Reproduction of gametes is known as
Meiosis and has half the complement of dna (sex cells)
Reproduction of cells other than gametes is called
mitosis and they have the full complement of dna.
cytokinesis
The cell cycle has 5 phases
G0, G1, S, G2, M
G0
the resting state of a cell
Checkpoints in the cell cycle occur at
G1 / S phase
G2 / M phase
What is the role of the checkpoints
the check points make sure there are no issues, and they can halt the cycle if there are any issue
Failure at a check point halting the cycle is associated with cancer
non-cancerous cells: abnormalities detected and corrected or cell destroyed
problem cancer cells, avoid destruction and proliferate
Control of cell division is controlled by
checkpoints and stimulation by hormones or nutrients (cell division can be stimulated or enhanced)
What is cancer
a disease caused by an uncontrolled division of abnormal cells in a part of the body.
Cancer refers to
a malignant tumor (neoplasm)
A malignant tumor is charicterised by
rapid growth, anaplasia, nuclear irregularities, loss of normal tissue structure.
Anaplasia is
loss of cell differentiation.
Benign tumors are
not cancerous but can develop into cancer.
Grow slow
well defined capsule
Not invasive
well differentiated
low mitotic index
do not metastasise (spread)
Cancer is a chronic disease that can be characterised by
remission and relapse.
Carcinomas
arise from endothelial and epithelial tissues (hepatocellular carcinoma)
Sarcomas
arise from connective tissues (osteogenic sarcoma)
Adenoma
benign tumor arising from glandular or ductal epithelium
Adenocarcinomas
carcinomas arising from glandual or ductal epithelium (breast cancer)
Terato-
arise from germ cells (teratocarcinoma)
HIV or immunosuppressant drugs can substantially increase the incidence of some cancers including Lymphoma, herpes virus-caused cervical cancer
Lymphoma, herpes virus-caused cervical cancer
Organ transplant recipients on immunosuppressants
don’t have higher rates of cancer (breast, prostate, colon), so immune surveillance not significant in preventing all types of cancer.
Immune system can work on
small number of cancer cells but unable to destroy large growths
The immune system has what to start fighting the cancer
Tumor specific antigens (TSA)
Tumor associated antigens (TAA)
phagocytes, NK cells, NK T cells, cytotoxic T cells, specific antibodies and complement eliminate cells.
Hep C virus is the
most common cause of chronic hepatitis, cirrhosis, and hepatocellular cancer
Cancer of the liver is
usually secondary to metastases and is the most common site of metastatic tumors.
Risk factors for cancer of the liver
chronic hep b, c and lesser extent D. Cirrhosis, dietary exposure to aflatoxin moulds and drinking water contaminated with arsenic.
Immune systems role
to react to infections and tissue damage to keep cells in control.
Bacterial causes of cancer is from
Helicobacter pylori usually asymptomatic those susceptible H Pylori can cause stomach ulcers that in turn can turn cancerous.
Risk factors for cancer
Smoking
Diet
Obesity
Alcohol
Ultraviolet radiation
enviornment (working, air)
Ionising radiation (xrays etc)
Electromagnetic fields (high voltage power lines)
Chargrilled meat produces
heterocyclic aromatic amines which are known carcinogens
Other issues with diet `as a risk factor for cancer is
Aflatoxin is produced by mould and contaminate foods in humid climates
High fat / low fibre western diets can increase colon cancer by 30 – 40 %
pickled and salty foods
What is a carcinogen
a substance capable of causing cancer in living tissue.
Alcohol risk factors for what cancer
oral cavity, pharynx, larynx, oesophagus and liver cancers
Alcohol and cigarette combination increase risk.
Ultraviolent radiation
Principle source is sunlight
caused by basal cell carcinoma, squamous cell carcinoma and melanoma.
Occupational hazards include
asbestos, diesel fumes and dyes.
cancers include respiratory tract, lungs and bladder.
Gene enviornment interation
is envionmental factors cause genetic mutations, there is increasing evidence that enviornment and lifestyle exposure to genes are critical in preventing cancer.
Preventing cancer
increasing physical activity
improve diet
avoid UV radiation
Decrease alcohol consumption
Cease smoking.
Physical activity does what?
Decreasing insulin levels, obesity, inflammatory mediators, Increased gut motility. Decreased exposure to sex hormones
Clinical manifestations of cancer
Infection
Leucopenia
Thrombocytopenia
Anemia
Pain
Fatigue
Paraneoplastic syndromes
Cachexia
Infection in cancer
risk increases when neutrophil and lymphocyte counts fall. other ways to get infections - hospital acquired infections, bugs from staff, visitors and procedures re IDC, cannulas and wound management.
increased risk following surgery
Those with temperatures, we cover with prophylactic antibiotics.
