Copy Of Cancer Detection And Testing Print 22

What is Staging? • Staging describes the extent or

severity of an individual’s cancer • It is base on the extent of the original (primary) tumor and the extent of spread in the body.

Staging is important: – Staging helps the doctor plan a person’s

treatment. – The stage can be used to estimate the person’s prognosis (likely outcome or course of the disease). – Knowing the stage is important in identifying clinical trials (research studies) that may be suitable for a particular patient.

Elements of Staging Systems  Location of the primary tumor  Tumor size and number of tumors,  Lymph node involvement  Cell type and tumor grade  Presence or absence of metastasis

TNM System: The TNM system is based on : • the extent of the tumor (T) • the extent of spread to the lymph nodes (N) • the presence of metastasis (M). – A number is added to each letter to indicate

the size or extent of the tumor and the extent of spread.

Primary Tumor (T)  TX - Primary tumor cannot be

evaluated  T0 – No evidence of primary tumor  Tis - Carcinoma in situ (early cancer that has not spread to neighboring tissue)  T1, T2, T3, T4 - Size and/or extent of the primary tumor

Regional Lymph nodes  NX - Regional lymph nodes cannot

be evaluated  N0 - No regional lymph node involvement (no cancer found in the lymph nodes)  N1, N2, N3 - Involvement of regional lymph nodes (number and/or extent of spread)

Distant Metastasis (M)  MX - Distant metastasis cannot be

evaluated  M0 - No distant metastasis (cancer has not spread to other parts of the body)  M1 - Distant metastasis (cancer has spread to distant parts of the body)

Examples:  breast cancer T3 N2 M0  It refers to a large tumor that has spread

outside the breast to nearby lymph nodes, but not to other parts of the body.

 Prostate cancer T2 N0 M0  It means that the tumor is located only in the

prostate and has not spread to the lymph nodes or any other part of the body.

 Stage I ( T1, N0, MO)- Early Stage  Stage II (T2, N1, M0) – local Spread  Stage III ( T3, N2, M0)- extensive

spread but no metastasis.  Stage IV (T4, N3, M+) Advanced stage, with distant metastasis

5 Main Categories of Cancer – In situ is early cancer that is present

only in the layer of cells in which it began. – Localized is cancer that is limited to the organ in which it began, without evidence of spread.

– Regional is cancer that has spread

beyond the original (primary) site to nearby lymph nodes or organs and tissues. – Distant is cancer that has spread from

the primary site to distant organs or distant lymph nodes. – Unknown is used to describe cases for

which there is not enough information to indicate a stage.

Stages of Cancer Stage

Definition

Stage 0

Carcinoma in situ (early cancer that is present only in the layer of cells in which it began).

Stage I, Stage II, and Stage III

Higher numbers indicate more extensive disease: greater tumor size, and/or spread of the cancer to nearby lymph nodes and/or organs adjacent to the primary tumor.

Stage IV

The cancer has spread to another organ.

Why Cancer Detection and Testing Important?  Detecting cancers early is an important

step in preventing significant health problems.

Four Possible Outcomes.  True Positive  False Positive  True Negative  False Negative

 When a test is performed to detect a

disease, there are four possible outcomes:  True positive - test indicates that a patient

has a disease that the patient does indeed have  False positive - test indicates that a patient

has a disease when they do not

 True negative - test indicates the patient

is disease-free, and this is indeed the case  False negative - test indicates the

patient is healthy when in fact the patient has the disease

 Sensitivity refers to how accurately a test

identifies people who have the disease.  Specificity refers to how accurately a test

identifies people who do not have the disease  The best medical tests have high sensitivity and

high specificity.

Non - Invasive

Invasive Techniques Analysis of Biopsy

Complete Blood Count Fine Needle Aspiration (CBC) Core Needle Biopsy Ultrasound MRI PET Scan CT Scan

Immunohistochemistry (IHC) Fluorescent In Situ Hybridization (FISH)

 Ultrasound uses reflection of sound waves to

create an image of a part of the body  MRI uses magnetic fields and radio waves to

produce images of the body.  PET scans use radioactive molecules to create a

dynamic image of internal tissues and organs. PET scans are able to measure the metabolic activity of cells, not just their structure.

 CT scans use x-rays to take multiple

image slices in order to create a 3D image.  X-rays utilized high energy beams to

create an image.

