Class 5 -Cellular Regulation - Student Copy.pdf

Cellular Regulation Exemplars: Benign brain tumor, Malignant tumors (colon/rectal, melanoma, osteosarcoma) Fall 2024 Rebecca Jones MN, RN, GNC(C), LC Burden of Disease in Canada Trends in Cancer Rates: – Most commonly affects Canadians aged 50 years and older – Incidence rates across Ca...

Cellular Regulation Exemplars: Benign brain tumor, Malignant tumors (colon/rectal, melanoma, osteosarcoma) Fall 2024 Rebecca Jones MN, RN, GNC(C), LC Burden of Disease in Canada Trends in Cancer Rates: – Most commonly affects Canadians aged 50 years and older – Incidence rates across Canada vary – 1 in 2 Canadians are expected to develop cancer during their lifetime Lung, breast, colorectal and prostate cancer are the most common types of cancer in Canada (excluding non-melanoma skin cancer) à based on 2017 estimates – These cancers account for half (50%) of all new cancer cases Cellular Regulation – Review Cellular replication is activated in the presence of cellular degeneration and death or based on physiological need – E.g. new cells are made as old cells die or “stop and go” mechanism in time of need Sometimes, these signals can function abnormally – A “go” signal can be produced when it should not – A “stop” signal may be ignored by surrounding cells Such errors could result in uncontrolled growth and the development of neoplasms Cancer – Review Disease of the cell – Cancer is not a tumor – It is an abnormal growth resulting from uncontrolled proliferation; it serves no physiologic function – Is also referred to as a neoplasm: new growth of abnormal cells Cancer begins when an abnormal cell is transformed by the genetic mutation of its DNA Two major dysfunctions are present in the process of cancer: 1. Defective cellular proliferation (growth) 2. Defective cellular differentiation (undifferentiation occurs) Differentiated cells Benign vs. Malignant The terms “tumor” and “neoplasm” do not automatically mean a malignancy They can be benign or malignant…what is the difference? Benign Neoplasm Malignant Neoplasm Systemic Effects of Malignant Tumors Weight loss and cachexia (severe tissue wasting) – Related to increased metabolic demand, altered carbohydrate and protein metabolism, cachectic factors Anemia – R/t chronic bleeding, bone marrow depression, anorexia, decreased food intake Bleeding – R/t Erosion of blood vessels, tissue ulceration Infections – R/t bone marrow depression, impaired immune response Paraneoplastic Syndromes – R/t release of substances by tumor cells that affect neurological function, blood clotting, hormonal effects Hyper-coagulation Effusions – Inflammation causing fluid buildup in body cavities Benign vs. Malignant Neoplasms Normal vs. Cancerous Cells Cancer Invasion and Metastasis Metastasis: the spread of cancer cells from the site of the original tumor to distant tissues & organs through the body Is a complex process that requires cells to have many new abilities – Spread – Survive – Proliferate in distant locations – Destination must be receptive to growth of cancer Invasion – Local Spread Is a prerequisite for metastasis (the first step in the metastatic process) Cancer often spreads first to regional lymph nodes through the lymphatic system and then to distant organs through the bloodstream Invasion then requires the cancer attach to specific receptors and survive in the specific environment Pathways of Spread Dissemination of cancer may occur through 1 of 3 pathways: 1. 2. 3. Classification of Cancer - Review Tumors can be classified according to: 1. 2. 3. Tumor classification systems are intended to provide a standardized way to: – Communicate the status of the cancer to members of the health care team – Assist in determining the most effective treatment plan – Evaluate the treatment plan – Predict prognosis – Compare like groups for statistical purposes 1. Anatomic Site Classification Tumor is identified by the tissue of origin, anatomic site and the behavior of the tumor (e.g. benign or malignant) Examples: – Carcinomas originate from embryonal ectoderm (skin/glands) and endoderm (mucous membrane linings of the respiratory tract, GI tract & GU tract) – Sarcomas originate from embryonal mesoderm (connective tissue, muscle, bone, fat) – Lymphomas and leukemias originate from the hematopoietic system 2. Histologic Classification The appearance of abnormal cells and degree of differentiation are evaluated pathologically For many tumor types, 4 grades are used to evaluate abnormal cells based on the degree to which the cells resemble the tissue of origin – Grade I: Cells differ slightly from N cells (mild dysplasia) and are well differentiated – Grade II: Cells are more abnormal (moderate dysplasia) and moderately differentiated – Grade III: Cells are very abnormal (severe dysplasia) and poorly differentiated – Grade IV: Cells are immature and primitive (anaplasia) and undifferentiated; cell of origin is difficult to determine 3. Clinical Staging Classifying the extent and spread of disease is termed staging Stage 0: cancer in situ Stage I: tumor limited to the tissue of origin; localized tumor growth Stage II: limited local spread Stage