Oncological Disease Conditions PDF

ONCOLOGICAL DISEASE CONDITIONS. URINARY TRACT CANCERS  Urinary tract cancers include those of the urinary bladder, kidney and renal pelvis, ureter, and other urinary structures, such as the prostate. Tobacco use continues to be a leading cause of all urinary tract cancers. CANCER OF KIDNEY ...

ONCOLOGICAL DISEASE CONDITIONS. URINARY TRACT CANCERS  Urinary tract cancers include those of the urinary bladder, kidney and renal pelvis, ureter, and other urinary structures, such as the prostate. Tobacco use continues to be a leading cause of all urinary tract cancers. CANCER OF KIDNEY  It affects almost twice as many men as women.  The most common type of renal tumor is,  Renal cell or renal adenocarcinoma, accounting for more than 85% of all kidney tumors.  These tumors may metastasize early to the lungs, bone, liver, brain, and contralateral kidney.  One third of patients have metastatic disease at the time of diagnosis. RISK FACTORS CLINICAL MANIFESTATIONS  Many renal tumors produce no symptoms, initially and are discovered on a routine physical examination as a palpable abdominal mass.  The classic triad of signs and symptoms, which occurs in only 10% of patients, comprises hematuria, pain, and a mass in the flank.  The usual sign that first calls attention to the tumor is painless hematuria, which may be either intermittent and microscopic or continuous and gross.  There may be a dull pain in the back from the pressure produced by compression of the ureter, extension of the tumor into the perirenal area, or hemorrhage into the kidney tissue.  Colicky pains occur if a clot or mass of tumor cells passes down the ureter.  Symptoms from metastasis may be the first manifestations of renal tumor and may include unexplained weight loss, increasing weakness, and anemia. ASSESSMENT AND DIAGNOSTIC FINDINGS  The diagnosis of a renal tumor may require,  Intravenous urography,  Cystoscopy examination,  Nephrotomograms,  Renal angiograms,  Ultrasonography, or a  CT scan MANAGEMENT  The goal of management is to eradicate the tumor before metastasis occur. SURGICAL MANAGEMENT  A radical nephrectomy -This includes removal of the kidney (and tumor), adrenal gland, surrounding perinephric fat and Gerota’s fascia, and lymph nodes.  Radiation therapy,  Hormonal therapy,  Chemotherapy may be used along with surgery.  Immunotherapy- For patients with bilateral tumors or cancer of a functional single kidney, nephron-sparing surgery (partial nephrectomy) may be considered.  Favorable results have been achieved in patients with small local tumors and a normal contralateral kidney.  Nephron-sparing surgery is increasingly being used to treat patients with solid renal lesions.  Laparoscopic nephroureterectomy  RENAL ARTERY EMBOLIZATION  The renal artery may be occluded to impede the blood supply to the tumor and thus kill the tumor cells.  After angiographic studies are completed, a catheter is advanced into the renal artery, and embolizing materials (Gelfoam, autologous blood clot, steel coils) are injected into the artery and carried with the arterial blood flow to occlude the tumor vessels mechanically.  This decreases the local blood supply, making removal of the kidney (nephrectomy) easier.  It also stimulates an immune response because infarction of the renal cell carcinoma releases tumor associated antigens that enhance the patient’s response to metastatic lesions.  The procedure may also reduce the number of tumor cells entering the venous circulation during surgical manipulation PHARMACOLOGICAL THERAPY  Depending on the stage of the tumor, percutaneous partial or radical nephrectomy may be followed by treatment with chemotherapeutic agents.  The use of biologic response modifiers such as interleukin-2 (IL-2) and topical instillation of bacillus Calmette-Guerin (BCG) in the renal pelvis continue to be studied, with both treatments currently used in clinical practice.- to increase their ability to kill cancer cells. NURSING MANAGEMENT  The patient with a renal tumor usually undergoes extensive diagnostic and therapeutic procedures, including surgery, radiation therapy, and medication (or systemic) therapy.  After surgery, the patient usually has catheters and drains in place to maintain a patent urinary tract, to remove drainage, and to permit accurate measurement of urine output.  