Cancer Subtopics – Flashcards

Most common 60-70 Affects women 4x as much as men

Transitional cell carcinoma of the bladder Most bladder tumors are papillomatous growths within the bladder

Cigarette smoking Esposure to dyes used in rubber and other industries, women w radiation for cervical cancer, patients who received cyclophosphamide, patients who take the diabetes drug pioglitazone Individuals w chronic bladder infection and lower UTISs Patients w indwelling catheters for long periods of time

-Microscopic or gross, painless hematuria (chronic or intermittent). -Bladder irritability w dysuria, frequency, urgency.

-Obtain urine sample to identify atypical or cancer cells -Other urine tests assess for specific factors associated w bladder cancer (such as bladder tumor antigens). -Can be detected via CT, ultrasound, MRI. -Presence of cancer is confirmed via systoscopy and biopsy. MOST RELIABLE TEST.

Cystoscopy w biopsy

At an early stage, when it is still treatable Bladder cancers are graded based on cell types and staged based on extent of invasiveness of cancer

Used to classify the malignant potential of tumor cells, using scale from well differentiated (closely resembling the normal tissue) to undifferentiated (poorly differentiated).

Stage I: Cancer is in the inner lining of the bladder but has not invaded the bladder muscle wall. Stage II: Cancer has invaded the bladder wall but is still confined to bladder. Stage III: Cancer has spread through the bladder wall to surrounding tissue. It may also have spread to the prostate in men or the uterus or vagina in women. Stage IV: Cancer has spread to the lymph nodes and other organs, such as lungs, bones, or liver.

- History and physical examination - Urinalysis - Urine cytology studies - Cystoscopy with biopsy - Ultrasound - CT scan

-Surgical therapy • Transurethral resection with fulguration • Laser photocoagulation • Open loop resection with fulguration • Cystectomy (segmental, partial, or radical) - Radiation therapy - Intravesical immunotherapy • Bacille Calmette-Guérin (BCG) • α-interferon (Intron A) - Intravesical chemotherapy • mitomycin • thiotepa • valrubicin (Valstar) - Systemic chemotherapy and immunotherapy

radical cystectomy radical cystectomy Urinary diversion

-Drinking a large volume of fluid for the first week after the procedure - Teach the patient to monitor color and consistency of the urine - Urine is pink for first several days (NOT bright red or clots) - Approximately 7-10 days after surgery, patient may notice red or rust colored flecks in the urine (From healing tumor resection site) - Administer opiod analgesics for a brief period after the procedure, along w stool softeners. -Help family cope w fears about cancer, surgery, and sexuality -Emphasize importance of follow up care - Follow up cystoscopies are required on a regular basis after surgery for bladder cancer.

Radiation in cobination w cystectomy Cisplatin, vinblastine, doxorubicin, methotrexate

Urethral catheter Intravesical therapy EMPTY Change the patient's position every 15 minutes during the instillation for maximum contact in all areas of the bladder.

Bacille Calmette-Guérin (BCG), a weakened strain of Mycobacterium bovis This is an example of intravesicle therapy

High rate of disease recurrence and progression

Hispanics = Most likely to be diagnosed African American = Most likely to die

Early detection (Pap test) Mortality rate has significantly declined

(1) infection with high-risk strains of human papillomavirus (HPV) 16 and 18, (2) immunosuppression, (3) low socioeconomic status, (4) chlamydia infection, and (5) smoking.12

Early cervical cancer generally has no symptoms. However, an unusual discharge, AUB, or postcoital bleeding eventually occurs. The discharge is usually thin and watery but becomes dark and foul smelling as the disease advances. The vaginal bleeding initially presents as spotting. As the tumor enlarges, bleeding becomes heavier and more frequent (Fig. 53-9). Pain is a late symptom and is followed by weight loss, anemia, and cachexia.