III: extensive local and regional spread Stage IV: metastasis Is completed after the diagnostic workup and determines the treatment options Exemplar: Benign Brain Tumor It is estimated that 55,000 Canadians are surviving with a brain tumor, and that every day, 27 Canadians are diagnosed with one (Brain Tumor Foundation of Canada, 2019) Brain tumors can occur in any part of the brain or spinal cord – Primary à arising from tissues within the brain – Secondary à resulting from a metastasis from a malignant neoplasm elsewhere in the body. Secondary brain tumors are the most common type Meningioma makes up 54% of all benign brain tumors – Benign tumor of the meninges occurring at both cranial and spinal sites – Produces symptoms from local mass effect due to compression of neural structures or may present with seizure Benign Brain Tumor – Clinical Manifestations The clinical manifestations of brain tumors depend mainly on the location, the rate of growth, and the size of the tumor Generally, how will our patient present? Benign Brain Tumor - Complications If the tumor mass obstructs the ventricles or occludes the outlet, ventricular enlargement (hydrocephalus) can occur As a tumor expands, patients may develop manifestations of increased ICP, cerebral edema, or obstruction of the CSF pathways Unless treated, all brain tumors eventually cause death from increasing tumor volume leading to increased ICP Meningioma – Risk Factors Family history Headaches Neurological deficits Seizure Radiotherapy Meningioma – Diagnosis Diagnosis confirmed by the characteristic appearance on magnetic resonance imaging (MRI) with and without contrast enhancement *definitive diagnosis* CT Scan – may not be as cut and dry but more accessible (until MRI can be done) Asymptomatic lesions may be followed up with serial observation – The majority of incidental meningiomas show minimal growth – They may be observed without surgical intervention unless specific symptoms appear of the tumor demonstrating growth Meningioma – Treatment Treatment of symptomatic meningioma is usually surgical resection (open) In some cases, local radiotherapy is used as primary treatment Radiation therapy considered as adjuvant treatment for grade III meningiomas and in some cases grade II lesions Meningioma – Follow-Up/Monitoring All meningiomas should have a 6 month MRI follow-up after diagnosis then annually After 5 years, the interval can be doubled In those patients who have not had treatment of their meningioma, any change in headache pattern or development of new or progressive neurological symptoms should prompt a return for evaluation of the tumor In patients with seizure presentation, maintenance of anticonvulsant therapy may be required Benign Brain Tumor - Assessment Baseline neurological data LOC and cognitive function Motor abilities Sensory perception Integrated function (including bowel and bladder function) Balance and proprioception Coping abilities of the patient and family History of nervous system infections and trauma Presence of seizures, syncope, nausea and vomiting, pain, headaches, and physical limitations Benign Brain Tumor – Goals of Care Maintain normal ICP Maximize neurological functioning Be free from pain and discomfort Be aware of the long-term implications with respect to prognosis and cognitive and physical functioning Benign Brain Tumor – Interventions Assist the family in understanding what is happening to the patient and in emotionally supporting the family Safety – protecting both patient and self (if client manifests aggression) – Close supervision of activity; use of side rails; use of restraints; padding of the rails and the area around the bed; and a calm, reassuring approach to care are all essential techniques for the care of these patients If client confused à minimization of environmental stimuli, creation of a routine, and use of reality orientation If seizures present à seizure precautions, anticonvulsant medications Motor and sensory dysfunction à assist with self-care and mobility If communication impaired à establish a communication system that can be used by both the patient and the staff Nutritional intake may be decreased because of the patient’s inability to eat, loss of appetite, or loss of desire to eat à may need assistance or alternative way to provide nutrition may need to be considered Exemplar: Colorectal Cancer A malignant disease of the colon, the rectum, or both Colorectal cancer includes two types of cancers: 1. Cancer of the colon (large intestine or bowel) referred to as colon cancer 2. Cancer of the rectum (the end portion of the large intestine) or rectal cancer Because both types of cancer have many features in common, so they are collectively called colorectal cancer Second-most common cause of cancer death in Canada Colorectal Cancer Most common type is Adenocarcinoma The most common sites of metastasis are the regional lymph nodes, liver, lungs, and peritoneum – Because venous blood leaving the colon and rectum flows through the portal vein and inferior rectal vein, the liver and lung are common sites of metastasis – The cancer spreads from the liver to other sites, including the lungs, bones, and