CANCER

Large Group of Diseases

Epidemiology
Affects every age group - Most > 65 yo
> in men than women
> industrialized sectors & nations.
> 1.5 million Americans diagnosed each year
> 560,000 die annually of
malignant process
Men - Lung, prostate,
colorectal
Women - Lung, breast,
colorectal
5 year survival rate

NEOPLASIA
Any new or continued cell growth not
needed for normal development or for
replacement of dead and damaged tissues
Neoplasia is always abnormal
The new cells could be benign or
malignant
Neoplastic cells develop from normal cells

Pathophysiology
Hypertrophy is cell growth that causes tissue to
increase in size by enlarging each cell

Hyperplasia is growth that causes tissue to
increase in size by increasing the number of cells

Neoplasia is any new or continued cell growth not
needed for normal development or replacement of
dead and damaged tissues
Characteristics of Normal Cells
Have limited cell division
normal cells divide for one of two reasons
To develop normal tissue
To replace lost or damaged tissue

Show specific morphology

Have a small nuclear-cytoplasmic ratio

Perform specific differentiated functions




How are cancer cells different from
normal cells?
They follow no rules
They exhibit the following characteristics
Dysplasia
Hyperplasia
Metaplasia
Characteristics of Cancer Cells
Lose some or all differentiated function.
Cancer cells have no useful purpose

Adhere loosely together

Grow by invasion
invasion and persistent growth make
untreated cancer deadly



Characteristics of Cancer Cells
Carcinogenesis is another name for cancer
development

Transformation of a normal cell into a cancer
cell involves mutation of the genes (DNA) of
the normal cell

Only one cell has to undergo malignant
transformation for cancer to begin

Benign tumors grow by expansion, whereas
malignant tumors grow by invasion

Most tumors arise from cells that are capable
of cell division

Key Concepts
Primary prevention of cancer involves avoiding
exposure to know causes of cancer
Secondary prevention of cancer involves
screening for early detection
Tobacco use is a causative or permissive factor
in 30% of all malignant neoplasms
Tumors that metastasize from the primary site
into another organ are still designated as
tumors of the originating tissue
Basic Features of Cancer Cells
Unregulated cell growth
Ability to invade other tissues
Ability to initiate new growth at distant sites
Ability to escape detection and destruction
by the immune system
Cell Characteristics
Normal Cell
No rapid division
Contact inhibited
Adhere tightly
together
Do not break
loose or migrate
Differentiated and
have specific
function

Malignant Cell
Rapid growth
Do not recognize or
respect tissue
borders
Break off and migrate
Lose differentiation
Reproduction out of
control


How Do Cancers Get Started?
It is called carcinogenesis
It is the process by which normal cells
become malignant cells
Many factors can cause cancer or
contribute to the transformation of a cell
from normal to malignant
Tumor Doubling Times
Once the cancer goes through about 30
doublings, it has reached roughly the size of a
marble, about 1 cm in diameter
This size tumor contains about one billion cancer
cells
This is about the earliest stage a cancer can be
detected
Much of the life span of a cancer is silent


Metastasis
Metastasis occurs through a progression of
steps:
Extension into surrounding tissue
Blood vessel penetration
Release of tumor cells
Invasion
Local seeding
Bloodborne metastasis
Lymphatic spread
Cancer Classification
Cancer grading and staging help
standardize diagnosis, treatment, and
prognosis

Grading on the basis of cell appearance
and activity compares the cancer cell with
its normal parent tissue

Staging classifies clinical aspects of the
cancer and determines exact location and
degree of metastasis at diagnosis


Cancer Development
Carcinogenesis takes years and depends on
several tumor and client factors. Three
interacting factors influence cancer
development:

Chemical carcinogenesis
Dietary factors
Personal factors
Cancer Development
Viral Carcinogenesis

Only a few viruses are proven to be
carcinogenic, there are many more that
are suspected to play major roles in
cancer development

When viruses infect body cells, they break
the DNA chain and insert their own
genetic material into the DNA chain

Viruses that cause cancer are oncoviruses
Malignancies Associated with a
Known Viral Origin
Epstein-Barr virus-- nasopharyngeal
carcinoma

