NCM 106: ONCOLOGY NOTES Stage 3 T1-T2 N1/N2 M0

T3-T4 N1/N2 M0
TNM Staging of Malignant Tumors
Stage 4
Tumor Size
- T1 – tumor less than 3 cm (1 ½
inches) in size
- T2 – tumor is greater than 3 cm
- T3 – tumor can be any size, but near
the airway or has spread to local
areas such as the chest wall or
diaphragm
- T4 – tumor is any size, but is located
in the airway or has invaded local
structures such as the heart or the
esophagus
Lymph Nodes
- N0 – No lymph nodes are affected
- N1 – Tumor has spread nearby
nodes on the same side of the body
- N2 – Tumor has spread to nodes
further away but on the same side
of the body
- N3 – Cancer cells are present in
lymph nodes on the other side of
the chest from the tumor or in
nodes near the collarbone or neck
muscles
Metastases
- M0 – No metastases are present
- M1 – The tumor has spread
(metastasized) to other regions of
the body or the other lung
TNM Staging of Malignant Tumors
Any T Any N M1
 Purposes
- Help to plan the treatment
strategies
- Give an indication of prognosis
- Assist in the evaluation of the results
of treatment
- Enable facilities around the world to
collate information more
productively
 Grading of Cancer
- Accurately describes the malignant
characteristics of individual tumor
- Compares cancer cell with its normal
counterpart
 Structure
 Functions
- The more lower the degree of
differentiation, the more aggressive
a malignant tumor is
GX Grade cannot be assessed
G1 Well differentiated (low grade
tumor)
G2 Moderately differentiated
(intermediate grade tumor)
G3 Poorly differentiated (high grade
tumor)
G4 Undifferentiated (high grade
tumor)

