhoea, constipated)
• Blood present in urine or stool
Lump in breast or other part of
the body
• Any lump found in the breast when doing a self
examination.
• Any lump in the scrotum when doing a self exam.
• Other lumps found on the body.
Nagging cough • Change in voice/hoarseness
• Cough that does not go away
• Sputum with blood
Obvious change in moles Use the ABCD RULE
• Asymmetry: Does the mole look the same in all parts or are
there differences?
• Border: Are the borders sharp or ragged?
• Colour: What are the colours seen in the mole?
• Diameter: Is the mole bigger than a pencil eraser (6mm)?
Difficulty in swallowing • Feeling of pressure in throat or chest which makes
swallowing uncomfortable
• Feeling full without food or with a small amount of food

275
Ten Steps of Cancer Prevention: Protective Factors
 Increase consumptions of fresh vegetables. (Especially those of the cabbage family)
 Increase fiber intake.
 Increase intake of vit- A
 Increase intake of foods rich in vitamin – C
 Practice weight control.
 Risk Factors:
 Reduce amount of dietary fat.
 Reduce intake of salt- cured, smoked and nitrate- cured foods.
 Stop cigarettes smoking
 Reduce alcohol in take
 Avoid exposure to the sun.
Recommendations of the American Cancer society for early detection of common Cancer
Test of procedure Populations
Sigmoidoscopy M/F, 50 and over, every 3-5 yrs.
Fecal occult blood test M/F, 50 and over, every
Digital Rectal Examination M/F, 40 and over, every year
Pap test F, sexually active after 18, yearly
Pelvis examination F,18-40 yrs., 1-3 years with pap
Endometrial tissue sample F, at menopause
Breast self examination F, 20 and over monthly
Clinical breast examination F,20-40, every 3 years
Mammography F,40-49, every 1-2 yrs. 50 over, every year
Health Counseling and cancer M/F, over 20, every 3 years
Check up (thyroid, Prostate, Ovaries,
Lymphnodes, skin, oral)
M/F, Over 40, every year
Factors Predisposing Cancer Patients to Infection
 Impaired skin and mucous membrane integrity, due to loss of body’s 1st line defense.
 Chemotherapy: Suppress bone marrow, WBC decrease, and organ damage fibrotic lungs.
 Radiation therapy: Bone marrow suppression and organ dysfunction.
 Malignancy: Infiltrate bone marrow and decrease W.B.C. production.
 Malnutrition: Immune suppresses and impaired skin integrity.
 Medications: Antibiotics disturb the balance of normal flora (becomes pathogenic).
 Corticosteroids and NSIDS mask the inflammatory response.
 Urinary Catheter: Creat port and mechanisms of entry of organism.
 I.V. Catheters: site of entry of organisms.
 Other invasive procedures (surgery, paracenthesis, brain tubes, Endoscopy, ventilators): create
port of entry.
 Contaminated equipment: - growth of microorganism.

Warning Signs & Prevention of Cancer
276
 Age: - age increase, organ function decreases.
 Chronic illness:- impaired organ function and altered immune response .
 Prolonged hospitalization: Allows increased exposure to nosocomial infection and colonization
of new organism.
Potential sources of fatigue in Cancer Patient:
 Pain, pruitus.
 Altered nutrition related to anorexia, nausea, vomiting, Cachexia
 Electrolyte imbalance due to vomiting, Diarrhea.
 Altered protection related to neutropenia, thembocytopenia, anemia
 Impaired tissue integrity related to stomatitis mucositis
 Impaired physical mobility related to neurologic – impairments, surgery, bone metastasis, pain
and analgesic use.
 Knowledge deficit related to disease process, treatment
 Anxiety related to fear, diagnosis, role changes, and uncertainty of future.
 Ineffective breathing patterns related to caught, shotness of breath and dysponia.
 Sleep pattern disturbances.
Cancer Control: Cancer control consists of a series of measures based on present medical knowledge
in the field of prevention, detection, diagnosis, treatment after care and rehabilitation, aimed at
reducing significantly the number of new cases, increasing the number of cares and reducing the
invalidism due to cancer. The basic approach to the control of cancer is through primary and
secondary prevention. It is estimated that at least one- third of all cancers are preventable.
Primary prevention: Control of tobacco and alcohol consumption, maintain personal hygiene, reduce
radiation exposure, minimize occupational exposures, immunizations (liver cancer- hepatitis – B), food,
drugs, and cosmetics are tested for carcinogens, control air pollution, treatment of precancerous
lesions, legislation, cancer education regarding warning signs.
Secondary prevention: Cancer registration, Hospital based registries, Population based registries,
Early detection of cases (Screening), Treatment (Free from pain is right of cancer patient)
The seven warning signs of cancer:
1. Change in bowel or bladder habits.
2. A sore which does not heal.
3. Unusual bleeding or discharge.
4. Thickening or lump in the breast, testicles, or elsewhere.
5. Indigestion or difficulty swallowing.
6. Obvious change in the size, colour, shape, or thickness of a wart, mole, or mouth sore.
7. Nagging cough or hoarseness.
The following symptoms may also indicate some types of cancer:
 Persistent headaches
 Unexplained loss of weight or loss of appetite
 Chronic pain in bones or any other areas of the body
 Persistent fatigue, nausea, or vomiting

277
 Persistent low-grade fever, either constant or intermittent
 Repeated infection
 Coughing-up blood
Cancer Prevention, Control and Research Department usually conduct following programs at:
1. Cancer Awareness/Education Program
a. Hospital Based Cancer Awareness/Education Program
b. Community Based Cancer Awareness Program
c. School Cancer Education Program
d. Cancer Orientation Training to District Level Primary Health Workers
e. Cancer Awareness through Mass Media
f. Cancer Awareness Exhibition
g. Celebration of “National Cancer Awareness Day” (10th Asoj)
h. Celebration of “World No Tobacco Day” (31st May)
i. Celebration of “World Cancer Day” (4th February)
j. Cancer Prevention and Control District Co-ordination Committee
2. Cancer Screening and Early Detection Program
The objective of this program is to reduce the mortality by finding precursor lesions of cancer by
providing the screening services at hospital and in the community. It includes:
a. Cervical Cancer Early Detection Program
b. Breast Cancer Screening
c. Oral Cancer Screening
3. Cancer Education Materials Development and Distribution
Different types of Cancer education materials like leaflets, pamphlets, booklets, digital flex and
flip charts, calendar were developed in Nepali language and were distributed to the
government and non-governmental organizations, general public and health workers.
4. National Cancer Registry Program (Hospital Based)
All cancer diagnosed cases were collected from collaborating hospitals and data analysis was
done.
Nurses Role in Prevention of Cancer
Nurse plays an important role in all programs run by the department related to cancer control and
prevention. Some roles are as follow:
 Care Provider (screening the cancer-VIA test, Pap smear)
 Educator
 Counsellor
 Trainer
 Researcher


