DISTURBANCES IN

CELLULAR FUNCTIONING
PART 1. DEFINITION OF
TERMS
Anaplasia – a change in the structure and orientation
of cells, characterized by a loss of differentiation and
reversion to a more primitive form. Anaplasia is
characteristic of malignancy.

Biologic Response Modifier (BRM) Therapy – use

of agents or treatment methods that can alter the
immunologic relationship between the tumor and the
host to provide a therapeutic benefit.
Biopsy – a diagnostic procedure to remove a small
sample of tissue to be examined microscopically to
detect malignant cells.

Brachytherapy – delivery of radiation through

internal implants.

Carcinogenesis – process of transforming normal

cells into malignant cells.
Chemotherapy – use of drugs to kill tumor cells by
interfering with cellular functions and reproduction.

Cytokines – substances produced by cells of the

immune system to enhance production and functioning
of components of the immune system.

Dysplasia – any abnormal development of tissues or

organs.
Extravasation – leakage of medication from the veins
into the subcutaneous tissues.

Hyperplasia – an increase in the number of cells of a

body part that result from an increased rate of cellular
division.

Metaplasia – the reversible conversion of normal

tissue cells into another, less differentiated cell type in
response to chronic stress or injury.
Metastasis – spread of cancer cells from the primary
tumor to distant sites.

Myelosuppression – suppression of the blood cell –

producing functions of the bone marrow.

Nadir – lowest point of WBC depression after therapy

that has toxic effects on the bone marrow
Neoplasia – the new and abnormal development of
cells that may be benign or malignant.

Neutropenia – abnormally low absolute neutrophil

count.

Oncology – field of study of cancer.

Palliation – relief of symptoms associated with

cancer.
Thrombocytopenia – decrease in the number of
circulating platelets; associated with the potential for
bleeding.

Vesicant – substance that can cause tissue necrosis

and damage, particularly when extravasated.

Xerostomia – dry oral cavity resulting from decreased

function of salivary glands.
PART 2. EPIDEMIOLOGY
most cancers occur in people
older than 65 years of age.

Higher in men and higher in

industrialized sectors and nations.

The leading causes of cancer

deaths in the United States are
lung, prostate, and colorectal for
men and lung, breast, and
colorectal for women.
PART 3. PATHOPHYSIOLOGY
OF THE MALIGNANT
PROCESS
 Predisposing/etiologic factors
 

Genetic mutation of cellular DNA

 
Transformation of normal cell to abnormal cell
 

Abnormal cells form a clone and proliferate abnormally

(Pressure, obstruction, pain, effusion, ulceration and necrosis, vascular
thrombus, embolus, thrombophlebitis)
 

Further proliferation and invasion of surrounding tissues

 
Gain access to lymph and blood vessels
 
Metastasis
 
During the lifespan,PROLIFERATIVE
various PATTERNS
body tissues normally
experience periods of rapid or proliferative growth that
must be distinguished from malignant growth activity.

Cancerous cells are described as malignant neoplasms.

They demonstrate uncontrolled cell growth that follows
no physiologic demand.
 CHARACTERISTICS OF MALIGNANT CELLS

The cell membranes are altered in cancer cells.

Cell membrane of malignant cells contains proteins

called tumor-specific antigen. These proteins distinguish
the malignant cell from a benign cell of the same tissue
type.

Malignant cellular membranes also contain less

fibronectin - a cellular cement.
Nuclei of cancer cells are large and irregularly shaped
(pleomorphism).

Nucleoli, structures within the nucleus that house

RNA, are larger and more numerous in malignant cells,
perhaps because of increased RNA synthesis.

Mitosis (cell division) occurs more frequently in

malignant cells than in normal cells. As the cells grow
and divide, more glucose and oxygen are needed.
 INVASION AND METASTASIS
by circulatory patterns and by specific affinity for
certain malignant cells to bind to molecules in specific
body tissue.

Invasion, which refers to the growth of primary tumor

into the surrounding host tissues, occurs in several ways.
Mechanical pressure exerted by rapidly proliferating
neoplasms may force fingerlike projections of tumor cells
into surrounding tissue and interstitial spaces.
Malignant cells are less adherent and may break off
from the primary tumor and invade adjacent structures.