Non- Invasive: CBC  It provides information about the number,

parts, shape, and structure of the different cell types found in blood.  3 main types of blood cells:  WBC  RBC  Platelets

MRI When contrast agent is not used an MRI can show:

When contrast agent is used MRI can show:

• contrast agent is not used an MRI •size and location of benign or can show: malignant growths •The shape, size, appearance, and •enlarged lymph nodes location of organs, bones, and •changes in blood flow joints extracellular volume •The presence of abnormal growths •Signs of inflammation or infection

Positron Emission Tomography (PET)  Is an imaging technique that uses radioactive

molecules to create a dynamic image of internal tissues and organs.  It produce images that reveal the activity of living tissue.  PET scans use radioactively labeled tracers (radiotracers) that are injected into the bloodstream

Computed Tomography  It uses x-rays in the same way as a

conventional x-ray but instead of taking one image a CT scanner takes multiple images, or slices.  It can provide a 3 dimensional image of an internal structure, it can detect differences in tissue density.

Fine Needle Aspiration (FNA) Core Needle Biopsy (CNB)

Biopsy  Is the removal of cells, tissue, or fluid

for examination.

Types of Biopsy  Excisional biopsy- removes all

suspicious tissue.  Incisional biopsy- removes a sample of tissue from a mass.  Needle Aspiration- aspiration of small amount of core tissue from a suspicious area.

Invasive Techniques  Fine needle aspiration (FNA) uses a

small needle to collect small samples of a lesion.  Core needle biopsy (BPA) uses a

larger needle to collect samples of a lesion

Fine Needle Aspiration Sample Removed

Core Needle Biopsy

Needle Size

Removes only a very small portion of the lesion Removes a small portion in most cases, occasionally removes the entire lesion 22-27 gauge 11-18 gauge

Pathology Type

Cytopathology

Histopathology

Interpretation Time

Immediately

Delayed

Diagnostic Abilities

Limited ability to specifically diagnose benign lesions No ability to differentiate between in situ and invasive breast cancer

Disadvantages

Cannot be used for additional study

Strong ability to specifically diagnose benign lesions. Some ability to differentiate between in situ and invasive breast cancer. More invasive, time consuming, expensive

Advantages

Inexpensive, quick, readily available, and very safe

Effectiveness

Sensitivity: 75.8-98.7% Specificity: 60-100% Positive Predictive Value: 93.5-100%

Can be used for additional study and has more specific diagnostic abilities than FNA Sensitivity: 91-99.6%% Specificity: 98-100% Positive Predictive Value: 10

Analysis of FNA  Benign - the mass is not of much concern and will

not cause any significant problems as long as it remains unchanged.  Atypically indeterminate - a diagnosis cannot be obtained from the sample. Other tests are needed to determine the nature of the lesion.  Suspicious/probably malignant - not a diagnosis of cancer. This type of diagnosis requires additional investigation because the sample has abnormal characteristics. This lesion should be biopsied with a more complete method to determine whether a malignancy (cancer) is present.

 Malignant - a diagnosis of cancer;

should be biopsied and tested for exact tumor makeup to prepare for treatment.  Unsatisfactory - a diagnosis cannot be determined from the sample because of insufficient sample size, processing or other machine or human errors.

Examination of Tissue Samples  Immunohistochemistry (IHC)

 Fluorescence in Situ

Hybridization (FISH)

Immunohistochemistry (IHC)  Is a technique used to determine the

presence and level of specific cellular proteins.  An example: Three proteins of particular

interest in breast cancer are HER2, the estrogen receptor (ER) and the progesterone receptor (PR).

Fluorescence in Situ Hybridization (FISH)  Is a cytogenetic technique used to detect

and localize the presence or absence of specific DNA sequences on chromosomes.  FISH uses fluorescent probes that bind to

only those parts of the chromosome with which they show a high degree of sequence similarity.

Cancer Specific Techniques  Mammography uses low dose x-ray

to create an image of a breast.  Sigmoidoscopy uses a small tube containing viewing equipment to view the colon.  Virtual Colonoscopy uses an MRI or CT scan to create an image of the inside of the colon.

 Pap smears use a sample of cells from the

cervix to detect cervical cancer. Pap smears may also detect ovarian and uterine cancers that have migrated to the cervix.  Prostate specific antigen (PSA) test

measures levels of a glycoprotein in the blood. Elevated levels of PSA are associated with prostate cancer

Sentinel Lymph Node Biopsy (SLN)  is used to detect metastasis.