Breaking Bad News and Counselling to the Patients
278
Unit : 40
BREAKING BAD NEWS AND COUNSELLING TO
THE PATIENTS
Breaking Bad News: Information contains serious adverse consequences for patient and their families.
Defined as, "any information that produces negative alteration to receiver’s present and future
prospective".
Conditions: Life threatening illness/terminal illness
 Malignancy
 HIV/AIDS
 Irreversible systemic failure
 Disabling operations, e.g. amputation
 Chronic debilitating illnesses
Why is breaking bad news difficult?
 Breaking bad news is unpleasant- emotionally charging
 Our own psychology- fear of death
 No one likes to tell someone that his or her life is about to change adversely
 No one enjoys seeing another person cry or experience pain
 Avoids confrontation of own feelings about death and the dying process
 Senders own negative emotional reactions to the bad news
Reaction to bad news: It may be Mild, Moderate to Severe
Depends on:
 Degree of badness
 Past experience
 Expectation
 Personality;- immature, emotionally unstable
 Spiritual belief
 Philosophical standpoint
 Perceived social support
 Way of receiving information
Severe Reaction to Bad News: as given by Klubler Ross
1. Denial: “Daze” “No, not me!” anxiety
2. Anger: “Why me?”
• Patient is irritable, demanding, critical
• Angry at themselves, caretakers, doctors, God

279
3. Bargaining: “Yes, me, but……..”
• Buy additional time
• Reaffirm faith in God/Natural Power
4. Depression: “Yes, me”
• Impending loss of everything
• Pervasive despondency
5. Acceptance: “Yes, me and I am ready”
Accepts inevitability
• Not every one passes through those stages
• Vary in time duration
General Guidelines for Disclosure:
 In past: no disclosure
 Current, disclosing diagnosis has become the norm, and we now have legal and ethical
obligations to tell our patients any detail about their illness, if that is pts’ wish
 American Hospital Association (1973): “Patients’ Bill of Rights” pts have a “right to obtain
complete current information regarding diagnosis, treatment, and prognosis in terms the patient
can be reasonably expected to understand”
 Third view: flexible approach consideration of psychological, social and personal factors
Communication of Bad News
Keys: breaking bad news
 Plan well
 Develop strategies based on personal, cultural & social experiences
 Empathy, compassion, involvement are essential
 Good listener
Strategies for Communicating Bad News
1. Planning Before Starting
• Difficult task • Confirm diagnosis, prognosis
• Clear management plan • Answers for possible queries
2. Delivery the news
• Graded
• Many do not want to hear at once
• What the pt. knows already & what the pt. wants to know
• Tailor information to each pt’s concern, knowledge and understanding
• Simple language
3. Give time to integrate information
• Crowded information may confuse • Give time to ask questions
4. Soften bad news with good news
• Patient wants information that provides hope
• Focus on positive symptoms
• Tell about most favorable outcome of particular ill
• Convey you are always ready for help

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5. Never tell falsehood:
• Maintain trust
What to tell?
 The truth if at all possible  Use simple non-technical language
 Tell calmly  Tell treatment options
When to tell?
 When all relevant results are available
 With implications of Rx and prognosis can be given
Whom to tell?
 To the pt but use discretion when prognosis is very poor
 Closest relatives
Where to tell?
 In privacy (when can give adequate time)
Who tells?
 The health team leader (Physician)  But each consultant has his own policy
Summary: (ABCDE)
A. Advance preparation B. Building a therapeutic relationship
C. Communicating well D. Dealing with the patient and family reactions
E. Encouraging/validating emotions (empathy)
Seven Cs of Care of Terminally Ill patient
 Concern: Compassion, worth, tender and involvement.
 Competence: Skill and knowledge about illness management eg pain, nausea, shortness of
breath, insomnia.
 Communication: allowing patient to speak
 Children: Allowing children to visit patient, brings consolation.
 Cohesion: Family cohesion
 Cheerfulness: Gentle and appropriate sense of human. Humor can be palliative.
 Consistency: Continuing, persistent attention and involvement till the end.
Counselling to the Patients
Counselling is the advice and support that is given to people to help them deal with problems and
make important decisions. Counselling helps people respond to their mixed emotions about life’s
challenges in healthy ways. Counsellors cannot always solve problems, but they provide a safe place
for people with cancer to talk about their concerns. Because counsellors are separate from person’s
life, they provide a helpful, outside viewpoint. Living with cancer is a huge challenge for everyone. It
is normal to feel distressed while living with cancer. Not only the patient also his/her family members,
care giver, relatives, friends needs counselling. So, seeking help is important when your feelings`
affect your ability to cope with your daily life.
Introduction:
 Counseling is a helping relationship which includes:
• Someone seeking help
• Someone willing to help

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• Capable and trained to help
• In a setting that permits help to be given.
• Counseling is a two way process between counselor and client to assist client in altering,
improving or resolving his or her present behavior, difficulty or discomfort and also to
discover the coping mechanism.
Counselling helps patient to:
 Learn ways to cope with a cancer diagnosis and feel less overwhelmed and more in control
 Explore what your cancer experience means to you
 Manage depression and anxiety
 Manage cancer symptoms and treatment side effects, such as pain and fatigue
 Learn how to communicate effectively with the health care team
 Address relationship issues and financial concerns that are causing distress
 Explore options and get feedback about important decisions
 Consider workplace issues and strategies
 Talk about concerns you may have about what comes next after finishing treatment
 Learn how to help your family understand and adjust to changes in routine as a result of a
cancer diagnosis
 Explore and resolve sexual issues related to cancer
 Counselor may be psychiatrics, psychologists, licensed clinical social worker, oncology social
worker, psychiatric clinical nurse specialist, licensed counselor etc.
Purpose of counseling
 Reduce the fear and stress
 Maintain emotional stability
 Allow appropriate time to adjust
 Accept life’s reality
Why counseling is necessary in cancer patient
 A cancer diagnosis brings many changes in a patient’s life: physical, emotional and mental.
 Patients may become self-conscious about how cancer has changed their appearance, and this
may affect their lifestyle or self-esteem. It’s a difficult adjustment, and one that physicians rarely
address in the exam room.
 For patients whose cancers cause disfigurement, doctors and counselors help by discussing
reconstructive surgery options or by better
 Counseling is necessary to every cancer patient. It should be especially needed to patient
undergone mastectomy and amputation of limbs to increase the self esteem and to improve their
feelings to the changed body image.
 Counseling is necessary at the end part or palliative to either accept the reality or to live a
quality of life within that period of time.
Healing the whole person
 While the Body Image Therapy Service focuses mostly on head and neck and breast cancer
patients, Fingeret says she hopes to see the program expand to all patients
 “Every cancer patient experiences body image concerns,” she says. “It’s relevant and
applicable to all.”

