Gastric Cancer

Definition
Gastric cancer consists of two pathological variants, intestinal and diffuse. The
intestinal-type is the end-result of an inflammatory process that progresses from
chronic gastritis to atrophic gastritis and finally to intestinal metaplasia and dysplasia.
This type is more common among elderly men, unlike the diffuse type, which is
more prevalent among women and in individuals under the age of 50.
The diffuse-type, characterized by the development of linitis plastica, is
associated with an unfavorable prognosis because the diagnosis is often delayed until
the disease is quite advanced. Gastric H. pylori infection is highly associated with this
type as with the intestinal-type.

Anatomy and Physiology

The stomach is located in the upper part of the abdomen just beneath the
diaphragm. The size, shape, and position may vary with posture and with content
because it is distensible and on a free mesentery.
An empty stomach is roughly the size of an open hand. It can fill much of the
upper abdomen when distended with food and may descend into the lower abdomen or
pelvis upon standing. The duodenum extends from the pylorus to the ligament of Treitz
in a sharp curve that almost completes a circle. It is so named because it is about equal
in length to the breadth of 12 fingers, or about 25 cm. It is largely retroperitoneal and the
position is relatively fixed.
The stomach and duodenum are closely related in function and in pathogenesis
and manifestation of disease. The stomach may be divided into seven major sections.
The cardia is a 1–2 cm segment distal to the esophagogastric junction. The fundus
refers to the superior portion of the stomach that lies above an imaginary horizontal
plane that passes through the esophagogastric junction. The antrum is the smaller
distal, one-fourth to one-third of the stomach. The narrow, 1–2-cm channel that
connects the stomach and duodenum is the pylorus. The lesser curve refers to the
medial shorter border of the stomach, whereas the opposite surface is the greater
curve.
 The angularis is along the lesser curve of the stomach where the body and
antrum meet. This junction is accentuated during peristalsis.

Signs and Symptoms

Symptoms of early disease, such as pain relieved by antacids, resemble those
of benign ulcers and are seldom definitive, because most gastric tumors begin on the
lesser curvature of the stomach, where they cause little disturbance of gastric function.
Symptoms of progressive disease include dyspepsia (indigestion), early satiety,
weight loss, abdominal pain just above the umbilicus, loss or decrease in appetite,
bloating after meals, nausea and vomiting, and symptoms similar to those of peptic
ulcer disease.

Diagnosis
Physical Examination
Physical examination may provide clues to diagnose gastric cancer. The
presence of anemia, occult blood in the stool, and weight loss may suggest a
malignancy. A midepigastric palpable mass or nodular liver may be helpful in localizing
the process to the abdomen.
Genetic Screening
Genetic screening has been advocated in family members of young patients with
the diffuse-type of gastric cancer. There are no mutational hotspots, so screening for
CDH1 mutations requires a survey of the entire gene. Prophylactic gastrectomy has
been performed on carriers of truncating germ-line CDH1 mutations.
Radiological Diagnosis
Abdominal computed tomography (CT) has been used in gastric cancer tumor
staging. The CT scan (Figure 12) can demonstrate the size and location of the cancer,
wall thickness, presence or absence of fat between the mass and adjacent organs, as
well as nodal, vascular, or visceral spread of tumor.
Endoscopic Diagnosis
Endoscopy provides the most specific and sensitive means of diagnosis of
gastric cancers. Gastrointestinal endoscopy allows the physician to visualize and biopsy
the mucosa of the esophagus, stomach, duodenum, and most of the jejunum.