Because of the location of the surgical incision, the position of the patient during surgery, and nature of the surgical procedure, pain and muscle soreness are common.  The patient requires frequent analgesia during the postoperative period and  Assistance with turning, coughing, use of incentive spirometry, and deep breathing are encouraged to prevent atelectasis and other pulmonary complications.  The patient and family require assistance and support to cope with the diagnosis and uncertainties about the prognosis. CANCER OF THE BLADDER  Cancer of the urinary bladder is more common in people aged 50 to 70 years.  There are two forms of bladder cancer: superficial (which tends to recur) and invasive.  About 80% to 90% of all bladder cancers are transitional cell (which means they arise from the transitional cells of the bladder); the remaining types of tumors are squamous cell and adenocarcinoma.  The predominant cause of bladder cancer today is cigarette smoking. Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder (Chart 45-14). RISK FACTORS CAUSES  The predominant cause of bladder cancer today,  Cigarette smoking.  Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder. CLINICAL MANIFESTATIONS  Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck.  Visible, painless hematuria is the most common symptom of bladder cancer.  Infection of the urinary tract is a common complication, producing frequency, urgency, and dysuria.  Any alteration in voiding or change in the urine, however, may indicate cancer of the bladder.  Pelvic or back pain may occur with metastasis ASSESSMENT AND DIAGNOSTIC STUDIES  The diagnostic evaluation includes,  Cystoscopy (the mainstay of diagnosis),  Excretory urography, a  CT scan,  Ultrasonography, and  Bimanual examination with the patient anesthetized.  Biopsies of the tumour and adjacent mucosa are the definitive diagnostic procedures.  Transitional cell carcinomas and carcinomas in situ shed recognizable cancer cells.  Cytologic examination of fresh urine and saline bladder washings provide information about the prognosis, especially for patients at high risk for recurrence of primary bladder tumours. MEDICAL MANAGEMENT  Treatment of bladder cancer depends on the grade of the tumor, the stage of tumor growth, and the multicentricity (having many centers) of the tumor. The patient’s age and physical, mental, and emotional status are considered when determining treatment modalities. SURGICAL MANAGEMENT  Transurethral resection or fulguration (cauterization) - may be performed for simple papilloma's (benign epithelial tumors). After the bladder sparing surgery, intravesical administration of BCG is the treatment of choice.  Patients with benign papillomas should undergo cytology and cystoscopy periodically for the rest of their lives because aggressive malignancies may develop from these tumor.  A simple cystectomy (removal of the bladder) or a radical cystectomy is performed for invasive or multifocal bladder cancer. 1. Radical cystectomy in men involves removal of the bladder, prostate, and seminal vesicles and immediate adjacent peri vesical tissues. 2. In women, radical cystectomy involves removal of the bladder, lower ureter, uterus, fallopian tubes, ovaries, anterior vagina, and urethra. It may include removal of pelvic lymph nodes. Removal of the bladder requires a urinary diversion procedure. PHARMACOLOGIICAL THERAPIES  Chemotherapy with a combination of methotrexate, 5-fluorouracil, vinblastine, doxorubicin (Adriamycin), and cisplatin has been effective in producing partial remission of transitional cell carcinoma of the bladder in some patients.  Intravenous chemotherapy may be accompanied by radiation therapy. The development of new chemotherapeutic agents such as gemcitabine and the taxanes has opened up promising new perspectives in the treatment of bladder cancer.  However, the preliminary phase II data must be confirmed in adequately conducted phase III trial.  Topical chemotherapy delivers a high concentration of medication (thiotepa, doxorubicin, mitomycin, ethoglucid, and BCG) to the tumor to promote tumor destruction. BCG is now considered the most effective intravesical agent for recurrent bladder cancer because it enhances the body’s immune response to cancer.  The optimal course of BCG appears to be a 6-week course of weekly instillations, followed by a 3-week course at 3 months in tumors that do not respond.  