Hepatitis B virusPrimary liver carcinoma

Human Papilloma virusCervical
carcinoma, and other genital carcinomas
Cancer Prevention
Avoidance of known of potential carcinogens

Modification of associated factors

Removal of at-risk tissues

Screening programs

Gene therapy
Influence of Immunosurveillance on
Cancer Development
It is believed that we all have single cell
mutations that could develop into cancers if the
immune system did not attack the tumor cells
Various carcinogens may transform cells to
malignant potential, but the immune system
effectively nips it in the bud before the cancer can
grow

Benign Neoplasm Characteristics
Cells resemble normal cells of tissue from
which it originated
Does not infiltrate
Is encapsulated
Rate of growth is usually slow
Does not spread by metastasis
Does not recur when removed


Carcinogenesis: Malignant
Transformation
Three-step cellular process:
Initiation
Promotion
Progression
Ability To Metastasize Requires
Multiple Steps
Invasion of adjacent tissues
through basement
membranes
Entrance into nearby vessels
Evasion of the immune
system
Reentrance into distant
tissues
Implantation of malignant cell
in new tissue
Cancer Prevention & Detection
External Factors Causing Cancer
Chemical Carcinogenesis

Some chemicals are complete carcinogens

Some chemicals are pure initiating agents,
or incomplete carcinogens.

Cancers of nerve tissue, cardiac muscle,
and skeletal muscle are rare. These cells
do not normally undergo cell division



Cigarette smoking is
the most preventable
cause of cancer-
related death in the
US
Risk Factors For Cancer

Over 70% of all cancers are
associated with lifestyle choice

Primary and Secondary Levels of
Cancer Prevention
Primary prevention
refers to simple measures taken early to avoid
the development of cancer
Secondary prevention
targets specific populations and refers to
activities such as testing or screening
Diagnosis
Diagnosis of cancer requires a tissue biopsy

Types: Needle, incisional & excisional

Tumor Staging
TNM system of the American Joint Committee on
Cancer is preferred for solid tumors

T = The extent of the tumor
Characteristics of a given tumor
N = The extent of spread to the lymph nodes
Presence or absence of involved nodes
M = Presence or absence of metastases
Reasons for Staging
The extent to which a disease has spread is
prognostic
Extent of disease often dictates treatment
Accurate staging allows collection of data that
eventually provide information about treatment
outcomes for each type of cancer and each
stage of disease.
How Is Staging Done?
Begins with
History & Physical
CBC, chemistry tests of liver &
kidney function and a Urine Analysis
A wide variety of tests is available
to evaluate the extent of a particular disease
X-rays
Computerized axial tomography (CAT) scans
Magnetic resonance imaging (MRI) scans
Nuclear medicine scans

Tumor Markers
Biochemical indicators of neoplastic activity found in
the blood
Alpha-fetoprotein (AFP)
Carcinoembryonic antigen (CEA) Colon, rectum,
pancreas, stomach, lung, breast & ovary
CA 125 Epithelial ovarian neoplasms, breast,
colorectal
CA 19-9 Colorectal, pancreas, stomach, liver
Human chorionic gonadotropin (HCG) testicular
teratoma
Prostate-specific antigen (PSA) Adenocarcinoma of
prostate
Teratoma
Tests To Evaluate
Extent of the
Cancer
X-Rays
CAT scans
Magnetic Resonance Imaging (MRI)
Nuclear Med Scans
Fluroscopic Studies

Principles Of Therapy
Major treatment modalities
Surgery
Radiation therapy
Chemotherapy
Hormonal therapy
Curative and Palliative Treatment
Curative Tx
Intent is to
eradicate malignant
dx
Therapy should be
aggressive

Palliative Tx
Given when the
disease is not curable
Survival time is limited
To alleviate symptoms
Improve quality of life
Adjuvant Therapy
The use of a therapy, usually chemotherapy,
along with another treatment modality
Adjuvant therapy is given with curative intent
Pharmacology of Chemotherapy Agents
Chemotherapy Drugs Interfere
with steps of the cell cycle

Chemotherapy is classified according to the
pharmacologic action of effect on cellular
reproduction

Cell-cycle specific
Cell-cycle nonspecific drugs
See Table Antineoplastic Agents
Treatment Issues
Drug dosagecalculated according to the type
of cancer and the clients size