Malignant cells are thought to possess or produce

specific destructive enzymes (proteinases), such as
collagenases (specific to collagen), plasminogen
activators (specific to plasma), and lysosomal hydrolyses
 METASTATIC MECHANISMS
Lymph and blood are key mechanisms by which cancer
cells spread.

The most common mechanism of metastasis is

lymphatic spread, which is transport of tumor cells
through the lymphatic circulation.

Tumor emboli enter the lymph channels by way of the

interstitial fluid that communicates with lymphatic fluid.
Malignant cells also may penetrate lymphatic vessels by
invasion.

Malignant cells either lodge in the lymph nodes or pass

between lymphatic and venous circulation.

Tumors arising in areas of the body with rapid and

extensive lymphatic circulation are at high risk for
metastasis through lymphatic channels (breast tumors).
Another metastatic mechanism is hematogenous
spread, by which malignant cells are disseminated
through the bloodstream.

Hematogenous spread is directly related to the

vascularity of the tumor.

Malignant cells also have the ability to induce the

growth of new capillaries to meet their needs for
nutrients and oxygen (angiogenesis).
 CARCINOGENESIS
A three-step cellular process: initiation, promotion,
and progression.

Initiation – carcinogens escape normal enzymatic

mechanisms and alter the genetic structure of the
cellular DNA. The alterations are reversed by DNA repair
mechanisms or apoptosis but others escape these
protective mechanisms.
Promotion – repeated exposure to promoting agents
(co-carcinogens) causes the expression of abnormal or
mutant genetic information.

Progression – the cellular changes formed during

initiation and promotion now exhibit increased
malignant behavior. These cells now show a propensity.
 
PART 4. CHARACTERISTICS
OF BENIGN AND
MALIGNANT NEOPLASMS
PART 5. ETIOLOGY
1. Viruses and bacteria

 Viruses are thought to incorporate themselves in the

genetic structure of cells, thus altering future
generations of that cell population

2. Physical agents

 Include exposure to sunlight or radiation, chronic

irritation or inflammation, and tobacco use.
3. Genetic and familial factors

May be due to genetics, shared environments, cultural or

lifestyle factors, or chance alone.

4. Dietary factors

Dietary substances can be proactive (protective),

carcinogenic, co-carcinogenic

Dietary substances associated with an increased cancer risk

include fats, alcohol, salt-cured or smoked meats, foods
containing nitrates and nitrites, and a high caloric dietary
intake
Foods to reduce cancer risk are: high fiber foods,
cruciferous vegetables, carotenoids and vitamins C & E

Benzopyrene – charcoal broiled meat or fish or foods

fried in repeatedly used cooking oil.

Nitrosamines – powerful carcinogens used as

preservatives for tocino, longganisa, bacon and hotdog.
Formation may be inhibited by taking antioxidants like
Vitamin C
5. Chemical agents

Polycyclic hydrocarbons – found in cigarette smoke,

industrial agents and smoked foods

Aflatoxin – found in peanuts and peanut butter

Other chemicals include asbestos, formaldehydes,

pesticides
Most hazardous chemicals produce their toxic effects
by altering the DNA structure in body sites distant from
chemical exposure. Liver, lungs, kidneys are the organs
systems most often affected
6. Hormonal agents

Tumor growth may be promoted by disturbances in

hormonal balance either by the body’s own
(endogenous) hormone production or by administration
of exogenous hormones
PART 6. WARNING SIGNS OF
CANCER BY THE AMERICAN
CANCER SOCIETY (CAUTION
US)
C – Change in bowel or bladder habits

Changes in stream/flow of urine or its color and

amount
Changes in the caliber and color of stools
Presence of blood in stools
Difficulty in urination and defecation
A – A sore that does not heal

Skin irritations are usually self-limiting. If changes in

the skin and underlying muscles take time to heal, it is
recommended to have it examined.
U – Unusual bleeding or discharge

Unusual discharges in the breast, for non-

breastfeeding women
 
T – Thickening or lump in the breast

I – Indigestion and difficulty in swallowing

O – Obvious change in wart or mole

N – Nagging cough or hoarseness of voice

U – Unexplained anemia

S – Sudden weight loss

PART 7. EARLY DETECTION
 BREAST SELF EXAMINATION
Performed every 7 to 10 days after menses

Postmenopausal clients or clients who have had a

hysterectomy should select a specific day of the month and
perform BSE monthly on that day
First – while in the shower or bath, when the skin is
slippery with soap and water, examine your breasts, use
the pads of your second, third, fourth fingers to press
every part of the breast firmly.

