327: Abnormal Cell Growth

Define hyperplasia.

increase in number of cells

Define hypertrophy.

increase in cell size

What are the two common types of altered cell growth?

1) Benign - does not usually require intervention

2) Malignant - indicates cancer

What are 9 characteristics of normal cells?

1) Specific morphology (shape, size, etc)

2) Small nuclear to cytoplasmic ratio

3) At least 1 specific function

4) Tight adherence because of proteins

5) Non-migratory (stays in area of origin)

6) Orderly and well-regulated growth

7) Contact inhibition (stops dividing appropriately)

8) Apoptosis (destruction of abnormal cells)

9) Euploidy (complete set of 23 pairs of chromosomes)

What is one characteristic that distinguishes a normal cell from a benign one?

Benign have continuous or inappropriate cell growth. They grow in the wrong place or at the wrong time due to a problem with cell regulation.

What are some examples of benign tumor cells?

Moles, uterine fibroid tumors, skin tags, endometriosis, & nasal polyps.

What are 10 characteristics of cancer (malignant) cells?

1) Rapid or continuous cell division

2) Anaplastic (Unlike parent cell)

3) Large nuclear-to-cytoplasmic ratio

4) Specific normal functions lost

5) Loose adherence

6) Migration

7) No contact inhibition

8) Growth by invasion

9) Abnormal chromosomes (aneuploid)

10) High mitotic index

Define carcinogenesis/ oncogenesis.

Cancer development

Define malignant transformation.

Process of changing a normal cell to a cancer cell

What are the 4 steps in malignant transformation?

1) Initiation: damage to cell DNA causes a change in gene expression, leading to a loss of cell regulation.

2) Promotion: promoters (which are often many normal hormones like insulin & body proteins) enhance cell growth.

3) Progression: continued change of cancer, making it more malignant over time & getting its own blood supply.

4) Metastasis: spreads to other parts of the body.

Define latency period.

The time between a cell's initiation & development of an overt tumor. Can range from months to years.

Explain metastasis.

Metastasis occurs when cancer cells break off and move to other parts of the body to create metastatic or secondary tumors.

Even though the cancer is now in a new spot, it is still defined by where it came from. For example, if breast cancer spreads to the lungs it is still breast cancer just in the lungs, not lung cancer.

What are 7 ways metastasis occurs?

1) Extension into surrounding tissues

2) Blood vessel penetration

3) Release of tumor cells

4) Invasion

5) Local seeding

6) Bloodborne metastasis

7) Lymphatic spread

Look at figure 21-3 pg. 376 in Iggy.

Will cancer in soft tissue like the breast cause death?

Alone it will not. Death can occur if it spreads to a vital organ & disrupts life functions.

Define grading.

Classifies cellular aspects of cancer. It compares it to the parent cell from which it arose. High grade means it is poorly differentiated and more aggressive.

Define ploidy.

Description of cancer cells by chromosome number and appearance. Euploidy is normal.

Describe the T in the TNM classification system.

T: Primary tumor

Tx- primary tumor cannot be assessed

T0- no evidence of primary tumor

Tis- carcinoma in situ

T1, T2, T3, T4- Increasing in size and/or local extent

Describe the N in TNM classification system.

N: Regional lymph nodes

Nx- regional lymph nodes cannot be assessed

N0- No regional lymph node metastasis

N1, N2, N3- Increasing involvement of regional lymph nodes

Describe the M in the TNM classification system.

M: Distant metastasis

Mx- presence of distant metastasis cannot be assessed

M0- no distant metastasis

M1- distant metastasis

Look at McCance fig 12-25 on PP slide 13.

Define doubling time.

The amount of time it takes for a tumor to double in size

Define mitotic index.

The percentage of actively dividing cells within a tumor. <10% is a slow growing tumor, while > 85% is faster.

Define oncogene activation (initiation).

the main mechanism of carcinogenesis.

What are oncogenes?

A gene that has potential to cause cancer. They are part of every cell's normal makeup. They only become a problem if they are overexpressed as a result of exposure to carcinogenic agents or events of loss of cell regulation.