Medical Management
There is no successful treatment for gastric carcinoma except removal of the
tumor. If the tumor can be removed while it is still localized to the stomach, the patient
may be cured. If the tumor has spread beyond the area that can be excised, cure is less
likely. In many patients, effective palliation to prevent discomfort caused by obstruction
or dysphagia may be obtained by resection of the tumor.
If surgical treatment does not offer cure, treatment with chemotherapy may offer
further control of the disease or palliation. Commonly used single-agent
chemotherapeutic medications include 5-fluorouracil (5-FU), cisplatin (Plati- nol),
doxorubicin (Adriamycin), etoposide (Etopophos), and mitomycin-C (Mutamycin). For
improved response rates it is more common to administer combination therapy,
primarily 5-FU–based therapy, with other agents.
Radiation therapy is mainly used for palliation in patients with obstruction, GI
bleeding secondary to tumor, and significant pain. Assessment of tumor markers (blood
analysis for antigens indicative of cancer) such as carcinoembryonic antigen (CEA),
carbohydrate antigen (CA 19-9), and CA 50 may help determine the effectiveness of
treatment. If these values were elevated before treatment, they should decrease if the
tumor is responding to the treatment.
Nursing Responsibilities
1. Monitor nutritional intake and weigh patient regularly.
2. Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor
albumin and prealbumin levels to determine if protein supplementation is needed.
3. Provide comfort measures and administer analgesics as ordered.
4. Frequently turn the patient and encourage deep breathing to prevent pulmonary
complications, to protect skin, and to promote comfort.
5. Maintain nasogastric suction to remove fluids and gas in the stomach and
prevent painful distention.
6. Provide oral care to prevent dryness and ulceration.
7. Keep the patient nothing by mouth as directed to promote gastric wound healing.
Administer parenteral nutrition, if ordered.
8. When nasogastric drainage has decreased and bowel sounds have returned,
begin oral fluids and progress slowly.
9. Avoid giving the patient high-carbohydrate foods and fluids with meals, which
may trigger dumping syndrome because of excessively rapid emptying of gastric
contents.
10. Administer protein and vitamin supplements to foster wound repair and tissue
building.
11. Instruct to eat small, frequent meals rather than three large meals.
12. Instruct to educe fluids with meals, but take them between meals.
13. Stress the importance of long term vitamin B12 injections after gastrectomy to
prevent surgically induced pernicious anemia.
14. Encourage follow-up visits with the health care provider and routine blood studies
and other testing to detect complications or recurrence.
 Bibliography
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-
surgical nursing. Philadelphia: Wolters Kluwer.
RNPedia. (n.d.). Gastric cancer nursing care plan & management. Retrieved from
https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/gastric-
cancer/#:~:text=Nursing%20Intervention&text=Frequently%20turn%20the
%20patient%20and,to%20prevent%20dryness%20and%20ulceration.
Tadesse Haye. Review on Gastric Cancer. Nov Appro in Can Study. 3(1).
NACS.000555.2019. DOI: 10.31031/NACS.2019.03.000555.

National Cancer Institute. (n.d.). Anatomy of the lung. Welcome to SEER Training | SEER
Training. https://training.seer.cancer.gov/lung/anatomy
Bone Cancer

Chondrosarcoma
Definition
Chondrosarcoma is a rare form of cancer that typically occurs in the bones but
often may appear near bones in the soft tissue. The pelvis, knee, and neck are the most
prominent sites for chondrosarcoma tumors. Very occasionally, it reaches the base of the
skull.
The distinguishing characteristic of chondrosarcoma is that it creates cartilage
through its cells. Most forms of chondrosarcomas develop gradually and have a low
chance of spreading to other organs and bones so that they are eliminated. Others are
rising quickly and risk metastasis high.