PAP (Identifies changes in cervical cells) and HPV (used to identify high risk strains 16 and 18)

21 3 5 5 Polcoscopy(an examination of the cervical tissue under magnification)

HPV vaccination Currently three vaccines are available to protect against HPV: (1) Gardasil protects against types 6, 11, 16, and 18; (2) Cervarix offers protection against HPV types 16 and 18; and (3) Gardasil 9 protects against HPV types 6, 11, 16, 18 and five other HPV types. These vaccines are given in three IM doses over a 6-month period and have few side effects. The CDC recommends that all children, males and females, be vaccinated at age 11 to 12, but vaccination can be started as early as age 9.

bevacizumab (Avastin)

surgery or combo of chemo and radiation. (Or drug therapy Avastin)

Most common cancer among men Second leading cause of cancer death in men

Prostate cancer

by direct extension, through the lymph system, or through the bloodstream. Spread by direct extension involves the seminal vesicles, urethral mucosa, bladder wall, and external sphincter. The cancer later spreads through the lymphatic system to the regional lymph nodes. The bloodstream seems to be the mode of spread to the axial skeleton: pelvic bones, head of the femur, lower lumbar spine, and finally liver and lungs.

Age, ethnicity, family history. Risk rises markedly after age 50. However, many cases occur in younger men who sometimes have a more aggressive type of cancer. African american men have highest rate of prostate cancer, diagnosed at earlier age, have more advanced disease at time of diagnosis, have higher mortality rate than do white men. Reason is unknown, however differences in survival may be related to body composition, dietary factors, endogenous hormones. Not clear fi smoking is a risk factor. Also not clear if BPH affects risk. Dietary factors (red meat) and high fat dairy products may increase risk. As well as low intake in fruits and veges. Environment may also play a role - increased in those who work with pesticides

Sporadic = Most (70%), damage to the genes occurs by chance after a person is born. Familial prostate cancer (20%) = Occurs because of a combination of shared genes and shared environment. Occurs when two or more first degree relatives are diagnosed w prostate cancer. Hereditary (inherited) (5% - rare) =gene mutation passed. 3 or more first degree relatives, three generations, two or more close relatives No genetic tests exist to determine if man is predisposed to prostate cancer

Initially, none Then LUTS (similar to BPH), then pain in the lumbosacral area that radiates down to the hips or legs, when combined w urinary symptoms, may indicate metastasis

Management of pain Spreading to bones (common) = very painful, especially in back and legs.

PSA screening On DRE, an abnormal prostate may feel hard, nodular, and asymmetric.

True

55-69 2 (Individualized schedule for high risk men)

levated levels of PSA (normal level, 0 to 4 ng/mL [0 to 4 mcg/L]), a glycoprotein produced by the prostate, do not necessarily indicate prostate cancer. Mild elevations in PSA may occur with aging, BPH, recent ejaculation, constipation, acute or chronic prostatitis, or after long bike rides. In addition, cystoscopy, indwelling urethral catheters, and prostate biopsies may also produce transient elevations in PSA levels. Neither PSA nor DRE is a definitive diagnostic test for prostate cancer. If PSA levels are continually elevated or if the DRE is abnormal, a biopsy of the prostate tissue is usually indicated. Biopsy of prostate tissue is necessary to confirm the diagnosis of prostate cancer. The biopsy is typically done using a transrectal approach. In a transrectal ultrasound (TRUS) procedure, an ultrasound probe enables the urologist to visualize abnormalities where the biopsy needles are going to be placed into the prostate. When a suspicious area is located, biopsy needles are inserted through the wall of the rectum into the prostate to obtain tissue samples. A pathologic examination of the specimen is done to assess for malignant changes. Can also do MRI/Ultrasound fusion biopsy Elevated level of prostatic isoenzyme of serum acid phophatase is another indicator, especially if cancer has spread outside of the prostate

Finasteride and dutasteride

Nearly 100%

Tumor, Node, and Metastasis System TNM

• History and physical examination • Digital rectal examination (DRE) • Prostate-specific antigen (PSA) • Prostatic acid phosphatase (PAP) • Transrectal ultrasound (TRUS) • Biopsy of prostate and lymph nodes • CT scan, MRI • Bone scan (to evaluate for metastatic disease)

-Active Surveillance • Annual PSA and DRE Surgery • Radical prostatectomy • Cryotherapy • Orchiectomy (for metastatic disease) Radiation Therapy • External beam for primary, adjuvant, and recurrent disease • Brachytherapy Drug Therapy • Androgen deprivation therapy (Table 54-7) • Chemotherapy for metastatic disease

This strategy is appropriate when the patient has (1) a life expectancy of less than 10 years (low risk of dying of the disease); (2) a low-grade, low-stage tumor; and (3) serious coexisting medical conditions

perineal, due to proximity to anus

Erectile dysfunction and urinary incontinence.

