2A Nurse Caring Family Concepts
Neoplastic Disorders
Week 15 April 28, 2003
Neoplasm or Cancer (CA) Facts
• Definition: uncontrolled growth of cells with no
useful function; grows at expense of healthy tissues
• 200+ kinds identified; most common in US are lung,
breast, colon, prostate & skin
• 2nd leading US cause of death after CV diseases
• Death rates with most kinds level or decreasing; 8
million in US alive today who have history of CA
• Rate of women dying from lung CA increasing
• Incidence & death rate higher in African-Americans
Cancer Biology: A Proliferation Defect
• Stem cells:
—Original, undifferentiated cell that differentiates to give
rise to mature functioning cells
—Proliferation rate varies according to tissue type
• Cancer cells
—Proliferate in same manner & rate as tissues from which
they originate
—Proliferate indiscriminately & continuously
—Lose characteristic of contact inhibition & have no regard
for cellular boundaries
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Cancer Biology: A Differentiation Defect
• Normal cells differentiate; progress from immature
cell (potential to perform all body functions) to
mature cell capable of only a specific function
• Proto-oncogenes:
—Genes that control growth of cell
—Lock cell in mature functioning state
• Oncogenes:
—Mutated proto-oncogenes
—Unlocks cellular regulation
—Allows return to immaturity & tumor formation
BENIGN TUMORS
MALIGNANT TUMORS
• Appear similar to
normal cells
• Usually encapsulated
• Partially differentiated
• No metastasis
• Rarely reoccur
• Slight vascularity
• Expanding mass
• Only life-threatening in
certain locations (brain)
• Appear abnormal; unlike
parent cells
• No capsule
• Poorly differentiated
• Frequent metastasis
• Frequent recurrence
• Increased vascularity
• Expansive & infiltrative
• Life-threatening via
tissue destruction &
tumor spread
Cancer Development: Stage 1- Initiation
• Environmental exposure causes first, irreversible
changes in cell DNA.
• Creates neoplasm-potential
• Initiating factors are carcinogens:
—Chemical: cigarette smoke, asbestos, uranium
—Physical: radiation, UV light, breast implants
—Genetic: CA rarely inherited but predisposition
can be familial
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Cancer Development: Stage 2 - Promotion
• Reversible proliferation of altered, initiated cells
from exposure to promoters
• Promoting factors cause more changes in DNA,
decreased differentiation & tumor development
• Promoting agents include:
—Hormones: estrogen assoc with endometrial CA
—High fat/calorie: breast, gallbladder & colon CA
—Alcohol intake: oral, esophagus & liver CA
—Cigarette smoke: lung, esophageal & bladder CA
—Prolonged severe stress may be promoter
Cancer Development: Stage 3 - Progression
• Final stage in cancer when continued exposure &
changes in DNA result in malignant tumor
• Characterized by increased
—Tumor growth rate
—Invasiveness of tumor into adjacent tissue
—Metastasis of tumor cells to distant tissues or
organs
Metastasis
• Some tumors develop rapidly (others remain in situ)
• Tumor compresses blood vessels, results in necrosis
& inflammation
• Inner cells die when deprived of blood & nutrients,
leading to more necrosis.