In high-risk cancers, maintenance BCG administered for 3 weeks every 6 months may limit recurrence and prevent progression.  The adverse effects associated with this prolonged therapy, however, may limit its widespread applicability. The patient is allowed to eat and drink before the instillation procedure, but once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding.  At the end of the procedure, the patient is encouraged to void and to drink liberal amounts of fluid to flush the medication from the bladder. RADIATION THERAPY  Radiation of the tumor may be performed preoperatively to reduce microextension of the neoplasm and viability of tumor cells, thus reducing the chances that the cancer may recur in the immediate area or spread through the circulatory or lymphatic systems.  Radiation therapy is also used in combination with surgery or to control the disease in patients with an inoperable tumor.  The transitional cell variety of bladder cancer responds poorly to chemotherapy. Cisplatin, doxorubicin, and cyclophosphamide have been administered in various doses and schedules and appear most effective.  Bladder cancer may also be treated by direct infusion of the cytotoxic agent through the bladder’s arterial blood supply. a large, water-filled balloon placed in the bladder produces tumor necrosis by reducing the blood supply of the bladder wall (hydrostatic therapy).  The instillation of formalin, phenol, or silver nitrate relieves hematuria and strangury (slow and painful discharge of urine) in some patients INVESTIGATIONAL THERAPY  The use of photodynamic techniques in treating superficial bladder cancer is under investigation.  This procedure involves systemic injection of a photosensitizing material (hematoporphyrin), which the cancer cell picks up.  A laser-generated light then changes the hematoporphyrin in the cancer cell into a toxic medication. This process is being investigated for patients in whom intravesical chemotherapy or immunotherapy has failed. MALIGNANT TUMORS OF FEMALE REPRODUCTIVE SYSTEM CANCER OF THE CERVIX  Carcinoma of the cervix is predominantly squamous cell cancer (10% are adenocarcinomas).  It is the third most common female reproductive cancer.  Cervical cancer occurs most commonly in women ages 30 to 45, but it can occur as early as age 18. RISK FACTORS PATHOPHYSIOLOGY  There are several different types of cervical cancer.  Most cancers originate in squamous cells, while the remainder are adenocarcinomas or mixed adenosquamous carcinomas.  Adenocarcinomas begin in mucus-producing glands and are often due to HPV infection.  Most cervical cancers, if not detected and treated, spread to regional pelvic lymph nodes, and local recurrence is not uncommon.  Early cervical cancer rarely produces symptoms. CLINICAL MANIFESTATIONS  A thin watery vaginal discharge often noticed after intercourse or douching.  Discharge, irregular bleeding, or bleeding after sexual intercourse occur, the disease may be advanced.  In advanced cervical cancer, the vaginal discharge gradually increases and becomes watery and, finally, dark and foul-smelling from necrosis and infection of the tumor.  The bleeding, which occurs at irregular intervals between periods (metrorrhagia) or after menopause, may be slight (just enough to spot the undergarments) and occurs usually after mild trauma or pressure (eg, intercourse, douching, or bearing down during defecation).  As the disease continues, the bleeding may persist and increase.  Leg pain, dysuria, rectal bleeding, and edema of extremities signal advanced disease.  As the cancer advances, it may invade the tissues outside the cervix, including the lymph glands anterior to the sacrum. ASSESSMENT AND DIAGNOSTIC FINDINGS  Pap smear results, followed by  Biopsy results identifying severe dysplasia -Biopsy results may indicate carcinoma in situ. Carcinoma in situ is technically classified as severe dysplasia and is defined as cancer that has extended through the full thickness of the epithelium of the cervix, but not beyond. This is often referred to as preinvasive cancer.  In later stages, pelvic examination may reveal a large, reddish growth or a deep, ulcerating lesion. The patient may report spotting or bloody discharge. MANAGEMENT  Conservative treatment may consist of monitoring,  cryotherapy (freezing with nitrous oxide), or laser therapy.  A loop electrocautery excision procedure (LEEP) may also be used to remove abnormal cells. In this procedure, a thin wire loop with laser is used to cut away a thin layer of cervical tissue.  