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Cellular Aberration

Common Terminology
Cellular Aberration:an alteration in the cellular structures and functions Neoplasm: new growth, abnormal cellular reproduction Tumor: a growth of neoplastic cells clustered together Benign:characterized by abnormal cell division but does not metastasize

more on terminology
Malignant:abnormal cell division with ability to invade surrounding cells, metastasize and recur Cancer: malignant growth accompanied by abnormal cell division, invasion of surrounding tissues and metastasis to distant sites Metastasis:ability of the cancer cells to disseminate and establish growth in another area of the body at a distance from its origin

Etiologic Factors
Viruses: Oncogenic Viruses (prolonged or frequent viral infections may cause breakdown of the immune system) Carcinogens: factors in the environment that act to cause cell mutation

more on etiology
Chemical Carcinogens E.g. Industrial Compounds (vinyl chloride: asbestos, polycyclic aromatic hydrocarbons: air pollution, fertilizers, dyes: aniline dye, hair bleach, drugs: nicotine

Other carcinogens
Physical Carcinogens E.g. Radiation: radioactive isotopes, ultraviolet rays Physical Irritation:pipe smoking, multiple deliveries

more on carcinogens
Hormones: HRT Genetics: familial patterns like retinoblastoma, lung Ca, breast Ca ONCOGENE: repressed genetic code

Predisposing Factors
Age: Older individual and young children are more prone Gender: both gender are predispose Women: reproductive organs Men: reproductive and life styles

On factors
Urban VS Rural Dwellers: more exposure to carcinogens Geographical Distribution: influence of environmental factors like diet

more on predisposition
Occupation: chemical and industrial hazards Heredity: familial history Stress: decrease immunocompetence Pre cancerous lesions Lifestyle: smoking, diet

Pathogenesis of Cancer
Cellular Transformation and Derangement Theory:cellular transformation as a result of exposure to agents Failure of the Immune Response Theory: inability of the immune system to destroy cancer cells

Mechanisms of Carcinogenesis
Berenblum (1940) proposed the two step mutational model INITIATION: related to the carcinogens that initiates the mutation process; alteration of the DNA structure PROMOTION: also called co-carcinogens that stimulates replication of mutant cells

Comparison of Benign and Malignant Neoplasms

Similar to cell of origin Encapsulated Compresses Slow growth rate Seldom recur after excision Necrosis and ulceration unusual Dissimilar from cell of origin Non encapsulated Invades Rapid growth rate Frequently recur after excision Necrosis and ulceration common

Summary of Chemical Carcinogens and their Sites of Action ( Bullock, 1996)

1. Polycyclic
Aromatic hydrocarbon 2. Aromatic Amines 3. Alkylating Agents 4. Nitrosamines 5. Naturally occurring Products Aflatoxin, betel nut liver and mouth Dyes, naphthalene Nitrogen mustard Food preservatives bladder lungs, larynx,bladder stomach, intestines

Soot, tar

Site of Action
lips, tongue, oral cavity

Virus Implicated in Malignant Neoplasia

Virus C-type RNA B-type RNA Herpes II Epstein Barr Human Papilloma Associated Cancer Leukemia Breast Cancer Cancer of the Cervix Nasopharyngeal Cancer of the Cervix

Pathophysiologic Mechanisms
The DNA virus infects the cell; it becomes incorporated into the genes; DNA that is infected is transmitted to subsequent generations The RNA virus infects the cell; the virus contribute to the genetic information of the host cell; the viruses uses an enzyme to be protected and not be destroyed by the immune system Reverse Transcriptase: enzyme that binds with DNA altering genetic endowment of the cell

Pathophysiologic Basis of Malignant Neoplasia (Udan, 2002)

Cancer Cell Proliferation: it disrupts normal cell growth and interfere with tissue function Resulting Alterations: 1. Pressure: increase in the size 2. Obstruction: compression of hollow organs and vessels 3. Pain: pressure on nerve endings; anoxia to tissues; release of pain mediators 4. Effusion:lymph flow obstruction e.g. ascites 5. Ulceration: erosion of blood vessels, tissue pressure ischemia develops Paraneoplastic Syndrome: production of enzymes, hormones and other substances

