Disturbances in Cellular Functioning mikEL rlh mantong
 DEFINITION OF TERMS
A. Anaplasia – a change in the structure and orientation of cells,
characterized by a loss of differentiation and reversion to a
more primitive form. Anaplasia is characteristic of malignancy.
B. Biologic Response Modifier (BRM) Therapy – use of agents or
treatment methods that can alter the immunologic relationship
between the tumor and the host to provide a therapeutic
benefit.
C. Biopsy – a diagnostic procedure to remove a small sample of
tissue to be examined microscopically to detect malignant cells.
D. Brachytherapy – delivery of radiation through internal
implants.
E. Carcinogenesis – process of transforming normal cells into
malignant cells.
F. Chemotherapy – use of drugs to kill tumor cells by interfering
with cellular functions and reproduction.
G. Cytokines – substances produced by cells of the immune
system to enhance production and functioning of components
of the immune system.
H. Dysplasia –abnormal development of tissues/organs.
I. Extravasation – leakage of medication from the veins into the
subcutaneous tissues.
J. Hyperplasia – an increase in the number of cells of a body part
that result from an increased rate of cellular division.
K. Metaplasia – the reversible conversion of normal tissue cells
into another, less differentiated cell type in response to chronic
stress or injury.
L. Metastasis – spread of cancer cells from the primary tumor to
distant sites.
M. Myelosuppression – suppression of the blood cell – producing
functions of the bone marrow.
N. Nadir – lowest point of WBC depression after therapy that has
toxic effects on the bone marrow
O. Neoplasia – the new and abnormal development of cells that
may be benign or malignant.
P. Neutropenia – abnormally low absolute neutrophil cnt.
Q. Oncology – field of study of cancer.
R. Palliation – relief of symptoms associated with cancer.
S. Thrombocytopenia – decrease in the number of circulating
platelets; associated with the potential for bleeding.
T. Vesicant – substance that can cause tissue necrosis and
damage, particularly when extravasated.
U. Xerostomia – dry oral cavity resulting from decreased function
of salivary glands.
 EPIDEMIOLOGY
A. most cancers occur in people older than 65 years of age.
B. Higher in men and higher in industrialized sectors and nations.
C. The leading causes of cancer deaths in the United States are
lung, prostate, and colorectal for men and lung, breast, and
colorectal for women.
 PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS
A. PATHO
1. Predisposing/etiologic factors
2. Genetic mutation of cellular DNA
3. Transformation of normal cell to abnormal cell
4. Abnormal cells form a clone and proliferate
abnormally (Pressure, obstruction, pain, effusion,
ulceration and necrosis, vascular thrombus, embolus,
thrombophlebitis)
5. Further proliferation and invasion of surrounding
tissues
6. Gain access to lymph and blood vessels
7. Metastasis
B. PROLIFERATIVE PATTERNS
1. During the lifespan, various body tissues normally
experience periods of rapid or proliferative growth that
must be distinguished from malignant growth activity.
2. Cancerous cells are described as malignant neoplasms.
They demonstrate uncontrolled cell growth that follows
no physiologic demand.
C. CHARACTERISTICS OF MALIGNANT CELLS
1. The cell membranes are altered in cancer cells.
2. Cell membrane of malignant cells contains proteins
called tumor-specific antigen. These proteins distinguish
the malignant cell from a benign cell of the same tissue
type.
3. Malignant cellular membranes also contain less
fibronectin - a cellular cement.
4. Nuclei of cancer cells are large and irregularly shaped
(pleomorphism).
5. Nucleoli, structures within the nucleus that house
RNA, are larger and more numerous in malignant cells,
perhaps because of increased RNA synthesis.
6. Mitosis (cell division) occurs more frequently in
malignant cells than in normal cells. As the cells grow and
divide, more glucose and oxygen are needed.
D. INVASION AND METASTASIS
1. by circulatory patterns and by specific affinity for
certain malignant cells to bind to molecules in specific
body tissue.
2. Invasion, which refers to the growth of primary tumor
into the surrounding host tissues, occurs in several ways.
Mechanical pressure exerted by rapidly proliferating
neoplasms may force fingerlike projections of tumor cells
into surrounding tissue and interstitial spaces.
3. Malignant cells are less adherent and may break off
from the primary tumor and invade adjacent structures.
