4.

CELLULAR ABERRATION
The Biology of Cancer part 3
CARCINOMA OF THE BREAST
¢ Most common non-skin malignancy in women
¢ Most important risk factor is gender – only 1% of
breast cancer occur in men
¢ Incidence rises throughout the woman’s lifetime,
peaking at age of 75 to 80 years, and then
declining slightly thereafter
¢ Women who reach menarche when younger than
11 years of age have 20% increased risk
compared with women who are more than 14
years of age at menarche
¢ Late menopause also increases risk
CARCINOMA OF THE BREAST
¢ Full term pregnancy at ages younger than 20
years have half the risk of nulliparous women or
women over age 35 at their first birth
¢ Other risk factors: first-degree relatives with
breast cancer, atypical hyperplasia,
race/ethnicity, estrogen exposure, breast density,
radiation exposure
¢ Carcinoma of the contralateral breast or
endometrium
¢ Geographic influence
CARCINOMA OF THE BREAST
¢ Diet – caffeine decreases risk and moderate to
heavy consumption of alcohol increases risk
¢ Obesity

¢ Exercise

¢ Breastfeeding – the longer you breastfeed, the

greater the reduction risk
¢ Environmental toxins

¢ Tobacco

¢ Major risk factors for the development are

hormonal and genetic
CARCINOMA OF THE BREAST
¢ Carcinoma in-situ or DCIS (ductal carcinoma in-
situ)
¢ LCIS (lobular carcinoma in-situ)

¢ Invasive ductal carcinoma in-situ

¢ Invasive lobular carcinoma in-situ

¢ Medullary carcinoma

¢ Mucinous (colloid) carcinoma

¢ Tubular carcinoma

¢ Invasive papillary carcinoma

¢ Metaplastic carcinoma
CARCINOMA OF THE BREAST
¢ Major prognostic factors:
1. Invasive carcinoma vs in-situ disease
2. Distant metastases
3. Lymph node metastases
4. Tumor size
5. Locally advanced disease
6. Inflammatory carcinoma
 AJCC Staging
Stage T: Primary Lymph Node M: distant 5-year
Cancer (LNs) metastases survival (%)
0 DCIS or LCIS None Absent 92
I Invasive None Absent 87
carcinoma
<2cm
II Invasive None Absent 75
carcinoma 1 to 3 positive Absent
>2cm LNs
<5cm
III >5cm 1 to 3 positive Absent 46
Any size >4 positive Absent
With skin or 0 to 10 Absent
chest wall positive
involvement
or
inflammatory
carcinoma
IV Any size Negative or Present 13
carcinoma positive LNs
CARCINOMA OF THE BREAST
¢ Presence of lump
¢ Nipple inversion

¢ Breast discharges

¢ Changes in the skin – “peau d’orange”

¢ Diagnostics: mammography, UTZ, MRI

(possibly), biopsy
¢ Treatment: surgery, chemotherapy and
radiotherapy
 Female

Male
CARCINOMA OF THE BREAST
¢ Lumpectomy
¢ Partial or Segmental Mastectomy or
Quadrantectomy
¢ Total Mastectomy