Anatomy and Physiology

The structure of a long bone allows for the best visualization of all of a bone's
parts. A long bone has two parts: the diaphysis and the epiphysis. The diaphysis is the
tubular shaft that runs between the proximal and distal ends of the bone. The hollow
region in the diaphysis is called the medullary cavity, which is filled with yellow marrow.
The walls of the diaphysis are composed of dense and hard compact bone.
The broader section at each end of the bone is called the epiphysis, filled with
spongy bone. Red marrow fills the spaces in the spongy bone. Each epiphysis meets the
diaphysis at the metaphysis, the narrow area that contains the epiphyseal plate (growth
plate), a layer of hyaline (transparent) cartilage in a growing bone. When the bone stops
growing in early adulthood (approximately 18–21 years), the cartilage is replaced by
bony tissue, and the epiphyseal plate becomes an epiphyseal line.
The medullary cavity has a delicate membranous lining called the endosteum,
where bone growth, repair, and remodeling occur. The outer surface of the bone is
covered with a fibrous membrane called the periosteum. The periosteum contains blood
vessels, nerves, and lymphatic vessels that nourish compact bone. Tendons and ligaments
also attach to bones at the periosteum. The periosteum covers the entire outer surface
except where the epiphyses meet other bones to form joints. In this region, the epiphyses
are covered with articular cartilage, a thin layer of cartilage that reduces friction and acts
as a shock absorber.
 Like those of the skull, flat bones consist of a layer of diploë (spongy bone), lined
on either side by a layer of compact bone. The two layers of small bone and the spongy
interior bone work together to protect the internal organs. If the outer layer of cranial
bone fractures, the brain is still protected by the intact inner layer.
Bone contains a relatively small number of cells entrenched in a matrix of
collagen fibers that provide a surface for inorganic salt crystals to adhere. These salt
crystals form when calcium phosphate and calcium carbonate combine to create
hydroxyapatite, incorporating other inorganic salts like magnesium hydroxide, fluoride,
and sulfate as it crystallizes, or calcifies, on the collagen fibers. The hydroxyapatite
crystals give bones their hardness and strength, while the collagen fibers provide them
with the flexibility to not brittle.
Although bone cells compose a small amount of the bone volume, they are crucial
to bones' function. Four types of cells are found within bone tissue: osteoblasts,
osteocytes, osteogenic cells, and osteoclasts
The osteoblast is the bone cell responsible for forming new bone and is located in
the growing portions of bone, including the periosteum and endosteum. Osteoblasts,
which do not divide, synthesize, and secrete the collagen matrix and calcium salts. As the
secreted form surrounding the osteoblast calcifies, the osteoblast becomes trapped within
it; thus, it changes in structure and becomes an osteocyte, the primary cell of mature bone
and the most common type of bone cell. Each osteocyte is located in a space called a
lacuna and is surrounded by bone tissue. Osteocytes maintain the mineral concentration
of the matrix via the secretion of enzymes. Like osteoblasts, osteocytes lack mitotic
activity. They can communicate with each other and receive nutrients via long
cytoplasmic processes that extend through canaliculi, channels within the bone matrix.
If osteoblasts and osteocytes are incapable of mitosis, then how are they replenished
when old ones die? The answer lies in the properties of the third category of bone cells—
the osteogenic cell. These osteogenic cells are undifferentiated with high mitotic activity,
and they are the only bone cells that divide. Immature osteogenic cells are found in the
deep layers of the periosteum and the marrow. They differentiate and develop into
osteoblasts.
The dynamic nature of bone means that new tissue is formed continuously, and
old, injured, or unnecessary bone is dissolved for repair or calcium release. The cell
responsible for bone resorption, or breakdown, is the osteoclast. They are found on bone
surfaces, are multinucleated, and originate from monocytes and macrophages, two types
of white blood cells, not from osteogenic cells. Osteoclasts are continually breaking down
old bone, while osteoblasts are continuously forming new bone. The ongoing balance
between osteoblasts and osteoclasts is responsible for the constant but subtle reshaping of
a bone.

Signs and Symptoms

Symptoms of chondrosarcoma may vary depending on the location of the tumor.
The following are the most common symptoms of chondrosarcoma. However, each
individual may experience symptoms differently. Symptoms may include:
● Large mass on the affected bone
● Feeling of pressure around the mass
 ● Pain that increases gradually over time. It is usually worse at night and may be
relieved by taking anti-inflammatory medicines, such as ibuprofen. It is not
usually relieved through rest.
● Pain that is usually worse at night and may be relieved by taking anti-
inflammatory medicines, such as ibuprofen
● Local swelling

Diagnosis
Because most chondrosarcoma tumors grow so slowly, they may not be diagnosed
for years. In some cases, tumors are discovered during imaging tests for unrelated
problems. A biopsy may be needed to confirm the diagnosis.

Imaging tests

An X-ray may identify a suspicious area of bone for further examination. Other
imaging tests, such as magnetic resonance imaging (MRI) and computerized tomography
(CT), can offer additional information about the tumor.

Biopsy

Doctors can confirm a diagnosis of chondrosarcoma by removing a sample of

suspicious tissue with a needle or a scalpel and testing it in a lab. A biopsy must be
performed in a certain way so that it doesn't make it more difficult to remove the cancer
during a later operation.

Management
Surgery is the primary treatment for chondrosarcomas. The goal is to remove the
cancer and a margin of healthy tissue around it. The type of surgery you undergo will
depend on the location of your chondrosarcoma.