4. Malignant cells are thought to possess or produce
specific destructive enzymes (proteinases), such as
collagenases (specific to collagen), plasminogen activators
(specific to plasma), and lysosomal hydrolyses
E. METASTATIC MECHANISMS
1. Lymph and blood are key mechanisms by which
cancer cells spread.
2. The most common mechanism of metastasis is
lymphatic spread, which is transport of tumor cells
through the lymphatic circulation.
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3. Tumor emboli enter the lymph channels by way of the
interstitial fluid that communicates with lymphatic fluid.
4. Malignant cells also may penetrate lymphatic vessels
by invasion.
5. Malignant cells either lodge in the lymph nodes or
pass between lymphatic and venous circulation.
6. Tumors arising in areas of the body with rapid and
extensive lymphatic circulation are at high risk for
metastasis through lymphatic channels (breast tumors).
7. Another metastatic mechanism is hematogenous
spread, by which malignant cells are disseminated
through the bloodstream.
8. Hematogenous spread is directly related to the
vascularity of the tumor.
9. Malignant cells also have the ability to induce the
growth of new capillaries to meet their needs for
nutrients and oxygen (angiogenesis).
F. CARCINOGENESIS
1. A three-step cellular process: initiation, promotion,
and progression.
2. Initiation – carcinogens escape normal enzymatic
mechanisms and alter the genetic structure of the cellular
DNA. The alterations are reversed by DNA repair
mechanisms or apoptosis but others escape these
protective mechanisms.
3. Promotion – repeated exposure to promoting agents
(co-carcinogens) causes the expression of abnormal or
mutant genetic information.
4. Progression – the cellular changes formed during
initiation and promotion now exhibit increased malignant
behavior. These cells now show a propensity.
 ETIOLOGY
A. Viruses and bacteria
1. Viruses are thought to incorporate themselves in the
genetic structure of cells, thus altering future generations
of that cell population
B. Physical agents
1. Include exposure to sunlight or radiation, chronic
irritation or inflammation, and tobacco use.
C. Genetic and familial factors
1. May be due to genetics, shared environments, cultural
or lifestyle factors, or chance alone.
D. Dietary factors
1. Dietary substances can be proactive (protective),
carcinogenic, co-carcinogenic
2. Dietary substances associated with an increased
cancer risk include fats, alcohol, salt-cured or smoked
meats, foods containing nitrates and nitrites, and a high
caloric dietary intake
3. Foods to reduce cancer risk are: high fiber foods,
cruciferous vegetables, carotenoids and vitamins C & E
4. Benzopyrene – charcoal broiled meat or fish or foods
fried in repeatedly used cooking oil.
5. Nitrosamines – powerful carcinogens used as
preservatives for tocino, longganisa, bacon and hotdog.
mikEL rlh mantong
Formation may be inhibited by taking antioxidants like
Vitamin C
E. Chemical agents
1. Polycyclic hydrocarbons – found in cigarette smoke,
industrial agents and smoked foods
2. Aflatoxin – found in peanuts and peanut butter
3. Other chemicals include asbestos, formaldehydes,
pesticides
4. Most hazardous chemicals produce their toxic effects
by altering the DNA structure in body sites distant from
chemical exposure. Liver, lungs, kidneys are the organs
systems most often affected
F. Hormonal agents
1. Tumor growth may be promoted by disturbances in
hormonal balance either by the body’s own (endogenous)
hormone production or by administration of exogenous
hormones
 WARNING SIGNS OF CANCER BY THE AMERICAN CANCER SOCIETY
(CAUTION US)
A. C – Change in bowel or bladder habits
1. Changes in stream/flow of urine or its color and
amount
2. Changes in the caliber and color of stools
3. Presence of blood in stools
4. Difficulty in urination and defecation
B. A – A sore that does not heal
1. Skin irritations are usually self-limiting. If changes in
the skin and underlying muscles take time to heal, it is
recommended to have it examined.