Prostate cancer Cryotherapy (cryoablation) is a surgical technique for prostate cancer that destroys cancer cells by freezing the tissue. It has been used both as an initial treatment and as a second-line treatment after radiation therapy has failed. A TRUS probe is inserted to visualize the prostate gland. Probes containing liquid nitrogen are then inserted into the prostate. Liquid nitrogen delivers freezing temperatures, thus destroying the tissue. The treatment takes about 2 hours under general or spinal anesthesia and does not involve an abdominal incision. Possible complications include damage to the urethra and, in rare cases, an urethrorectal fistula (an opening between the urethra and rectum) or a urethrocutaneous fistula (an opening between the urethra and skin). Tissue sloughing, ED, urinary incontinence, prostatitis, and hemorrhage can also occur.

Brachytherapy involves placing radioactive seed implants into the prostate gland, allowing higher radiation doses directly in the tissue while sparing the surrounding tissue (rectum and bladder). The radioactive seeds are placed in the prostate gland with a needle through a grid template guided by TRUS (Fig. 54-7) to ensure accurate placement of the seeds.

Prostate cancer growth is largely dependent on the presence of androgens. Androgen deprivation therapy (ADT) reduces the levels of circulating androgens to reduce the tumor growth. Androgen deprivation can be produced by inhibiting androgen production or blocking androgen receptors The hypothalamus produces luteinizing hormone-releasing hormone (LH-RH), which stimulates the anterior pituitary to produce luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH stimulates the testicular Leydig cells to produce testosterone. LH-RH agonists super stimulate the pituitary, downregulating the LH-RH receptors, and leading to a refractory condition in which the anterior pituitary is unresponsive to LH-RH. These drugs cause an initial transient increase in LH and FSH; 1280testosterone abruptly rises resulting in a flare. Symptoms may worsen during this time. However, with continued administration, LH and testosterone levels are decreased. LH-RH agonists include leuprolide (Lupron, Lupron Depot, Eligard), goserelin (Zoladex), and triptorelin (Trelstar) (Table 54-7). These drugs essentially produce a chemical castration similar to the effects of an orchiectomy. These drugs are given by subcutaneous or IM injections on a regular basis. Viadur is an implant that is placed subcutaneously and delivers leuprolide continuously for 1 year. Degarelix is an LH-RH antagonist that lowers testosterone levels to castration levels. Unlike the LH-RH agonists, degarelix does not cause a testosterone flare because it acts directly to block LH and FSH receptors. It is given as a subcutaneous injection, and results are seen in 3 days. Abiraterone (Zytiga) works by inhibiting an enzyme, CYP17, which is needed for the production of testosterone. This drug is given orally to men with castration-resistant prostate cancer, and improves overall survival by 4 to 5 months.

The use of chemotherapy has primarily been limited to treatment for those with hormone-refractory prostate cancer (HRPC) in late-stage disease. In HRPC the cancer is progressing despite treatment. This occurs in patients who have taken an antiandrogen for a certain period. The goal of chemotherapy is mainly palliative.

Orchiectomy, surgical removal of testes (may be done alone or after prostatectomy).

The etiology of BPH is not completely understood. However, hormonal changes associated with aging are believed to be contributing factors.1 Dihydroxytestosterone (DHT), one of several sex hormones, stimulates prostate cell growth. Excess amounts of DHT can cause overgrowth of prostate tissue. As men age, they have a decrease in testosterone but continue to produce and accumulate high levels of DHT, resulting in prostate enlargement. Another possible cause of BPH is an increased proportion of estrogen

Risk factors for BPH include aging, obesity (in particular increased waist circumference), lack of physical activity, alcohol consumption, erectile dysfunction, smoking, and diabetes.4 A family history of BPH in a first-degree relative may also be a risk factor.