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 Most of patients struggle with isolation because they become unhappy with their bodies. Through
counseling,it helps them regain social confidence. It’s all part of a larger goal for medical
professionals to treat every stage of a patient’s cancer journey
Time of counseling
 After diagnosis is made
 After each therapy is completed
 When new symptoms arises
Counseling before and after surgery
 Once a person has been diagnosed, and the diagnosis has been fully explained to him/her,
he/she needs counseling before and after the cancer surgery.
 The counseling, which will provide before the surgery, gives the person a detailed view of the
type of operation that will be performed, and temporary or permanent side effects pertaining
to the surgery.
 Books/brochures in the appropriate language written about the types of cancer may be lent to
the patients to help them on their own time.
Explaining availability of resources
 Most of the time, a patient is not aware of available resources that he/she may be qualified for
under some existing program.
 This includes both resources covered by insurance companies as well as resources free to the
community.
 To obtain these resources can sometimes be difficult to understand so counselor should explain
about this.
Explaining treatment choices
 Once the doctors provide a copy of the treatment choices that are available to the patients,
counselor will explain to the patients the various cancer treatment choices .
 The association's priority is to make sure that the patients fully understand all aspects of
potential treatments such as surgery, radiation therapy, chemotherapy, and their side effects
Steps of counseling
1. Preparation
• Know all facts before meeting • Read the notes
• Find out what the patient wants to be present • Ensure comfort and privacy
• Minimizes the risk of interruption
2. What does the patient know?
3. Give the warning shot
4. Allow denial
5. Explain and check understanding
6. Is more information needed?
7. Listen to concern
8. Encourage ventilation of feelings
9. Summary and plan
10. Offer availability

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Phases of counseling
 Phase I: Establishment of relationship. Counselor relationship which includes respect, trust and
sense of psychological comfort with several session.
 Phase II: Assessment. Encourage to talk about their problem and collect data through several
specific skills (observation, inquiry, guessess and record)
 Phase III: Setting goals. It involves making commitment to a set of condition and course of action
or out come.
 Phase IV: Intervention. The intervention used will depends upon the approaches by the
counselor, the problem and the individual.
 Phase V: Termination and follow up. The counseling session is terminated with effective technique
and patient is told when to follow up.
Communicator styles:
 Quietly Assenting
 Emotionally Expressive
 Storyteller
 Stoic Observer
 Inquisitive of Detail
 Critical Self-observer.
 The communicator styles are indicative of the multitude of ways in which patients participate in
counseling discussions and they make it possible to describe the varying expressions of patient
communication
Points to remember
 Maintain privacy
 What did patient/ family knew?
 What does he/she wants to know?
 Do not give false hope but provide appropriate hope
 Provide only what information is needed
 Allow for nonverbal communication
 Allow expression of anger and sorrow
 Aim on better quality of life in this part of life
 Prepare for future reality
 Retain individuality and self respect to the end.
Counselling and Altered Body Image
 Cancer patients are forced to cope with many assaults to body image throughout the course of
disease and treatment. Entry into health care system is often accompanied by depersonalization.
 Threats to self-concept are enormous as patients face the realization of illness, possible disability
and death. To accommodate treatments or because of the disease, many cancer patients are
forced to alter their lifestyles. Priorities and values change when body image is threatened.
 Disfiguring surgery, hair loss, cachexia, skin changes, altered communication patterns, and sexual
dysfunction are some of the devastating results of cancer and its treatment that threaten the
patient’s self esteem and body image.
 The counselors identify these potential threats and assess the patient’s ability to cope with the
changes.

