oncology
Content
“Karnikos”
Neoplasm
“Cancer adheres to any part that it seizes
upon in an obstinate manner like the crab.”
product of new growth
abnormal mass of tissue
The crab depicts the manner of growth of
the disease.
exceeds and is uncoordinated with
that of the normal tissues
persists in the same excessive
manner after cessation of the stimuli
which evoked that change
Cancer
More than 100 neoplastic diseases that
involve all body organs
Uncontrolled growth of one of more cells
Progression from normal tissue to invasive
cancer is 5 – 20 years
Driven by a series of accumulative genetic
changes
Terminologies
Neoplasia – “new growth”
Tumor – swelling originally due to
inflammation
Oncology – study of tumors or neoplasms
purposeless, preys on the host,
autonomous
1.2 million in US are diagnosed with cancer
every year
Greatest increase seen in lung CA
Number of CA deaths increased by 11%
during past 40 years
Epidemiology
Geographic and Environmental Factors
Gastric CA in Japan
Racial differences due to
environmental influences
Epidemiology
Second leading cause of death in the US
after heart disease
Ranks fourth for males and first for females
as leading cause of death
Ranks second for children as cause of death,
after accidents
Epidemiology
Age
Late age
Cancers of certain age groups
Heredity
Inherited cancer syndromes
(Rhabdomyosarcoma)
Familial cancers (Breast, colon, ovary
and brain)
Terminologies
Do not invade adjacent structures
- grows to a large size
Benign - designated by the suffix
Do not spread to distant sites
- it obstructs important channels in the body
“-oma”
Usually not lethal
- it ulcerates or bleeds
Malignant – “sarcomas, carcinomas”
Life-threatening
- it produces endocrine disturbances
Benign Tumors
- if it forms in a critical location
Tissue of Origin
Benign
Malignant
Tissue of Origin
Benign
Malignant
Composed of
More Than One
Neoplastic Cell
Type (Mixed
Tissue of Tumors)
Origin
Benign
Composed
One
1. of
Salivary
Parenchymal Cell
glands
Type
A. Mesenchymal
Tumors 2. Breast
1.
Lipoma
3.
Pleomor
Malignant mixed tumor of
phic
adenoma
salivary gland
Fibroade
Fibrosarcoma
Malignant cystosarcoma
noma
phyllodes
Liposarcoma
Connective
tissue and
Chondroma
3.
Renal Anlage
derivatives
Osteoma
2. Endothelial and
related tissues
3.
Fibroma
Malignant
Angiosarcoma
Lymphangioma
Lymphangiosarcoma
Muscle
Benign
2.
Basal cell
3.
Glands or ducts
4.
Respiratory passages
5.
Malignant
Tumors
Neuroectoderm
Basal cell carcinoma
Adenoma
Leiomyosarcoma
Rhabdomyoma
Rhabdomyosarcoma
Adenocarcinoma
Bronchogenic
carcinoma
Nevus
Malignant melanoma
6.
Renal epithelium
Renal tubular adenoma
Renal cell carcinoma
7.
Liver cells
Liver cell adenoma
Hepatocellular
carcinoma
8.
Urinary tract epithelium
Transitional cell papilloma
Transitional cell
carcinoma
Leukemias
Leiomyoma
Malignant
Composed of One Parenchymal Cell Type
1. Totipotential cells in
Mature teratoma, dermoid
Immature teratoma,
gonads
or in embryonic
cyst
B. Epithelial
Tumors
Squamous cellteratocarcinoma
papilloma
Squamous cell
rests
carcinoma
1. Stratified squamous
Chondrosarcoma
Wilms’ tumor
Osteosarcoma
Hemangioma
Blood cells
Benign
vs.
Composed of More Than
One Neoplastic Cell Type
From More Than One
Germ Layer Tissue of Origin
Teratogenous
Tumor Progression
Cancer is a
multistep
process
Initiation
Carcinogen
Cell
Tumor
Abnormal Cell
Promotion
Carcinogen
The
Switc
h
from
Norm
al to
Abnor
mal
Growt
h
Activa
tion
of
Onco
genes
Oncogenes
encode
proteins that
promote cell
growth
Inhibi
tion
of
Tumo
r
Suppr
essor
Gene
s
Tumor
Suppressor
Genes apply
brakes to cell
proliferation
The
Switc
h
from
Norm
al to
Abnor
mal
Growt
h
Altera
tion
in cell
cycle
Dereg
ulatio
n of
cell
cycle
contr
ol
Apopt
osis
Growth
Local
Invasion
What
cause
s the
switc
h?