Drug scheduleregular basis and are timed to
maximize cancer cell kill and minimize damage
to normal cells. The entire planned schedule is
the course of chemotherapy

Drug administrationmostly IV due to rapid
effects and agents are irritating and damaging
to tissues



Serious Side Effects of Chemotherapy
Alopecia (hair loss)
Nausea and vomiting
Open sores on mucous membranes (mucositis)
Altered bowel elimination
Decreased mobility
Hematopoietic system changes
Bone marrow suppression
Decreased leukocyte numbers
Decreased numbers of circulating erythrocytes
(anemia)
Thrombocytopenia

Immunosuppression places the client at extreme risk for
infections and is the major dose-limiting side effect of
cancer chemotherapy
Most infections that develop in a client with neutropenia
result from overgrowth of the clients own normal flora


Principles For Use of Combination
Chemotherapy
Only drugs that are active against the tumor to
be treated are included
The drugs should have a different mechanism
of action to minimize the possibility of drug
resistance
The drugs should have different toxic side
effects, thus allowing administration of full
doses of each active agent
Each drug should be given at an optimal dose
& schedule & at consistent intervals
Multible Cycles of Chemotherapy
According to the log
cell kill hypothesis:
Treatment must be
repeated many times to
achieve control
At any given exposure
chemotherapy drugs kill
only a fraction of the
cells

Hormonal Therapy An Example
Testosterone converts into
Dihydrotestosterone (DHT)

DHT is a hormone believed to contribute to
the development of prostate cancer

The goal of hormone manipulation is to
inhibit the formation of testosterone

Radiation Therapy
Goal is to destroy tumor cells while sparing
normal cells

Radiation is delivered from a distance by a
machine

OR close to the patient via an implanted or
injected radioactive source
(Brachytherapy Internal Radiation)
Brachytherapy or Internal Radiation
Placement of sealed radioactive sources
close to the tumor to provide a high dose of
radiation directly to the tumor

Does not cause irreparable damage to
radiosensitive normal tissues

Currently used for cancers of the cervix,
prostate, lung, breast, brain and melanomas
of the eye
Nursing Care
Pain management
Pain may result from a variety
of stimuli
Careful assessment is critical
in order to identify the physical
causes and psychosocial
factors that modulate pain
intensity & its perception
Cancer Pain
Bone Metastasis
Nerve compression
Lymphatic or venous
obstruction
Ischemia
Organ obstruction
Skin inflammation,
ulceration, infection,
necrosis
Nutritional Support
Protein-calorie malnutrition
Occurs when this
macronutrient intake cannot
meet the bodys metabolic
needs
From 40 80 % of all cancer
patients experience some
degree of malnutrition
Factors that Lead to Development
of Cancer Cachexia
Taste changes
Altered hypothalamic control of appetite
Psychological & emotional factors
Pain
Mechanical interference from tumor or
treatment side effects

Nursing Care
Decreasing fatigue
Improving body image & self-esteem
Grieving
Potential complications
Infection
Septic shock
Bleeding & hemorrhage
Promoting home & community-based care.
Teaching patient self-care
Continuing care home care/hospice
General Interventions for
Clients with Cancer
General Disease-Related
Consequences of Cancer
Cancers that are left untreated cause
Impaired immune and hematopoietic (blood
producing) function
Altered gastrointestinal structure and function
Motor and sensory deficits
Decrease respiratory function
Surgery as Cancer Treatment
Oldest form of cancer treatment used for:

Prophylaxis
Diagnosis (biopsy)
Cure
Control
Palliation
Determining efficacy of therapy
Reconstruction
Radiation Therapy for Cancer
Purpose: to destroy cancer cells with minimal
exposure of the normal cells to the damaging
actions of radiation
Mechanism of action
Killing Effect
Teletherapy
Brachytherapy

CYBER KNIFE

A form of radiation therapy
Non invasive alternate to surgery
Delivers high dose radiation
Uses a Robotic radiosurgery system
No simulation necessary prior to treatment
Method of painting the tumor
Shorter treatment time
Minimal side effects