¢ Modified Radical Mastectomy

¢ Radical Mastectomy
(http://www.webmd.com/breast-cancer/breast-cancer-
surgery)
LUMPECTOMY
¢ This is also referred to as breast-conserving
therapy.
¢ The surgeon removes the cancerous area and a
surrounding margin of normal tissue.
¢ A second incision may be made in order to
remove the lymph nodes.
¢ This treatment aims to maintain a normal breast
appearance when the surgery is over.
LUMPECTOMY
¢ After the lumpectomy, a five- to eight-week
course of radiation therapy is often used to treat
the remaining breast tissue.
¢ The majority of women who have small, early-
stage breast cancers are excellent candidates for
this treatment approach.
LUMPECTOMY
¢ Women who are not usually eligible for a
lumpectomy include:
1. those who have already had radiation therapy
to the affected breast,
2. have two or more areas of cancer in the same
breast that are too far apart to be removed
through one incision,
3. or have cancer that was not completely
removed during the lumpectomy surgery
During a partial or segmental mastectomy or quadrantectomy, the surgeon
removes more breast tissue than with a lumpectomy. The cancerous area and
a surrounding margin of normal tissue are removed, and radiation therapy is
usually given after surgery for six to eight weeks.
With a simple or total mastectomy, the entire breast is removed, but no lymph
nodes are removed in this procedure. Simple mastectomy is most frequently
used for further cancer prevention or when the cancer does not go to the lymph
nodes.
The surgeon removes all of the breast tissue along with the nipple in a modified
radical mastectomy. Lymph nodes in the armpit are also removed. The chest
muscles are left intact. For many patients, mastectomy is accompanied by either
an immediate or delayed breast reconstruction. This can be done quite
effectively using either breast implants or the patient's own tissue -- usually
from the lower abdomen.
RADICAL MASTECTOMY
¢ The surgeon removes all of the breast tissue
along with the nipple, lymph nodes in the armpit,
and chest wall muscles under the breast.
¢ This procedure is rarely performed today because
modified radical mastectomy has proved to be as
effective, and is less disfiguring.
NURSING INTERVENTIONS
1. Monitor for adverse effects of radiation therapy
such as fatigue, sore throat, dry cough, nausea,
anorexia.
2. Monitor for adverse effects of chemotherapy;
bone marrow suppression, nausea and vomiting,
alopecia, weight gain or loss, fatigue, stomatitis,
anxiety, and depression.
3. Realize that a diagnosis of breast cancer is a
devastating emotional shock to the woman.
4. Provide psychological support to the patient
throughout the diagnostic and treatment process.
5. Involve the patient in planning and treatment.
NURSING INTERVENTIONS
6. Describe surgical procedures to alleviate fear.
7. Prepare the patient for the effects of chemotherapy, and
plan ahead for alopecia, fatigue.
8. Administer antiemetics prophylactically, as directed, for
patients receiving chemotherapy.
9. Administer I.V. fluids and hyperalimentation as
indicated.
10. Help patient identify and use support persons or family
or community.
11. Suggest to the patient the psychological interventions
may be necessary for anxiety, depression, or sexual
problems.
12. Teach all women the recommended cancer-screening
procedures.
(http://nursingcrib.com/nursing-notes-reviewer/breast-cancer/)
CERVICAL CARCINOMA
¢ CIN – cervical intraepithelial neoplasia
¢ CIN is a precancerous lesion

¢ Classified according to degree of dysplasia

¢ CIN I – low grade dysplasia, also classified as

LSIL or low-grade squamous intraepithelial
lesion
¢ CIN II and CIN III – both high grade dysplasia,
also classified as HSIL or high-grade squamous
intraepithelial lesion
CERVICAL CARCINOMA
¢ CIN is associated with productive HPV infection
(HPV 16)
¢ Most LSILs regress spontaneously with only a
small percentage progressing to HSIL
¢ LSIL does not progress directly to invasive
carcinoma
CERVICAL CARCINOMA
¢ Squamous cell carcinoma is the most common
histologic subtype
¢ Accounts for approximately 80% of cases

¢ HSIL is an immediate precursor

¢ Second most common type is cervical

adenocarcinoma (15%)
¢ Adenosquamous carcinoma accounts for 5%

¢ Peak incidence for invasive cervical carcinoma is

45 years
CERVICAL CARCINOMA
¢ Risk factors are related to both host and viral
characteristics:
1. Multiple sexual partners
2. A male partner with multiple previous or current
sexual partners
3. Young age at first intercourse
4. High parity
5. Persistent infection with a high oncogenic risk HPV
(HPV 16 and 18)
6. Immunosuppression
7. Certain HLA subtypes
8. Use of OCP
9. Use of nicotine
CERVICAL CARCINOMA
¢ More than half of invasive cervical cancers are
detected in women who did not participate in
regular screening
¢ Cervical cancer screening and prevention

1. Pap smear
2. Cervical biopsy
3. HPV vaccination
4. Surgical removal
5. Adjunctive radiotherapy and chemotherapy
CERVICAL CARCINOMA
¢ Surgery
1. Early invasive cancers – cone biopsy
2. Highly invasive cancers – hysterectomy with
lymph node dissection
¢ Prognosis depends on the stage at which the
cancer has been detected
ENDOMETRIAL CARCINOMA
¢ The most common invasive cancer of the female
genital tract
¢ Accounts for 7% of all invasive cancer in women

¢ Uncommon in women younger than 40 years of

age
¢ Peak incidence is in 55 to 65 year old women
ENDOMETRIAL CARCINOMA
¢ Risk factors:
1. Age
2. Unopposed estrogen
3. Endometrial atrophy
4. Obesity as well as thin physique
5. Hypertension
6. Diabetes
ENDOMETRIAL CARCINOMA
¢ No current available screening test
¢ May be asymptomatic for a certain period of time
¢ Irregular or postmenopausal bleeding with excessive
leukorrhea
¢ Uterine enlargement may be absent in the early
stages
¢ Diagnosis is established with biopsy or curettage and
histologic examination of the tissue
¢ Prognosis depends on the stage and type of carcinoma
¢ Treatment consists of surgical removal (TAHBSO
with removal of tissues suspected of being involved)
alone or in combination with radiotherapy
LEIOMYOSARCOMA