cone biopsy or conization (removing a cone-shaped portion of the cervix) is performed when biopsy findings demonstrate CIN III or HGSIL, equivalent to severe dysplasia and carcinoma in situ. SURGICAL MANAGEMENT RADIATION THERAPY  Radiation, which is often part of treatment to reduce recurrent disease, may be delivered by an external beam or by brachytherapy (method by which the radiation source is placed near the tumor) or both.  The field to be irradiated and dose of radiation are determined by stage, volume of tumor, and lymph node involvement. Treatment can be administered daily for 4 to 6 weeks followed by one or two treatments of intracavitary radiation.  Interstitial therapy may be used when vaginal placement has become impossible due to tumor or stricture.  Platinum-based agents are being used to treat advanced cervical cancer.  Pelvic exenteration, in which a large portion of the pelvic contents is removed CANCER OF THE OVARY  Ovarian cancer causes more deaths than any other cancer of the female reproductive system.  About 75% of cases are detected at a late stage.  The ovary is a common site of primary as well as metastatic lesions from other cancers. Most cases affect women ages 50 to 59.  A woman with ovarian cancer has a threefold to fourfold increased risk for breast cancer, and women with breast cancer have an increased risk for ovarian cancer. CUASES  No definitive causative factors have been determined, but  oral contraceptives appear to provide a protective effect.  Heredity plays a part, and many physicians advocate pelvic examinations every 6 months for women who have one or two relatives with ovarian cancer. Despite careful examination, ovarian tumors are often difficult to detect because they are usually deep in the pelvis. No early screening mechanism exists at present, although tumor markers are being explored. Transvaginal ultrasound and Ca-125 antigen testing are helpful in those at high risk for this condition. Tumor-associated antigens are helpful in follow-up care after diagnosis and treatment but not in early general screening  Risk factors also include nulliparity and infertility. Older age is a major risk factor because the incidence of this disease peaks.  High dietary fat intake, mumps before menarche, use of talc in the perineal area, and family history are suspected to increase risk, STAGES OF OVARIAN CANCER CLINICAL MANIFESTATIONS  Symptoms are nonspecific and vague include,  Increased abdominal girth,  Pelvic pressure,  Bloating, indigestion,  Flatulence,  Increased waist size,  Leg pain, and  Pelvic pain  Ovarian cancer is often silent, but enlargement of the abdomen from an accumulation of fluid is the most common sign.  A palpable ovary in a woman who has gone through menopause. ASSESSMENT AND DIAGNOSTIC STUDIES  Enlarged ovary must be investigated.  Pelvic examination  Pelvic imaging techniques MEDICAL MANAGEMENT  SURGICAL MANAGEMENT  Surgical staging, exploration, and reduction of tumor mass are the basics of treatment.  Surgical removal is the treatment of choice; the preoperative workup includes, a  barium enema or colonoscopy,  upper gastrointestinal series,  chest x-rays, and  intravenous urography.  CT scans and immunoscintigraphic, the use of radioactive antibodies, may be used preoperatively to rule out intra-abdominal metastasis.  Staging the tumor is important to guide treatment (Chart 47-9).  A total abdominal hysterectomy with removal of the fallopian tubes and ovaries and the omentum (bilateral salpingooophorectomy and omentectomy) is the standard procedure for early disease. PHARMACOLOGICAL THERAPY  Chemotherapy often follows surgery, usually with  Cyclophosphamide (cytoxan),  Doxorubicin (adriamycin),  Cisplatin (platinol-aq)- Cisplatin is used frequently in chemotherapeutic treatment of ovarian cancer, both alone and in combination with other agents, and in intraperitoneal applications  Carboplatin (paraplatin)- Carboplatin may be used in the initial treatment of advanced ovarian cancer in combination with other chemotherapeutic agents  Paclitaxel (taxol). -Paclitaxel is contraindicated in patients with hypersensitivity to medications formulated in polyoxyethylated castor oil and in patients with baseline neutropenia  Hexamethylmelamine (hexalen),  Ifosfamide (ifex),  Bone marrow transplantation, and peripheral blood stem cell support may also be used.  