Side Effects of Radiation Therapy
Vary according to the site
Local Skin Changes
Altered Taste Sensations
Fatigue
Inflammatory Responses
Nursing Care of Clients
Undergoing Radiation Therapy
Teach accurate objective facts to help client
cope
Do not remove markings
Administer skin care
Do not use lotions or ointments
Avoid direct exposure of the skin to the sun
Care for xerostomia (dry skin)
Bone exposed to radiation is more vulnerable to
fracture

Hormonal Manipulation
Some hormones make hormone-sensitive
tumors grow more rapidly
Some tumors require specific hormones to
divide, therefore decreasing the amount to
these hormones to hormone-sensitive tumors
can slow the cancer growth rate and increase
survival time
Side Effects of Hormone Therapy
Androgens and antiestrogen receptor drugs
cause masculinizing effects in women
For men and women receiving androgens,
acne may develop, hypercalcemia is
common, and liver dysfunction may occur
with prolonged therapy
Feminine manifestations often appear in men
who take estrogens
Testicular and penile atrophy also occurs.


Immunotherapy: Biological
Response Modifiers (BMRs)
Drugs that modify the clients biological responses
to tumor cells
Cytokines: enhance the immune system, make it
work better
Two types of BRMs
Interleukinscharge up
Interferonsslow down
Gene Therapy
Experimental as a cancer treatment
Renders tumor cells more susceptible to
damage or death by other treatments
Injection into tumor cells, enabling the immune
system to better recognize cancer cells as
foreign and kill them
Targeted therapycombine biologic therapy
and gene therapy
Side effect allergic reaction

Loss & Grief
Kubler Ross Stages of Grieving
Denial
Anger
Bargaining
Depression
Acceptance

Dr. Roberta Temes
Stages of Grieving
Numbness

Disorganization

Reorganization

Culture and death
Grieving used to be much more ritualistic
than it is today. In generations past there
were set periods of time when certain
customs must be observed:
Widows wore all black clothing for one year
and drab colors forever after.
Mourners could not attend social
gatherings for months.
Laughter and gaiety were discouraged for
weeks or months.
Some may be religious in nature, others
family or traditions
Palliative Care
Terminology
Palliative care
Broad concept of care that focuses on
the comfort of the patient
Hospice care
Dying is a normal process and should
not be hastened or postponed
End-of-life care
Assessment of Loss & Grief
Define the nature of findings and symptoms
Perform history and physical examination
Evaluate problem
Discuss care options
Symptoms at the End of Life
Pain
Dyspnea
Delirium
Depression
Fatigue and weakness
Sleep disturbances
Cachexia
End-of-Life Symptom Management:
Pain
Incidence
Etiology and assessment
Pharmacologic management
Opioid and adjuvant analgesics
Analgesic dosing
Analgesic rescue dosing
Nonpharmacologic management
End-of-Life Symptom Management:
Dyspnea
Incidence
Etiology and assessment
Pharmacologic management
Opioids, anti-anxiety agents,
bronchodilators, corticosteroids
Nonpharmacologic management
Oxygen therapy
End-of-Life Symptom Management:
Delirium
Incidence
Etiology and assessment
Pharmacologic management
Nonpharmacologic management
Hydration
Oxygenation
End-of-Life Symptom Management:
Depression
Incidence
Etiology and assessment
Pharmacologic management
Nonpharmacologic management
Psychotherapy
Cognitive-behavioral techniques
End-of-Life Symptom Management:
Fatigue/Weakness
Incidence
Etiology and assessment
Pharmacologic management
Nonpharmacologic management
Modify exercise, activity, and rest patterns
Self-care activity assistance

End-of-Life Symptom Management:
Sleep Disturbances
Incidence
Etiology and assessment
Pharmacologic management
Nonpharmacologic management
Avoid stimulants and interruptions
Establish a regular sleep schedule
Keep mentally and physically active
End-of-Life Symptom Management:
Cachexia-Anorexia Syndrome
Incidence
Etiology and assessment
Pharmacologic management
Nonpharmacologic strategies
Dietary supplements
Role of Nurses
Nursing role
Establish trust
Work with interdisciplinary team
Focus on quality of life, control symptoms
Be available, nonjudgmental, and
nonthreatening
Listen, advocate, empower
Support the caregivers
Support of the Grieving Family:
Tasks of Mourning
Accepting the reality of the loss
Experiencing the pain of the loss
Adjusting to the environment in which the
deceased is missing
Finding a way to remember the deceased
while moving forward with life

