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.