Leucopenia
decrease in white blood cells by invading and affecting the bone marrow. Chemotherapy and radiotherapy also damages the bone marrow.
risk of infection due to decrease in WBC.
Thrombocytopenia
A low platelet count is a major cause of haemorrhage in people with cancer. It usually results from chemotherapy or bone marrow involvement by the malignancy.
Anaemia is
a decrease in haemoglobin in the blood
First sign of anaemia is
fatigue
In bowel cancer,
occult bleeding resulting from anaemia. Chronic bleeding causes iron deficiency,malabsorption or iron and severe malnutrition.
Anaemia is associate with
Reduced treatment effectiveness
Increased mortaity
Increased transfusion requirements
Reduced performance and quality of life
Treatment for anaemia includes
Synthetic EPO
Blood transfusions
Anaemia predisposes to hypoxia
to hypoxia.
If a tumor become hypoxic its has been shown to promote tumour resistance to radiotherapy and some chemotherapies.
Severe aneamia can
delay surgery if presurgical transfusions are required, and low haemoglobin before or during chemo may require dose reductions or delays in administration.
These things contribute to a decrease in overall treatment effectiveness.
Pain
as a rule late stage cancer strongly linked with pain, 60-80% in those terminally ill with cancer.
Painless nodes
can be very serious and should be checked.
Pain is
influenced by fear, anxiety, sleep loss, fatigue, and overall physical deterioration.
The way pain is perceived and its impact are completely individual.
Mechanisms of pain include
Pressure, obstruction, stretching, tissue destruction and inflammation
Other mechanisms of pain include
Effusions they are common: pleural, pericardial or peritoneal spaces are often the presenting sign of some tumours (lung cancer, breast cancer, lymphomas). They present with chest pain, SOB, cough.
Priorities with regards to pain include
Control pain rapidly
Continue to evaluate and prevent recurrence
Combination therapies worK: traditional analgesics, novel agents
Match to person psychological response
Deal with depression and sleep disturbances
Fatigue and sleep disturbances
is subjective (fatigue)
Tired, Weak, lack of energy: consequence of cancer itself and treatment
May be an early symptom of malignancy
Cause is largely unknown, but probably mutifactorial: physiological, biochemical and psychological
Suggested lack of ATP and buildup of metabolic products like lactic acid.
Insomnia may be self-perpetuating: napping, going to bed earlier, getting out of bed later
Paraneoplastic syndromes
symptom complexes that cannot be explained by the local aor distant spread of the tumour
Some cancers cause paraneoplastic syndromes and
make substances that mimic bodies hormones or trigger an immune response
(Paraneoplastic syndromes)
Oat cell carcinoma releases
Pancreatic cancer has
Fibrosarcoma has
ADH like substance that causes fluid retention and SIADH and hyponatraemia
ACTH like substance that causes Cushing syndrome
insulin like substance that causes hypoglycaemia
It is often the symptoms of these syndromes that leads to diagnosis of the cancer
Cachexia
the most severe form of malnutrition.
–Can lose 80% of adipose and skeletal muscle mass
Signs and symptoms of cachexia
anorexia, early satiety, weight loss, taste alterations and altered metabolism.
Early satiety is
a condition marked by feeling full after you have eaten a small amount of food, or before you finish a normal-sized meal.
Cachexia is
More common in children and older adults, more pronounced as the disease progresses.
They respond less well to chemotherapy, more prone to toxic side effects.
Tumour markers are
substances produced by cancer cells or that are found on plasma cell membranes, in the blood, CSF or urine may be Hormones, Enzymes, Genes, Antigen.
Tumour markers are used to:
–screen and identify individuals at high risk for cancer
–diagnose specific types of tumours
–observe clinical course of cancer
Tumour cell markers have limitations:
Nearly all markers elevated in benign conditions
Not usually elevated early in malignancy
Limited value as screening tests
Not specific enough to diagnose malignancy, but good for assessing response to therapy
Extremely high levels indicate poor prognosis and possible more aggressive treatment
Most markers decrease with treatment and increase with recurrence or spread of the tumour
TNM staging is
Tissue, Nodes and Matastises
T0
T1
T2
T3
(With regards to breast tumour)
Free of tumour
Lesion less than 2cm
Lesion 2 - 5cm
Skin and or chest wall involved by invasion
N0
N1
N2
No axcillary nodes involved.
Mobile nodes involved
Fixed nodes involved.