• Tumor cells secrete enzymes that break down
protein, destoying tissue & facilitating tumor spread
• Malignant cells break loose, infiltrate into adjacent
tissue or travel via lymph or blood to other organs
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Metastasis - continued
• Tumor cells create conducive environment in new
site & produce vascular supply within metastatic site
similar to primary site
• Cells of primary tumor & metastatic site may
develop from single cell or group of identical cells;
as primary & metastatic sites develop, cells become
more heterogenous & more difficult to treat
• Some cells become resistant to chemotherapy &
radiation therapy
• Biologic therapy promising; cells don t develop
resistance
Cancer & the Immune System
• Immune system provides surveillance, searching for
malignant cells
• When normal cells become cancer cells, some
antigens on cell surface change (malignancy signal),
attracting cells involved in immune response
• These immune defenders (including lymphocytes,
cytotoxic T cells, natural killer cells, macrophages)
eliminate malignant cells in variety of ways
• Tumors thought to develop when this surveillance
system breaks down or is overwhelmed somehow
Classification of Tumors
Classifying tumors provides way to:
- Communicate status of cancer to health care
team members
- Determine most effective treatment plan
- Evaluate treatment plan
- Determine prognosis
- Compare similar groups of tumors statistically
• Tumor classification systems:
1. Anatomic site
2. Histologic analysis
3. Extent of disease
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Anatomic Site Tumor Classification
Tumors identified according to:
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Tissue of origin: what type of tissue gave
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rise to tumor (, connective tissue,
hematopoietic tissue, etc)
Anatomic site: where tumor located (bone,
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plasma, etc)
Whether tumor is benign or malignant
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Histologic Analysis Tumor Classification
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Tumors identified according to:
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Appearance of cells & degree of
differentiation (dysplasia)
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I: mild dysplasia; well-differentiated
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II: more dysplasia, moderate
differentiation
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III: severe dysplasia, poorly differentiated
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IV: immature, primitive (anaplasia),
undifferentiated
Extent of Disease Tumor Classification
¥ Classified according to tumor location & spread
through clinical staging
— 0: cancer in situ
— I: limited to tissue of origin; localized growth
— II: limited local spread
— III: extensive local & regional spread
— IV: metastasis
• TNM Classification: standardized clinical staging
system according to tumor size (T), degree of
spread to lymph nodes (N) & metastasis (M)
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Seven Warning Signs of Cancer
1. Change in bowel or bladder habits (prolonged
diarrhea or discomfort)
2. Sore that does not heal anywhere on the body
3. Unusual bleeding or discharge anywhere in body
4. Solid lump, often painless, in the breast or testes or
anywhere on the body
5. Indigestion or difficulty swallowing
6. A change in a wart or mole (color, size, shape)
7. Persistent cough or hoarseness without reason
Prevention of Cancer
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Reduce exposure to carcinogens & promoters
Balanced diet; reduce fat & preservatives
Regular exercise regimen
Adequate, consistent rest (6-8 hours per night)
Regular health examination
Eliminate/reduce stress
Consistent periods rest & relaxation
Know warning signs of cancer
Learn and practice self-examination
Seek immediate care if cancer suspected
Diagnosis of Cancer
• Tumor markers are substances produced by
malignant cells & can be detected in blood or body
fluid (CEA, AFP)
• X-ray, ultrasound, MRI & CT can detect tumorrelated changes in tissues or organs
• Radioisotope scans trace metabolic pathways
• Cytologic studies used to screen or confirm (Pap)
• Biopsy is definitive diagnosis of cancer; done via
needle, incisional or excisional. Determines if:
—Benign or malignant
—Tissue of origin
—Degree of cellular differentiation
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Complications of Cancer
• Infection r/t lowered resistance, ulceration &
necrosis from tumor compression; neutropenia
• Weight loss r/t anorexia, fatigue, stress & increased
demands placed on body by reproducing tumor cells
• Anemia r/t anorexia, decreased food intake, chronic
bleeding, bone marrow depression
• Bleeding r/t blood vessel erosion and/or tissue
ulceration by tumor cells. Bone marrow depression
may contribute to poor clotting
Complications of Cancer - continued
• Obstruction of organ or blood vessel
—Superior vena cava obstructed by tumor. S/sx:
facial edema, periorbital edema, distended neck
& chest veins, headache & seizures
—Spinal cord compression. S/sx: intense,
localized, persistent back pain aggravated by
Valsalva s maneuver
—Third space syndrome: shifting of fluid from
vascular to interstitial space. S/sx: hypovolemia,
hypotension, tachycardia, decreased urine
output, increased urine specific gravity.