C. U – Unusual bleeding or discharge
1. Unusual discharges in the breast, for non-
breastfeeding women
D. T – Thickening or lump in the breast
E. I – Indigestion and difficulty in swallowing
F. O – Obvious change in wart or mole
G. N – Nagging cough or hoarseness of voice
H. U – Unexplained anemia
I. S – Sudden weight loss
 EARLY DETECTION
A. BREAST SELF EXAMINATION
1. Performed every 7 to 10 days after menses
2. Postmenopausal clients or clients who have had a
hysterectomy should select a specific day of the month
and perform BSE monthly on that day
3. First – while in the shower or bath, when the skin is
slippery with soap and water, examine your breasts, use
the pads of your second, third, fourth fingers to press
every part of the breast firmly.
4. Second – look at your breasts in a mirror stand with
your arms at your side
5. Third – raise your arms overhead and check for any
changes in the shape of your breasts, dimpling of the skin,
or any changes in the nipple.
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6. Fourth – place your hand on your hips and press down 3. Following excision, a frozen section or a permanent
firmly, tightening the pectoral muscles. Observe for paraffin section is prepared to examine the specimen.
asymmetry or changes, keeping in mind that your breasts 4. The advantage of the frozen section is the speed with
probably do not match exactly. which the section can be prepared and the diagnosis
7. Fifth – while lying down, feel your breasts as described made, because only minutes are required for this test.
in 1. When examining your right breast, place a folded 5. Permanent paraffin section takes about 24 hours;
towel under your right shoulder and put your right hand however, it provides clearer details that the frozen
behind your head. section.
8. Mark your calendar that you have completed your 6. Procedure is usually performed in an outpatient
breast self examination. Note any changes or unique surgical setting.
characteristics you want to check with your health care 7. Obtain an informed consent.
provider. F. Complete blood count (CBC)
B. TESTICULAR SELF EXAMINATION G. Computed tomography (CT) scan
1. The best time to perform this examination is right 1. Use of narrow beam x-ray to scan successive layers of
after a shower when your scrotal skin is moist and tissue for a cross sectional view
relaxed, making the testicles easy to feel H. Magnetic resonance imaging (MRI)
2. gently lift each testicle. Each one should feel like an 1. Use of magnetic fields and radiofrequency signals to
egg, firm but not hard, and smooth with no lumps create sectioned images of various body structures
3. using both hands, place your middle fingers on the I. Tumor marker identification
underside of each testicle and your thumb on top 1. Analysis of substances found in blood or other body
4. Gently roll the testicle between the thumb and fingers fluids that are made by the tumor or by the body in
to feel for any lumps, swelling, or mass response to the tumor.
5. If you notice any changes from one month to the next, J. Fluoroscopy
notify your physician or nurse practitioner. 1. Use of x-rays that identify contrasts in body tissue
densities; may involve the use of contrast agents.
 DIAGNOSTIC TESTS K. Ultrasonography
A. Biopsy 1. High frequency sound waves echoing off body tissues
1. Is the definitive means of diagnosing cancer and are converted electronically into images; used to assess
provides histological proof of malignancy. tissues deep within the body.
2. Involves the surgical incision of a small piece of tissue L. Endoscopy
for microscopic examination. 1. Direct visualization of a body cavity or passageway by
B. Fine needle aspiration insertion of an endoscope into a body cavity or opening;
1. Is the aspiration of cells and tissue fragments through allows tissue biopsy, fluid aspiration and excision of small
a needle that has been guided to a suspected malignant tumors; both diagnostic and therapeutic
tissue. M. Positron emission tomography (PET scan)
2. Is the procedure of choice if high risk of malignancy. 1. Computed cross sectional images of increased
3. Well tolerated with little trauma. concentration of radioisotopes in malignant cells provide
4. A local anesthetic may be used. information about biologic activity of malignant cells; help
5. May be guided by CT scan or ultrasound. distinguish between benign and malignant processes and
C. Needle core biopsy responses to treatment.
1. This involves obtaining a core of tissue through a N. Radioimmunoconjugates
specially designed needle introduced into a suspected 1. Monoclonal antibodies are labeled with a radioisotope