Paclitaxel, cisplatin, and carboplatin are most often used because of their excellent clinical benefits and manageable toxicity.  Leukopenia, neurotoxicity, and fever may occur. LIPOSOMAL THERAPY  Liposomal therapy- delivery of chemotherapy in a liposome, allows the highest possible dose of chemotherapy to the tumor target with a reduction in adverse effects.  Liposomes are used as drug carriers because they are nontoxic, biodegradable, easily available, and relatively inexpensive.  This encapsulated chemotherapy allows increased duration of action and better targeting.  The encapsulation of doxorubicin lessens the incidence of nausea, vomiting, and alopecia.  The patient must be monitored for bone marrow suppression. Gastrointestinal and cardiac effects may also occur.  These medications are administered by oncology nurses as a slow intravenous infusion over 60 to 90 minutes. ADJUNCT THERAPIES  Genetic engineering and identification of cancer genes may make gene therapy a future possibility. Gene therapy is under investigation.  Radiation may be helpful and is more useful in some types of ovarian cancer than others. NURSING MANAGEMENT  Nursing measures include,  Emotional support,  comfort measures, and  information,  plus attentiveness and caring, are meaningful aids to the patient and her family. CANCER OF UTERUS INTRODUCTION  Most uterine cancers are endometrioid (that is, originating in the lining of the uterus).  After breast, colorectal, and lung cancer, endometrial cancer is the fourth most common cancer in women and the most common pelvic neoplasm RISK FACTORS  Age: at least 55 years; median age, 61 years  Postmenopausal bleeding  Obesity that results in increased estrone levels (related to excess weight) resulting from conversion of androstenedione to estrone in body fat, which exposes the uterus to unopposed estrogen  Unopposed estrogen therapy (estrogen used without progesterone, which offsets the risk of unopposed estrogen)  Other: nulliparity, truncal obesity, late menopause (after 52 years of age) and, possibly, use of tamoxifen  Other risk factors include infertility, diabetes, hypertension, gallbladder diseas. DIAGNOSTIC STUDIES  Annual checkups, including a gynecologic examination.  Any woman who is experiencing irregular bleeding should be evaluated promptly.  If a menopausal or perimenopausal woman experiences bleeding, an endometrial aspiration or biopsy is performed to rule out hyperplasia, a possible precursor of endometrial cancer. The procedure is quick and painless.  Ultrasonography can also be used to measure the thickness of the endometrium. (Postmenopausal women should have a very thin endometrium due to low levels of estrogen; a thicker lining warrants further investigation.)  A biopsy or aspiration is diagnostic. MEDICAL MANAGEMENT  Treatment of endometrial cancer consists of,  Depending on the stage, the therapeutic approach is individualized and is based on stage, type, differentiation, degree of invasion, and node involvement.  Total hysterectomy (discussed later in this chapter) and  Bilateral salpingo-oophorectomy and node sampling.  Whole pelvis radiotherapy is used if there is any spread beyond the uterus.  Preoperative and postoperative treatments for stage II and beyond may include pelvic, abdominal, and vaginal intracavitary radiation.  Recurrent cancer usually occurs inside the vaginal vault or in the upper vagina.  metastasis usually occurs in lymph nodes or the ovary. Recurrent lesions in the vagina are treated with surgery and radiation.  Recurrent lesions beyond the vagina are treated with hormonal therapy or chemotherapy. Progestin therapy is used frequently.  Patients should be prepared for such side effects as nausea, depression, rash, or mild fluid retention with this therapy BREAST CANCER INTRODUCTION  Current statistics indicate that a woman’s lifetime risk for developing breast cancer is 1 in 8, but this risk is not the same for all age groups.  For example, the risk for developing breast cancer by age 35 years is 1 in 622; the risk for developing breast cancer by age 60 years is 1 in 23.  Approximately 80% of breast cancers are diagnosed after the age of 50.  Women who are diagnosed with early stage localized breast cancer have a 5-year survival rate of 98% (ACS, 2002) RISK FACTORS  BRCA-1 or BRCA-2 genetic mutation  Women with gene mutation have a 50% to 90% chance of developing breast cancer and a 50/50 possibility of developing breast cancer before 50 years of ag  Increasing age Greatest risk for breast cancer occurs after age 50.  