M0
M1
M2
No metastases
Demonstrable metastases
Suspected metastases
Stages of cancer include
Stage 1 - 4
Stage 1 cancer
cancer is confined to an organ or tissue of origin
Stage 2 cancer
is locally invasive
Stage 3 cancer
has spread to nearby structures such as lymph nodes
Stage 4 cancer
has metastasized to distant parts of the body
Diagnosis and evaluation of cancer involve
Tumour markers
imaging techniques
biopsy
sentinel nodes
Clinical staging (TNM system)
Imaging techniques include
xray, CT scan, Pet and SPECT, Ultrasound, MRI, Digital mammography, virtual colonoscopy and sentinal node mapping for breast cancer staging.
Papanicolaou test (Pap smear)
not just for screening for cervical cancer, but also body secretions, nipple drainage, anal washings, pleural or peritoneal fluid and gastic washings.
Tissue biopsy
excisional, needle, bronchoscopy, endoscope, cystoscope and may involve a frozen section.
Immunohistochemistry
use antibiodies to identify cancer source, especially metastitic tumours
Syndrome associated with end stage malignancies
cachexia
A type of tumour that is capable of secreting hormone like substances
paraneoplastic
screening tool for breast cancer
mamogram
term used to describe an increase in cell number
hyperplasia
last stage of carcinogenesis
progression
What are the stages of carcinogenesis
tumor initiation, tumor promotion, malignant conversion, and tumor progression
Term used to describe distant spread of malignancy
metastasis
normal cell death
apoptosis
another term for tumour
neoplasm
malignancy of connective tissue
sarcoma
this causes cell injury and damage
hypoxia
this type of neoplasm is usually encapsulated
benign
cells that are pre neoplastic often appear this way
dysplasic
Dysplasic / dysplasia
abnormal growth or development of cells, tissue, bone, or an organ
Common complication of a malignancy
hypercalcaemia
anaerobic pathogen know to cause gangren
clostridium
term used to describe an increase in size of skeletal muscle cells
hypertorphy
Term used to describe the process of a cell type changing its characteristics
Metaplasia
Screening tool for cancer of cervix
Papanicolaou (pap smear)
an activated oxygen species
superoxide
these substances cause oncogenesis
carcinogenes
aggressive type of skin cancer
melanoma
term used to describe viruses capable of causing a malignancy
oncogenic
this type of radiation damages cell structure and contents
ionising
A patient has a tissue growth that was diagnosed as cancer. Which of the following growth types could it be?
Neoplasm
Which of the following is the most significant cause of complications and death in cancer patients?
Infection
Human papillomavirus vaccines;
partially protect against cervical cancer
Individuals with cancer are often at risk of infections because of
leucopenia
A 30-year-old female is diagnosed with cancer. Testing reveals the cancer cells have spread to local lymph nodes. This cancer would be stage:
3
Oncogenes are:
Body cells are not immortal and can only divide a limited number of times.
Telomeres are protective caps on each chromosome and are held in place by telomerase.
Telomeres become smaller and smaller with each cell division.
Cancer cells become immortal by repairing telomeres.
Which of the following checkpoints determines that chromosomes are intact before allowing the cycle to proceed to mitosis?
G2/M
The most important environmental risk factor for cancer is exposure to:
cigarette smoke
A 25-year-old female develops a tumour of the breast glandular tissue. This type of tumour is classified as:
adenocarcinoma
Which feature is characteristic of malignant tumour?
invades local tissues and structures
A 45-year-old female was recently diagnosed with cervical cancer. She reports a sexual history of numerous partners. Which of the following is the most likely cause of her cancer?
human papilloma virus
Genital warts;
is often an asymptomatic infection;
are caused by papillomaviruses;
are strongly linked with cervical carcinoma;
Which of the following compounds has been shown to increase the risk of cancer when used in combination with smoking?
Alcohol
Common sites for metastasis of prostate cancer include
spine and liver
Cell chromosomes are duplicated during the:
s phase
Metastasis is:
the ability to establish a secondary neoplasm at a new site
The best explanation for higher rates of cancer in older populations is:
the development of cancer requires several mutations over time
Tumour cells can evade the immune system by:
changing their antigens over time;
having antigens that are weak immunogens;
secreting immunosuppressive substances;
replicating very quickly;
A 50-year-old female is suffering from anorexia, anemia, severe tissue wasting and weight loss. She was previously diagnosed with cancer. Which of the following describes her symptoms?
Cachexia
Which of the following signs is usually the first clinical manifestation of breast cancer?
Painless lump
In cancer, vascular endothelial growth factor stimulates;
angiogenesis.
Physical activity was shown to reduce the risk of which of the following types of cancer?
Colon
A 21-year-old female is infected with HPV following unprotected sexual intercourse with a male she recently met. She is now at higher risk of developing which of the following cancers?