brain – The cancer can also spread directly into adjacent structures The growing tumor can obstruct the bowel Other complications include bleeding, perforation, peritonitis, and fistula formation Colorectal Cancer – Risk Factors Age >50 years Alcohol (>4 drinks per week) Chronic inflammatory bowel disease Cigarette smoking Colorectal polyps Familial adenomatous polyposis (FAP) Family history of CRC, ovarian, endometrial, or breast cancer (women) Diet high in red meat consumption Obsesity Colorectal Cancer – Clinical Manifestations How will our patient present? Colorectal Cancer – Screening Asymptomatic people should be screened with a fecal immunochemical test (FIT) every 2 years. Abnormal FIT results should be followed up with colonoscopy within 8 weeks Average risk = Ages 50 to 74 with no first-degree relative diagnosed with colorectal cancer and no personal history of pre-cancerous colorectal polyps requiring surveillance or inflammatory bowel disease (e.g. Crohn’s disease or ulcerative colitis) ColonCancerCheck recommends that people with no symptoms who are at increased risk of getting colorectal cancer get screened with a colonoscopy. Someone at increased risk should start screening at age 50, or 10 years earlier than the age their relative was diagnosed with colorectal cancer, whichever comes first The amount of time someone should wait until getting screened again after a normal colonoscopy result should be based on their family history: – Every 5 years for people with a first-degree relative who was diagnosed with colorectal cancer before age 60 – Every 10 years for people with a first-degree relative who was diagnosed with colorectal cancer at age 60 or older Colorectal Cancer – Diagnosis General physical exam including a digital rectal examination Laboratory tests Testing of stool sample for occult blood Colonoscopy Biopsy of colon or rectal tissue CT scan of abdomen and pelvis: to see the tumor and if the cancer has spread Colorectal Cancer – Treatment Various types of surgery can be done based on a multitude of factors (e.g. tumor resection vs. hemicolectomy) – Success of surgery depends on resection of the tumor with an adequate margin of healthy bowel and resection of the regional lymph nodes Chemotherapy/radiation based on staging Colorectal Cancer – Nursing Assessment Subjective: – Past health history: Previous breast or ovarian cancer, familial adenomatous polyposis (FAP), polyps, inflammatory bowel disease; family history of colorectal, breast, or ovarian cancer – Medications: Use of any medication affecting bowel function (e.g., cathartics, antidiarrheal agents) – Reports of weakness, fatigue, weight loss, N/V, change in bowel habits, abdominal or low back pain Objective: – Pallor, cachexia, lymphadenopathy (later signs) – Palpable abdominal mass (late sign), distension, ascites, and hepatomegaly (liver metastasis) – Anemia; positive fecal occult blood; palpable mass on digital rectal examination; positive sigmoidoscopy, colonoscopy, barium enema, or CT scan; positive biopsy Colorectal Cancer – Goals of Care Appropriate treatment (removal of tumor, adjunctive therapy) Normal bowel elimination patterns Quality of life appropriate to disease prognosis Relief of pain Feelings of comfort and well-being Colorectal Cancer – Nursing Interventions If surgery – relevant pre-op, intra-op, and post-op care Monitor the patient’s bowel patterns Monitors the patient’s diet modification, and assess the adequacy of his nutrition intake Direct the patient to follow a high fiber diet Caution him to take laxatives or an antidiarrheal medications only as prescribed by the doctor Inform the patient about screening and early detection Exemplar: Malignant Melanoma Melanoma is a tumor arising in melanocytes, the cells producing melanin The most aggressive of all skin cancers Causes the majority of skin cancer deaths – Unlike most cancers whose incidence is stable or decreasing, the incidence of melanoma is steadily rising à one of the fastest growing cancers worldwide – The Canadian Cancer Statistics Advisory Committee (2019) estimated that nearly 7800 new cases would be diagnosed in Canada in 2019, and nearly 1 300 Canadians would die from the disease Melanoma can occur in the eyes, ears, gastrointestinal tract, and oral and genital mucous membranes When it begins in the skin, it is called cutaneous melanoma Melanoma has the ability to metastasize to any organ, including the brain and heart Malignant Melanoma The leading cause of melanoma is (UV) radiation from the sun or artificial sources (tanning beds, sunlamps) According to the World Health Organization (WHO), 85% of melanomas among Canadian men and women aged 30+ years are attributed to UV radiation exposure UV radiation damages the deoxyribonucleic acid (DNA) in skin cells, causing mutations in their genetic code, thus altering the cells Also a genetic predisposition Types of Melanoma Superficial spread melanoma (SSM) – About 66% of all melanomas – May start from an existing mole (dysplastic nevus) Nodular melanoma (NM) – A nodule appears, usually not related to an existing mole Lentigo maligna melanoma (LMM) – Less common – Most commonly appears