Most chondrosarcomas are suitable for limb salvage surgery, where the cancer is
removed and the affected bone is replaced or reconstructed. A small percentage of
chondrosarcomas require amputation. This option is chosen when a tumor involves major
nerves, blood vessels, or is so large that removal essentially destroys the function of the
limb.

Radiation

If your tumor is in a location such as the base of the skull, which makes it difficult
to remove all the cancer, your doctor might suggest using radiation therapy before or
after the operation.
 Chemotherapy

Chondrosarcoma is typically a very slow-growing cancer and chemotherapy

targets cells that grow very quickly, so this treatment is generally not very effective.
Some rare variations of chondrosarcoma do grow more swiftly, so chemotherapy may be
helpful in these cases.

Nursing Responsibilities
1. 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.
2. Review the treatment plan with the oncologist
3. Aware of expected outcomes and possible complications.
4. Assess the patient's general physical and emotional status.
5. Assessment of the patient's understanding of the disease and proposed treatment.
6. Ensure that the correct dose and drug are administered by the correct route to the
right patient.
7. Assess and manage side effects of drugs: manage nausea and vomiting,
inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea
and vomiting with specific nursing and medical interventions
8. Monitor lab results (drugs withheld if blood counts seriously low); blood and
blood product administration
9. Assess for dehydration, oncologic emergencies
10. Teach regarding fatigue, immunosuppression precautions
11. Provide emotional and spiritual support to clients and families
Ewing sarcoma
Definition
Ewing's sarcoma is a rare form of cancer tumor in your bones, or the soft tissue
surrounding your bones, including cartilage or nerves. It typically affects individuals
between 10 and 20 years of age and has a high rate of cure.
Ewing's sarcoma affects about 200 children and young adults in the United States
per year and occurs somewhat more often in males. Although adults can get sarcoma
from Ewing, this is uncommon. This affects many white men and is only present in
African Americans or Asian Americans.

Anatomy and Physiology

The structure of a long bone allows for the best visualization of all of a bone's
parts. A long bone has two parts: the diaphysis and the epiphysis. The diaphysis is the
tubular shaft that runs between the proximal and distal ends of the bone. The hollow
region in the diaphysis is called the medullary cavity, which is filled with yellow marrow.
The walls of the diaphysis are composed of dense and hard compact bone.
The broader section at each end of the bone is called the epiphysis, filled with
spongy bone. Red marrow fills the spaces in the spongy bone. Each epiphysis meets the
diaphysis at the metaphysis, the narrow area that contains the epiphyseal plate (growth
plate), a layer of hyaline (transparent) cartilage in a growing bone. When the bone stops
growing in early adulthood (approximately 18–21 years), the cartilage is replaced by
bony tissue, and the epiphyseal plate becomes an epiphyseal line.
The medullary cavity has a delicate membranous lining called the endosteum,
where bone growth, repair, and remodeling occur. The outer surface of the bone is
covered with a fibrous membrane called the periosteum. The periosteum contains blood
vessels, nerves, and lymphatic vessels that nourish compact bone. Tendons and ligaments
also attach to bones at the periosteum. The periosteum covers the entire outer surface
except where the epiphyses meet other bones to form joints. In this region, the epiphyses
are covered with articular cartilage, a thin layer of cartilage that reduces friction and acts
as a shock absorber.
Like those of the skull, flat bones consist of a layer of diploë (spongy bone), lined
on either side by a layer of compact bone. The two layers of small bone and the spongy
interior bone work together to protect the internal organs. If the outer layer of cranial
bone fractures, the brain is still protected by the intact inner layer.
Bone contains a relatively small number of cells entrenched in a matrix of
collagen fibers that provide a surface for inorganic salt crystals to adhere. These salt
crystals form when calcium phosphate and calcium carbonate combine to create
hydroxyapatite, incorporating other inorganic salts like magnesium hydroxide, fluoride,
and sulfate as it crystallizes, or calcifies, on the collagen fibers. The hydroxyapatite
crystals give bones their hardness and strength, while the collagen fibers provide them
with the flexibility to not brittle.
 Although bone cells compose a small amount of the bone volume, they are crucial
to bones' function. Four types of cells are found within bone tissue: osteoblasts,
osteocytes, osteogenic cells, and osteoclasts
The osteoblast is the bone cell responsible for forming new bone and is located in
the growing portions of bone, including the periosteum and endosteum. Osteoblasts,
which do not divide, synthesize, and secrete the collagen matrix and calcium salts. As the
secreted form surrounding the osteoblast calcifies, the osteoblast becomes trapped within
it; thus, it changes in structure and becomes an osteocyte, the primary cell of mature bone
and the most common type of bone cell. Each osteocyte is located in a space called a
lacuna and is surrounded by bone tissue. Osteocytes maintain the mineral concentration
of the matrix via the secretion of enzymes. Like osteoblasts, osteocytes lack mitotic
activity. They can communicate with each other and receive nutrients via long
cytoplasmic processes that extend through canaliculi, channels within the bone matrix.
If osteoblasts and osteocytes are incapable of mitosis, then how are they replenished
when old ones die? The answer lies in the properties of the third category of bone cells—
the osteogenic cell. These osteogenic cells are undifferentiated with high mitotic activity,
and they are the only bone cells that divide. Immature osteogenic cells are found in the
deep layers of the periosteum and the marrow. They differentiate and develop into
osteoblasts.
The dynamic nature of bone means that new tissue is formed continuously, and
old, injured, or unnecessary bone is dissolved for repair or calcium release. The cell
responsible for bone resorption, or breakdown, is the osteoclast. They are found on bone
surfaces, are multinucleated, and originate from monocytes and macrophages, two types
of white blood cells, not from osteogenic cells. Osteoclasts are continually breaking down
old bone, while osteoblasts are continuously forming new bone. The ongoing balance
between osteoblasts and osteoclasts is responsible for the constant but subtle reshaping of
a bone.