Cervical
A 35-year-old male has enlarged lymph nodes in the neck and a mediastinal mass. He is diagnosed with Hodgkin’s lymphoma. Which of the following abnormal cells would be expected with this disease?
Reed-Sternberg cell
Which of the following malignant skin lesions is the most serious?
malignant melanoma
Which of the following is the most significant cause of complications and death in cancer patients?
infection.
A 50-year-old male develops melanoma. One potential reason for development of this condition is:
exposure to UV radiation
Which hormone promotes breast development during puberty?
oestrogen.
A 62-year-old female tells her healthcare provider she has been experiencing regular night sweats that cause her to wake up drenched. She also remarks that she has been unintentionally losing weight. Physical exam reveals enlarged lymph nodes on her neck that do not appear to be painful. She should be screened for which of the following cancers?
Hodgkin’s lymphoma
The most common childhood cancer is:
acute lymphoblastic leukaemia
A 45-year-old male presents with persistent, severe stomach pain. Testing reveals a peptic ulcer. Further laboratory tests reveal the presence of Helicobacter pylori. Which of the following is of concern for this patient?
gastric cancer
Prostate cancer:
is the leading type of cancer in men.
A 25-year-old female develops a tumour of the breast glandular tissue. This type of tumour is classified as:
adenocarcinoma
A 60-year-old male with a 40-year history of smoking presents with chest pain, cough and an atypical Cushing’s syndrome. Tests reveal widespread metastatic cancer. Which of following is the most likely type of cancer?
small cell carcinoma
Known causes of acute leukaemia include:
chemotherapy treatment for other cancers
A 45-year-old female was recently diagnosed with cervical cancer. She reports a sexual history of numerous partners. Which of the following is the most likely cause of her cancer?
human papilloma virus
Carcinoembryonic antigen (CEA)
Indicates colorectal cancer and / or breast cancer
CA 15-3
Indicates breast cancer
Neuron specific enolase
Indicates lung cancer
a fetoprotein (AFP)
Indicates Hepatic cancer
CA 125
Indicates ovarian cancer
Common cancers include
Breast, prostate, colorectal, melanoma, lung, testicular, liver, cervical, childhood, leukaemia and lymphoma.
What is the most common cancer in men
prostate cancer
What is the most common cancer in women
breast cancer
What is the breast structure
Fat, fibrous connective tissue and glandular tissue
Factors affecting variations in shape of breasts
hormonal, genetic, nutritional, endocrine, muscle tone, age and pregnancy
Risk factors of breast cancer
Sex, Age, history of breast cancer, hormonal influences, obesity, long term use of postmenopausal hormone therapy, alcohol, physical inactivity.
Most women don't actually have any identifiable risk factors that have breast cancer.
Examinations for detecting breast cancer
Mammography and self examination
Most inherited forms of breast cancer are caused by
BRCA 1(chromosome 17) and BRCA2 (chromosome 13)
BRCA1 is known as
a tumor suppressor gene but a mutation in BRCA1 has a lifetime risk of 60 - 85% chance of breast cancer or elevated chance of ovarian cancer
Treatment options
Prophylactic surgery: bilateral mastectomy, bilateral oophrectomy or both
Surveillance
CM of breast cancer
painless lump
bone pain
retraction of breast tissue
Treatment for breast cancer
Surgery
Radiation
Chemotherapy
Hormonal drugs and other modulators
Screening program mainly for
people over the age of 50
Average age for death of breast cancer is
68yrs
Risk factors of prostate cancer
Age
Family history
increase intake of dietary fats
decrease intake of fruit and vegetables
Increased risk in african decents
Prostate cancer is
typically slow growing cancer with alterations to urinary flow which occurs much later than BPH
CM of prostate cancer
Urgency, frequency, nocturia, hestancy, haematuria, blood ejaculate. Weight loss, anaemia and SOB when metastatic, lower back pain or pathological #.
DRE prostate feels hard and lumpy
Treatment for prostate cancer
Expectant therapy (watchful waiting)
Surgery
Radiotherapy
Hormone therapy with LH blocking drugs to reduce testosterone levels
Orchiectomy
Chemotherapy has limited effectiveness
Two types of radiation therapy for prostate cancer
Brachytherapy - implantation of isotopes
external beam therapy
Risk factors of colorectal cancer
Advanced age over 50
Family history of cancer, crohns disease, ulcerative colitis and familial adenomatous polyposis
Diet - high fat, high sugar, low fibre
Refined diets lacking in Vit A, C and K
What is being looked for when screening for colorectal cancer
stools with occult blood - aneamia is the CM that sends patient to seek investigations.