What are 5 factors that can cause cancer?

1) Chemical carcinogenesis- tobacco, alcohol

2) Physical carcinogenesis- chronic irritation, UV rays

3) Viral carcinogenesis- oncoviruses break DNA & insert their own

4) Dietary factors- poorly understood

5) Personal factors- age, genetics, being on immunosuppressant

What are 5 viruses that can cause cancer?

1) Epstein Barr

2) Hep B

3) Hep C

4) HPV

5) Human lymphotrophic virus types I & II

What are the 7 warning signs of cancer?

CAUTION:

Changes in bowel or bladder habits

A sore that does not heal

Unusual bleeding or discharge

Thickening or lump in breast or elsewhere

Indigestion or difficulty swallowing

Obvious change in wart or mole

Nagging cough or hoarseness

What are 5 primary cancer prevention techniques?

1) Avoidance of known or potential carcinogens

2) Modification of associated factors

3) Removal of "at-risk" tissues

4) Chemoprevention- use of drugs to disrupt steps of cancer

5) Vaccination

What does secondary cancer prevention consist of? What are 5 specific screening tests & who gets them?

Screening

1) Annual mammogram ages 40-44 (optional), annual ages 45-54 (necessary), annual or biennial > 55

2) Annual breast exam women > 40, q 3 years ages 20-39

3) Colonoscopy at 50 then q 10 years

4) Annual FOB test for all adults

5) Digital rectal exam men > 50

What are 4 general disease-related consequences of cancer?

1) Reduced immune and blood-producing function- treatment reduces WBCs & platelets

2) Altered GI structure and function- GI obstruction from tumors or cachexia

3) Motor and sensory deficits- when cancers invade bone or brain or compress nerves

4) Decreased respiratory function- disrupts gas exchange & leads to death

What is the purpose of radiation therapy?

destroy cancer cells with minimal damaging effects on surrounding normal cells

What are the 2 types of rays used in radiation?

Gamma (stronger, deeply penetrate tissue) & beta (weaker)

What is the difference between teletherapy and brachytherapy?

Tele: radiation delivered by external beam

Brachy: radiation delivered by internal devices

What is a benefit of teletherapy?

Because the source is external, the patient is not radioactive and not a hazard to others.

What are the 2 types of teletherapy radiation?

1) Intensity-modulated (IMRT)- breaks one beam into thousands of smaller ones, allowing different intensities to be delivered to specific areas of tumor.

2) Stereotactic body (SBRT)- Uses 3D tumor imaging to identify exact location. Patient must be in exact position for all (3-5) treatments. Lots of tattoos will be placed that should NOT be tampered with in any way.

What are the 2 types of brachytherapy?

1) Sealed, implant: radiation is sealed or implanted within tumor. Can be permanently left in place. The patient emits radiation, so they are a hazard to others. However, the urine and stools do not.

2) Unsealed: radiation is instilled in body fluids so both patient & waste are hazardous.

What is the source with brachytherapy?

The patient

What are 4 side effects of radiation?

Vary according to site & normal tissue in the area radiation passes through:

1) Local skin changes and hair loss (likely permanent depending on total absorbed dose)

2) Altered taste sensations d/t metabolic release from dead cells

3) Fatigue related to increased energy demands

4) Inflammatory responses that cause tissue fibrosis and scarring

What are 6 nursing interventions for a patient receiving external radiation therapy?

1) Do not remove markings

2) Administer skin care gently

3) Use lotions to protect skin according to department policy

4) Avoid direct skin exposure to sunlight

5) Care for xerostomia (dry mouth)

6) Bone exposed to radiation more vulnerable to fracture

What are nursing interventions for patient with sealed implants?

Look at Iggy chart 22-1

What are 3 nursing interventions for patient with unsealed radiation?

1) Be aware of the specific radiation's half-life.

2) Do not touch waste or body fluids with your skin.

3) Client avoids close contact with others for days.

Describe chemotherapy.

Treatment of cancer with chemical agents. Its effects are systemic, providing the opportunity to kill metastatic cancer. Chemo also exerts its effects on healthy cells, such as the skin, hair, intestinal tissues, spermatocytes, ovaries, & blood-forming cells.