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Types of Body Image Disturbances
 The types of body image disturbances depend upon the disease itself and the management. The
tumor can be the cause of disturbance or the surgery and amputation done can also be the
cause. Radiation therapy leads to skin changes and chemotherapy causes hair loss. There can be
weight loss, gait, posture and vision disturbances which can cause altered body image.
Counselling in Altered Body Image
 Assessment for body image changes as a result of disfiguring treatments is necessary to
facilitate the patients’ adjustment to changes in appearance of functional abilities. The patient
and concerned others are informed beforehand that thinning or complete loss of hair is a
potential adverse effect of various radiation therapies and chemotherapeutic agents. It can be
temporary or permanent. The extent of alopecia depends on the dose and duration of therapy.
These treatments cause alopecia by damaging stem cells and hair follicles. As a result, the hair is
brittle and may fall out or break at the surface of the scalp. Loss of other body hair is less
frequent.
 Hair loss usually begins within 2 to 3 weeks after the initiation of treatment; regrowth begins
within 8 weeks after the last treatment.
 Some patients who undergo radiation to the head may sustain permanent hair loss. It can be
considered minor problem when compared with potentially life threatening consequences of
cancer. For many patients, however, hair loss can be a major assault on body image, resulting in
depression, anxiety, anger, rejection and isolation.
 The counselor should provide the above information about alopecia and support to support the
patient and family in coping with disturbing effects of therapy, such as hair loss and change in
body image. Patients are encouraged to acquire a wig or hairpiece before hair loss occurs so
that replacement matches their own hair. Use of attractive scarves and hats may make the
patient feel less conspicuous.
 A positive approach is essential when caring for the patients with altered body image. To help
the patient retain control and positive self esteem, it is important to encourage independence
and continued participation in self care and decision making.
 Patient should be assisted to assume those tasks and participate in those activities that are
personally of most value. Any negative feelings that the patient has or threats to body image
should be identified and discouraged.
 The nurse serves as a listener and counselor to both the patient and family. Referral to a support
group can provide the patient with additional assistance in coping with changes resulting from
cancer or its treatment.
 Patients who experience alterations in sexuality and sexual function are encouraged to discuss
concerns openly with their partner.
 Alternative forms of sexual expression are explored with the patient and partner to promote
positive self worth and acceptance. The nurse who identifies serious physiologic, psychological or
communication difficulties related to sexuality or sexual function is in key position to assess the
patient and partner to seek for the counseling if necessary.
 Patient should be encouraged for continued participation in activities and decision making.
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Appendix I
Terminology Related to Cancer
 Benign: Nonmalignant form of a neoplasm
 Carcinogen: Any cancer-causing substance or organism
 Differentation: Determination of how developed, or mature, the cancer cells are in a tumor
 Dysplasia: Abnormal growth of tissue
 In Situ: In the original place or site without any expansion or spread
 Invasion: The direct migration and penetration by cancerous cells into neighboring tissues
 Lesion: A pathologic change in tissue resulting from disease or injury
 Malignant: Having the properties of locally invasive and destructive growth and metastasis
 Metastasis: Spread of a disease process from one part of the body to another
 Oncogenes: Mutated forms of genes that cause normal cells to grow out of control and become
cancer cells
 Oncogenic: Causing or being suitable for the development of a tumor
 Recurrence: The return of cancer after all visible signs of it had been eradicated previously
 Remission: Lessening in severity of disease symptoms; the period of time when a cancer is
responding to treatment or is under control
 Adenocarcinoma: Malignant neoplasm composed of glandular tissue
 Adenoma: Benign neoplasm composed of glandular tissue
 Anaplastic: A term used to describe cancer cells that divide rapidly and have little or no
resemblance to normal cells.
 Carcinoma: Malignant neoplasm of any epithelial tissue
 Fibroma: Benign neoplasm of any epithelial tissue
 VFibrosarcoma: Malignant neoplasm of deep fibrous tissue
 Lipoma: Benign neoplasm of adipose (fat) tissue
 Liposarcoma: Malignant neoplasm of adipose (fat) tissue
 Melanoma: Tumor characterized by a dark appearance; most commonly occurs in the skin or in
the eye
 Neuroma: Tumor derived from nervous tissue
 Myeloma: Tumor composed of cells derived from bone marrow
 Sarcoma: Malignant neoplasm of connective tissue
 Basal Cell Carcinoma (BCC): A cancer that begins in the lowest layer of the epidermis of the
skin
 Kaposi Sarcoma: Type of cancer found in the tissues under the skin or mucous membranes that
line the mouth, nose, and anus; most commonly seen in patients with acquired immunodeficiency
syndrome (AIDS)
 Melanoma of the Skin: A malignant skin cancer that arises from the melanocytes in the
epidermis, usually caused by exposure to ultraviolet radiation
 Squamous Cell Carcinoma (SCC): A cancer that begins in the squamous cells located in the
upper levels of the epidermis of the skin
 Gastrointestinal Stromal Tumor (GIST): A very rare cancer affecting the digestive tract or
nearby structures within the abdomen

Appendix
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 Nephroma: Tumor of the kidney
 Urothelial Carcinoma, syn. Transitional Cell Carcinoma: Cancer arising in the urothelium lining
the urinary tract
 Wilms Tumor: Rare type of kidney cancer that affects children
 Hodgkin Disease: Abnormal malignant enlargement of lymph nodes, spleen, and liver;
indicated by the presence of Reed-Sternberg cells
 Leukemia: Cancer of the blood indicated by malignant increase in the number of white blood
cells
 Lymphangioma: Mass or tumor of lymph vessels
 Lymohoma: Tumor of lymphoid tissue, including lymphocytes and plasma cells
 Bronchogenic Carcinoma: Carcinoma that arises from the mucosa of the large bronchi
 Mesothelioma: A carcinoma of the mesothelium lining of the lining of the lungs or heart, usually
associated with exposure to asbestos dust
 Oat Cell Carcinoma: Highly malignant form of lung or bronchogenic cancer in which cells
appear small and rounded under a microscope
 Ductal Carcinoma In Situ (DCIS): A breast cancer that is confined to the ducts and has not
spread into the tissue of the breast
 Germ Cell Tumor: Cancer that begins in the egg-producing cells of the ovaries
 Stromal Cell Tumor: Cancer that begins in the cells of the ligaments of the ovaries
 Astrocytoma: A tumor that arises form small, star-shaped cells in the brain and spinal cord
 Glioma: Cancer that arises from the glial cells of the nervous system
 Medulloblastoma: Cancer that develops from the primitive nerve cells in the cerebellum
 Meningioma: Benign and slow-growing tumor of the meninges
 Neuroblastoma: A cancer of the nervous system
 Glomus Tumor: A benign but locally invasive tumor arising out of glomus tissue found in the
middle ear, jugular bulb, and carotid artery
 Retinoblastoma: A malignant ocular tumor of retinal cells
 Chondroma: A common benign tumor arising from cartilage cells
 Chondrosarcoma: A large malignant tumor arising from cartilage cells
 Ewing Tumor, syn. Ewing Sarcoma: A malignant tumor found in bone or soft tissue
 Giant Cell Tumor: A tumor of the tendon sheath that can be either benign or malignant
 Leiomyoma: Benign tumor of smooth (nonstriated) muscle
 Leiomyosarcoma: Malignant tumor of smoot (nonstraited) muscle
 Liposarcoma: A malignant tumor of adipose (fat) tissue; occurs in the retroperitoneal tissues and
the thigh
 Osteofibroma: Benign lesion of bone consisting chiefly of fairly dense, moderately cellular,
fibrous connective tissue
 Osteosarcoma: A fast-growing malignant type of bone cancer that develops in the osteoblast
cells that form the outer covering of bone
 Rhabdomyoma: Benign tumor of striated muscle
 Rhabdomyossarcoma: A highly malignant tumor of striated muscle
 Multiple Endocrine Neoplasia (MEN): A group of disorders characterized by functioning tumors
in more than one endocrine gland
 Pheochromocytoma: A vascular tumor of the adrenal gland