on the sun-exposed faces of the elderly Acral lentiginous melanoma (ALM) – Occurs on the palms or the soles of the feet or under the nail – Accounts for the majority of malignant melanomas for dark-skinned people but for only a small percentage of all melanomas for light-skinned people Malignant Melanoma – Clinical Manifestations Typically occurs on the lower legs (women) and trunk and head (men) ABCDEs – review this* Mole that changes shape or color Mole that is itchy or has a burning or tingling feeling Mole that has been bleeding Malignant Melanoma – Treatment Surgery – Standard treatment for the primary site of melanoma (where the cancer started) – Surgery to cure melanoma is usually done after a biopsy – For lower risk melanomas, the excision margin (area removed by surgery) may be 1 cm or less – Wider margins of up to 2 cm are often recommended for higher risk lesions. A skin graft is sometimes required. This is when skin is taken from one part of your body to help repair another part of your body. Lymph nodes are not usually removed if there is no evidence of spread Radiation therapy (may be used after lymph nodes are removed) Chemotherapy (used in some cases depending on staging) Malignant Melanoma – Interventions Wound care teaching Discuss the importance of sun safety, including wearing protective clothing, sunscreen, hats and sunglasses, and avoiding sun during high ultraviolet peak times Provide support and education about the likelihood of recurrence, and the risk of melanoma in family members Nurse should explain to patients how to perform skin and lymph node examinations. Patients with a history of melanoma are encouraged to monitor their skin and lymph nodes regularly, and to inform their physician of new or changing lesions or palpable lymph nodes. Having a spouse or other partner assist in skin examination is helpful Follow-up routinely with their dermatologist at the recommended intervals, depending on the stage of the melanoma Malignant Bone Tumors A sarcoma is a malignant tumor in the connective tissues of the body (fat, muscles, blood vessels, nerves, bones, or cartilage) Occur most often during childhood and young adulthood They are characterized by their rapid metastasis and bone destruction Most common: osteosarcoma, Ewing sarcoma, chondrosarcoma Exemplar: Osteosarcoma Osteosarcoma is the most common bone cancer in children and young adults – The peak age of incidence is between 10 and 25 years Malignant primary bone tumor Extremely aggressive and is characterized by rapid growth and metastasis Usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur Secondary osteosarcoma is known to occur in adults older than age 60 and is most commonly associated with Paget’s disease Metastasis is present in 10 to 20% of individuals on diagnosis, with the lung being the most frequent site Osteosarcoma - Symptoms Symptoms in early stage are often attributed to extremity injury or normal growing pains – Swelling near a bone – Bone or joint pain – Bone injury or bone break for no clear reason Primary clinical manifestations: gradual onset of pain and swelling, especially around the knee The neoplasm grows rapidly and can restrict joint motion if the tumor is close to a joint structure Osteosarcoma – Treatment Treatment may include surgical resection (limb salvage procedure) to save a limb or remove affected tissue, or amputation – Quality-of-life considerations also factor into the decision regarding limb salvage or amputation Chemotherapy is used to treat the cancer and may be used before and after surgery Osteosarcoma – Nursing Assessment Assess for: – Location and severity of pain – Localized pain at the affected site (may be severe or dull) that may be attributed to trauma or the vague complaint of “growing pains” à pain often is relieved by a flexed position – Swelling, changes in circulation, and joint function, movement, and sensation – Weakness caused by anemia and decreased mobility – Palpable bony mass – Limping – Progressively limited ROM – Child may avoid physical activity, be unable to hold heavy objects – Presence of pathological fractures Osteosarcoma – Goals of Care Have satisfactory pain relief Maintain preferred activities as long as possible Demonstrate acceptance of body image changes resulting from chemotherapy, radiation, and surgery Remain free from injury Verbalize a realistic idea of disease progression and prognosis Osteosarcoma – Interventions Pain should be carefully monitored and the nurse should ensure that the patient has adequate pain medication Regular rest periods should be provided between activities Prepare the child and family for prescribed treatment modalities, which may include surgical resection by limb salvage to remove affected tissue, amputation, and chemotherapy Communicate honestly with the child and family and provide support Prepare for prosthetic fitting as necessary The child may have challenges adapting to a changed self-image and may benefit from consulting with a child life worker or counsellor Instruct the child and parents about the potential development of phantom limb pain that may occur after amputation Education about community resources