CM of colorectal cancer
Bleeding
Change in bowel habits (diarrhoea or constipation)
Sense of urgency, incomplete emptying of bowel
Pain - very late symptom
Diagnosis for colorectal cancer
DRE, faecal occult blood test
Barium enema and xray
Sigmoidoscopy
Treatment of bowel cancer / colorectal cancer
Surgery
Radiation and chemotherapy
Melanoma ABCDE rule
Asymmetry
Borders irregular
Colours different
Diameter change in size
Evolution
Risk factors for melanoma
Fair skinned people (blond, red hair who sunburn and freckle easily)
Family history of malignant melanoma
Presence of marked freckling on upper back
History of three or more blistering sunburns before 20 yrs of age
Presence of actinic keratoses
Lowest risk in asians and pacific islanders
Treatment of melanoma
Excision, sentinel lymph node sampling
Systemic adjuvant therapy
Lung cancer risk factors
Smoking
Asbestos especially if a smoker
Family history if in presence of smoking as well
CM for lung cancer
Chronic cough, SOB and wheezing
Haemoptysis
Chest pain when breathing
Hoarseness, difficulty swallowing
Pleural effusion, atelectasis and dysponea
Paranoeplastic disorders
Diagnosis and treatment of lung cancer
Xray, bronchoscipy, lung biopsy, lymph biopsy, CT, MRI,US or PET scan
Surgery - Lovectomy, pneumonectomy, segmental
Radiotherapy - main treatment or palliation of symptoms
Chemotherapy - usually for metastases
Two types of testicular cancer
Semionmas and non-seminomas
Seminomas
from the seminiferous epithelium of the testes, most common
Non-seminomas
usually contain mixed cells, teratomas or choriocarcinoma (highly malignant)
CM of testicular cancer
Slightly enlarged testes without pain initially
Daull heaviness in groin
Abdominal, groin or testicular pain from haemorrhage of the tumour
Testicular cancer is diagnosed by
physical exam
Ultrasound, CT scan
Tumour markers AFP, hCG and LDH
Stage 1 of testicular cancer
Tumour confined to testes prognosis is often 5yrs survival 95%
Stage 2 testicular cancer
Tumour spread to lymph nodes
Stage 3 testicular cancer
Metastases to other organs, sperm banking should be considered
Treatment for testicular cancer
Orchiectomy
Radiotherapy for seminomas
Chemotherapy for non-seminomas
Liver cancers include
Hepatocellular carcinoma
Cholangiocarcinoma
Metastatic tumours
Hepatocellular carcinoma
arises from the liver cells
most common
increased incidence related to Hep C infections
Cholangiocarcinoma
Primary cancer of bile duct cells
Metastatic tumours
more common than primary tumours
CM for Hepatocellular cancer
weakness, anorexia, weight loss, fatigue
Bloating, fullness
Abdominal pain
Ascites, often obscures weight loss
Mild jaundice
Increased in liver size
Diagnosis of hepatocellular cancer
Often well advanced when diagnosed
Ultrasound, CT Scan
Liver biopsy
Altered LFTs
CM
Treatment for hepatocellular cancer
Subtotal hepatectomy
Palliative chemo and radiotherapy
Transplant
Liver cancer is usually
secondary to another cancer
Ascites
accumulation of fluid in the peritoneal cavity.
Cancer of the Cervix
Also known as Cervical intraepithelial neoplasia (CIN), usually no CM
Risk factors of cervical cancer
Smoking
Human papiloma virus (HPV)
Diagnosis of cervical cancer
Pap smear
Colposcopy - biopsy
Cervical intraepithelial neoplasia
CIN1
mild dysplasia
CIN2
moderate dysplasia
CIN3
Sever dysplasia - cancer insitu
Treatment for cervical cancer
depends on extent from cone resection to hysterectomy
Prevention of cervical cancer
Screening - pap smears
HPV vaccination - Gardasil
What is the most common childhood cancer
Leukaemia with Acute lymphoblastic leukeamia being the biggest (ALL_
Aetiology of childhood cancer
Unknown
Genetics
Radiation, chemicals, human T cell leukaemia virus
Higher risk if twin with leukaemia
Signs and symptoms of ALL
Febrile illness
pallor
bleeding (petechiae, purpura)
bone pain
anorexia
respiratory distress
testicular enlargement
White blood cell cancers
Leukaemia
Lymphoma
Leukaemia comes from
bone marrow but spreads through blood and lymph nodes
Lymphoma comes from
lymphatic tissue and spreads throughout the body throat, gut, epithelium.