What are 8 types of chemo drugs?

1) Antimetabolites (5-FU, methotrexate, -ine)

2) Antitumor antibodies (-cin, -- vesicants)

3) Antimitotic agents (-taxel)

4) Plant Alkaloids (Vin-, -- vesicants)

5) Alkylating agents (high-mod N/V)

6) Topoisomerase inhibitors

7) Miscellaneous chemotherapeutic agents

8) Combination chemotherapy

What is the scheduling for chemo?

Usually q 3-4 weeks but may be dose-dense (rounds closer together)

What is the purpose of intermittent chemo?

To allow normal cells to repopulate between rounds of treatment. Unfortunately the cancer cells may repopulate as well, which causes failed treatment.

Why do cytotoxic drugs injure normal issues as well?

They lack selective toxicity

Where does serious toxicity occur with cytotoxic drugs?

In tissues with a high growth fraction (more proliferating cells) such as hair follicles, GI epithelium, bone marrow, and sperm forming cells.

Why do solid tumors respond poorly to cytotoxic drugs?

They have a low growth fraction (number of proliferating cells). Cytotoxic drugs are most active against proliferating cells.

What are surgery and irradiation the treatment of choice for? Drugs?

Solid tumors

Disseminated cancers

Cytotoxic drugs can cause myelosuppression. What can this lead to?

Neutrophilia, anemia & thrombocytopenia

Why are chemo drugs often used along with radiation or surgery?

To kill off any cells left after the treatment

What is the difference with noncytotoxic drugs?

Noncytoxic drugs are not phase specific & they lack the characteristic toxicities of cytotoxic anticancer drugs.

Is it serious if a neutropenic patient develops an infection?

Yes! Immediate & vigorous intervention is required

What are common issues that can occur with chemo?

Extravasation from vesicants. The primary nursing intervention is prevention: carefully monitor for blood return at site they are given.

What must the nurse ensure when administering IV or oral chemo?

That they are wearing a gown, goggles, gloves, full face shield (all must be chemo resistant to keep you from absorbing drug).

What are 6 side effects of chemo?

1) Infection

2) Mucositis- stomatitis

3) Alopecia

4) Changes in cognitive function

5) Peripheral neuropathy

6) Chemo induced N/V (CINV)

When is the infection risk the highest?

At nadir (lowest point in WBC count)

What is neutropenia?

Absolute neutrophil count < 1

What is mucostitis?

Sores in mucous membranes. It is a dose-limiting side effect of cancer therapy & a common reason for stopping or delaying treatment.

What is mouth care for patients with mucositis?

Iggy chart 22-8

Besides mouth care q 12 h, what other treatments may be used for someone with mucositis or stomatitis?

"Swish & spit" - anti-inflammatory, anesthetic, etc.

Lidocaine, diphenhydramine

What is the best treatment for CINV?

Triple drug treatment (steroid, precipitant & anti-emetic)

What is care for someone with peripheral neuropathy?

Iggy chart 22-9

What do antiemetics for CINV end in?

-setron

What is hormonal manipulation and why may it be used for cancer?

Changing the body's normal hormone responses. Steroids, steroid analogues, or enzyme inhibitors may be used to block receptors and prevent cancer cells from receiving normal hormonal growth stimulation.

Hormones cause hormone-sensitive tumors to grow more rapidly.

What are 7 side effects of hormonal manipulation?

1) Masculinizing effects in women

2) Feminizing effects in men (gynecomastia)

3) Risk for venous thromboembolism

4) Acne

5) Hypercalcemia

6) Liver dysfunction

7) Bone loss

What is photodynamic therapy?

Selective destruction of cancer cells via chemical reaction triggered by different types of laser light

What must the patient receiving photodynamic therapy be taught?

They will experience general sensitivity to light for up to 12 weeks after injection of photosensitizing drug, so they need to wear sunglasses & other protection from sun.

What are biological response modifiers (BRMs)?