malignant tissue. and injected intravenously into the patient; the antibodies
2. A local anesthetic is used. that aggregate at the tumor site are visualized with
D. Incisional biopsy scanners.
1. Removal of a small wedge of tissue from a larger
tumor mass.  TUMOR STAGING AND GRADING
2. Is the preferred method for diagnosing soft tissue and A. Grade
bony sarcomas and used for large tumors that will need 1. Grade 1 – cells differ slightly from normal cells and are
major surgery. well differentiated (mild dysplasia)
E. Excisional biopsy 2. Grade 2 – cells are more abnormal and are moderately
1. Excision of the entire suspected tumor mass with no differentiated (moderate dysplasia)
attempt to obtain generous margins of adjacent normal 3. Grade 3 – cells are very abnormal and are poorly
tissue. differentiated (severe dysplasia)
2. Procedure of choice for small accessible tumors. 4. Grade 4 – cells are immature and undifferentiated; cell
of origin is difficult to determine (anaplasia)
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B. Stage 5. Instruct the client regarding preventive measures
1. Stage 0 – carcinoma in situ 6. Instruct the client to monitor for lesions that do not
2. Stage 1 – tumor limited to the tissue of origin; heal or that change characteristics
localized tumor growth 7. Instruct the client to have moles or lesions removed
3. Stage 2 – limited local spread that are subject to chronic irritation
4. Stage 3 – extensive local and regional spread 8. Instruct the client to avoid contact with chemical
5. Stage 4 – distant metastasis irritants
C. TNM CLASSIFICATION 9. Instruct the client to wear layered clothing and use
1. T – the extent of the primary tumor sunscreen lotions with an appropriate skin protection
a. TX – primary tumor cannot be assessed factor when outdoors
b. T0 – no evidence of primary tumor 10. Instruct the client to avoid sun exposure between 11
c. Tis – carcinoma in situ AM and 3 PM
d. T1, T2, T3, T4 – increasing size and/or local extent of 11. Assist with surgical excision of the lesion as prescribed
the primary tumor B. BREAST CANCER
2. N – the absence or presence and extent of regional 1. Is classified as invasive when it penetrates the tissue
lymph node metastasis surrounding the mammary duct and grows in an irregular
a. NX – regional lymph nodes cannot be assessed pattern
b. N0 – no regional lymph node metastasis 2. Metastasis occurs via lymph node
c. N1, N2, N3 – increasing involvement of regional 3. Diagnosis is made by breast biopsy through a needle
lymph nodes aspiration or by surgical removal of the tumor with
3. M – the absence or presence of distant metastasis microscopic examination of malignant cells
a. MX – distant metastasis cannot be assessed 4. Assessment
b. M0 – no distant metastasis a. Mass felt during BSE
c. M1 – distant metastasis b. Asymmetry, with the affected breast being higher
 DIFFERENT TYPES OF CANCER c. Bloody or clear nipple discharge
d. Skin dimpling, retraction, or ulceration
A. SKIN CANCER
e. Skin edema or peau d’orange skin
1. Is a malignant lesion of the skin, which may or may
f. Axillary lymphadenopathy
not metastasize g. Lymphedema of the affected arm
2. Skin cancer causes include chronic friction and 5. Non surgical interventions
irritation to a skin area and exposure to ultraviolet rays. a. Chemotherapy
3. Diagnosis is confirmed by a skin biopsy that is positive b. Radiation therapy
for cancer cells c. Hormonal manipulation via the use of medication in
4. Types: post-menopausal women or other medications such
as tamoxifen (Nolvadex) for estrogen receptor-
a. Basal cell – the most common type, basal cell cancer
positive tumors.
arises from the basal cell contained in the epidermis. 6. Surgical interventions
1) Waxy border a. 1. Lumpectomy
2) papule, red, central crater 1) tumor is excised and removed
3) metastasis is rare 2) lymph node dissection may also be performed
b. Squamous cell – the second most common type of b. 2. simple mastectomy
skin cancer in whites; squamous cell cancer is the 1) breast tissue and the nipple are removed
tumor of the epidermal epidermal keratinocytes and 2) lymph nodes are left intact
can infiltrate surrounding structures, metastasize to c. 3. modified radical mastectomy
lymph nodes, and subsequently be fatal. 1) breast tissue, nipple, and lymph nodes are
1) Oozing, bleeding, crusting lesion removed
2) Potentially metastatic 2) muscles are left intact
3) Large tumors associated with a higher risk for 7. monitor vital signs
metastasis 8. position the client in Semi-Fowler’s position
c. Malignant melanoma – may occur any place on the 9. turn from the back to the unaffected side, with the
body, especially where birthmarks or new moles are affected arm elevated above the level of the heart to
apparent. Cancer of the melanocytes can promote drainage and prevent lymphedema
metastasize to the brain, bones, lung, liver and skin 10. encourage coughing and deep breathing
and is ultimately fatal. 11. if a drain (usually Jackson – Pratt) is in place, maintain
1) Irregular, circular, bordered lesion with hues of suction and record the amount of drainage and drainage
tan, black or blue characteristics
2) Rapid infiltration into tissue, rapid metastasis,
significant rate of morbidity and mortality
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12. assess operative site for infection, swelling, or f. Anorexia
presence of fluid collection under the skin flaps or in the g. Weakness
arm h. Diminished or absent breath sounds, respiratory
changes
13. place a sign above the bed stating: No IV’s, No
4. INTERVENTIONS
injections, No BP’s, No venipuncture in affected arm; the
a. Monitor vital signs
affected arm is protected and any intervention that could
b. Monitor for breathing patterns and breath sounds
traumatize the affected arm is avoided.