287
 Pituitary Adenoma: A benign tumor arising in the pituitary gland
 Brachytherapy, syn. Seed Implantation: Procedure by which radioactive "seeds" are placed
inside cancerous tissue and positioned to kill nearby cancer cells
 Cryosurgery: The use of freezing temperatures to destroy tissue
 Debulking Surgery: Excision of a major part of a tumor that cannot be completely removed
 Palliative Surgery: Surgery that is performed to relieve pain or other symptoms but not to cure
cancer or prolong a patient's life
 Radiofrequency Ablation (RFA): Procedure in which a surgical oncologist uses a small probe to
deliver heat from radiofrequency energy to kill cancerous tissue; used primarily to treat liver,
prostate, renal, bone, and breast cancer
 Mohs Surgery: Surgical procedure that involves removing and examining a piece of tumor in the
skin but by bit until the entire lesion is removed
 Colectomy: Excision of all or part of the colon
 Esophagectomy: Excision of the diseased portion of the esophagus and all associated tissues
that might contain cancer
 Pancreaticoduodenectomy, syn. Whipple Operation: Partial excision of the stomach, complete
excision of the gallbladder, a portion of the bile duct, head of the pancreas, portions of the
small intestine, and regional lymph nodes to stop the spread of cancer in these areas
 Cystectomy: Surgical removal of part or all of the bladder
 Fulguration: Destruction of tissue by means of high-frequency electric current; commonly used to
remove tumors from inside the bladder
 Nephrectomy: Excision of a kidney
 Transurethral Resection of Bladder Tumor (TURB): Excision of a tumor from the bladder
through the urethra using a resectoscope
 Lymphadenectomy: Excision of a lymph node
 Bone Marrow Transplant (BMT): Transfer of bone marrow from one person to another
 Peripheral Stem Cell Transplant: The collection and freezing of stem cells from the blood, which
are then reintroduced into the patient after chemotherapy
 Lobectomy: Excision of a lobe (of the lung)
 Pneumonectomy: Excision of the lung
 Wedge Resection: Excision of part of a lobe of the lung
 Prostatectomy, syn. Transurethral Resection of the Prostate (TURP): Removal of prostate
through the urethra using a resectoscope
 Loop Electrosurgical Excision Procedure (LEEP): Gynecologic procedure that uses a thin low-
voltage electrified wire loop to cut out cancerous tissue in the cervix
 Mastectomy: Excision of a breast to remove a malignant tumor
 Modified Radical Mastectomy: Excision of a breast along with some of the underlying muscle
and lymph nodes in the adjacent armpit
 Radical Mastectomy: Excision of the breast as well as the underlying muscles and lymph nodes
in the adjacent armpit
 Simple Mastectomy: Excision of a breast, leaving the underlying muscles and the lymph nodes
intact
 Myomectomy: Excision of myomas
 Craniectomy: Excision of part of the cranium to access the brain
 Sterotactic Radiosurgery: Radiation therapy technique for treating brain tumors by aiming high-
does radiation beams directly at the tumors

Appendix
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 Enucleation: Removal of an eyeball
 Iridectomy: Excision of part of the iris (for very small melanomas)
 Laryngectomy: Excision of all or part of the larynx, usually to treat cancer of the larynx
 Amputation: Surgical removal of an entire limb
 Limb Salvage Surgery: Surgical procedure in which only the cancerous section of bone is
removed but nearby muscles, tendons, and other structures are left intact
 Parathyroidectomy: Excision of a parathyroid gland
 Thyroidectomy: Excision of the thyroid gland
 Transsphenoidal Resection: Excision of a pituitary adenoma by making an incision through the
nose to the bottom of the skull where the pituitary gland is located
 External Beam Radiation: Procedure by which a beam of high-energy radiation is applied
externally directly to the tumor to minimize damage to other tissues
 Radiation Therapy: The use of high-energy x-rays or other particles to kill cancer cells
 Aromatase Inhibitors: Group of drugs designed to reduce estrogen levels in a woman's body
and stop the growth of cancer cells that depend on estrogen to live and grow
 Chemoprevention: The use of natural or synthetic products to keep cancer at bay or to stop the
disease process before it becomes invasive
 Chemotherapy: Regimen of therapy that uses chemicals to treat cancer
 Adjuvant Chemotherapy: Chemotherapy given in addition to surgery, to destroy remaining
residual tumor or to tumor or to reduce the risk of recurrence
 Interstitial Chemotherapy: Placement of chemotherapy drugs directly into a tumor
 Intrathecal Chemotherapy: Delivery of chemotherapy drugs into the spinal canal
 Palliative Chemotherapy: Chemotherapy that is given to relieve pain or other symptoms of
cancer but not to cure it
 Epidermal Growth Factor Receptor (EGFR) Inhibitor Therapy: Drugs that interfere with the
growth of individual cancer cells
 Hormonal Therapy: Use of hormones to stop a tumor from growing, to relieve symptoms caused
by a tumor, or to replace the hormone that is needed by the body to function properly after a
body part is removed due to cancer
 Immunotherapy, syn. Biologic Therapy: Method of boosting the body's natural defenses to
fight cancer by using materials made either by the body or in a laboratory to bolster, target, or
restore immune system function
 Gynecologic Oncology: Medical specialty concerned with the diagnosis and treatment of
cancers of the female reproductive system
 Gynecologic Oncologist: Physician who specializes in the care and treatment of women with
gynecologic cancers
 Archived Tumor Sample: Tumor sample that has been routinely preserved and stored. Tumor
tissue is commonly preserved for storage by being treated with preservative called formalin and
then embedded in paraffin (wax).
 BRCA1 and BRCA2: Genes that normally help control cell growth. A person who inherits an
altered version of the BRCA1 and/or BRCA2 gene(s) has a higher risk of developing breast and
ovarian cancer.
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Appendix II
Oncology Nursing as a Specialty
Principles of Oncology Nursing: Cancer management is an interdisciplinary endeavor, thus an
understanding of the principles of oncology nursing is fundamental to the effective practice of all
other oncology subspecialties. Oncology nurses are engaged in collaborative practice with all
members of the healthcare team to provide optimal management of patients with cancer. Their
professional practice requires detailed knowledge of the biologic and psychosocial dimensions of
cancer as a disease, and its impact upon the lives of patients and their loved ones. Oncology nurses
have key roles as caregivers, as well as providers of patient and family education, in clinical cancer
research, in health care administration, and as advanced oncology nurse practitioners. Cancer nurses
also are continuously involved in the enhancement of nursing practice through research, continuing
education, and advanced education.
Oncology nursing as a Specialty: Historically, nurses have had a special role in the care of patients
with cancer, a role that was especially significant in those few institutions devoted exclusively to
cancer care before the National Cancer Act of 1971. However, the expanded research and
treatment program against cancer that has occurred during the past quarter century has been a
catalyst for the development of oncology nursing as a separate specialty. The recognition of cancer
as a major national health problem was key to formally establishing the specialty of oncology
nursing. This increased attention to cancer coincided with and complemented a major new emphasis in
the nursing profession toward expanded roles in comprehensive patient care. Many oncology nurses
first worked as both nurses and data managers for cancer research studies. As oncology called for
increasingly more complex therapy, the collaborative relationship between nurse and physician
became the best way to provide uniquely comprehensive patient care.
The Oncology Nursing Society (ONS) was established by a small group of nurses working primarily in
research settings with medical oncologists involved in clinical research. Its initial goals were to provide
a forum for discussing practice issues in cancer nursing and to develop mechanisms for nurses to
contribute to this new and evolving specialty area. There was a need to promote the advanced
practice of oncology nurses in different care settings, to develop national as well as local networking,
and to develop continuing education programs. Research in cancer nursing subsequently became a
high priority of the ONS. The success of this national organization has contributed to the recognition
of oncology nursing as a valued specialty. The ONS Foundation is the largest funder of oncology
nursing research outside of the United States government. The ONS and the American Nurses'
Association have developed Professional Practice Standards and the ONS has developed Advanced
Practice Standards. These standards serve as a definition of the highest quality of oncology nursing
practice.
Oncology Nursing Education: Educational curricula have been developed and implemented to
provide oncology nurses with an appropriate understanding of genetics; cancer biology;
epidemiology; prevention; detection and diagnosis; treatment and symptom management; nursing
practice issues; and trends in cancer care. Cancer nursing texts and journals, such as Oncology
Nursing Forum, Clinical Journal of Oncology Nursing, Cancer Nursing, and Seminars in Oncology
Nursing, focus on these topics. Cancer nursing is part of the general undergraduate curricula and
more than 25 graduate nursing educational curricula offer a masters degree with a specialty in
oncology. In addition, doctoral programs and oncology nursing professorships have been established.
More than 30% of ONS members have a bachelor's degree in nursing. Which is based on the
membership demographics of the ONS, shows the highest nursing degrees of ONS members.

