Cancer DiseaseChristine Joy Bandala

Liver Cancer • Occurs majority to male• Hepatocellular carcinoma– most common

cause of primary liver cancer• Other cause:• Cholangiomas and bile duct carcinomas

• 80% of people with primary liver cancer has liver cirrhosis

• Cirrhosis is a risk factor• 50-60% is caused by hepatitis Cinfection• 20% - is due to Hepatitis B

Liver Cancer

Metastatic liver carcinoma is more common than primary carcinoma

Clinical ManifestationsDifficult to diagnose liver cancer in early stage

cause it resembles with cirrhosis(Eg, hepatomegaly, spleenomegaly , jaundice

weight loss, peripheral edema, ascites and portal hypertension)

Other CM: abd pain in R epigastric or right upper quadrant anorexia, vomiting and inc. abd girth, pulmonary embolism

Liver Cancer• Diagnostic Studies• Liver scan. MRI, hepatic angiography,

endoscopic retrograde cholangiopancreatography elevated AFP

• Nursing and Collaborative Management• 1. Prevention, Identification and treatment

of Hep B and C virus, and chronic alcohol ingestion

• 2. Treatment is dependent with liver cancer size and number of tumors present of spread beyond the liver, age and overall patient health

Liver Cancer

• 3. surgical excision, or liver transpalant of tumor is localized to one portion of the liver (15%)

• 4.Other therapies• - radiofrequency ablation, cryosurgery,

alcohol injection and chemotherapy and or chemoembolization

Liver Cancer

• Radiofrequency ablation– A thin needle is inserted in the core of tumor,

then electrical energy is used to create heat in a specific location for a limited time

– Done with tumor less than 5 cm and considered resectable and palliative purpose

• Cyroablation– Used when tumor is unresectable but has no

signs of metastasis – Open surgical approach where cryoprobes are

placed. Liquid nitrogen /argon gas is introduced to the liver and freezes the tissue

Liver Cancer• Percutaneous Ethanol Injection (PEI)/

Percutaneous acetic Injection (PAI)– Used for unresectable liver that has not metastasized

outside the liver– A catheter is inserted into the liver guided via

ultrasound, then ethanol or acetic acid is injected for 6-8 treatments over a 3-4 hour period with 2 -3 injections per week

SE. transient pain, intraperitoneal hemorrhage bile duct necrosis, hepatic infarction, transient hypotension

Chemotherapy5 flourouracil and leucovorin can be administered systemically or regionally,

Sorafinib (Nexavar) : TI

Liver Cancer• Chemoembolization• Minimally invasive, • a catheter is placed into the arteries to the tumor

Nursing Management of all procedures1.making the patient comfortable2. Address the signs and symptoms

manifested3. Most interventions are the same to clients

with liver cirrhosis

Liver Transplant• Practical option for clients with end stage

liver cancer

• Not recommended to patients with wide spread liver disease

• Candidates must go through rigorous physical exam

• CI: for pts with sever pulmonary hypertension, morbid obesity, obstructed splanchnic blood flow

• Donors can be live or cadaver

Liver Transplant• Comp for donor: billiary problems, hepatic

artery thrombosis, wound infection, postoperative ileus and pneumothorax

• Split organ transplant• Comp: rejection:

– Hyperacute rejection– Acute rejection– Chronic rejection

• Ist 2 months after surgery is the most critical for monitoring

Pancreatic cancer• Adenocarcinomas originating from the

epithelium of the ductal system

• More than half of the tumor originates in the head of pancreas

• Poor prognosis patient dies within 3-12 mos of initial diagnosis and 5 year survival rate is less than 5 %

Pancreatic Cancer• Etiology• Unknown cause but high risk with DM and

with chronic pancreatitis• Risk factors: cigarette smoking family

history of pancreatic cancer, high fat diet, and exposure to benzidine and coke

• Smokers and alcohol drinkers are twice likely to develop pancreatic cancer

Pancreatic Cancer• CM• Left hypochondriac pain that radiates at the

back, obstructive jaundice, anorexia rapid and progesive weight loss

• Diagnostic Stagingtransabdominal ultrasound and CT scan-

initial study and provides information on metastasis involvement.