Different types of leukaemia
Acute lymphocytic leukaemia (ALL)
Chronic lymphocytic (CLL)
Acute myeloid leukaemia (AML)
Chronic myeloid leukaemia (CML)
What infections can predispose patient to leukemia
HIV, Hepatitis C and Malaria
Manifestations leukaemia
presence of blast cell: immature and undifferentiated.
bone marrow crowding and suppression reducing RBC (anaemia) Decrease platelets: thrombocytopenia (bleeding)
Decrease neutrophils - leukopenia (increase infections)
Bone erosion - causing pain
Lymphadenopathy - spills and resides in lymph
Splenomegaly - made its way to spleen
Hepatomegaly - in liver
Brain - causing neuro s&s
Anorexia: weightloss and difficulty swallowing.
Diagnosis of leukemia
blood and bone marrow
Treatment for leukaemia
Chemotherapy treatment of choice
various combinations with supportive measures
blood transfusions
antimicrobials, antivirals
allopurinol decreases uric acid level from increase DNA breakdown
CNS prophylaxis - prefer not to do chemo to brain
Bone marrow or stem cell tranplantation
Imatinib is
a tyrosine kinase inhibitor it has a good effect but not curative - reducing philadelphia chromosome in CML
Chronic lymphocytic leukaemia
is the most common form of leukaemia in adults
Stem cell transplants
taken from bone marrow, peripheral blood and umbilical blood (best)
Donors of stem cells
Your own - autologous
Sibling
Unrelated
(given by IV infusion)
Main treatments for leukaemias
Chemotherapy and bone marrow transplantation
exception Imatinib for CML as it has the tyrosine kinase inhibitor.
Graft versus host doner
donors immune system attacks recipiend due to poor HLD matching my require immunosuppresent drugs.
Lymphomas are
A diverse group of meoplams that develp from the proliferation of malignant lymphocytes in the lymphatic system (lymphoid tissue; nodes, sub mucosa lymphatic tissue)
2 catergories of lymphoms
non hodgkins lymphoma (NHL) - originates from lymph tissue
hodgkins lymphoma (HL) - originates from lymph nodes
Non hodgkins lymphoma can be from what cells
B or T cells and classified depending on maturity (immature or mature) and site.
Each lymphoma may also be describes as low-grade, aggressive or very aggressive.
Slow growing (indolent) lymphomas signs and symptoms
painless
usually disseminated (spread from lymph to bone marrow
eventually transform into aggressive tumours
More aggressive lymphomas signs and symptoms
fever, night sweats and weight loss
increase risk of infections due to diminished antibody response
high tumour growth increased susceptibility to chemotherapy
Diagnosis of Non hodgkin lymphoma
Lymph biopsy
Blood exam, marrow biopsy, CT MRI and bone scans to determine stage or spread of disease
Treatment of NHL
Localised - radiation
Disseminated disease (Combination radiation and chemotherapy)
Monoclonal antibodies
Hodgkin lymphoma
originates from lymph nodes which tend to be B cells they have a diagnositc cell called the Reed-Sternberg giant cell.
HL generally occurs in
adulthood and commonly involved the cervical, axillary, inguinal and retroperitoneal lymph nodes.
Treatment stage 1 HL
irradiated individual nodes
Treatment stage 3 - 4 HL
Chemotherapy
Concerns about radiation
has risk of developing leukaemia - if localised reduces risk.
Surgery in relation to cancer is used for
Diagnosis
Staging
Curative
Debulking
Palliative
Ionizing radiation
damages the cancer cells DNA and components of the microenviornment.
Radiotherapy can be administered
Externally (Beam) or internally (brachytherapy)
Radiation is used fro
primary or adjuvant therapy
palliative to reduce symptoms
Oncologic emergencies
How does radiation work
Rapidly proliferating or poorly differentiated cells of cancerous tumours are more likely to be injured than are the more slowly proliferating cells of normal tissue.
Administration of radiation
external beam (teletherapy)
Brachytherapy (radioactive implant) may be sealed or unsealed
Oral or radioisotopes or injected directly into tumour site
Sterotactic radiotherapy
Gamma knife surgery
Adverse effects
Anorexia, nausea, emess and diarrhoea
fatigue
bone marrow suppression
radiation burns to skin, alopecia
pain and difficulty eating - poor nutrition
Impotence, erectile dysfunction, vaginal dryness, discharge, dyspareunia, stenosis
Radioresponsiveness
how a tumor responds to irradiation. The more hypoxic the tumour, the more resistent to radition that normal or well-oxygenated cells.
Maintaining adequate oxygen delivery, haemoglobin levels are important from a nursing perspective.
Radiosensitivity of the tumour
fast growing respond better than slow growing.