Appendix
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Membership in the ONS offers opportunities for the study and education necessary to qualify for the
OCN and AOCN credentials by passing the certification examinations. Increasingly, educational
preparation at the master's level is specified in many oncology job descriptions. For example, a
master's degree is required for oncology clinical nurse specialists and nurse practitioners. Typically,
over 20% of the ONS members are pursuing additional education at the baccalaureate or graduate
level.
Oncology Nursing Research: The evolution of oncology nursing research to guide oncology nursing
practice has been extraordinary over the past 25 years. From a modest beginning in the 1970s,
nursing research evolved in the 1980s to the identification of research priorities, companion studies in
cooperative group clinical trials, as well as initial programs of research and funding. In the 1990s,
continued advances have included mature programs of research, multisided studies, increased funding
sources, research through state-of-the-knowledge conferences, and major areas of studies (e.g.,
fatigue, quality of life, pain) that are having a noteworthy impact on cancer care. The ONS has
conducted six research priority surveys since 1981. The top 10 research priorities from the most
recent survey were pain; quality of life; early detection of cancer; prevention/risk reduction;
Neutrogena/ immunosuppression; hospice/end-of-life care; oncology emergencies; suffering; fatigue;
and ethical issues.
As a result of today's healthcare environment, nurses are being challenged by insurers, health-policy
makers, and managed care organizations to demonstrate the effectiveness of their care through
research that examines the link between specific nursing interventions and patient outcomes. Since the
inception of the ONS, more than 300 nursing research studies have been funded. The ONS and the
National Cancer Institute (NCI) sponsor two cancer nursing research short courses each year to help
nurses with their study designs and to address use of research findings. Additionally, the ONS has
developed a new research agenda to identify types of research needed; areas that need additional
research, and resources necessary to achieve research goals.
Health Policy: Historically, professional nurses have been extensively involved in political advocacy.
Professional nursing organizations provide opportunities for nurses to collectively address healthcare
issues and to influence the development of sound public policy. ONS's involvement with health policy
began with its incorporation as a specialty nursing professional organization in 1975. Today, the
ONS is recognized, alongside other professional organizations, as an important voice on issues
related to cancer care. For each Congressional session, the ONS Board develops a Health Policy
Agenda and actively advocates on Capitol Hill for those issues on behalf of patients and the
profession. Increasingly, ONS members are participating in equal parity with professionals of other
healthcare disciplines to promote development of health policy and associated regulations and serve
as consultants providing their unique perspective on proposed legislation. ONS members have been
appointed to the National Cancer Advisory Board, the National Cancer Institute Board of Scientific
Advisors, and the Institute of Medicine's National Cancer Policy Board. ONS has sponsored
educational sessions at its annual congress on health policy and advocacy skills for members, and, in
2002, sponsored regional workshops on health policy skills.
Advanced Practice in Oncology Nursing: The Oncology Nursing Society Statement on the Scope
and Standards of Advanced Practice in Oncology Nursing defines an oncology advanced practice
nurse (APN) as a registered nurse with a minimum of a master's degree in nursing. The APN has
acquired advanced, in-depth knowledge and preceptored clinical experiences in oncology that
enable her or him to exhibit a high degree of independent and collaborative judgment and clinical
skill in providing nursing care to patients with cancer and their families. The advanced practice of
oncology nursing is used throughout the cancer care continuum with APNs functioning in the acute care
setting, in private physician practices, in ambulatory clinics, in long-term follow-up clinics, in prevention
centers, in the provision of cancer genetic counseling, and in the provision of supportive and palliative
care.