¢ Uncommon malignant neoplasm

¢ Arise de novo from the myometrium or
endometrial stromal precursor cells
¢ Equally common before the and after menopause

¢ Peak incidence at 40 to 60 years of age

¢ Has a striking tendency to recur after removal

¢ More than half eventually metastasize through

the bloodstream to distant organs (lungs, bone,
and brain)
¢ 5-year survival rate averages about 40%
OVARIAN CARCINOMAS
¢ About 80% of ovarian tumors are benign and
mostly occur in young women between the ages of
20 to 45 years old
¢ Borderline tumors occur in slightly older ages

¢ Malignant tumors are more common in older

women
¢ Ovarian cancer accounts for 3% of all cancers in
females
Choriocarcinoma
PROSTATE CARCINOMA
¢ Adenocarcinoma of the prostate is the most common
form of cancer in men
¢ Accounts for 29% of cancer in the US
¢ Typically a disease of men over age 50
¢ Screening is recommended to begin at age 40
¢ Uncommon in Asia
¢ Risk factors: genetics, diet and lifestyle (still not
clear)
¢ Diet: fatty foods has been implicated, those rich in
lycopene are suspected of preventing or delaying the
development
¢ Androgens play an important role in the development
PROSTATE CARCINOMA
¢ Most men that underwent TURP have incidental
finding of focal cancer, and do not progress when
followed up after 10 years
¢ Older men are typically followed up

¢ Younger men with longer life expectancy may

undergo needle biopsy to look for additional
cancer
¢ Diagnostics include PSA levels (most important
test – cutoff point is 4ng/ml), transrectal needle
biopsy, imaging studies (to check for metastatic
osteoblastic carcinoma to the vertebrae)
PROSTATIC CARCINOMA
¢ PSA
1. Prostatic Specific Antigen
2. 40 to 49 years – 2.5 ng/ml
3. 50 to 59 years – 3.5 ng/ml
4. 60 to 69 years – 4.5 ng/ml
5. 70 to 79 years – 6.5 ng/ml
Note:
a. numbers 2 to 5 shows the upper age-specific PSA
reference ranges
b. For the test to be valid, there must be at least three
PSA measurements available over a period of 1.5 to
2 years
c. A man who has a significant rise, even though the
latest serum level may be below the normal cutoff
(<4ng/ml) should undergo additional work-up
MANAGEMENT
¢ Surgery – radical prostatectomy
¢ Antibiotic prophylaxis – quinolones and those
that cover anaerobic bacteria (during biopsy)
¢ Radiation like brachytherapy

¢ Cryotherapy

¢ Chemotherapy

¢ Hormonal therapy
¢ http://emedicine.medscape.com/article/379996-followup
¢ http://www.medicinenet.com/prostate_cancer/page8.htm#_Toc49
8458220
MANAGEMENT
¢ Post-op effects of surgery:
1. Risks of anesthesia
2. Post-op bleeding
3. Impotence – treat with sildenafil (Viagra)
tablets, alprostadil (Caverject) injections into
the penis, devices like penile prosthesis
4. Incontinence
¢ http://www.medicinenet.com/prostate_cancer/page8.htm#_Toc49
8458220
PENILE CARCINOMA
¢ CIS (carcinoma in-situ) – Bowen disease and
bowenoid papulosis
¢ Strong association with HPV infection (HPV 16)
¢ Bowen disease occurs in the genital region of
both men and women, usually over the age of 35
years
¢ In men Bowen occur in the skin of the shaft of
the penis
¢ Bowen disease appears as a solitary, thickened,
gray-white, opaque plaque
¢ Bowen disease transforms into infiltrating
squamous cell carcinoma in approximately 10%
of patients
PENILE CARCINOMA
¢ Bowenoid papulosis
1. Occurs in sexually active adults
2. Younger age group
3. Presence of multiple (rather than solitary)
reddish-brown papules
4. Never develops into an invasive carcinoma
5. In many cases, spontaneously regresses
PENILE CARCINOMA
¢ Invasive carcinoma
1. SCC of the penis is an uncommon malignancy
2. Circumcision offers protection
3. HPV 16 is the most common culprit
4. HPV 18 is also implicated
5. Cigarette smoking elevates the risk
6. Usually found in patients between the ages 40
and 70
TESTICULAR TUMORS
ESOPHAGUS