Resulting Alterations: 1. Anemia: cancer cells produce chemicals that interfere with RBC production; increase iron uptake of cancer cells; bleeding 2. Hypercalcemia: parathyroid like hormones are produced and increasing bone breakdown; enhanced by immobilization and dehydration

more on pathophysiologic basis

Anorexia- Cachexia Syndrome: deprivation of cellular nutrition
Resulting Alterations: 1. Tissue Wasting: Negative Nitrogen Balance (fat metabolism); reversion of anaerobic metabolism (depletion of glycogen reserve); CHON depletion 2. Edema: Tumors take up Na+ (water retention masking malnutrition) 3. Anorexia: Cancer cells produces anorexigenic substances that acts on satiety center

Warning Signals of Cancer

C-hange in bowel and bladder habits A-a sore that does not heal U-nusual bleeding or discharge T-hickening or lump in the breast or anywhere else I-ndigestion or difficulty in swallowing O-bvious change in wart or mole N-agging cough or hoarseness of the voice

Diagnostic Tests
Cytologic Examination Biopsy Ultrasound MRI Radiologic Exams Radiodiagnostic Techniques CT Scan Laboratory Tests: Prostatic Acid Phosphatase, Prostatic Specific Antigen, Carcinoembryonic Antigen Endoscopic Exams Monoclonal Antibodies

Cancer Prevention
Skin: Avoid over exposure to sun light Oral: Annual oral Examination Breast: Monthly BSE from age 20 Lungs: avoid smoking; annual chest x-ray Colon: Digital rectal Exam for 40 years old and above; rectal biopsy; proctoscopic exam; guiac stool examination for 50 years and above Uterus: Annual Pap smear Basic: Annual PE

Dietary Recommendations
Cut down on total fat intake Eat more high fiber food ( raw fruits and vegetables; whole grain cereals Include food rich in Vitamin A and C in daily diet Include cruciferous vegetables in the diet Moderation on alcoholic beverages Moderation in use of salt

Therapeutic Modalities for Cancer

Surgery Chemotherapy Radiation Therapy Immunotherapy Bone Marrow Transplant

Surgical Interventions
Classification of Interventions: a. Preventive: excision of pre cancerous lesions b. Diagnostic: Biopsy/Fresh frozen section c. Curative: Removal of the entire tumor (en bloc resection) d. Reconstructive: Improvement of structure and function e. Palliative: relief of distressing symptoms; retardation of metastasis E.g. Oophorectomy in breast Ca

Surgical Intervention

Objectives: 1. To destroy all malignant tumor cells without excessive destruction of normal cells 2. To control tumor growth

Action of Chemotherapy
Chemotherapy damages the genes inside the nucleus of cells. Some drugs damage cells at the point of splitting. Some damage them while they are busy making copies of all their genes before they split. Cells that are at rest (most normal cells, for instance) are much less vulnerable to chemo damage. With more than one type of drug, there is more chance of killing more cells.

The combination will include chemo drugs that damage cells at these different stages in the process of cell division. The fact that chemo drugs kill dividing cells helps to explain why chemotherapy causes side effects. It affects healthy body tissues that grow all the time. The skin, hair and digestive system, for example. The hair is always growing. The skin and the lining of the digestive system is constantly renewing itself. And tissues that are growing have dividing cells - that are at risk from chemotherapy

Normal cells can repair damage more quickly than cancer cells. So the damage to healthy cells doesn't usually last. Most side effects disappear once the treatment is over, and many only occur for the days while receiving the drugs (for example, sickness or diarrhoea).

more on fatigue
Cancer fatigue is the most common side effect of cancer treatment and affects between 7 and 9 out of 10 people (70 - 90%). Many people with cancer say that it is the most disruptive side effect of all. Fatigue is often worse for people who: Have a combination of treatments Have a cancer in its advanced stages and Are elderly

Signs and Symptoms of Fatigue

Lack of energy - just want to stay in bed all day Feeling I just cannot be bothered to do much Problems sleeping Finding it hard to get up in the morning Feeling anxious or depressed Pain in your muscles - find it hard to climb stairs or walk short distances Being short of breath after doing small tasks, like having a shower or making bed Finding it hard to concentrate, even if watching TV or talking to a good friend Being unable to think clearly or make decisions easily Loss of interest in doing things you usually enjoy Negative feelings about yourself and others

more on tips
If toothpaste stings, or brushing teeth becomes a problem, try a 'bicarbonate of soda' mouth wash instead (one teaspoon dissolved in a mug of warm water) Use dental floss daily but be careful not to harm gums Keep lips moist by using Vaseline or a flavoured lip balm Avoid neat spirits, tobacco, hot spices, garlic, onion, vinegar and salty food when your mouth is sore Choose meals that are moist with gravies and sauces, to make swallowing easier Drink at least one and a half litres (3 pints) of fluid a day - tea or coffee, fruit and vegetable juices, soft drinks or water Eating fresh pineapple can keep your mouth fresh and moist but avoid acidic fruits (eg oranges, grapefruit) if your mouth is sore