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Role of the Oncology Nurse: Oncology nurses practice in a variety of settings including acute care
hospitals, ambulatory care clinics, private oncologists' offices, radiation therapy facilities, home
healthcare agencies, and community agencies. They practice in association with a number of oncology
disciplines, including surgical oncology, radiation oncology, gynecologic oncology, pediatric oncology,
and medical oncology. The majorities of ONS members are involved in direct patient care and
practice at the generalist level, with 43% working in a hospital/multi-hospital system, 24% in the
outpatient/ambulatory care setting, 11% in physician offices, and 3% in hospice or home care.
Positions in the outpatient and home care setting have increased as more patients are being treated
out of the hospital setting. The roles of the oncology nurses vary from the intensive care focus of bone
marrow transplantation to the community focus of cancer screening, detection, and prevention.
Patient Assessment: Nurses are expected to be expert in assessing a patient's physical and
emotional status, past health history, health practices, and both the patient's and the family's
knowledge of the disease and its treatment. The oncology nurse reviews the treatment plan with the
oncologist, is aware of expected outcomes and possible complications, and independently assesses
the patient's general physical and emotional status. It is essential that a detailed nursing history and
physical examination be completed. An oncology nurse is expected to be aware of the results and
general implications of all relevant laboratory, pathology, and imaging studies. Assessment of the
patient's understanding of the disease and proposed treatment is fundamental in allaying anxiety
and formulating a care plan. Obtaining this information will help avoid misunderstanding and
confused expectations. Thorough patient preparation improves compliance with treatment programs
and may impact treatment outcomes as well.
A nursing care plan is developed in response to the particular needs identified from the assessment.
At a minimum, this plan promotes (1) the patient's understanding of therapy goals, treatment
schedules, and possible side effects of therapy; (2) physical and psychological preparation for
therapy; (3) physical and psychological comfort; and (4) compliance.
Patient Education: The nurse often has a better opportunity than any other member of the healthcare
team to develop the required rapport for effective educational efforts with patients and their
families. Patient and family education starts before therapy and continues during and after therapy.
Continual reinforcement throughout the treatment course helps to ensure success. Appropriate written
and visual teaching aids may be used, as well as referrals to other professionals or community
programs, such as cancer support groups. Such education includes structured and unstructured
experiences to assist patients with coping with their diagnosis, long-term adjustments, and symptoms;
to gain information about prevention, diagnosis and care; and to develop skills, knowledge, and
attitudes to maintain or regain health status. This planned education uses a combination of methods
that best meet the needs, capabilities, and learning style of the patient.
Coordination of Care: The oncology nurse plays a vital role in coordinating the multiple and complex
technologies now commonly employed in cancer diagnosis and treatment. This coordination
encompasses direct patient care; documentation in the medical record; participation in therapy;
symptom management; organization of referrals to other healthcare providers; both patient and
family education; as well as counseling throughout diagnosis, therapy, and follow up. The nurse should
serve as the patient's first line of communication. Ideally, the patient and family should feel free to
contact the oncology nurse by phone during the entire treatment program. Many patients travel long
distances, so the importance of communication by telephone must be emphasized. It allows continuous
patient communication, early recognition of emergencies, and regular emotional support.
Direct Patient Care: The majority of ONS members provide direct patient care involving
chemotherapy. National certification for chemotherapy currently does not exist. Each institution should
have written policies for chemotherapy certification, administration of anti neoplastic drugs (all
routes), safe drug handling and disposal, management of untoward reactions, such as allergic

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reactions, and methods for documentation. The ONS currently offers a chemotherapy trainers course.
These trainers may then offer chemotherapy-training courses in the community to oncology nurses
based on ONS guidelines and curriculum.
Symptom Management: Oncology nurses are challenged on a daily basis to deal with the numerous
symptoms patients with cancer and their families encounter as a result of their cancer or its treatment.
Nurses triage patient problems and assist in the evaluation of symptoms and initiation of interventions.
For example, subjective and objective data, including information about the last chemotherapy
treatment and knowledge of the patient's history, guide the nurse in determining the patient's
disposition and treatment.
Supportive Care: Oncology nurses are closely involved with numerous supportive care issues
encountered by cancer patients and their families. This chapter does not allow a detailed discussion
of the numerous areas of supportive and palliative care, but two areas deserve special mention, that
is, the involvement of nurses in pain management and in survivorship.
Because nurses spend more time with patients experiencing pain than does any other health
professional, it is of utmost importance that the nurse be knowledgeable about pain assessment and
both pharmacological and nonpharmacologic management of pain, in order to provide good pain
control as well as patient and family education. However, as with other healthcare professions,
barriers to providing effective pain control exist within nursing as well. The major problems are
misconceptions and fears about addiction, drug tolerance, sedation, and respiratory depression; lack
of knowledge about pain assessment and analgesics; and under treatment with analgesics. This is
understandable when one considers the minimal time that is devoted to pain control in traditional
undergraduate nursing curricula. Fortunately, these problems are now being addressed, and the
education programs and resources available have improved considerably. State cancer pain
initiatives, guidelines, and organizational position statements have been excellent efforts toward
improving pain management. The ONS developed a position paper on cancer pain that delineated
the scope of practice for nurses with different levels of expertise. Even the Joint Commission for
Accreditation for Healthcare Organizations has recognized the problem of inadequate pain
management and changed their standards of care to emphasize appropriate management.
Psycho-Oncology: We are not ourselves when nature, being oppressed, commands the mind to suffer
with the body.”
Quality of life as an outcome variable for patients treated at all stages of cancer has received
increasing attention in recent years. More concern also has been directed toward recognizing and
treating the distressed patient or family member. Stresses on oncologists have also been identified,
particularly those related to delivering bad news. Research is more actively exploring social,
behavioral, and psychological contributions to cancer prevention, detection, and survival. Psycho-
oncology, which has emerged slowly since 1975 as a subspecialty of oncology, focuses on these
psychosocial issues along the continuum from prevention to care at all stages of disease. A body of
information is now available, training programs exist, and a research agenda has been formulated.


293
Appendix III
Professional Standards of Oncology Nursing Practice and Role
of Nurse
Standards of Care
I. Assessment: The oncology nurse systematically and continually collects data regarding the
health status of the client.
II. Diagnosis: The oncology nurse analyzes assessment data in determining nursing diagnosis.
III. Outcome Identification: The oncology nurse identifies expected outcomes individualized to the
client.
IV. Planning: The oncology nurse develops an individualized and holistic plan of care that
prescribes interventions to attain expected outcomes.
V. Implementation: The oncology nurse implements the plan of care to achieve the identified
expected outcomes for the client.
VI. Evaluation: The oncology nurse systematically and regularly evaluates the client's responses to
interventions in order to determine progress toward achievement of expected outcomes.
Standards of Professional Performance
I. Quality of Care: The oncology nurse systematically evaluates the quality of care and
effectiveness of oncology nursing practice.
II. Performance Appraisal: The oncology nurse evaluates his or her own nursing practice in
relation to professional practice standards and relevant statutes and regulations.
III. Education: The oncology nurse acquires and maintains current knowledge in oncology nursing
practice.
IV. Collegiality: The oncology nurse contributes to the professional development of peers,
colleagues, and others.
V. Ethics: The oncology nurse's decisions and actions on behalf of clients are determined in an
ethical manner.
VI. Collaboration: The oncology nurse collaborates with the client, significant others, and
multidisciplinary cancer care team in providing client care.
VII. Research: The oncology nurse contributes to the scientific base of nursing practice and the field
of oncology through the review and application of research.
VIII. Resource Utilization: The oncology nurse considers factors related to safety, effectiveness,
and cost in planning and delivering client care.
Source: American Nurses Association and the Oncology Nursing Society.
Role of a Nurse in Preventive Oncology
Cancer prevention is broadly defined as a variety of self-care activities, which individuals may use to
decrease their cancer risk. Nursing must play a more active role in cancer prevention education. As
the health industry’s largest work force a nurse carry a responsibility to participate fully in teaching
cancer prevention to patients and community members. Many ways nurses can be involved in the