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Treatment Goal  Is to cure the client– eradicate the

tumor.  When cure is not possible, controlling or arresting a tumor growth becomes the goal– to prolong the survival.  Palliation or alleviation of symptoms.

Treatments  Surgery  Radiation Therapy  Hormonal Therapy  Targeted Therapy  Antibodies  Cancer Vaccines  Complimentary and Alternative

Medicines  Chemotherapy

Surgery  The first line of treatment for many

solid tumors.  May be sufficient to cure the patient by removing all cancerous cells.  Surgery is often used in combination with radiation and/or chemotherapy

Types of Treatment  Local Excision- simple surgery with small

margin of normal tissue surrounding tumor.

 En bloc Dissection- removal of tumor, tissues,

and any contiguous structures.

Surgery on Cancer in Situ  Electrosurgery- application of

electrical current to cancerous cells  Cryosurgery- deep freezing with liquid nitrogen  Chemosurgery- applied chemotherapeutic agents layer by layer with surgical incision.  Co2 laser- use of laser for laser excision.

Radiation  May be used in conjunction with

surgery and/or drug treatments.  The goal of radiation is to kill the cancer cells directly by damaging them with high energy beams

Radiation Therapy  Radiation treatments utilize high-energy

waves to kill cancer cells.  Use of high energy moving through

space or medium to treat disease.  It can be used alone or in conjunction

with other treatments (e.g. chemotherapy and surgery) to cure or stabilize cancer.

Objectives:  This treatment seeks to relieve

symptoms of the cancer and to prolong survival, making life more comfortable.

Indications  Used to treat tumors- ionizing

radiation transfers energy to molecules present in cancer cells.  Different tissues have different radio

sensitivities– rapidly dividing tissues (testes, ovaries, lymphoid tissues, and bone marrows) are more sensitive.

Types of Radiation  Electromagnetic- radiation in wave form  Xrays- linear accelerators  Electrons- delivered by machines  Gamma- rays – delivered by machines that

contain radioactive sources (Cobalt 60), or radioactive substances ( seeds, threads)

 Particulate – radiation in the form of heavy

particles. (beta particles- High speed electrons)

Pre- operative Radiation Therapy  It can kill tumor cells at margins of

the tumor site.  It can keep the cancer under control and prevent metastases, and also convert technically inoperable tumors into operable ones.

Postoperative Radiation  It can destroy cancer cells still

present around the margins after a tumor has been surgically removed.

Internal Radiation  Is the process of implanting

radioactive material onto or near the tumor or placing radioactive sources into the body.  Implantation of radioactive substance within a client.  It can be temporary or permanent.  Also called brachytherapy

Types of Internal Radiation  Unsealed sources: Isotopes  Liquid and administered orally.

 Sealed Sources: Radium needles and

radon seeds.  Radioactive substance encased in metal

capsule placed in body cavity.  Delivers radiation directly to tumor

External Radiation  It utilizes a machine to deliver radiation

to the tumor.  This therapy is primarily an outpatient treatment.  Most protocols last approximately 4-7 weeks with treatments given 5 days per week  Also called as Teletherapy- external source of radiation. ( machine is a distance from client)

2 Types of External Radiation  Natural Radioactive Source - gamma

rays delivered via machine to lesion.  Machine is the linear accelerator-

high voltage electric current delivers electrons to client.

Photon Radiation  It uses high energy rays composed of

particles of energy called photons. Photon radiation acts by disrupting the molecules of the target cells, interfering with normal cell functions. There are several types of photon radiation:

 Gamma rays: are produced by the

breakdown of radioactive isotopes of elements such as Cobalt-60 and radium  X-rays: originate from machines that excite electrons using cathode ray tubes or linear accelerators.

Administration of Radiation Therapy  Internal  Seed implants  Brachytherapy

 External  External Beam Radiation Therapy  3-D Conformal Therapy and Intensity

Modulated Radiation Therapy (IMRT)

Benefits  Destroys quickly dividing cells at the

margins of tumors. Surgery may miss these cells leading to recurrence of disease.  Can successfully eradicate growth without permanently damaging the adjacent normal tissue. If these tumors can be treated early before metastasis, there is a very high rate of curability.

 In conjunction with other treatments, may

cure tumors that are not responsive to any single agent.