Second – look at your breasts in a mirror stand with your

arms at your side
Third – raise your arms overhead and check for any
changes in the shape of your breasts, dimpling of the
skin, or any changes in the nipple.

Fourth – place your hand on your hips and press down

firmly, tightening the pectoral muscles. Observe for
asymmetry or changes, keeping in mind that your
breasts probably do not match exactly.
Fifth – while lying down, feel your breasts as described
in 1. When examining your right breast, place a folded
towel under your right shoulder and put your right hand
behind your head.

Mark your calendar that you have completed your

breast self examination. Note any changes or unique
characteristics you want to check with your health care
provider.
 TESTICULAR SELF EXAMINATION
The best time to perform this examination is right
after a shower when your scrotal skin is moist and
relaxed, making the testicles easy to feel

gently lift each testicle. Each one should feel like an

egg, firm but not hard, and smooth with no lumps

using both hands, place your middle fingers on the

underside of each testicle and your thumb on top
Gently roll the testicle between the thumb and fingers
to feel for any lumps, swelling, or mass

If you notice any changes from one month to the next,
notify your physician or nurse practitioner.
PART 8. DIAGNOSTIC TESTS
Biopsy

Is the definitive means of diagnosing cancer and

provides histological proof of malignancy.

Involves the surgical incision of a small piece of tissue

for microscopic examination.
Fine needle aspiration
Is the aspiration of cells and tissue fragments through a
needle that has been guided to a suspected malignant
tissue.

Is the procedure of choice if high risk of malignancy.

Well tolerated with little trauma.

A local anesthetic may be used.

May be guided by CT scan or ultrasound.

Needle core biopsy

This involves obtaining a core of tissue through a

specially designed needle introduced into a suspected
malignant tissue.

A local anesthetic is used.

Incisional biopsy

Removal of a small wedge of tissue from a larger tumor

mass.

Is the preferred method for diagnosing soft tissue and

bony sarcomas and used for large tumors that will need
major surgery.
Excisional biopsy

Excision of the entire suspected tumor mass with no

attempt to obtain generous margins of adjacent normal
tissue.

Procedure of choice for small accessible tumors.

Following excision, a frozen section or a permanent
paraffin section is prepared to examine the specimen.

The advantage of the frozen section is the speed with

which the section can be prepared and the diagnosis
made, because only minutes are required for this test.
Permanent paraffin section takes about 24 hours;
however, it provides clearer details that the frozen
section.

Procedure is usually performed in an outpatient

surgical setting.

Obtain an informed consent.

Complete blood count (CBC)

Computed tomography (CT) scan

Use of narrow beam x-ray to scan successive layers of
tissue for a cross sectional view

Magnetic resonance imaging (MRI)

Use of magnetic fields and radiofrequency signals to
create sectioned images of various body structures
Tumor marker identification
Analysis of substances found in blood or other body
fluids that are made by the tumor or by the body in
response to the tumor.

Fluoroscopy
Use of x-rays that identify contrasts in body tissue
densities; may involve the use of contrast agents.
Ultrasonography
High frequency sound waves echoing off body tissues
are converted electronically into images; used to assess
tissues deep within the body.