Dealing with Loss
Losses occur throughout
life, but their cumulative
effects may be
ACUTELY felt in later
years
Each loss represents a
small death
Types of Loss
Concrete or tangible
Death
Removal of a body
part
Changes in physical
health
Divorce or separation
Property loss
Relocation or job
layoff
Types of Loss
Psychological, symbolic
or intangible
Ones prestige,
power, dreams, plans,
ambition, confidence,
security & pride
Death of a spouse
or life partner
Roles that can be
lost:
Friend / lover
Confidant
Homemaker
Comforter
Adults /Grieving Process
Everyone experiences grief in different
ways
It is a process in which a person
experiences loss & sadness associated with
that loss
This sadness may seem overwhelming and
disabling at times
It can include feelings of anger, frustration,
guilt, and sorrow
Grieving Process
A number of authors have described stages
or phases of grieving
Grieving is manifested in thoughts, feelings,
and behaviors
There is no one timetable by which a person
progresses through the grief process
Recovery from grief - Best Predictors
Sufficient finances
Social supports
Being on the younger end of the age
continuum
Higher levels of education
Living in a smaller/supportive community
Physical needs of the Dying
Client
Comfort
Pain control
Relief for respiratory
difficulties
Nutrition / starvation
Hydration /
dehydration
Physical Signs of Impending Death
Loss of muscle tone
Slowing of the circulation
Changes in respirations
Sensory impairment
Psychosocial needs of the Dying
Client and family
Acceptance of often
conflicting,
confusing and often
overwhelming
emotions
Freedom to express
these emotions
Emotional Impact of Death &
Loss on the Nurse
Affects the emotions and
equilibrium of the
caregiver
Reminded of ones own
mortality
Many find it easy to
relieve physiological
symptoms but difficult to
become involved at the
interpersonal level
Nurses Self Care
Understand the
grieving process
Acknowledge ones
own personal limits
Formulate a
philosophy of life
(with regard to self)
Know when to get
away & take care of
self
Need to have a
personal support
system
Legal-Ethical
Responsibilities
Euthanasia - implies
that under some
circumstances death is
preferable to life
Passive - Removing
support or
withholding Rx
Active - An act of
commission
Advance Directives
Living will
Durable power of attorney for health care
Provides specific instructions
Health care proxy
A witnessed statement
appointing someone else
(relative or trusted friend) to
manage health care Rx decisions when client
is unable to.
Appointed health care proxy may not witness the
documentation.
Autopsy
(Legal Aspects)
Required by law
when:
Person dies with
24 hours of
admission to
hospital
Suicide
Homicide
Unknown cause
Suspected child
abuse
Criminal activity
Organ & Tissue Donation
National Organ Transplant Act,
1984
Consent
Voluntary
Harvest Time
Specific Cancers
Bone Cancer
Malignant bone tumors may be primary or
secondary
Primary tumors of the prostate, kidney, thyroid
and lung often metastasize to the bone
Metastatic tumors greatly outnumber primary
malignant bone tumors

Bone Cancer
Osteosarcoma or
osteogenic sarcoma


Ewings
Sarcoma

Bone Cancer
Chondrosarcoma
typically affects the pelvis and proximal
femur


Fibrosarcoma
an uncommon; slow growing tumor that can
metastasize to the lungs

Breast Cancer
Leading cause of death in women in the US
Considered non-invasive
when it remains within the
duct
Classified as invasive
when it penetrates the
tissue surrounding the
duct and grows in an
irregular pattern




Heredity or genetically
related susceptibility


Hormone regulation

Sex hormones may act
as tumor promoters
Hormone replacement
therapy



Breast Cancer

Breast Cancer
Collaborative Care
Axillary Node
Dissection

Often performed
regardless of treatment
selected
Provides most powerful
prognostic data
Helps define further
treatment
Breast Cancer
Etiology and Risk Factors
Factors under study
Alcohol
Fat intake
Obesity
Physical inactivity

Environmental factors
Pesticides
Chemical exposure
Radiation exposure


Increasing age
increases risk
Most women who
develop breast cancer
have none of the
identifiable risk factors