Stages T N M
Stage 0 Tis N0 M0
Stage 1 T1-T2 N0 M0
Stage 2 T3-T4 N0 M0
 Cancer of the CNS  Classification
- Heterogenous group of CA:
Tumors of the CNS are CELLULAR by
 Brain
origin
 Spinal Cord
- Can originate from:
 Neural Tissue
- Low Grade Tumors
 Non-Neural Tissue
 Well differentiated
 Low in mitotic activity
- High Grade Tumors
 Etiology/Risk Factors
 Mitotically active
- Ionizing radiation – has been linked
 Display increase cell
to the development of some CNS
proliferation
tumors including meningiomas,
 Necrosis
gliomas, and nerve sheath tumors
Note: Cellular radiation or
 Common Clinical Features
electromagnetic field
- Patient exhibit a number of clinical
- Poor dietary habits – increase
features
ingestion of food cured with
- There will be an increase ICP
nitrosamines increases the risk
- Triad symptoms will be expected in
- Hereditary – only a small factor that
increase ICP
predispose to CNS tumors
 Headache
(Environment > Hereditary)
 Nausea/Vomiting
 Papilledema
 Most Common Metastatic Pathway
- Other CNS signs and symptoms to
- Metastatic lesions originate sites
look at for
and travel to the brain through
 Seizures
blood vessels or the lymphatic
 Mental Status Changes
systems
 Focal Neurologic Signs
- Most common:
 Intracranial Hemorrhage
 Lungs – 35%
 Breast Cancer – 2%
 Screening and Recovery
 Melanoma – 10%
- Ki-67 (MIB-1) – used to measure
 Renal Cell – 10%
proliferation
 Colorectal – 5%
- Higher Ki-67 is predictive of CA
- The etiology of brain tumor is still
illusive; it is difficult to initiate
prevention and or doing screening
programs
 Breast Cancer
- Most frequent cancer among
women
- Impacts over 1.5 million women
each year
 Etiology/Risk Factor
- No known single cause/idiopathic
- A heterogenous disease, most likely
developing, as a result of a variety of
risk factors that are different from
woman to woman
- Gender: More common in women
than men
- Age: most breast cancer cases are
diagnosed in women 40 years of age
and older but majority of cases
occur in women over age 50
- Personal history of cancer: a
previous history of breast cancer
increases woman’s lifetime risk for
developing a second breast cancer in
the opposite breast
- Family history of cancer and
genetics: Women with family
history of breast cancer in one first
degree relative; family history of
breast cancer in two first degree
relative
- Hormonal factors: Early menarche
and Late menopause
- Greater total duration of years of
regular menses are also associated
- Having no children (nulliparity) or
the first full term pregnancy after
age 30
- Use of contraceptive or hormone
replacement therapy
- Obesity and dietary fat: associated
with an increase risk of breast
cancer in postmenopausal women
- Alcohol consumption: the age at
which drinking begins; amount and
type of alcohol; duration of
consumption
 Benign Breast Tissue
- Women typically experience
clinically at some time in their lives
but are never biopsied
- Benign breast lesions are classified
into 3 groups
 Non proliferative tissues
 Proliferative lesions without
Atypia
 Proliferative lesions with
Atypia
 Noninvasive Breast CA
- “Carcinoma in Situ”
- Precancerous lesions confined to the
duct and lobule of the breast
- 2 types:
 Ductal Carcinoma in situ
(DCIS)
 Lobal Carcinoma in situ (LCIS)
- Ductal Carcinoma in situ
 Cancerous cells are found in
the lining of breast duct
 May become invasive
- Lobal Carcinoma in situ
 Cancerous cells are found in
the lobules of the breast
 7-12x more likely to progress
to invasive cancer in the
same or opposite breast
 Common in pre-menopausal
patients
 Noninvasive BRCA Clinical
Manifestations
- Usually present with no palpable
lesion or symptoms
- DCIS
 Lump
 Nipple discharge
 Paget disease of the breast
- LCIS
 Asymptomatic
 Incidental finding
 Invasive Breast Cancer
- “Infiltrating Breast Cancer”
- Type of Cancer that has spread
beyond the basement membrane of
the breast duct and lobule and into
surrounding tissue
- Considered systemic because of its
ability to metastasize through the
vascular and lymphatic system
 Invasive BRCA Clinical
Manifestation
- Firm, painless, possibly immobile
lump
- Changes in size or shape of the
breast
- Swelling on all parts of the breast
- Unilateral nipple discharge that is
clear, pink, bloody or black
- Enlarged, firm, nontender lymph
nodes
- Skin discharges
- Dimpling
- Erythema
- Ulceration
- Thickening
 Clinical Features
- Mass > 1cm (hard, irregular,
immovable) thickening in breast or
axilla
- Spontaneous, persistent, unilateral
discharge that is serosanguineous,
bloody or watery
- Change in size, shape, or texture of
the breast (asymmetry)
- Dimpling or puckering of the skin
- Scaly skin around the nipple
- Redness, ulceration, edema or
dilated veins
- Peau d’ orange
- Enlargement of lymph nodes in the
axilla
 Diagnosis
- FNA (Fine Needle Aspiration) Biopsy
 Preferred technique if the
masses are palpable
- Advantages
 Can be done in the office
setting
 Use minimal anesthesia
 Low incidence of damage to
surrounding tissue
- CNB (Core Needle Biopsy)
 Provides a core tissue from
dominant mass
- Advantages:
 More sample to be taken
 Can differentiate in situ from
invasive CA
- Stereotactic FNA
 For non
palpable/microtumors
- Contraindications
 Lesions close to chest wall or
skin
 Anticoagulant therapy
  Obesity
 Medical conditions that
would make positioning on
the exam table difficult
- Incisional Biopsy and Excisional
Biopsy
 If the mass are large;
involves removal of only a
portion of the mass
(incisional)
 Removal of the entire mass
and a margin of tissue
around it (excisional)
 Surgery
- MRM (Modified Radical
Mastectomy)
- Total Mastectomy
- Simple Mastectomy
- Lumpectomy
 Complications
- Impaired wound healing
- Infection nerve injury lymphedema
- Shoulder dysfunction