Endoscopy
Direct visualization of a body cavity or passageway by
insertion of an endoscope into a body cavity or opening;
allows tissue biopsy, fluid aspiration and excision of
small tumors; both diagnostic and therapeutic
Positron emission tomography (PET scan)

Computed cross sectional images of increased

concentration of radioisotopes in malignant cells provide
information about biologic activity of malignant cells;
help distinguish between benign and malignant processes
and responses to treatment.
Radioimmunoconjugates

Monoclonal antibodies are labeled with a radioisotope

and injected intravenously into the patient; the
antibodies that aggregate at the tumor site are visualized
with scanners.
PART 9. TUMOR STAGING
AND GRADING
Grade 1 – cells differ slightly from normal cells and are
well differentiated (mild dysplasia)

Grade 2 – cells are more abnormal and are moderately

differentiated (moderate dysplasia)

Grade 3 – cells are very abnormal and are poorly

differentiated (severe dysplasia)

Grade 4 – cells are immature and undifferentiated; cell

of origin is difficult to determine (anaplasia)
Stage 0 – carcinoma in situ

Stage 1 – tumor limited to the tissue of origin;

localized tumor growth

Stage 2 – limited local spread

Stage 3 – extensive local and regional spread

Stage 4 – distant metastasis

TNM CLASSIFICATION

T – the extent of the primary tumor

N – the absence or presence and extent of regional

lymph node metastasis

M – the absence or presence of distant metastasis

 
Primary tumor (T)

TX – primary tumor cannot be assessed

T0 – no evidence of primary tumor

Tis – carcinoma in situ

T1, T2, T3, T4 – increasing size and/or local extent of

the primary tumor
Regional lymph nodes (N)

NX – regional lymph nodes cannot be assessed

N0 – no regional lymph node metastasis

N1, N2, N3 – increasing involvement of regional lymph

nodes
Distant metastasis (M)

MX – distant metastasis cannot be assessed

M0 – no distant metastasis

M1 – distant metastasis

PART 10. DIFFERENT TYPES
OF CANCER
 SKIN CANCER
Is a malignant lesion of the skin, which may or may not
metastasize

Skin cancer causes include chronic friction and

irritation to a skin area and exposure to ultraviolet rays.

Diagnosis is confirmed by a skin biopsy that is positive

for cancer cells
Types:

Basal cell – the most common type, basal cell cancer

arises from the basal cell contained in the epidermis.

Waxy border
papule, red, central crater
metastasis is rare
Squamous cell – the second most common type of skin
cancer in whites; squamous cell cancer is the tumor of
the epidermal epidermal keratinocytes and can infiltrate
surrounding structures, metastasize to lymph nodes,
and subsequently be fatal.

Oozing, bleeding, crusting lesion

Potentially metastatic
Large tumors associated with a higher risk for
metastasis
Malignant melanoma – may occur any place on the
body, especially where birthmarks or new moles are
apparent. Cancer of the melanocytes can metastasize to
the brain, bones, lung, liver and skin and is ultimately
fatal.

Irregular, circular, bordered lesion with hues of tan,

black or blue
Rapid infiltration into tissue, rapid metastasis,
significant rate of morbidity and mortality
Instruct the client regarding preventive measures

Instruct the client to monitor for lesions that do not

heal or that change characteristics

Instruct the client to have moles or lesions removed

that are subject to chronic irritation

Instruct the client to avoid contact with chemical

irritants
Instruct the client to wear layered clothing and use
sunscreen lotions with an appropriate skin protection
factor when outdoors

Instruct the client to avoid sun exposure between 11 AM

and 3 PM

Assist with surgical excision of the lesion as prescribed

 BREAST CANCER
Is classified as invasive when it penetrates the
tissue surrounding the mammary duct and grows in
an irregular pattern

Metastasis occurs via lymph node

Diagnosis is made by breast biopsy through a

needle aspiration or by surgical removal of the
tumor with microscopic examination of malignant
cells
Assessment
Mass felt during BSE
Asymmetry, with the affected breast being higher
Bloody or clear nipple discharge
Skin dimpling, retraction, or ulceration
Skin edema or peau d’orange skin
Axillary lymphadenopathy
Lymphedema of the affected arm
Non surgical interventions

Chemotherapy

Radiation therapy

Hormonal manipulation via the use of medication

in post-menopausal women or other medications
such as tamoxifen (Nolvadex) for estrogen receptor-
positive tumors.
Surgical interventions
1. Lumpectomy
tumor is excised and removed
lymph node dissection may also be performed