ERCP(endoscopic retrograde cholangiopancreatography) allows visualization of pancreatic duct and biliary study, pancreatic secretions and tissues can be collected for tumor markers (CA 19-9)

Pancreatic Cancer• Collaborative Care• Surgery: most effective care

»Classical surgery : radical pancreaticoduodenectomy or whipple procedure

• Cholecystojejunostomy• Total pancreaticoduodonectomy with

spleenecotmy • Biliary Stents (Cotton Leung Stents)

Pancreatic Cancer• Chemotherapy• Gencitabine in combinatio with

capecitabine or erlotinib

• Nursing Management• 1. Provide symptomatic and supportive

nursing care• 2. Pain relief• 3. adequate nutrition• 4. Help patient and family members in

the grieving process

Bladder Cancer• The most frequent type of cancer in the

urinary tract is transitional cell carcinoma

• Common between 60-70 yrs. Old• PF: cigarette smoking, exposure to dyes

used to rubber and cable industries and chronic abuse of phenacetin-containing analgesics.

• Women who is treated with cervical cancer and patients receiving cyclophosphomide also have increased risk with unknown cause

Bladder Cancer

• CM: painless hematuria, bladder irritability with dysuria, frequancy and urgency

• Dx. Urine specimen specimen for cytology can be obtained to determine presence of neoplastic or atypical cells.

• Cystoscopy- the most reliable test for detecting bladder tumor.

• Clinical Staging is determined by depth of invasion of the bladder and surrounding tissue

Bladder Cancer

• Jewett Strong Marshall Classification• Superficial (CIS- carcinoma in situ, O, A)• Invasiveness (B1, B2, C)• Metastasis (D1 to D4)

• Low grade tumors (Superficial) are more responsive to transvesical chemotherapy and transurethral resection of bladder tumor (TURBT)

Bladder Cancer• Collaborative Care• 1. Surgical Treatment

transurethral resection with fulguration, laser photocoagulation, open loop resection with fulguration, cystectomy (segmental, partial, radical)

• 2. Radiation therapy• 3. Intravesical immunotherapy

• Bacille Calmette – Guerin (BCG)• A interferon

• 4. Intravesical Chemotherapy• Thiotepa, valrubin

• 5. Systemic Chemotherapy

Bladder Cancer• Transurethral resection with fulguration

(electrocautery)• Treatment of superficial lesions with low recurrence

rate• To control bleeding in patients with poor operative

risk or who has advance tumor

• Laser photocoagulation• Treat of superficial bladder cancer• Adv. Bloodless destruction of lesions, minimal risk for

perforation, lack of need for urinary catheter

• Open loop resection• Snaring of polyp type of lesion• Used to control bleeding for large superficial tumors and

multiple lesions• used together with segmental resection•

Bladder Cancer• Postoperative Management:

1. Instruct patient to drink large volume of fluid each day for the ist week following the procedure2. taught patient self monitor the urine3. instruct patient that pinkish urine is normal within the the ist several days but should not be bright red or with clots4. 7-10 days following the procedure, patient may observe urine, dark red or rust colorred flecks in the urine5. 15-20 min sitz bath, 2-3 times a day6. folloe cystoscopy schedule whch is every 3-6 months for 3years and yearly thereafter

Bladder Cancer• Radiation therapy when cancer is inoperable or

when surgery is refused

• Combined with systemic chemotherapy (cisplatin, vinblastin, doxorubucin, and methotrexate)

• Intravesical Therapy• Protocol varies but cycle is for 6-12 weeks• Patient position maybe changed every 15 min

• BCG• Thiotepa (alkylating agent) reduce WBC and

platelets within the bladder

Breast cancer• Common malignancy to women, 2nd cause of

death• Etiology and risk factors• Heredity, hormonal regulation, dietary fat intake,

weight gain in adolescence, obesity and alcohol intake

• Combined hormone therapy (estrogen and progesterone)

• Pathophysiology– May arise from epithelial lining of the ducts (ductal carcinoma) or epithelium lobules (lobular carcinoma)

Breast Cancer Types• Types of Breast Cancer• 1. Non invasive Breast Cancer

• Ductal carcinoma in Situ (infiltrating ductal cell carcinoma) tamoxifen, lumpectomy and radiation therapy