Signs and Symptoms

Children and young adults with Ewing sarcoma may experience the following
symptoms or signs. Sometimes, people with Ewing sarcoma do not have any of these
changes. Or, the cause of a symptom may be a different medical condition that is not
cancer.
● Stiffness, pain, swelling, or tenderness in the bone or in the tissue surrounding the
bone. About 85% of children and young adults with Ewing sarcoma have pain
that can come and go and be less severe at night.
● A lump near the surface of the skin that may feel warm and soft to the touch.
● A fever that does not go away.
A broken bone that happens without an injury. A tumor growing in the bone can
cause the bone to become weak or fracture.

Diagnosis
Imaging tests

Imaging tests help your doctor investigate your bone symptoms, look for cancer
and look for signs that the cancer has spread.
 Imaging tests may include:

● X-ray
● Computerized tomography (CT)
● Magnetic resonance imaging (MRI)
● Positron emission tomography (PET)
● Bone scan
Removing a sample of cells for testing (biopsy)

A biopsy procedure is used to collect a sample of suspicious cells for laboratory

testing. Tests can show whether the cells are cancerous and what type of cancer you have.

Types of biopsy procedures used to diagnose Ewing sarcoma include:

● Needle biopsy. The doctor inserts a thin needle through the skin and guides it into
the tumor. The needle is used to remove small pieces of tissue from the tumor.
● Surgical biopsy. The doctor makes an incision through the skin and removes either
the entire tumor (excisional biopsy) or a portion of the tumor (incisional biopsy).
Determining the type of biopsy needed and the specifics of how it should be
performed requires careful planning by the medical team. Doctors need to perform the
biopsy in a way that won't interfere with future surgery to remove the cancer. For this
reason, ask your doctor for a referral to a team of experts with extensive experience in
treating Ewing sarcoma before the biopsy.

Testing the cancer cells for gene mutations

A sample of your cancer cells will be tested in the lab to determine which DNA
changes are present in the cells. Ewing sarcoma cells usually have changes in the EWSR1
gene. Most often the EWSR1 gene becomes fused with another gene called FLI1,
creating a new gene called EWS-FLI1. Testing the cancer cells for these gene changes
can help confirm your diagnosis and give your doctor clues about the aggressiveness of
your disease.

Management
Ewing sarcoma treatment usually begins with chemotherapy. Surgery to remove
the cancer usually follows. Other treatments, including radiation therapy, might be used
in certain situations.

Chemotherapy
 Chemotherapy uses powerful drugs to kill cancer cells. Chemotherapy treatment
usually combines two or more drugs that can be administered as an infusion into a vein
(IV), in pill form, or through both methods.