2. simple mastectomy
breast tissue and the nipple are removed
lymph nodes are left intact

3. modified radical mastectomy

breast tissue, nipple, and lymph nodes are removed
muscles are left intact
monitor vital signs

position the client in Semi-Fowler’s position

turn from the back to the unaffected side, with the

affected arm elevated above the level of the heart to
promote drainage and prevent lymphedema

encourage coughing and deep breathing

if a drain (usually Jackson – Pratt) is in place,
maintain suction and record the amount of drainage
and drainage characteristics

assess operative site for infection, swelling, or

presence of fluid collection under the skin flaps or in
the arm

place a sign above the bed stating: No IV’s, No

injections, No BP’s, No venipuncture in affected arm;
the affected arm is protected and any intervention
that could traumatize the affected arm is avoided.
Consult with the physician and physical therapist
regarding the appropriate exercise program and
assist client with prescribed exercise

Client instruction following mastectomy:

 Avoid overuse of the arm during the first few
months

 To prevent lymphedema, keep the affected arm

elevated
Encourage the client to perform BSE on the
remaining breast

Protect the affected hand and arm

Do not let the affected arm hang dependent

Do not carry pocketbook or anything heavy over

the affected arm
Avoid trauma, cuts, or bruises, or burns to the
affected side

Avoid wearing constricting clothing or jewelry on

the affected side

Wear gloves when gardening

Use thick oven mitts when cooking

Use a thimble when sewing

 LUNG CANCER
Malignant tumor of the bronchi and peripheral
lung tissue, is a leading cause of cancer-related
deaths in men and women in the United States

The lungs are a common target for metastasis from

other organs

Bronchogenic cancer (tumors originate in the

epithelium of the bronchus) spreads through direct
extension and lymphatic dissemination
Classified according to histological cell type, there
are two main types of lung cancer, small cell lung
cancer and non-small cell lung cancer.

Diagnosis is made by a chest x-ray, CT scan, or

MRI, which will show a lesion or mass and by
bronchoscopy and sputum studies, which will
demonstrate a positive cytological study for cancer
cells
CAUSES

Cigarette smoking, exposure to

“passive” tobacco smoke

Exposure to environmental and

occupational pollutants
ASSESSMENT

Cough

Wheezing, dyspnea

Hoarseness

Hemoptysis
Chest pain

Anorexia

Weakness

Diminished or absent breath sounds, respiratory

changes
INTERVENTIONS

Monitor vital signs

Monitor for breathing patterns and breath sounds

Place in a fowler’s position to help ease breathing

Administer oxygen as prescribed and
humidification to moisten and loosen secretions

Monitor pulse oximetry

provide a high calorie, high protein, high vitamin

diet
provide activity as tolerated, rest periods, and
active and passive range of motion exercises

monitor for bleeding and infection

 
NONSURGICAL INTERVENTIONS

radiation therapy may be prescribed for localized

intrathoracic lung cancers and for palliation of
hemoptysis, obstructions, dysphagia, superior vena
cava syndrome, and pain

chemotherapy may be prescribed for treatment of

nonresectable tumors or as adjuvant therapy
SURGICAL INTERVENTIONS
laser therapy: to relieve endobronchial obstruction

thoracentesis and pleurodesis: to remove pleural

fluid and relive hypoxia

thoracotomy with pneumonectomy: surgical

removal of one entire lung

thoracotomy with segmental resection: surgical

removal of a lobe segment
 
 PROSTATE CANCER
A slow growing malignancy of the prostate gland;
most prostate tumors are adenocarcinoma arising
from androgen-dependent epithelial cells

The risk increases in men with each decade after

the age of 50 years
Can spread by direct invasion of surrounding
tissues or by metastasis, through the blood stream
and lymphatics, to the bony pelvis and spine

The cause of prostate cancer is unclear, but

advancing age, heavy metal exposure, smoking, and
history of sexually transmitted disease are
contributing factors
ASSESSMENT

Asymptomatic in early stages

Hard, pea-sized nodule or irregularities palpated

on rectal examination

Gross, painless hematuria