Breast Cancer
Medullary carcinoma
Colloid carcinoma
Inflammatory carcinoma

Common site of metastatic disease are
bone, lungs, brain, and liver
Breast Cancer
Risk factors for breast cancer
include
Age
Nulliparity
Early menarche
Late menopause
Family history of breast cancer
Exposure to ionizing radiation
History of benign breast disease
First birth after age 30
A high alcohol and fat intake may increase the
risk for breast cancer
Cervical Cancer
A reproductive cancer can be preinvasive or
invasive
Preinvasive cancer
Invasive cancer
Metastasis is usually confined to the pelvis
Risk factors
Low socioeconomic status
Early age at first sexual contact
or first pregnancy
Multiple sex partners
Intrauterine exposure to DES
(diethylstilbestrol)
PAP test for screening
Colorectal Cancer
Cancer of the colon develops as a multistep
process
Tumors occur in all areas of the colon
Tumors spread by direct invasion
Risk factors
Genetic predisposition
Personal risk factors such as age and presence
of adenomatous polyps
Dietary factors related to high intake of foods
such as red meat and animal fat, refined
carbohydrates, or fried or broiled red meats
and fish
Black individuals have an increase incidence
Liver Cancer
Primary hepatic carcinoma is rare in the US
Usually develops as a metastatic process from
primary cancer site
Symptoms
Epigastric or
RUQ abdominal pain
Fatigue
Anorexia
Jaundice
Ascites
Bleeding
Detected by nuclear
radioisotope liver scan, needle biopsy confirms
Lung Cancer
Metastasize by direct extension through the
blood and invading lymph glands and vessels

4 major types of lung cancer
Small cell lung cancer (SCLC)
Epidermiod (squamous cell)
Adenocarcinoma
Large cell carcinoma

The last 3 types are referred to as non-small cell
lung cancers (NSCLCs) because of their similar
response to treatment

Lung cancers occur as a result of repeated
exposure to inhaled substances that cause
chronic tissue irritation or inflammation


Ovarian Cancer
Leading cause of death from female reproductive
organ malignancies
The most common is the serous adenocarcinoma
Grows rapidly,
spreads quickly,
and are often bilateraly,
with the worst prognosis
of all epithelial tumors

Spreads by
1. Peritoneal seeding
2. Direct spread to other organs in the pelvis
3. Distal spread through the lymphatic drainage
Pancreatic Cancer
Highly malignant
Primary tumors are generally adenocarcinomas
Grow rapidly and spread to surrounding organs
(stomach, duodenum, gallbladder, and intestine)
May result from metastasis
Renal Cancer
Referred to as adenocarcinoma of the kidney
Systemic effects include anemia, erythrocytosis,
hypercalcemia, liver dysfunction with elevated
liver enzymes, increased sedimentation rate,
hypertension, and other hormonal effects
Metastasis through the bone or lymph to the liver,
lungs, and long bones
Skin Cancer
Overexposure to sunlight is the major cause of skin
cancer
The most common skin cancers include;
Actinic or solar keratoses
common in chronic sun damaged skin and may
progress to squamous cell carcinoma
Squamous cell carcinoma
Predisposed by sun exposure and chronic
epithelial damage form repeated injury or
irritation

Skin Cancer
Basal cell carcinomas
Arising primarily form ultraviolet light, radiation
exposure, genetic predisposition, and chronic
irritation

Melanomas
Risk factors include genetic predisposition and
precursor lesions, which resemble unusual
moles
The ABCDEs of melanoma skin
cancer are
Asymmetry
Border irregularity
Color
Diameter
Evolution
Stomach Cancer
Malignant neoplasms found in the stomach

Adenocarcinomas are the most common
type, followed by lymphomas and
sarcomas

In advanced disease, invasion extends to
the stomach muscle or beyond


Thyroid Cancer
There are 4 types of thyroid cancers
Papillary carcinoma
A slow growing tumor
Good prognosis if localized
Follicular carcinoma
Primarily affects older clients
Invades blood vessels and metastasizes
Can adhere to the trachea, neck muscles,
great vessels, and skin resulting in dysphagia
and dyspnea
Fair prognosis if metastasis is minimal
Thyroid Cancer
Medullary carcinoma
Primarily affects clients over 50 years of age
Involves metastasis that occurs via regional
lymph nodes and invades surrounding
structures
Anaplastic carcinoma
A rapidly growing, extremely aggressive tumor
Directly invades adjacent structures, causing
stridor, hoarseness, and dysphagia
Poor prognosis

Pediatric cancers
Neuroblastoma
Solid tumor found only in infants and children
Most common tumor in children located outside
the cranium
Embryonal tumor arising from neural crest cells
Boys > girls, white > incidence
Peak age 22 mos
Approx. 80% present with metastasis
125
Neuroblastoma
About 50% of neuroblastomas develop in
the adrenal gland.