¢ Squamous cell carcinoma

¢ Adenocarcinoma
ESOPHAGUS

¢ Squamous cell carcinoma

a. More common worldwide
b. Risk factors: alcohol, tobacco use, poverty,
caustic esophageal injury, achalasia, Plummer-
Vinson syndrome (also known as Paterson-
Brown Kelley syndrome; triad of dysphagia,
upper esophageal webs and iron deficiency
anemia), and frequent consumption of very hot
beverages
c. Other risk factors: nutritional deficiencies,
polycyclic hydrocarbons, nitrosamines, and
other mutagenic compounds such as fungus
found on contaminated foods, HPV
ESOPHAGUS

¢ Squamous cell carcinoma

a. Onset is insidious
b. Ultimately produces dysphagia, odynophagia,
and obstruction
c. Patients subconsciously adjust to the
progressively increasing obstruction by altering
their diet from solid to liquid foods
d. Extreme weight loss and debilitation
e. Hemorrhage and sepsis may accompany tumor
ulceration
f. Occasionally the first symptoms are caused by
aspiration of food via a TEF
ESOPHAGUS

¢ Adenocarcinoma
a. Typically arises in a background of Barrett
esophagus and long-standing GERD
b. Other risk factors: tobacco use, obesity, prior
radiation therapy, diets poor in fresh fruits and
vegetables
c. Some H. pylori serotypes are associated with a
decreased risk perhaps by causing gastric
atrophy and reducing acid reflux
ESOPHAGUS

¢ Adenocarcinoma
a. Occasionally discovered in evaluation of GERD
or surveillance of Barrett esophagus
b. Commonly present with pain and difficulty in
swallowing, progressive weight loss,
hematemesis, chest pain, or vomiting
c. By the time symptoms appear, the tumor has
usually spread to submucosal lymphatic vessels
d. At the time of diagnosis, it is already at the
advanced stage
e. Overall 5-year survival is less than 25%
ESOPHAGUS

¢ Early stages of esophageal cancer is often treated

with surgery
¢ However in many instances a combination of
chemotherapy and radiotherapy is given prior to
surgery to optimize the benefit of surgical therapy
¢ In this situation the chemotherapy is usually given
at the same time as radiation therapy
¢ The most common chemotherapy used for this
purpose is a combination of cisplatin and flurouracil
(5-FU)
¢ After about two months of chemotherapy and
radiation patient is evaluated for surgery
(http://medicineworld.org/cancer/gi/esophageal/treatment.html)
ESOPHAGUS

¢ Surgery for esophageal cancer involves removal

of the part of esophagus that is involved with
cancer and joining the uninvolved part with
stomach.
¢ The lymph nodes in the area are also removed.

¢ If the cancer is in the upper part of the

esophagus the stomach may be pulled up to the
chest to compensate for the loss of length in the
esophagus.
(http://medicineworld.org/cancer/gi/esophageal/treatm
ent.html)
ESOPHAGUS

¢ If the cancer is in the lower part of the

esophagus, surgeon can remove lower part of the
esophagus and upper part of the stomach and
join the two ends together.
¢ Surgery may cure some of the patients with
esophageal cancer, however in many patients the
cancer may come back after the surgery.
(http://medicineworld.org/cancer/gi/esophageal/trea
tment.html)
ESOPHAGUS
¢ Treatment of esophageal cancer when the surgery is
not an option:
a. Because of the high position of the esophageal
cancer or due to the poor general condition of the
patient
b. Such patients are generally treated with a
combination of chemotherapy and radiation
c. several chemotherapy drugs that are active in
esophageal cancer. These include fluorouracil (5-
FU), cisplatin, mitomycin, bleomycin, doxorubicin,
methotrexate, paclitaxel, vinorelbine, topotecan,
and irinotecan
d. The most commonly used drugs are cisplatin
and flurouracil
(http://medicineworld.org/cancer/gi/esophageal/treatment.html)
ESOPHAGUS
¢ Pallative treatment:
a. PDT
b. Placement of stent
c. Pain control
(http://medicineworld.org/cancer/gi/esophageal/treatment.html)
ADENOCARCINOMA OF THE STOMACH
¢ The most common malignancy of the stomach
¢ Comprises over 90% of all gastric cancers