Infection: anti cancer drugs are immunosuppresives Recent Surgery: drugs retards wound healing Impaired Renal and Hepatic Function: drugs are nephrotoxic and hepatotoxic

Chemotherapy Room

Typical Patients in Chemotherapy

New Trend in Reducing Alopecia

New Trend
In the not-so-distant past, initial attempts at scalp cooling were made by placing crushed ice in plastic bags on the patient's head. This first anti-hair-loss treatment was followed by vinyl-filled crylon gel caps. But these products have limited therapeutic value; crushed ice melts and gel-insulated caps are uncomfortably cold

A painless hair-loss prevention device for patients undergoing chemotherapy. Designed as a hat, the SCS II cap is worn on the patient's head providing comfort and ease of use. Ultimately hair loss is prevented and problems previously associated with cold therapy treatment are eliminated.

Safe Handling of Agents

Wear mask, gloves and gown Skin contact with agents should be washed thoroughly and immediately Splashes on the eyes should be washed copiously with water Sterile cotton or pledget should be used when breaking an ampule Expel air or bubbles on wet cotton Vent vials to reduce internal pressure after mixing

more more
Label Iv bottle with ANTINEOPLASTIC CHEMOTHERAPY Contaminated needles should be disposed on a special container leak proof- puncture proof container Dispose half used agents on a special plastic bag labeled with hazardous waste Hand washing!

Radiation Therapy
High energy X-rays are used to kill cancer cells. The radiation doses in radiotherapy are also higher than those for normal X-ray procedures. Cancer cells are more sensitive to radiation than normal cells. So targeting cancer cells with radiation damages them and causes the tumour to shrink.

more on radiotherapy
It involves simulation and treatment planning, where the area to be treated is carefully defined and the radiation dose to be given is meticulously verified. Radiotherapy may be used as a sole treatment method or in conjunction with surgery and chemotherapy.

Sources of Radiation Therapy

Internal Radiation - places small radioactive wires into the tumour or as close to it as possible. This allows a high dose to be delivered to a small area. External Radiation - it uses a machine to deliver the dose to a large area; known as linear accelerator (LINAC); just like an Xray machine

Types of Radiation
Sealed- also known as brachytherapy; a wire is placed near the tumor Unsealed- administered through IV or orally

Side Effects of Radiatiotherapy

Skin Reactions: like erythema, moist desquamation, atrophy, depigmentation, ulcerative lesions Responsibilities: Keep area dry Wash area with water no soap, pat dry No ointment, powder or lotion Avoid heat; exposure to sun Use soft, cotton fabric for clothing

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4. 5.

more on side effects

Infection: as a result of bone marrow suppression Responsibilities: Hygiene Nutrition Adequate rest Monitor blood count

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Hemorrhage: as a result of destruction of platelets; it is easily damaged Responsibilities: 1. Avoid physical trauma 2. Avoid use of aspirin 3. Use direct pressure on injection site 4. Monitor platelet count

Side effects of Radiation

Fatigue: as a result of high metabolic demands for tissue repair and toxic waste removal Responsibilities: 1. Provide plenty of rest and sleep 2. Nutrition

more on side effects

Stomatitis: as a result of mouth dryness Responsibilities: Bland diet No smoking and alcohols Oral hygiene- saline rinse q 2h Sugarless lemon drops or mint Analgesic before meals

1. 2. 3. 4. 5.

more more more!

Diarrhea Nausea and Vomiting Headache Alopecia Cystitis Isolation

Principles of Radiation Protection

Distance: 3 feet distance in performing procedures Time: limit contact to 5 minutes; 30 minutes for the whole shift Shielding: use Pb shield during contact with patient

Teaching Guidelines
It is painless Lie still while the therapy is on going Treatment lasts for few minutes Machines produces sound and moves Personnel will not be inside the room Communication is possible; a monitor is placed outside the room No residual radioactivity after the procedure; resume normal activities