c. Place in a fowler’s position to help ease breathing
14. Consult with the physician and physical therapist
d. Administer oxygen as prescribed and humidification
regarding the appropriate exercise program and assist
to moisten and loosen secretions
client with prescribed exercise
e. Monitor pulse oximetry
15. Client instruction following mastectomy:
f. provide a high calorie, high protein, high vitamin
16. Avoid overuse of the arm during the first few months
diet
17. To prevent lymphedema, keep the affected arm
g. provide activity as tolerated, rest periods, and active
elevated
and passive range of motion exercises
18. Encourage the client to perform BSE on the remaining
h. monitor for bleeding and infection
breast
5.  NONSURGICAL INTERVENTIONS
19. Protect the affected hand and arm
a. radiation therapy may be prescribed for localized
20. Do not let the affected arm hang dependent
intrathoracic lung cancers and for palliation of
21. Do not carry pocketbook or anything heavy over the
hemoptysis, obstructions, dysphagia, superior vena
affected arm
cava syndrome, and pain
22. Avoid trauma, cuts, or bruises, or burns to the
b. chemotherapy may be prescribed for treatment of
affected side
nonresectable tumors or as adjuvant therapy
23. Avoid wearing constricting clothing or jewelry on the
6. SURGICAL INTERVENTIONS
affected side
a. laser therapy: to relieve endobronchial obstruction
24. Wear gloves when gardening
b. thoracentesis and pleurodesis: to remove pleural
25. Use thick oven mitts when cooking
fluid and relive hypoxia
26. Use a thimble when sewing
c. thoracotomy with pneumonectomy: surgical
C. LUNG CANCER
removal of one entire lung
1. About Lung Cancer
d. thoracotomy with segmental resection: surgical
a. Malignant tumor of the bronchi and peripheral lung
removal of a lobe segment
tissue, is a leading cause of cancer-related deaths in
D.  PROSTATE CANCER
men and women in the United States
1. About Prostate Cancer
b. The lungs are a common target for metastasis from
a. A slow growing malignancy of the prostate gland;
other organs
most prostate tumors are adenocarcinoma arising
c. Bronchogenic cancer (tumors originate in the
from androgen-dependent epithelial cells
epithelium of the bronchus) spreads through direct
b. The risk increases in men with each decade after the
extension and lymphatic dissemination
age of 50 years
d. Classified according to histological cell type, there
c. Can spread by direct invasion of surrounding tissues
are two main types of lung cancer, small cell lung
or by metastasis, through the blood stream and
cancer and non-small cell lung cancer.
lymphatics, to the bony pelvis and spine
e. Diagnosis is made by a chest x-ray, CT scan, or MRI,
d. The cause of prostate cancer is unclear, but
which will show a lesion or mass and by
advancing age, heavy metal exposure, smoking, and
bronchoscopy and sputum studies, which will
history of sexually transmitted disease are
demonstrate a positive cytological study for cancer
contributing factors
cells
2. ASSESSMENT
2. CAUSES
a. Asymptomatic in early stages
a. Cigarette smoking, exposure to “passive” tobacco
b. Hard, pea-sized nodule or irregularities palpated on
smoke
rectal examination
b. Exposure to environmental and occupational
pollutants
c. Gross, painless hematuria
3. ASSESSMENT
a. Cough
b. Wheezing, dyspnea
c. Hoarseness
d. Hemoptysis
e. Chest pain