Retention UTI Hydronephrosis, pyelonephritis, bladder damage if treatment for retention (urinary catheter) is delayed

• History and physical examination • Digital rectal examination (DRE) • Urinalysis with culture • Prostate-specific antigen (PSA) • Serum creatinine • Postvoid residual • Transrectal ultrasound (TRUS) • Uroflowmetry • Cystoscopy

Active Surveillance • Annual PSA and DRE Drug Therapy • 5α-Reductase inhibitors (e.g., finasteride [Proscar], dutasteride [Avodart], dutasteride plus tamsulosin [Jalyn]) • α-Adrenergic receptor blockers (e.g., silodosin [Rapaflo], alfuzosin [Uroxatral], doxazosin [Cardura], prazosin [Minipress], terazosin, tamsulosin [Flomax]) • Erectogenic drugs (e.g., tadalafil [Cialis]) Minimally Invasive Therapy* • Transurethral microwave thermotherapy (TUMT) • Transurethral needle ablation (TUNA) • Laser prostatectomy • Transurethral electrovaporization of the prostate (TUVP) Invasive (Surgery) Therapy* • Transurethral resection of the prostate (TURP) • Transurethral incision of the prostate (TUIP) • Open prostatectomy

Other diagnostic testing may include a urinalysis with culture to look for bacteria, white blood cells (WBCs), or microscopic hematuria, which indicate infection or inflammation. A prostate-specific antigen (PSA) blood test may be done to screen for prostate cancer. However, PSA levels may be slightly elevated in patients with BPH. Serum creatinine levels may be 1270ordered to rule out renal insufficiency. Because symptoms of BPH are similar to those of a neurogenic bladder, a neurologic examination may also be performed. In patients with an abnormal DRE and elevated PSA, a transrectal ultrasound (TRUS) is typically ordered. This examination allows for accurate assessment of prostate size and can help to differentiate BPH from prostate cancer. Biopsies can be taken during the ultrasound procedure. Uroflowmetry, a study that measures the volume of urine expelled from the bladder, is helpful to determine the extent of urethral blockage and thus the type of treatment needed. Postvoid residual urine volume is often assessed to determine the degree of urine flow obstruction. Cystoscopy, a procedure allowing internal visualization of the urethra and bladder, is performed if the diagnosis is unclear or to visualize the degree of prostatic enlargement.

(1) restore bladder drainage, (2) relieve the patient's symptoms, and (3) prevent or treat the complications of BPH

The most conservative treatment that may be recommended for some patients with BPH is referred to as active surveillance, or watchful waiting. When the patient has mild symptoms (AUA symptom scores of 0 to 7), a wait-and-see approach is taken. Teaching patients to make lifestyle changes can help relieve early or mild symptoms. Making dietary changes (decreasing intake of caffeine, artificial sweeteners, and spicy or acidic foods), avoiding drugs such as decongestants and anticholinergics, and restricting evening fluid intake may improve symptoms. In addition, a timed voiding schedule may reduce or eliminate symptoms, thus eliminating the need for further intervention. If the patient begins to have signs or symptoms that indicate an increase in obstruction, further treatment is indicated.

Two classes of drugs that are used to treat BPH include 5α-reductase inhibitors and α-adrenergic receptor blockers. Combination therapy using both types of drugs may be more effective in reducing symptoms than using one drug alone.

Transurethral resection of the prostate (TURP) is a surgical procedure involving the removal of prostate tissue using a resectoscope inserted through the urethra. TURP has long been considered the gold standard for surgical treatments of obstructing BPH. Results of a TURP are superior but at the cost of a longer hospital stay. The number of TURP procedures done in recent years has declined due to the development of less invasive technologies.6 In TURP no external surgical incision is made. A resectoscope is inserted through the urethra to excise and cauterize obstructing prostatic tissue (Fig. 54-4). A large three-way 1273indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemostasis and to facilitate urinary drainage. The bladder is irrigated, either continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus and blood clots The outcome for the majority of patients is excellent, with marked improvements in symptoms and urinary flow rates. TURP is a surgical procedure with a relatively low risk, but caregivers must be vigilant for signs or symptoms of transurethral resection syndrome (TUR or TURP syndrome). This condition is manifested by nausea, vomiting, confusion, bradycardia, and hypertension. TUR syndrome is the result of hyponatremia due to longer operative times and prolonged intraoperative bladder irrigation. Other postoperative complications include bleeding and clot retention. Because bleeding is a common complication, patients taking aspirin, warfarin (Coumadin), or other anticoagulants must discontinue these medications several days before surgery. BPH medications are also stopped after this procedure.