 Nursing Intervention
- Inform patient and family about
hospital and surgical routines
- Describe post-operative activity in
the immediate post-operative
period, position the arm on the
operative side so it is slightly
elevated with a flat pillow or folded
towel behind upper arm until the
patient is fully awake and
ambulatory
- Reinforce fully ambulation,
coughing, and deep breathing
- All intravenous access sites or
venipuncture need to be managed in
the nonoperative side
- Monitor wound for inflammation,
tenderness, swelling or purulent
drainage. Change dressing when
ordered
- Instruct patient in ARM CARE and
POST SURGICAL ARM EXERCISES
 Lung Cancer
- A cancer that develop in any area of
the lungs or bronchus
- Usually arises from the bronchial
endothelium
- Lung Cancer is one of the few
cancers that are known to result
from specific carcinogens
- Evidence exists that lung cancer is
the end stage of an interplay of
multiple factors resulting in genetic
damage result of ongoing exposure
to carcinogens
 Etiology/Risk Factors
- Active Smoking
 Smoking in relation to
development of lung cancer
is one of the strongest and
most extensively
documented causal
relationships in biomedical
research
 Account for 87% in lung
cancer deaths
 Risk increases for smokers:
 Who started at early age
 Smoked for a number of
years
  Smoked a greater number of
cigarettes per day
- Non-Smokers
 15% of lung cancers are
caused something other than
cigarette smoking
 About 10% incidence for
nonsmoker men
 About 20% incidence for
nonsmoker women
- Passive Smoking
 Passive smokers inhale a
complex mixture of smoke
ETS which is judged to be a
cause of lung CA
 People who are involuntarily
exposed to tobacco smoke in
a closed environment
- ETS (Environmental Tobacco Smoke)
 Classified as human (Class A)
Carcinogen
- Radon
 Colorless, odorless,
radioactive gas is produced
as result of the decay of
Uranium and Radium
 Classified as Human
Carcinogen
 Emits tiny airborne
radioactive elements that
situate in the lungs and emit
ionizing radiation to the
epithelial tissue
 Source: Underground mines
Home
- Asbestos
 May occur not only during
the mining and manufacture
of asbestos materials from
contact with such materials
in the home, school or
workplace
- Occupational Hazards and Air
Pollution
 Accounts for 9% to 15% of
reported lung cancers
 Examples of hazards in the
work can include coal
gasification, exposure of tar
and number of metals
 Indoor pollutants
 Outdoor pollutants
- Genetic Susceptibility
 Nonsmokers susceptibility is
determined by inheritance
 Genes contribute most
development of Lung Cancer
- Advancing Age
 Lung cancer disease is relatively
age-dependent
 9% affected in 50’s, 23% in 60’s,
36% in 70’s, 30% in 80’s and
beyond
- Race
 Most common in African
Americans to white
Americans
 About 170% for men and
464% in women
 Small Cell Lung Cancer
- Previously “Oat Cell Carcinoma”
- Centrally located around the main
bronchus
- Most aggressive type of lung cancer
- Rapid tumor doubling
- Early metastasis
- Accounts for 13% of all new lung
cancer cases
- Accounts for 60% of metastasis
 Clinical Manifestation
- Paraneoplastic Syndrome
- Persistent cough
- Shortness of Breath
- Blood streaked sputum
- Chest pain
- Hoarseness and voice changes
- Fatigue
- Weight loss
- Anorexia
 Non-Small Cell Lung Cancer
- Any type of epithelial lung cancer
other than SCLC
- Accounts for about 85% of all lung
cancers
- Clinical manifestation are similar to
SCLC
- Arises from proximal bronchi
- Subtypes:
 Lung adenocarcinoma (most
common) – arises from
alveolar surface or bronchial
mucosal glands
 Large-cell lung carcinoma –
found at the periphery of the
lung. Necrosis is common,
contain neuroendocrine
features
- Common Sites of Lung CA
metastases:
 Brain
 Bone
 Liver
 Adrenal Gland
 Lymph nodes
 Noninvasive Testing
- CBC, Chemistry profiles and liver
enzymes
- Chest X-ray – used to assess the
primary tumor as well as the
presence of any other pulmonary
abnormalities
- Chest CT Scan (upper abdomen) –
facilitates assessment of the
suspected primary tumor, the status
of lymph node, bony involvement,
tumor invasion, liver and adrenals
- MRI – more accurate that CT Scan.
May provide information about
invasion of pericardium, brachial
plexus, spinal cord, CNS
- Bone Imaging – sensitive for bone
metastases
- PET Scan – imaging technique based
on the biologic activity of neoplastic
cells compared to normal cells
 Invasive Testing
- Tissue sampling is necessary to
diagnose the type of:
 Lung CA
  Determine the presence of
metastatic disease (benign or
metastatic)
 If lymph nodes are involved
- Bronchoscopy – commonly used in
collecting tissue (bronchial)
- Mediastinoscopy – gold standard for
evaluation of lymph nodes
- The ASCO recommend FDG-PET Scan
for the staging of distant metastatic
disease
 Surgery
- Wedge Resection
- Lobectomy
- Pneumonectomy
 Encourage energy
conservation
 Provide sleep inducing
environment
- Providing Psychological Support
The nurse must help the patient and
family deal with the ff:
 The poor prognosis and
relatively rapid progression
of this disease
 Informed decision making
regarding the possible
treatment options
 Methods to maintain
patients’ quality of life
 End-of-life treatment options

 Nursing Management
- Managing Symptoms
 Instruct the patient and
family about the potential
side effects of the treatment
- Relieving Breathing Problems
 Promote Airway Clearance
(Pre-Op)
1. Chest Physiotherapy
2. Deep breathing exercise
3. Give bronchodilators and
supplemental oxygen as ordered

 Relieving Breathing Problems

(Post-Op)
1. Promote deep breathing exercises
2. Decrease dyspnea by promoting
lung expansion through proper
positioning
3. Patient education about energy
conservation
- Reducing Fatigue