¢ Incidence varies markedly with geography

¢ 20-fold higher in Japan, Chile, Costa Rica, and

Eastern Europe compared to North America,
Northern Europe, Africa and Southeast Asia
¢ Factors that decrease risk: intake of green, leafy
vegetables, and citrus fruits
¢ Factors that increase risk: N-nitroso compounds
and smoking used for food preservation
ADENOCARCINOMA OF THE STOMACH
¢ Other risk factors:
a. Age and gender are risk factors and the disease is more
common in men over the age of 55
b. Medical conditions that increase the risk for the disease
include pernicious anemia (vitamin B-12 deficiency),
chronic inflammation of the stomach (atrophic gastritis),
and intestinal polyps (noncancerous growths)
c. Genetic (hereditary) risk factors include hereditary
nonpolyposis colon cancer (HNPCC) syndrome and Li-
Fraumeni syndrome (conditions that result in a
predisposition to cancer), and a family history of
gastrointestinal cancer
d. People with type A blood also have an increased risk for
stomach cancer.
(http://www.oncologychannel.com/gastriccancer/riskfactors.shtml)
ADENOCARCINOMA OF THE STOMACH
¢ Abdominal discomfort or pain
¢ Blood in stool

¢ Bloating (especially after eating)

¢ Diarrhea or constipation

¢ Fatigue

(http://www.oncologychannel.com/gastriccancer/diagnosis.shtml)
ADENOCARCINOMA OF THE STOMACH
¢ Fecal occult blood test is used to detect microscopic
blood in the stool, which may indicate stomach or
other gastrointestinal (GI) cancers (e.g., colorectal
cancer).
¢ Complete blood count (CBC) is a simple blood test
used to measure the concentration of white blood
cells, red blood cells, and platelets.
¢ In an upper GI series, or barium swallow, the patient
drinks a thick, chalky liquid (barium) that coats the
esophagus and stomach and makes it easier to detect
abnormal areas on x-ray. In double-contrast barium
swallow, air is blown into the esophagus and stomach
to help the liquid coat the wall of the organs more
thoroughly
(http://www.oncologychannel.com/gastriccancer/diagnosis.shtml)
GASTROINTESTINAL STROMAL TUMOR
¢ GIST
most common mesenchymal tumor of the
abdomen
¢ More than half occur in the stomach

¢ Slightly more common in males

¢ Peak age of diagnosis in the stomach is

approximately 60 years
¢ Fewer than 10% occurring in individuals 40 years
of age
GASTROINTESTINAL STROMAL TUMOR
¢ Symptoms at presentation may be related to
mass effects
¢ Mucosal ulceration can cause blood loss

¢ May be discovered as an incidental finding

during radiologic imaging, endoscopy, or
abdominal surgery performed for other reasons
¢ GIST of the small intestine is more aggressive
than those arising in the stomach
GASTROINTESTINAL STROMAL TUMOR
¢ Surgery
¢ Chemotherapy

¢ Radiation therapy

¢ Supportive care
HEPATOCELLULAR CARCINOMA
¢ HCC
¢ There are more than 626,000 new cases per year
of primary liver cancer and most of them are
HCC
¢ About 82% occur in developing countries with
high rates of chronic HBV infection, such as in
southeast Asia and African countries
¢ In the US the incidence increased by 25%
between 1993 and 1998, mainly due to HCV and
HBV chronic infection
¢ Male:Female = 2.4:1
HEPATOCELLULAR CARCINOMA
¢ Other risk factors:
a. drugs, chemicals and medications
b. Aflatoxin B1 – from the fungus Aspergillus
flavus
c. Hemochromatosis
d. Cirrhosis
http://www.apjohncancerinstitute.org/cancer/liver.htm
HEPATOCELLULAR CARCINOMA
¢ In most patients:
a. (+) ill-defined upper abdominal pain
b. Malaise
c. Fatigue
d. Weight loss
e. Sometimes, awareness of abdominal mass or
abdominal fullness
HEPATOCELLULAR CARCINOMA
¢ In many cases:
a. The enlarged liver can be felt by palpation
b. Jaundice
c. Fever
d. GIT or esophageal variceal bleeding
HEPATOCELLULAR CARCINOMA
¢ Labs/Diagnostics:
a. Elevated serum alpha-fetoprotein (50%)
b. CEA
c. Glypican-3 tissue staining
d. Imaging studies
e. Biopsy
HEPATOCELLULAR CARCINOMA
¢ Management:
a. Chemotherapy
b. Radiation therapy
c. Resection
d. Liver transplantation
e. Supportive care: analgesics as needed, measure
abdominal girth (ascites), accurate monitoring of
intake and output, weight (edema), watch out for
bleeding, dietary restrictions, meticulous skin care,
neurologic assessment, psychosocial care
http://www.apjohncancerinstitute.org/cancer/liver.htm
http://findarticles.com/p/articles/mi_qa3689/is_199601/ai_n8743210/