Some men find that consuming alcohol, caffeine, or other bladder irritants tends to increase prostatic symptoms because the diuretic effect increases bladder distention. Compounds found in common cough and cold remedies such as pseudoephedrine (in Sudafed) and phenylephrine (in Allerest PE and Coricidin D) often worsen the symptoms of BPH. These drugs are α-adrenergic agonists that cause smooth muscle contraction. If this occurs, the patient should avoid these drugs. 1274 Teach patients with obstructive symptoms to urinate every 2 to 3 hours and when they first feel the urge. This will minimize urinary stasis and acute urinary retention. Instruct patients to maintain a normal level of fluid so that they do not become dehydrated. The patient may believe that if he restricts his fluid intake, symptoms will be less severe, but this only increases the chances of an infection while concentrating his urine.

Complications: Hemorrhage, bladder spasms, urinary incontinence, infeciton Bladder irrigation (remove blotted blood and ensure drainage) Painful bladder spasms may result following manual irrigation

Aseptic technique

About 30% to 50% of people with CRC have an abnormal KRAS gene.21 The KRAS gene, which is primarily involved in regulating cell division, belongs to a class of genes known as oncogenes. When mutated, oncogenes have the potential to cause normal cells to become cancerous.

CRC has an insidious onset, and symptoms do not appear until the disease is advanced. Common clinical manifestations include iron-deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits, and intestinal obstruction or perforation. Physical findings may include the following: • Early disease: Nonspecific findings (fatigue, weight loss) or none at all • More advanced disease: Abdominal tenderness, palpable abdominal mass, hepatomegaly, ascites

• Flexible sigmoidoscopy (every 5 years) • Colonoscopy (every 10 years) • Double-contrast barium enema (every 5 years) • CT colonography (virtual colonoscopy) (every 5 years) • Tests that primarily find cancer include the following: • High sensitivity fecal occult blood test (FOBT) (every year), or • Fecal immunochemical test (FIT) (every year)

Colonoscopy because the entire colon cancer is examined (only fifty percent of CRCs are detected by sigmoidoscopy).

Endoscopic and radiographic procedures can only reveal polyps when the bowel has been adequately prepared to eliminate stool. Provide teaching about bowel cleansing for outpatient diagnostic procedures, and administer cleansing preparations to inpatients. The patient should follow either a low-residue or a full liquid diet the day before the procedure until bowel cleansing begins. Bowel cleansing should follow a split-dose regimen. The evening before the procedure, the patient should drink 2 L of oral polyethylene glycol (PEG) lavage solution. The second 2 L dose should begin 4 to 6 hours before the procedure. A split-dose regimen started early morning the day of a procedure provides better cleansing for patients scheduled in the afternoon. Because many people find the PEG lavage solution difficult to drink and experience nausea and bloating, manufacturers have modified the PEG solutions to improve taste and palatability. Magnesium citrate solution or bisacodyl tablets or suppositories are sometimes given before the PEG lavage to remove the bulk of stool so that only 2 L of solution are needed.25 Encourage the patient to drink all of the solution. Stools will be clear or clear yellow liquid when the colon is clean.

Epithelium Head Common Bile Duct

The cause of pancreatic cancer remains unknown. Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine The most firmly established environmental risk factor is cigarette smoking

The pain is frequently located in the upper abdomen or left hypochondrium and often radiates to the back. It is commonly related to eating, and it also occurs at night

Tumor markers are used both for establishing the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Cancer-associated antigen 19-9 (CA 19-9) is elevated in pancreatic cancer and is the most commonly used tumor marker. However, CA 19-9 can also be elevated in gallbladder cancer or in benign conditions such as acute and chronic pancreatitis, hepatitis, and biliary obstruction.

The type of surgery depends on the size and location of the tumor. Pancreatic head tumors require the classic Whipple procedure or pancreaticoduodenectomy (Fig. 43-13), whereas pancreatic body and/or tail tumors require a distal pancreatectomy procedure. In the Whipple surgery, the proximal pancreas (proximal pancreatectomy), along with duodenum (duodenectomy), distal segment of the common bile duct and distal portion of the stomach (partial gastrectomy) are removed together followed by a surgical anastomosis of the pancreatic duct, common bile duct, and stomach to the jejunum. Occasionally, a total pancreatectomy is performed, which would cause diabetes and the patient would be dependent on exogenous insulin and pancreatic enzyme supplementation for life

Lung cancer

Small cell carcinoma