• Lobular carcinoma in Situ

• 2. Paget’s disease• Persistent nipple and areola lesions with or without

palpable mass, nipple changes are diagnosed as infection or dermatitis w/ch cause delays of treatment

• 3. Inflammatory breast Cancer• Most malignant form of all breast cancers, breast

looks red, feels warm and has thickened appearance resembling an orange peel (peau de orange)

Breast Cancer

Breast Cancer

Breast cancer• Clinical Manifestations• Detected as a lump or mammographic

abnormality in the breast• Irregular shaped poorly delineated non mobile

non tender

• Complication:• Recurrence either local, regional or distant,• Metastsis primarily occurs via lymphnode

Breast Cancer• Diagnostic study• Axillary lymph node involvement• Mammography, ultrasound , biopsy, MRI

• Collaborative care:• 1. Surgery• a. Breast conserving (lumpectomy) with

sentinel lymph node involvementB, Biopsy/dissection and or lymph node dissectionC. Simple mastectomyD. Modified radical mastectomy,E. Radical mastectomyF. OopherectomyG. adrenalectomy

Breast Cancer• Collaborative Therapy• 2. Radiation Therapy• 3. Chemotherapy• 4. Hormonal therapy• 5. Biologic and target therapy

Breast Cancer Estrogen and progesterone Status

Receptor positive receptor1. commonly well

differentiated2. diploid DNA and low

proliferative indices3. lower chance of recurrence4. hormone dependent and

responsive to hormonal therapy

Receptive Negative tumor

1. Poorly differentiated2. Aneuploid and higher

proliferative indices, 3. Frequently reoccur4. Unresponsive to hormonal

therapy

Breast Cancer• Post OP Care

• 1. Check for bleeding(hemovac or JP drain)• 2. dec incisional pain (splinting area during

coughing, DBE, managed cough)• 3. Prevent lymphedema • 4. maintain abduction of affected arm• 5. NO BP taking on affected arm• 6. Post mastectomy exercises

Breast cancer• Post mastectomy exercises• 1. Ball squezzing (8-10 hrs post op)• 2. hand wall climbing (7-10 day post op)• 3. back scratch: non operative scapula (7-10 day post

op)

• Follow up care• 1. CBE every 6 months for 2 years then annually• 2. manage postmastectomy pain syndrome• (EMLA: eutectic mixture of local anesthetics)• 3. avoid gardening• 4. wear gloves when performing household chores.

•

Breast Cancer• Radiation Therapy• Performed after locally excision of the breast

mass or surgery

• High dose brachytherapy• Alternative to traditional radiation treatment• Traditional – 5-6 weeks • Alternative- balloon catheter 1-5 days

Breast Cancer • Chemotherapy• 1. CMF (cyclophosphamide, methotrexate, 5-

fluorouracil)• 2. AC (adriamycin, cyclophosphamide) w/ or w/o

paclitaxel, or docetaxel• 3. CEF or CAF (cyclophosphamide, epirubicin or

adriamycin, 5 FU)• 4. vinorelbine new drug for metastatic cancer

• Hormone Therapy• Removes or blocks source of estrogen promoting

tumor regression

Breast CancerMechanism of action Examples

Blocks estrogen receptors TamoxifenToremifine (metastatic breast cancer in postmenopausal women)

Destroys estrogen receptor Fulvestrant (Faslodex), IM

Prevents production of estrogen by inhibiting aromatase

AnastrozoleLetrozoleExemestaneaminogluthetemide

Breast Cancer

• Breast reconstructive options1.Mammoplasty

-change of size and shape of breast

2.Breast augmentation-procedure to enlarge the breastImplant is placed into the pockets of the

breast and pectoralis fasciaSilicon envelopes are filled with

dextran ,saline or silicone

Breast Cancer

Breast Cancer

Breast Cancer

• Breast Reduction• To reduce breast size• Done through resecting

wedges of tissue from upper and lower quadrants of the breast tissue

• Excess skin is removed and areola and nipple is relocated

• Nursing Management Breast augmentation and Reduction

• 1. Drains are placed at surgical site and removed 2-3 days post op or when drainage is lesser < 20ml

• 2, wear bra continuously for 2-3 days post op• 3. resume normal activities 2-3 days after breast

reduction