Treatment for Ewing sarcoma usually begins with chemotherapy. The drugs may
shrink the tumor and make it easier to remove the cancer with surgery or target with
radiation therapy.

After surgery or radiation therapy, chemotherapy treatments might continue in

order to kill any cancer cells that might remain.

For advanced cancer that spreads to other areas of the body, chemotherapy might
help relieve pain and slow the growth of the cancer.

Surgery

The goal of surgery is to remove all of the cancer cells. But planning the operation
also takes into consideration how it will affect your ability to go about your daily life.

Surgery for Ewing sarcoma may involve removing a small portion of bone or
removing an entire limb. Whether surgeons can remove all of the cancer without
removing the entire limb depends on several factors, such as the size and location of the
tumor and whether it shrinks after chemotherapy.

Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays and protons, to kill
cancer cells.

During radiation therapy, the beams of energy are delivered from a machine that
moves around you as you lie on a table. The beams are carefully directed to the area of
the Ewing sarcoma in order to reduce the risk of damage to surrounding healthy cells.

Radiation therapy might be recommended after surgery to kill any cancer cells
that remain. It can also be used instead of surgery if the Ewing sarcoma is located in a
part of the body where surgery is not possible or would result in unacceptable functional
outcomes (such as loss of bowel or bladder function).

For advanced Ewing sarcomas, radiation therapy can slow the growth of the
cancer and help relieve pain.

Nursing Responsibilities
 1. 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.
2. Review the treatment plan with the oncologist
3. Aware of expected outcomes and possible complications.
4. Assess the patient's general physical and emotional status.
5. Assessment of the patient's understanding of the disease and proposed treatment.
6. Ensure that the correct dose and drug are administered by the correct route to the
right patient.
7. Assess and manage side effects of drugs: manage nausea and vomiting,
inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea
and vomiting with specific nursing and medical interventions
8. Monitor lab results (drugs withheld if blood counts seriously low); blood and
blood product administration
9. Assess for dehydration, oncologic emergencies
10. Teach regarding fatigue, immunosuppression precautions
11. Provide emotional and spiritual support to clients and families

Osteosarcoma
Definition
Osteosarcoma is a form of immature bone-causing cancer. This is the most
common form of cancer that occurs in bones and is usually located near the knee at the
end of the long bones. Many individuals living with osteosarcoma are under 25 years of
age and are believed to develop more often in males than in females.
 Osteosarcomas range from low-grade tumors requiring only surgery, to high-
grade tumors requiring aggressive treatment. Osteosarcoma patients are better treated at a
cancer center where an experienced sarcoma team and expertise offer comprehensive and
attentive treatment.