Personal or family history of breast cancer  Risk of developing breast cancer in the other breast increases about 1% per year. Risk increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer Risk increases if the mother was affected with cancer before 60 years of age. Risk increases four to six times if breast cancer occurred in two first-degree relatives.  Early menarche Menses beginning before 12 years of age  Nulliparity and late maternal age at first birth Women having their first child after 30 years of age have twice the risk for breast cancer as women having first child before 20 years of age.  Late menopause  Menopause after 55 years of age but women with bilateral oophorectomy before 35 years of age have one third the risk.  History of benign proliferative breast disease  Risk doubles in women with benign tumors with proliferative epithelial changes; risk quadruples with atypical hyperplasia or LCIS.  Exposure to ionizing radiation between puberty and 30 years of age.  Risk doubles; exposure to radiation causes potential aberrations while the breast cells are developing.  Obesity  Weak risk among obese postmenopausal women: estrogen is stored in body adipose tissue, and dietary fat increases pituitary prolactin, thus increasing estrogen production. Obese women diagnosed with breast cancer have a higher mortality rate, which may be related to these hormonal influences or perhaps a delayed diagnosis  Hormone replacement therapy  Reported risk for breast cancer related to hormone replacement therapy varies. Older women taking estrogen supplements for more than 5 years may have an increased risk; addition of progesterone to estrogen replacement decreases the incidence of endometrial cancer, but it does not decrease the risk of breast cancer.  Alcohol intake  As a risk factor, alcohol use remains controversial; however, a slightly increased risk is found in women who consume even one drink daily. The risk doubles among women drinking three drinks daily. In countries where wine is consumed daily (eg, France and Italy), the rate is slightly higher. Some research findings suggest that young women who drink alcohol are more vulnerable in later years. CLINICAL MANIFESTATIONS  Breast cancers occur anywhere in the breast, but most are found in the upper outer quadrant, where most breast tissue is located.  Generally, the lesions are nontender rather than painful,  Fixed rather than mobile, and  Hard with irregular borders rather than encapsulated and smooth.  Complaints of diffuse breast pain and tenderness with menstruation are usually associated with benign breast disease.  Marked pain at presentation, however, may be associated with breast cancer in the later stages.  Dimpling or for a peau d’orange (orange-peel) appearance of the skin (a condition caused by swelling that results from obstructed lymphatic circulation in the dermal layer).  Nipple retraction and lesions fixed to the chest wall may also be evident.  Involvement of the skin is manifested by ulcerating and fungating lesions. These classic signs and symptoms characterize breast cancer in the late stages. ASSESSMENT AND DIAGNOSTIC FINDINGS  Techniques to determine the histology and tissue diagnosis of breast cancer include,  FNA,  Excisional (or open) biopsy,  Incisional biopsy,  Needle localization,  Core biopsy, and  Stereotactic biopsy (all described previously).  Histologic examination of the cancer cells BREAST CANCER STAGING PROGNOSIS  It starts with a genetic alteration in a single cell.  It can take about 16 doubling times for a carcinoma to become 1 cm or larger, at which point it becomes clinically apparent.  Assuming that it takes at least 30 days for each doubling time, it would take a minimum of 2 years for a carcinoma to become palpable. MANAGEMENT SURGICAL MANAGEMENT  Lymphatic Mapping and Sentinel Node Biopsy.  Is changing the way these patients are treated because it provides the same prognostic information as the axillary dissection. A radiocolloid and/or blue dye is injected into the tumor site; the patient then undergoes the surgical procedure. RADIATION THERAPY  With breast-conserving surgery, a course of external-beam radiation therapy usually follows excision of the tumor mass to decrease the chance of local recurrence and to eradicate any residual microscopic cancer cells.  