Sterotactic radiotherapy is used
for brain tumours (narrow directed beams)
Hormone therapy such as tamoxifen
blocks the receptor eg tamoxifen blocks oestrogen in Breast Ca
Receptor agonist in hormone therapy
bind to receptor causing growth effects of the hormone, stimulates cancer cells to grow and become more vulnerable to chemotherapy
Antiestrogens
block estrogen receptors (tamoxifen)
only works on ER positive patients
should not take fluoxetine, etc to suppress hotflushes because they are strong inhibitors of CYP2D6 which prevent tamoxifen activation.
Amoratase inhibitor
block estrogen synthesis (Anastrozole)
only works on ER positive breast Ca in postmenopausal patients
Vesicant chemotherapeutic agents
Extravasation of this type of drug may result in the need for skin grafts.
If an IV line used for a vesicant drug infiltrates, it must be discontinued immediately.
This type of drug may not be infused at a site of previous irradiation
Administered intravenously
A 43-year-old patient with a strong family history of breast cancer considers taking tamoxifen (Nolvadex) for cancer prevention. Which assessment finding is a possible contraindication?
History of deep vein thrombosis (DVT)
A premenopausal woman has ER-positive breast cancer, and her prescriber has ordered tamoxifen. She asks the nurse if anastrozole would work better for her. What will the nurse tell her?
Until she is postmenopausal, anastrozole will not be effective.
To be curative, chemotherapy must eradicate:
enough cancer cells so that the body’s own defenses can kill any remaining cells.
A hospitalized patient with cancer is receiving chemotherapy and reports oral pain. Inspection of this patient’s oral mucosa reveals erythema and inflammation without denudation or ulceration. The nurse understands that;
the patient can use a mouthwash with a topical anesthetic to control pain
A nurse is preparing to administer a second infusion of trastuzumab to a patient who has breast cancer. The patient tells the nurse that she experienced chills, fever, pain, and nausea after her first infusion. What will the nurse do?
Reassure the patient that these symptoms will diminish with each infusion
The nurse wants to evaluate a nursing student’s understanding of chemotherapy. The nurse asks, “Which factor would be a major obstacle to successful chemotherapy?” What is the student’s best response?
The toxicity of anticancer drugs to normal tissues
A nurse provides teaching to a patient who will begin taking oral cyclophosphamide to treat non-Hodgkin’s lymphoma. Which statement by the patient indicates an understanding about how to minimize side effects while taking this drug?
I should drink plenty of fluids while taking this drug.
A nurse is teaching a group of nursing students about how cytotoxic anticancer drugs affect normal cells. Which statement by a student indicates an understanding of this teaching?
Cytotoxic drugs lack tissue specificity.
Gastrointestinal alterations, such as nausea and mucosal erosions, are common side effects of chemotherapy treatment because:
chemotherapy agents target rapidly dividing cells in the oral and intestinal linings
A patient is receiving intravenous vincristine (Oncovin). The patient complains of pain at the IV insertion site. The nurse examines the site and notes an area of erythema and edema. What will the nurse do?
Change the IV site and notify the provider of the extravasation
A 30-year-old female is diagnosed with cancer and commenced on chemotherapy treatment. Which of the following would help to relieve some of the side effects?
antiemetics
Adjuvant chemotherapy treatment is used:
after surgical removal of a tumour
A nursing student asks the nurse what differentiates antiestrogen drugs from aromatase inhibitors in the treatment of breast cancer. What is the correct response by the nurse?
Antiestrogen drugs increase the risk for endometrial cancer.
A patient with advanced cancer of the prostate begins treatment with leuprolide injections and will receive 7.5 mg IM once per month. After the first injection, the patient experiences an increase in cancer symptoms. What will the nurse tell the patient?
Desensitization to the drug over time will result in a decrease in these symptoms.
A patient with advanced prostate cancer will begin treatment with leuprolide. The provider has ordered flutamide to be given as adjunct therapy. The patient asks the nurse why both drugs are necessary. The nurse will tell the patient that:
flutamide suppresses initial tumor flare caused by leuprolide
A patient with chronic myeloid leukemia (CML) begins treatment with imatinib. Which statement by the patient indicates understanding of this medication?
Resistance to this drug may develop over time
A patient with cancer who is receiving chemotherapy develops a fever. The patient’s chest radiograph is normal. The patient’s neutrophil count is less than 1 x 109/L. The nurse expects the provider to:
begin empiric therapy with intravenous antibiotics;
The nurse would be correct to state that the purpose of angiogenesis inhibitors is to
suppress the formation of new blood vessels in tumors
A nursing student asks about the differences between cell-cycle phase–specific chemotherapeutic agents and those that are cell-cycle phase nonspecific. What will the nurse explain?