Anatomy and Physiology

The structure of a long bone allows for the best visualization of all of a bone's
parts. A long bone has two parts: the diaphysis and the epiphysis. The diaphysis is the
tubular shaft that runs between the proximal and distal ends of the bone. The hollow
region in the diaphysis is called the medullary cavity, which is filled with yellow marrow.
The walls of the diaphysis are composed of dense and hard compact bone.
The broader section at each end of the bone is called the epiphysis, filled with
spongy bone. Red marrow fills the spaces in the spongy bone. Each epiphysis meets the
diaphysis at the metaphysis, the narrow area that contains the epiphyseal plate (growth
plate), a layer of hyaline (transparent) cartilage in a growing bone. When the bone stops
growing in early adulthood (approximately 18–21 years), the cartilage is replaced by
bony tissue, and the epiphyseal plate becomes an epiphyseal line.
The medullary cavity has a delicate membranous lining called the endosteum,
where bone growth, repair, and remodeling occur. The outer surface of the bone is
covered with a fibrous membrane called the periosteum. The periosteum contains blood
vessels, nerves, and lymphatic vessels that nourish compact bone. Tendons and ligaments
also attach to bones at the periosteum. The periosteum covers the entire outer surface
except where the epiphyses meet other bones to form joints. In this region, the epiphyses
are covered with articular cartilage, a thin layer of cartilage that reduces friction and acts
as a shock absorber.
Like those of the skull, flat bones consist of a layer of diploë (spongy bone), lined
on either side by a layer of compact bone. The two layers of small bone and the spongy
interior bone work together to protect the internal organs. If the outer layer of cranial
bone fractures, the brain is still protected by the intact inner layer.
Bone contains a relatively small number of cells entrenched in a matrix of
collagen fibers that provide a surface for inorganic salt crystals to adhere. These salt
crystals form when calcium phosphate and calcium carbonate combine to create
hydroxyapatite, incorporating other inorganic salts like magnesium hydroxide, fluoride,
and sulfate as it crystallizes, or calcifies, on the collagen fibers. The hydroxyapatite
crystals give bones their hardness and strength, while the collagen fibers provide them
with the flexibility to not brittle.
Although bone cells compose a small amount of the bone volume, they are crucial
to bones' function. Four types of cells are found within bone tissue: osteoblasts,
osteocytes, osteogenic cells, and osteoclasts
The osteoblast is the bone cell responsible for forming new bone and is located in
the growing portions of bone, including the periosteum and endosteum. Osteoblasts,
which do not divide, synthesize, and secrete the collagen matrix and calcium salts. As the
secreted form surrounding the osteoblast calcifies, the osteoblast becomes trapped within
it; thus, it changes in structure and becomes an osteocyte, the primary cell of mature bone
and the most common type of bone cell. Each osteocyte is located in a space called a
lacuna and is surrounded by bone tissue. Osteocytes maintain the mineral concentration
of the matrix via the secretion of enzymes. Like osteoblasts, osteocytes lack mitotic
activity. They can communicate with each other and receive nutrients via long
cytoplasmic processes that extend through canaliculi, channels within the bone matrix.
If osteoblasts and osteocytes are incapable of mitosis, then how are they replenished
when old ones die? The answer lies in the properties of the third category of bone cells—
the osteogenic cell. These osteogenic cells are undifferentiated with high mitotic activity,
and they are the only bone cells that divide. Immature osteogenic cells are found in the
deep layers of the periosteum and the marrow. They differentiate and develop into
osteoblasts.
The dynamic nature of bone means that new tissue is formed continuously, and
old, injured, or unnecessary bone is dissolved for repair or calcium release. The cell
responsible for bone resorption, or breakdown, is the osteoclast. They are found on bone
surfaces, are multinucleated, and originate from monocytes and macrophages, two types
of white blood cells, not from osteogenic cells. Osteoclasts are continually breaking down
old bone, while osteoblasts are continuously forming new bone. The ongoing balance
between osteoblasts and osteoclasts is responsible for the constant but subtle reshaping of
a bone.

Signs and Symptoms

The most common symptoms of osteosarcoma include:
● Bone pain or tenderness.
● A mass (tumor) that can be felt through the skin.
● Swelling and redness at the site of the tumor.
● Increased pain with lifting (if it affects an arm).
● Limping (if it affects a leg).
● Limited movement (if it affects a joint).
● Broken bone (sometimes after a simple movement).

Diagnosis
To diagnose osteosarcoma, the doctor may begin with a physical exam to better
understand the symptoms.
Imaging tests

Imaging tests help your doctor investigate your bone symptoms, look for cancer
and look for signs that the cancer has spread.

Imaging tests may include:

● X-ray
● Computerized tomography (CT)
● Magnetic resonance imaging (MRI)
● Positron emission tomography (PET)
● Bone scan
Removing a sample of cells for testing (biopsy)
 A biopsy procedure is used to collect a sample of suspicious cells for laboratory
testing. Tests can show whether the cells are cancerous. Lab tests can determine the type
of cancer and whether it's aggressive (the grade).

Types of biopsy procedures used to diagnose osteosarcoma include:

● Needle biopsy. The doctor inserts a thin needle through the skin and guides it into
the tumor. The needle is used to remove small pieces of tissue from the tumor.
● Surgical biopsy. The doctor makes an incision through the skin and removes either
the entire tumor (excisional biopsy) or a portion of the tumor (incisional biopsy).
Determining the type of biopsy needed and the specifics of how it should be
performed requires careful planning by the medical team. Doctors need to perform the
biopsy in a way that won't interfere with future surgery to remove the cancer. For this
reason, ask your doctor for a referral to a team of experts with extensive experience in
treating osteosarcoma before the biopsy.

Management
Osteosarcoma treatment typically involves surgery and chemotherapy. Radiation
therapy might be an option in certain situations.