Meds that modify the patient's biological responses to tumor cells. Could be:

1) Cytokines, which enhance immune system & treat pancytopenia.

2) Interleukins or interferons, which attack &/or destroy cancer cells

What are side effects to BRMs like?

Generalized. Sometimes severe inflammatory reactions, peripheral neuropathy, skin rashes

What are targeted therapies?

Drugs targeted to a specific part of transcription pathway to block cancer cell reproduction.

Overall, cancer cells have more active signal transduction pathways and transcription factors that lead to excessive division of cancer cells, so these help to stop that.

What is the main action of tyrosine kinase inhibitors? Side effects?

inhibit activation of tyrosine kinases (family of enzymes that functions as on/off switch)

fluid retention, electrolyte imbalances, & bone marrow suppression

What do epidermal growth factor/receptor inhibitors do?

Block epidermal growth factor from binding to cell surface receptor, which activates tyrosine kinase.

Ex. Trastuzumab (Herceptin)

What do vascular endothelial growth factor/receptor inhibitors do?

Bind to vascular endothelial growth factor (VEGF) to prevent it from binding with its receptors on surfaces of endothelial cells present in blood vessels. This inhibits formation of new blood cells within a tumor.

Ex. Bevacizumab (Avastin)

What are multikinase inhibitors?

Inhibit activity of specific kinases in cancer cells and tumor blood vessels

Ex. Sunitinib (Sutent)

What are proteasome inhibitors?

Prevent formation of a large complex of proteins (proteasome) into cells, which helps regulate the genes that promote cell division & prevent cell death

Ex. Bortezomib (Velcade)

What are angiogenesis inhibitors?

They target a specific protein kinase known as mammalian target of rapamycin (mTOR). This greatly reduces the concentration of VEGF and disrupts pro-cell pathways.

Ex. Temsirolimus (Torisel)

What do monoclonal antibodies do?

Bind to target antigens (often specific cell surface membrane proteins). This prevents proteins from functioning & prevents cell division.

Ex. Rituximab (Rituxan)

What are 2 oncologic emergencies associated with the bloodstream? Describe them.

1) Sepsis: Organisms enter bloodstream & result in septic shock. Impaired immunity puts patients at risk.

2) Disseminated intravascular coagulation: Extensive, abnormal clotting that can result in extensive bleeding.

What is syndrome of inappropriate antidiuretic hormone?

Water is reabsorbed to excess by kidneys & put into system circulation. Retained water dilutes blood sodium levels, causing hyponatremia. Most commonly found in lung cancer.

When may spinal cord compression occur in cancer?

When a tumor enters the spine or vertebrae collapse from tumor degradation of the bone.

What are 5 ways to manage spinal cord compression?

1) Early recognition and treatment

2) High-dose corticosteroids

3) High-dose radiation

4) Surgery

5) External back or neck braces to reduce pressure in spinal cord

When does hypercalcemia most often occur in cancer? What are symptoms?

Bone metastasis

Fatigue, loss of appetite, N/V, constipation, polyuria, severe muscle weakness, loss of DTRs, paralytic ileus, dehydration, ECG change

What is superior vena cava syndrome (SVCS)? What are signs of it?

Superior vena cava compressed or obstructed by tumor growth. Can lead to painful, life-threatening emergency.

Facial edema, Stokes' sign, edema of arms and hands, dyspnea, erythema, epistaxis

What are 2 treatments for SVCS?

1) High-dose radiation therapy to upper chest to relieve airway obstruction

2) Metal stent in vena cava to relieve swelling

What is tumor lysis syndrome? What is treatment?

Large numbers of tumor cells are destroyed rapidly, which results in intracellular contents being released into bloodstream faster than the body can eliminate them.

High flow rates for hydration & IV sodium bicarbonate

What is palliative care?

Symptom management to enhance quality of life for those with chronic conditions.

Define advance directive.

a legal document that explains how you want medical decisions about you to be made if you cannot make the decisions yourself.

Define durable power of attorney.

authorizes someone else to handle certain matters, such as finances or health care, on your behalf.

Compare palliative and hospice care.

Iggy Table 7-2