Appendix
294
primary and secondary prevention in hospital and community.
Primary prevention: Primary prevention refers to life style change
 Stop tobacco in any form
 Dietary changes
 Small family norm
 Safe sex
 Limiting sun and chemical exposure
Secondary prevention: Secondary prevention refers early detection
Early detection entails by awareness activities increase awareness about:
 Warning signals
 Signs and symptoms
 Available screening facilities
Screening
 High risk group screening
 Mass screening
 Self screening
Awareness is the first step to prevent or control a disease
Health education
 Causes of cancer
 Risk factors
 Preventable cancer
Life style modification
 Avoid tobacco in any form
 Diet rich in Vit A, C & E
 Small family
 Marriage after the age of 18 and before the age of 30
 Safe sex
 Use of condom to prevent infections like STD HPV & HIV
 Limit sun and chemical exposure
Health promotion
 Encourage good health practices personal hygiene (oral and genital hygiene)
 Regular cancer checkups with professionals – clinical examination, pap smear, clinical breast
examination oral checkups
 Monthly breast examinations, oral self examination
Counseling
 Personal discussion
 Group discussion
 Pretest and post test counseling

295
Community level: Mass education programme
 Distribution of educational materials, booklets pamphlets etc.
 Role play, street play
 Exhibition of models, charts, posters
 Lecture with the help of AV aids
 Follow-up activities
 Evaluate the programmes conducted and arrange for regular follow-ups.
 Maintenance of records and reports
 Coordinate outreach programme
Tanning–self-education: conduct training programme for other department staff and community
health works.
Conclusion: Oncology nurse and general nurse are equally responsible for teaching prevention and
early detection methods of cancer.
Oncology Services available in Nepal
Even though the developed world has sophisticated technology and an array of the targeted
therapies and newer molecules for cancer treatment, Nepal has just initiated its struggle against
cancer and is very far away from the recent achievements in the field.
Considering the diagnostic back-up, radio-diagnosis and histopathology and their sub-specialties has
also improved over the last few years and has helped to pick up the disease in early stages.
Considering treatment of cancer in Nepal, at present, there are only 4 centers in the country treating
cancer patients with the radiation therapy facilities, thus providing a huge load of radiation services
every day. B. P. Koirala Memorial Cancer Hospital (BPKMCH), Bharatpur is a comprehensive cancer
center, established with the help of government of Nepal and People’s Republic of China and was
started in 1999 with two Linear accelerators, one telecobalt, one high dose rate (HDR) Brachytherapy
and was recently upgraded with IMRT. This center is the center of excellence in the country with state
of the art facilities. BPKMCH has been sending physicians from Nepal for training in various sub-
specialties to India and abroad.
The major challenge observed in oncology service in Nepal is the high cost of the treatment and
because of the lack of insurance, and a proper health policy, people have to bear all burden by
themselves. Another major challenge is the lack of awareness about the prognosis of disease as most
of the patients, their family, and even a lot of physicians and health care professionals consider
cancer as an incurable in its any stage. This leads to delay in presentation of patients to hospital and
thus increasing the number of advanced stages cancers and thus the morbidity and mortality. And,
also even the chemotherapeutic agents are available, the range is limited and newer molecules takes
a long time to reach developing courtiers and even though they reach, it will be affordable to only a
handful of patients. Latest development of cellular and molecular diagnostic modalities is not
available and will take years before they are available.
Various non-government organizations have been established to improve cancer awareness and
prevention in Nepal. Nepal Cancer Relief Society (NCRS, 1979), and Cancer Society Nepal (CSN,
2004) and Cancer Care Nepal (CCN, 2008) are the pioneer organizations working at different
levels for the very purpose.

Appendix
296
Advances in Surgical Oncology: Remarkable advances have occurred in surgical oncology, including
the development of doxorubicin hydrochloride for treating sarcoma, hyperthermia for treating deep-
seated tumors by localized magnetic-loop induction and an in vitro assay for cloning human tumor
cells.
Limb Preservation procedures for Skeletal and Soft tissue sarcomas: The protocol called for
doxorubicin to be given before radiationtherapy and surgical excision. All patients received identical
preoperative treatment with intraarterially administered doxorubicin. After percutaneous placement
of an intraarterial catheter by the Seldinger technique, catheter location was confirmed by
arteriogram.
Hyperthermia for Cancer therapy: At temperature between (106 degree Fahrenheit to 118 degree
Fahrenheit) cancer cells may be slightly more sensitive to heat than their normal cell counterparts. In
vitro and in vivo tumor models have shown irreversible damage and complete regression of various
tumors whereas normal cells were killed at temperatures at least one degree higher or more than
twice the duration of heating.
Advances in Medical Oncology: Medical oncology is the subspecialty of internal medicine that
focuses on treating cancer. There are two other types of clinical oncologists - surgical oncologists and
radiation oncologists. In most cases, when a person is diagnosed with cancer, medical oncologist takes
charge of the patient's overall care through all phases of the disease.
Department of Medical Oncology at Nepal Cancer Hospital & Research Centre Pvt. Ltd,
offers highest quality and advanced oncology care in a supportive and compassionate environment to
all patients to advance the treatment and prevention of cancers through innovative research. Its
mission is to achieve excellence in clinical and basic research, and cancer treatment through
multidisciplinary collaboration with surgical and radiation oncology specialists. Patients are taken
care by highly qualified and experienced Medical Oncologists, Pediatric Oncologists and
Hematologist, who works full time for this institute.
Chemotherapy Drug mixing is done at a separately designated area, under laminar air flow, to
ensure patient and staff safety to prevent health hazards. In order to make administration of
chemotherapy safe and more patient friendly, use of central catheters and ports is a routine in the
department.
Its sole focus is to cure cancer. It follows the current standards of care and protocols for each type
and stage of cancer. The strategies for early diagnosis, treatment management, rehabilitation, pain
relief and terminal care have been established in a comprehensive and multidisciplinary approach
for cancer care.
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297
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