Surgery

The goal of surgery is to remove all of the cancer cells. But planning the operation
also takes into consideration how it will affect your ability to go about your daily life.
The extent of surgery for osteosarcoma depends on several factors, such as the size of the
tumor and its location.

Operations used to treat osteosarcoma include:

● Surgery to remove the cancer only (limb-sparing surgery). Most

osteosarcoma operations can be done in a way that removes all of the cancer
and spares the limb so that function can be maintained. Whether this
procedure is an option depends, in part, on the extent of the cancer and how
much muscle and tissue need to be removed.
If a section of bone is removed, the surgeon will reconstruct the bone. The
method of reconstruction depends on your particular situation, but options
include metal prosthetics or bone grafts.
● Surgery to remove the affected limb (amputation). With advancements in
limb-sparing surgery, the need for amputation — removing a limb or part of
a limb — has greatly reduced over the years. If amputation is necessary,
advances in prosthetic joints can significantly improve outcomes and
function.
● Surgery to remove the lower portion of the leg (rotationplasty). In this
surgery, sometimes used for children who are still growing, the surgeon
 removes the cancer and surrounding area, including the knee joint. The foot
and ankle are then rotated, and the ankle functions as a knee. A prosthesis is
used for the lower leg and foot. Results typically enable the person to
function very well in physical activities, sports and daily living.
Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment usually

combines two or more drugs that can be administered as an infusion into a vein (IV), in
pill form, or through both methods.

For osteosarcoma, chemotherapy is often recommended before surgery

(neoadjuvant therapy). Doctors monitor how the cancer cells respond to the
chemotherapy in order to plan further treatments.

If the osteosarcoma shrinks in response to the chemotherapy, it may make limb-

sparing surgery possible.

If the osteosarcoma doesn't respond to treatment, it may indicate the cancer is

very aggressive. Doctors may recommend a different combination of chemotherapy drugs
or suggest a more aggressive operation to ensure all the cancer is removed.

Chemotherapy can also be used after surgery to kill any cancer cells that might
remain.

If osteosarcoma returns after surgery or spreads to other areas of the body,

chemotherapy might be recommended to try to slow the growth of the disease.

Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays and protons, to kill
cancer cells. Radiation might be an option in certain situations, such as when surgery isn't
possible or if surgeons can't remove all of the cancer during an operation.

During radiation therapy, the beams of energy are delivered from a machine that
moves around you as you lie on a table. The beams are carefully directed to the area of
the osteosarcoma in order to reduce the risk of damage to surrounding healthy cells

Nursing Responsibilities
1. 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.
2. Review the treatment plan with the oncologist
3. Aware of expected outcomes and possible complications.
 4. Assess the patient's general physical and emotional status.
5. Assessment of the patient's understanding of the disease and proposed treatment.
6. Ensure that the correct dose and drug are administered by the correct route to the
right patient.
7. Assess and manage side effects of drugs: manage nausea and vomiting,
inflammation and ulceration of mucous membranes, hair loss, anorexia, nausea
and vomiting with specific nursing and medical interventions
8. Monitor lab results (drugs withheld if blood counts seriously low); blood and
blood product administration
9. Assess for dehydration, oncologic emergencies
10. Teach regarding fatigue, immunosuppression precautions
11. Provide emotional and spiritual support to clients and families

Chronic cough
a long-standing Progressive cough
chest infections that keep coming back
coughing up blood
an ache or pain when breathing or coughing
persistent breathlessness
persistent tiredness or lack of energy
loss of appetite or unexplained weight loss
If you have any of these, you should see a GP.

Less common symptoms of lung cancer include:

changes in the appearance of your fingers, such as becoming more curved or their ends
becoming larger (this is known as finger clubbing)
difficulty swallowing (dysphagia) or pain when swallowing
wheezing
a hoarse voice
swelling of your face or neck
persistent chest or shoulder pain

 Bone pain
 Swelling of the face, arms or neck
 Headaches, dizziness or limbs that become weak or numb
 Jaundice
 Lumps in the neck or collarbone region

 Cancer Treatment Centers of America. (2018, March 13). What are the symptoms and signs of

lung cancer? https://www.cancercenter.com/cancer-types/lung-cancer/symptoms
 National Cancer Institute. (n.d.). Anatomy of the lung. Welcome to SEER Training | SEER

Training. https://training.seer.cancer.gov/lung/anatomy