Radiation treatment is necessary to obtain results equal to those of removal of the breast. If radiation therapy is contraindicated, mastectomy is the patient’s only option.  Radiation treatment typically begins about 6 weeks after the surgery to allow the incision to heal. If systemic chemotherapy is indicated, radiation therapy usually begins after completion of the chemotherapy.  External-beam irradiation provided by a linear accelerator using photons is delivered on a daily basis over 5 to 7 weeks to the entire breast region. CHEMOTHERAPY  Chemotherapy is administered to eradicate the micrometastatic spread of the disease.  Chemotherapy regimens for breast cancer combine several agents to increase tumor cell destruction and to minimize medication resistance.  doxorubicin (Adriamycin) (A) cyclophosphamide (Cytoxan) (C) methotrexate (M) 5-fluorouracil (F) paclitaxel (Taxol) (T) epirubicin (Ellence) (E) docetaxel (Taxotere) (T) Combination therapy: CMF CAF AC ACT CEF HORMONAL THERAPY  Androgens fluorymesterone (Halotestin)  Estrogens diethylstilbestrol (DES)  Corticosteroids prednisone  Antihormonal agents tamoxifen (Nolvadex) megestrol acetate (Megace)  aminoglutethimide (Cytadren)  anastrazole (Arimidix) CANCER OF THE LARYNX INTRODUCTION  Cancer of the larynx is a malignant tumor in the larynx (voice box).  It is potentially curable if detected early.  It represents less than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age. RISK FACTORS  The malignant growth may occur in three different areas of the larynx,  The glottic area (vocal cords),  Supraglottic area (area above the glottis or vocal cords, including epiglottis and false cords), and  Subglottis (area below the glottis or vocal cords to the cricoid) CLINICAL MANIFESTATIONS  Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech.  The voice may sound harsh, raspy, and lower in pitch.  Affected voice sounds are not early signs of subglottic or supraglottic cancer.  The patient may complain of a cough or sore throat that does not go away and pain and burning in the throat, especially when consuming hot liquids or citrus juices.  A lump may be felt in the neck.  Later symptoms include  dysphagia,  dyspnea (difficulty breathing),  unilateral nasal  obstruction or discharge,  persistent hoarseness,  persistent ulceration, and foul breath.  Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis. ASSESSMENT AND DIAGNOSTIC STUDIES  History and physical examination of the head and neck- will include assessment of risk factors, family history, and any underlying medical conditions.  An indirect laryngoscopy- using a flexible endoscope, is initially performed in the otolaryngologist’s office to visually evaluate the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway.  The lymph nodes of the neck and the thyroid gland are palpated to determine spread of the malignancy.  Computed tomography and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue and to help stage and determine the extent of a tumor.  MRI is also helpful in post-treatment follow-up in order to detect a recurrence.  Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after treatment. MEDICAL MANAGEMENT  Treatment of laryngeal cancer depends on the staging of the tumor, which includes the location, size, and histology of the tumor and the presence and extent of cervical lymph node involvement.  Treatment options include surgery, radiation therapy, and chemotherapy. SURGICAL MANAGEMENT  Depending on the location and staging of the tumor, four different types of laryngectomy (surgical removal of part or all of the larynx and surrounding structures) are considered:  Partial laryngectomy  Supraglottic laryngectomy  Hemilaryngectomy  Total laryngectomy  Some microlaryngeal surgery can be performed endoscopically. The CO2 laser can be used for the treatment of many laryngeal tumors, with the exception of large vascular tumors  Partial Laryngectomy.  A partial laryngectomy (laryngofissure– thyrotomy) is recommended in the early stages of cancer in the glottic area when only one vocal cord is involved.  A portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact and the patient is expected to have no difficulty in swallowing.  The voice quality may change.  Supraglottic Laryngectomy.  A supraglottic laryngectomy is indicated in the management of early (stage I) supraglottic and stage II lesions.  