Complications of Cancer - continued
• Metabolic emergencies occur due to production of
ectopic hormones by tumor
—Hypercalcemia: cancer cells secrete parathyroid
hormone-like substance. Sx: apathy, depression,
fatigue, muscle weakness, ECG changes,
polyuria, nocturia, nausea & vomiting
• Infiltrative emergency can occur when malignant
tumor infiltrates major organ
—Coronary artery rupture with head or neck
cancer, 2¡ to tumor invasion of arterial wall
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Leukemias
• Proliferation of immature WBCs in blood-forming
tissues of body; same characteristics as solid tumors
• Classified by: a) acute or chronic & b) cell type
from which they originate
—Chronic: slow course, average survival 4 years
—Acute: fatal in weeks if untreated
• Most common pediatric forms:
—Acute lymphoid leukemia (ALL): (malignant
cells are lymphocyte)
—Acute myelogenous leukemia (AML): malignant
cells are granulocytes)
Pathophysiology of Acute Leukemia
• Result of several factors, including genetic &
environmental influences (oncogenes, viruses,
radiation, Hiroshima, Chernobyl)
• Acute leukemia characterized by:
—Proliferation of immature lymphoid cells in bone
marrow suppresses production of normal cells,
leads to anemia, thrombocytopenia & lack of
normal functional leukocytes
—Cellular destruction occurs from infiltration,
competition for nutrients & damage to spleen,
liver, bone marrow, lymph nodes, CNS
Leukemia Clinical Manifestations
Multiple infections (neutropenia)
Severe hemorrhage (thrombocytopenia)
Anemia (RBC decrease)
Bone pain even at rest (crowding of bone marrow)
Weight loss & fatigue (hypermetabolism from
neoplastic growth, anorexia, pain, chemotherapy)
• Fever (hypermetabolism, infection)
• Lymphadenopathy, splenomegaly, hepatomegaly
(infiltration causes enlargement & discomfort)
• Headache, visual disturbance, drowsiness, vomiting
(CNS infiltration)
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Leukemia Diagnosis
• Peripheral blood smears show immature leukocytes
& low RBC counts
• Definitive diagnosis is based on bone marrow
biopsy revealing large # of immature blast cells
• Following confirmation of diagnosis, lumbar
puncture determines degree of CNS involvement
• Bone marrow biopsies/lumbar punctures traumatic;
—Explain to child & family
—Use effective pharmacologic measures &
nonpharmacologic measures
Lymphomas
• Malignant lymphocyte proliferation in lymph
system; etiology unknown
• Classified as
—Hodgkins:
§Mostly affects adolescents
§More curable than NHL; survival rates > 90%
—Non-Hodgkin Lymphoma (NHL):
§More common in children (< age 15) than
Hogkins
§Prognosis not as good as Hodkins; better for
localized than for disseminated disease
Hodgkin Disease
• Originates in lymph nodes & spreads to organs
(spleen, liver, bone marrow, lungs) via lymphatics
• Atypical cell used as marker for diagnosis is ReedSternberg cell, giant cell present in lymph node
• Ann Arbor staging system uses degree of lymph
involvement
– 1: enlargement of lymph nodes in 1 site
– 2: enlargement of lymph nodes in 2 or more sites
– 3: enlargement of the spleen
– 4: involves the liver, lung
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Hodgkin Disease Clinical Manifestations
• First indicator usually large, painless lymph node in
neck
• Enlarged mediastinal nodes cause persistent
nonproductive cough
• Splenomegaly & enlarged lymph nodes may cause
pressure effects
• General signs of cancer: weight loss, anemia, lowgrade fever, fatigue and night sweats
• Generalized pruritus is common
• Infections r/t abnormal lymphocyte proliferation
Non-Hodgkin Lymphoma (NHL)
• Disease usually diffuse rather than nodular
• Cell type poorly differentiated & dissemination
occurs early & rapidly,
• Mediastinal involvement & invasion of meninges
common
• Because most children present with widespread,
disseminated disease, clinical staging isn t helpful
• Best prognosis if lymphoma spread limited & slow
growing; rarely curable
NHL Clinical Manifestations
• Depends on anatomic site & degree of spread
—Painless swelling of the lymph nodes in the
neck, underarm, or groin
—Fever
—Night sweats
—Fatigue
—Weight loss without dieting
• In advanced stages, may cause intestinal or airway
obstruction or paralysis
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