Hormonal Treatments  It prevent cancer cell growth by

preventing the cells from receiving signals necessary for their continued growth and division

Targeted Therapy  They work by targeting specific

proteins and processes that are limited primarily to cancer cells or that are much more prevalent in cancer cells.  Inhibition of these processes prevents cancer cell growth and division.

Antibodies  This treatment involves the use of

antibodies to target cancer cells.  The antibodies may work by several different mechanisms, either depriving the cancer cells of necessary signals or causing the direct death of the cells.  Because of their specificity, antibodies may be thought of as a type of specific inhibitor.

Biological Response Modifiers  These treatments involve the use of

naturally occurring, normal, proteins to stimulate the body's own defenses against cancer.

Cancer Vaccines  It stimulate the body's defenses

against cancer.  The treatment aims to increase the

response of the body against the cancer cells.  Vaccines usually contain proteins found on

or produced by cancer cells. By administering these proteins,

Complementary and Alternative Medicines  These treatment methods are not

practiced by conventional western medicine.  They can include herbal, animal derived, and mind-body approaches to treating cancer.

Chemotherapy  It refers to a wide range of drugs

used to treat cancer.  These drugs generally work by killing dividing cells.

Goal of Chemotherapy  Is to cure malignancy  Control maybe the goal when cure is

not realistic; the aim is to extend survival and improve the quality of life.  Palliation may be the goal when neither cure nor control maybe achieved; this goal is directed toward client comfort.

Types of Chemotherapy Drugs  Antimetabolites  Genotoxic Drugs  Spindle Inhibitors  Other Chemotherapy Agents

Anti- Metabolites  Drugs that interfere with the

formation of key bio-molecules within the cell including nucleotides, the building blocks of DNA.  These drugs ultimately interfere with DNA replication and therefore cell division.

Types of Antimetabolites  Folate Antagonists  Purine Antagonists  Pyrimidine Antagonists

Folate Antagonist  also known as antifolates  It inhibit dihydrofolate reductase (DHFR),

an enzyme involved in the formation of nucleotides.  When this enzyme is blocked, nucleotides are not formed, disrupting DNA replication and cell division  Methotrexate and Pemetrexed

Purine Antagonists  It function by inhibiting DNA synthesis in two

different ways:  They can inhibit the production of the purine

containing nucleotides, adenine and guanine. If a cell doesn't have sufficient amounts of purines, DNA synthesis is halted and the cell cannot divide.  They may be incorporated into the DNA molecule during DNA synthesis. The presence of the inhibitor is thought to interfere with further cell division.

 6-Mercaptopurine, Dacarbazine, Fludarabine

 act Pyrimidine to block the synthesis Antagonists of pyrimidine

containing nucleotides (C and T in DNA; C and U in RNA).  The drugs used to block the construction of these nucleotide have structures that are similar to the natural compound.  By acting as 'decoys', these drugs can prevent the production of the finished nucleotides. They may exert their effects at different steps in that pathway and may directly inhibit crucial enzymes.

 5-fluorouracil  Arabinosylcytosine  Capecitabine  Gemcitabine  Decitabine

Genotoxic Drugs  Drugs that damage DNA. By causing

DNA damage, these agents interfere with DNA replication, and cell division  3 Treatments:  Alkylating Agents  Intercalating Agents  Enzyme Inhibitors

The genotoxic chemotherapy treatments include: Alkylating agents:  The first class of chemotherapy

agents used. These drugs modify the bases of DNA, interfering with DNA replication and transcription and leading to mutations

Intercalating agents  These drugs wedge themselves into the spaces between the nucleotides in the DNA double helix. They interfere with transcription, replication and induce mutations. Enzyme inhibitors  These drugs inhibit key enzymes, such as topoisomerases, involved in DNA replication inducing DNA damage.

Spindle Inhibitors  These agents prevent proper cell

division by interfering with the cytoskeletal components that enable one cell to divide into two.  Vinca Alkaloids

Paclitaxel (Taxol®) Docetaxel (Taxotere®) Ixabepilone (Ixempra®)

Additional  While many of the Chemotherapy commonly used

chemotherapy agents fit into one of the Agents three previously described groupings (Genotoxic, Cytoskeletal, and Antimetabolite), some of them work through mechanisms that do not neatly fit into one of these categories.  Arsenic trioxide (Trisenox®) Bleomycin Hydroxyurea Streptozocin

Chemotherapeutic Administration  Oral  IM/ SQ  IV  Central Venous Catheter  Venous Access Devices (VAD)  Intraarterial Route  Intraperitoneal Route