The hyoid bone, glottis, and false cords are removed.  The true vocal cords, cricoid cartilage, and trachea remain intact.  During surgery, a radical neck dissection is performed on the involved side.  Hemilaryngectomy.  A hemilaryngectomy is performed when the tumor extends beyond the vocal cord but is less than 1 cm in size and is limited to the subglottic area.  It may be used in stage I glottic lesions. In this procedure, the thyroid cartilage of the larynx is split in the midline of the neck and the portion of the vocal cord (one true cord and one false cord) is removed with the tumor. The arytenoid cartilage and half of the thyroid are removed.  Total Laryngectomy.  A total laryngectomy is performed in the most advanced stage IV laryngeal cancer, when the tumor extends beyond the vocal cords, or for recurrent or persistent cancer following radiation therapy.  In a total laryngectomy, the laryngeal structures are removed, including the hyoid bone, epiglottis, cricoid cartilage, and two or three rings of the trachea. The tongue, pharyngeal walls, and trachea are preserved.  A total laryngectomy will result in permanent loss of the voice and a change in the airway. RADIATION THERAPY  The goal of radiation therapy is to eradicate the cancer and preserve the function of the larynx.  The decision to use radiation therapy is based on several factors including,  The staging of the tumor (usually used for stage I and stage II tumors as a standard treatment option)  Patient’s overall health status,  Lifestyle (including occupation),  Personal preference  Radiation therapy may also be used preoperatively to reduce the tumor size. Radiation therapy is combined with surgery in advanced (stages III and IV) laryngeal cancer as adjunctive therapy to surgery or chemotherapy, and as a palliative measure.  A variety of clinical trials have combined chemotherapy and radiation therapy in the treatment of advanced laryngeal tumors.  Early studies suggest that combined modality therapy may improve the tumor’s response to radiation therapy. Radiation therapy combined with chemotherapy may be an alternative to a total laryngectomy. COMPLICATIONS  The complications from radiation therapy are a result of external radiation to the head and neck area, which may also include the parotid gland responsible for mucus production.  The symptoms may include acute mucositis, ulceration of the mucous membranes, pain, xerostomia (dry mouth), loss of taste, dysphasia, fatigue, and skin reactions. Later complications may include laryngeal necrosis, edema, and fibrosis. SPEECH THERAPY  The three most common techniques of alaryngeal communication are,  Esophageal speech,  Artificial larynx (electrolarynx),  Tracheoesophageal puncture NURSING DIAGNOSIS  Deficient knowledge about the surgical procedure and postoperative course.  Anxiety and depression related to the diagnosis of cancer and impending surgery.  Ineffective airway clearance related to excess mucus production secondary to surgical alterations in the airway.  Impaired verbal communication related to anatomic deficit secondary to removal of the larynx and to edema.  Imbalanced nutrition: less than body requirements, related to inability to ingest food secondary to swallowing difficulties.  Disturbed body image and low self-esteem secondary to major neck surgery, change in the structure and function of the larynx.  Self-care deficit related to pain, weakness, fatigue, musculoskeletal impairment related to surgical procedure. CANCER OF PROSTATE  Prostate cancer is the most common cancer in men other than nonmelanoma skin cancer.  Risk factors for prostate cancer include increasing age: the incidence of prostate cancer increases rapidly after the age of 50 years, and more than 70% of cases occur in men over 65 years of age.  pe but is rare in Asia, Africa, Central America, and South America. A familial predisposition may occur in 5% to 10% of cases of prostate cancer. Having a father or brother with prostate cancer doubles the risk; the risk increases further if several relatives have had prostate cancer and if the relatives were young at diagnosis. A diet high in red meat and fat increases the risk for prostate cancer (American Cancer Society, 2002). Large-scale studies are in progress to determine if prostate cancer can be prevented by use of selected supplements or finasteride (Proscar).