Symptoms also result from the tumor
spreading to different parts of the body.

Neuroblastoma may spread to bone, bone
marrow, liver, skin and lymph nodes.
126
Neuroblastoma
Prognosis is based on childs age and staging of
the tumor

Process of classifying tumors w/respect to:

Degree of differentiation
Potential for responding to treatment
Patient prognosis

Children < 1 yr have a better prognosis

127
Neuroblastoma
Etiology and pathophysiology

Cause is unknown

Although environmental factors
Prenatal drug exposure, is implicated
Tumor is often silent leading to late diagnosis
and poor prognosis

128
Neuroblastoma - Diagnosis
CT
Bone marrow aspiration
Urine testing
129
Neuroblastoma - Treatment
Depends on staging

Surgery is used for tumor removal following
biopsy

Radiation therapy
In more advanced cases
And may be palliative w/metastasis
Chemotherapy

130
Neuroblastoma - Prognosis
Age at diagnosis important indicator
< 1 year better
Stage I/II
80% - 90%
Disseminated disease & > 1 yr
10% - 30%
131
Assessing the Child with
Wilms Tumor
Usually asymptomatic
Most frequent admitting symptom is an
abdominal mass; parent often finds the mass,
which is located to one side of the midline of the
abdomen
Pain and hematuria may be present
HTN is present approx. 25%, because of > renin
production

132
Wilms Tumor
Nephroblasoma

Encapsulated tumor of kidney
Unilateral or bilateral
Originates from renal parenchyma and extends
into surrounding tissues
Grow rapidly
Peak incidence 3 to 4 years
Prognosis depends on stage at time of dx
Metastasis to lungs and liver
Often assoc. with congenital anomalies

133
Assessing the child with Wilms
Tumor
(Nephroblastoma)
Avoid palpitation during assessment
Excessive manipulation can cause seeding
of the tumor

Diagnosis of Wilms Tumor
US of abdomen and
IVP

CT and MRI of lungs
To detect metastasis
135
Treatment Wilms Tumor
Unless bilateral tumors are present
Surgery (nephrectomy)
Look for metastasis
Radiation to the abdomen and chemotherapy
can be used before and/or after surgery
Prognosis
Good (can exceed 90%)
136
Child & Family Education
Avoid palpation of abd prior to surg.
Provide parents with info
Nature of the disease
Tx options
Therapeutic and S/E of chemotherapy
Need to protect the remaining kidney
S/S of UTI
Avoid contact sports
137
Osteosarcoma
Most common bone cancer in children
Peak incidence between 10-25 yrs of age
Associated w/rapid growth spurt of adolescence
Most frequently affects the distal portion of femur;
also the humerus, tibia, jaw and phalanges
Localized pain in affected site
Often relived by flexing the extremity
Progressive, insidious or intermittent pain at
tumor site
Limping, limited ROM, palpable mass, eventually
pathological fracture
Frequently metastasizes to the lungs
Osteosarcoma
Diagnosis
Ct or MRI to detect
areas of metastasis
X-rays following
traumatic injury may
be first indication of
disease
Femur has a large mass involving
the metaphysis of bone. Tumor
has destroyed the cortex.

Therapeutic Management
Goals
Remove tumor and prevent spread of disease
Treatment may include radical resection and
amputation
Depending on location and/or surgeon may try
limb-salvaging procedures w/prosthetic
replacement
Chemotherapy before and after surgery
Thoracotomy if metastasis to the lung
Cure rate 75% without metastasis
Nursing Care
Comfort, pain management
Phantom limb pain if amputation
Utilize straightforward approach when
amputation is indicated
Allow for verbal expression for feelings
Emotional support pre and post-operative
important
Body image concerns
Especially in teens
Encourage early interaction with peers