Cell-cycle phase–specific drugs do not harm “resting” cells
Corticosteroids can be used for
hodgkins lymphoma, malignant lymphoma, breast cancer, multiple myeloma
Glucocorticoids
in high doses are toxic to lymphatic tissue, causing suppression of mitosis, regression or lymphatic tissue and cell death.
they also suppress nausea and vomiting and reduce cerebral oedema, reduce pain, improve appetite and promote weight gain.
Androgens are used
for breast cancer
Estrogens are used for
breast cancer and prostate cancer
Anti-estrogens are used for
endometrial cancer, breast cancer
Anti-androgens are used for
prostate cancer
Anti androgen such as Flutamide
Blocks effect of androgens, eg denying testosterone in prostate cancer
Aromatase inhibiotors prevent
androgen conversion to estrogen (early breast cancer)
Anti-angiogenesis drugs
Binds with vascular endothelial growth factor, released by many tumours to stimulate blood vessel growth. Eg. bevacizumab which suppresses formation of new blood vessels
Imatinib suppresses
cell proliferation and promotes apoptosis.
Chemotherapy is
a non-selective cytotoxic drug that target vital cellular machinery or metabolic pathways critical to both malignant and normal cell growth and replication.
Goal of chemotherapy
to eliminate enough tumour cells so body's defences can eradicate any remaining cells.
Compartment A of the cell cycle
(S Phase) cells rapidly divide best time to treat with chemotherapy.
Compartment C
cells no longer divide
Compartment B
cells resting phase G0
Combination chemotherapy
use of several agents, each has effect against a certain cancer. Avoids drug resistance associated with using just one drug.
Dose intensity
the direct relationship between the dose of the chemotherapy and the rate of killing of tumour cells. A small may increase in dose may dramatically increase the killing power, but increasing toxicities need to be considered.
Therapeutic index:
the relative effective dose needed to kill cancer cells as compared to the dose that would be harmful to normal cells. Is generally quite low and is one of the limiting factors in the escalation of chemotherapy use.
Adjuvant chemotherapy
the term to describe the use of drugs after local treatment or surgery/removal of primary tumour. Chemotherapy good for this space, where a person has minimal cancer remaining but who are at high risk for metastasis. Prevents the growth of micrometastatic deposits that are not clinically detectable.
Neoadjuvant chemotherapy
the early use of chemotherapy before definitive local control surgery or irradiation to decrease initial tumour size.
As a rule, chemotherapeutic drugs are much more toxic to tissues that
have a high growth fraction than to tissues that have a low growth fraction, because most cytotoxic agents are more active against proliferating cells than against cells in G0.
Solid tumours have a
low growth fraction and generally respond poorly to cytotoxic drugs. G0 cells do not perform the activities that most anticancer drugs are designed to disrupt. Because G0 cells are not active participants in the cell cycle, they have time to repair drug-induced damage before it can do them serious harm.
Cell-cycle (non-specific)
Effective whether tumour cells are dividing or in dormant phase. Act to sterilize the cell, eg. alkylating agents (cyclophosphamide), anti-tumour antibiotics (doxorubicin).
Cell-cycle (specific):
Must be administered at a time when tumour cells are proliferating, eg. vincristine causes mitotic arrest.
Tissue-specific:
Deprive tissue tumours of a substance necessary for proliferation, eg. antimetabolites (methotrexate).
Antibiotic type agents
bind to DNA to precent transcription from occuring
Antimetabolite agents
cause misreading or fracture of DNA - Methotrexate useful in treating B cell CLL
fever chills and secondary infections are all possible as adverse effects
Mitotic inhibitors
act during the M phase to prevent cell divisions
Vincristine is bone marrow sparing so ideal for lymphomas, ALL, Kaposis sarcoma, breast cancer and bladder cancer
can cause peripheral neuropathy, constipation, urinary hesitancy, vesicant extravasation, alopecia
Tyrosine kinase inhibitors
Imatinib
interferes with gene transcription into mRNA
Used for CML
Stops proliferation and kills cell
causes GI disterbances, fluid retention and fatigue
Specific cytotoxic drugs for breast cancer
Doxorubicin - anti cancer antibiotic
Cyclophosphamide - alkylating agent
Paclitaxel - mitotic inhibitor
Can be used prior to surgery to reduce the tumour size to do a lumpectomy rather than mastectomy
Can be used following surgery to help kill residual cells at the primary and distant sites.
Stomatitis is
oral ulces
What is the problem with bone marrow suppression with WBC
neutropenia
What is the problem with bone marrow suppression with RBC
Anaemia
What is the problem with bone marrow suppression with platelets
Thrombocytopenia
small cell lung cancer
is a neuroendocrine carcinoma that is aggressive, prone to early metastasis and frequently associated with paraneoplastic disorders such as a syndrome of ectopic adrenocorticotropic hormone (ACTH) production which causes Cushing's syndrome.