Point
mutat
ions
Transl
ocatio
ns
Gene
ampli
ficatio
n
Loss
of
heter
ozygo
zity
Damage to
the DNA
Stage
s of
Tumo
r
Growt
h
Transformatio
n
Metastases
Angio
genes
is
Conti
nued
tumor
growt
h
requir
es
persis
tent
new
blood
vesse
l
growt
h
Shed
ding
of
malig
nant
cells
into
the
venou
s
drain
age
Tumo
r cells
releas
e
solubl
e
factor
s that
requir
e
angio
genic
respo
nse
(angi
ogen
esis
factor
s)
Metas
tasis
Metas
tasis
Detac
hmen
t of
the
tumor
cells
from
each
other
Attac
hmen
t to
matri
x
comp
onent
s
Degra
datio
n of
extra
cellul
ar
matri
x
b
et
w
e
e
n
v
e
n
o
u
s
a
n
d
ly
m
p
h
at
ic
ci
rc
ul
at
io
n
Migra
tion
of
tumor
cells
Mech
anism
s of
Metas
tasis
Via
the
lymp
hatic
syste
m
C
a
n
c
er
c
el
ls
re
si
d
e
in
ly
m
p
h
n
o
d
e
s
or
p
a
ss
Ar
e
a
s
of
b
o
d
y
wi
th
e
xt
e
n
si
v
e
ly
m
p
h
at
ic
ci
rc
ul
at
io
n
(e
.g
.
br
e
a
st
)
M
e
c
h
a
ni
s
m
s
of
M
et
a
st
a
si
s
Via
the
circul
atory
syste
m
H
e
m
at
o
g
e
n
o
u
s
ro
ut
e:
bl
o
o
d
c
ar
ri
e
s
c
a
n
c
er
c
el
l
fr
o
m
o
n
e
si
te
to
a
n
ot
h
er
R
el
at
e
d
to
th
e
d
e
gr
e
e
of
v
a
sc
ul
ar
it
y
or
a
n
gi
o
g
e
n
e
si
s
in
th
e
tu
m
or
M
e
c
h
a
ni
s
m
s
of
M
et
a
st
a
si
s
Via
direct
sprea
d of
cance
r cells
(seedi
ng)
where
there
are
no
boun
daries
to
stop
growt
h
(e.g.
ovary,
stomach)
C
ar
ci
n
o
g
e
ni
c
A
g
e
nt
s
Chem
ical
carcin
ogens
Radia
nt
energ
y
Onco
genic
viruse
s
Horm
ones
Genet
ic
Immu
nodef
icienc
y
immune
effector cells
can eliminate
cells that
undergo
malignant
transformatio
n
development
of tumor is a
failure of
immune
surveillance
in
maintaining
tissue
homeostasis
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Organ
specif
ic
Genot
oxic
(caus
e
genet
ic
dama
ge)
Envir
onme
ntal
expos
ures
Activa
tion
of
endo
geno
us
muta
genic
pathw
ays
(nitric
oxide
& oxy
radica
ls)
Requi
res
accu
mulat
ed
expos
ure
Gross
chro
moso
mal
chang
es
Chem
ical
Carci
noge
ns
Two
stage
s of
chemi
cal
carcin
ogen
esis
e
ni
c
a
g
e
nt
Initiation
R
e
s
ul
ts
fr
o
m
e
x
p
o
s
ur
e
of
c
el
ls
to
a
n
a
p
pr
o
pr
ia
te
d
o
s
e
of
a
c
ar
ci
n
o
g
n
in
d
u
c
e
tu
m
or
s
in
in
iti
at
e
d
c
el
ls
b
ut
ar
e
n
o
nt
u
m
or
ig
e
ni
c
b
y
th
e
m
s
el
v
e
s
C
a
u
s
e
s
p
er
m
a
n
e
nt
D
N
A
d
a
m
a
g
e
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Promotion
C
a
Pr
o
d
u
c
e
re
v
er
si
bl
e
d
a
m
a
g
e
to
D
N
A
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Direct
Actin
g
Alkyla
ting
Agent
s
- use
as anticancer
drugs
cyclophospha
mide,
chlorambucil,
busulfan,
melphalan
and others
Polyc
yclic
Arom
atic
Hydro
carbo
ns
some of the
most potent
carcinogens
Pr
o
d
u
c
e
d
in
th
e
c
o
m
b
u
st
io
n
of
to
b
a
cc
o
a
s
in
ci
g
ar
et
te
s
m
o
ki
n
g
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Arom
atic
Amin
es
and
Azo
Dyes
E
x
er
ts
it
s
ef
fe
ct
s
in
th
e
li
v
er
“
T
h
e
ul
ti
m
at
e
c
ar
ci
n
o
g
e
n
”
In
te
r
m
e
di
at
e
s
wi
th
th
e
c
yt
o
c
hr
o
m
e
P4
5
0
o
x
y
g
e
n
a
s
e
s
y
st
e
m
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Natur
ally
occur
ring
carcin
ogens
Aflatoxin B1
Produced by
certain
strains of
Aspergillus
flavus
Found on
improperly
stored grains
and peanuts
Nitros
amin
es
and
amid
es
In the
gastrointestin
al tract
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
in
th
e
Di
et
Chem
ical
Carci
noge
ns in
the
Diet
High
fat,
low
fiber
conte
nt
Food
additi
ves
such
as
cycla
mides
,
nitrite
s and
sacch
arin
Heav
y
food
seaso
ning
Smok
ed or
salted
foods
Foods
conta
minat
ed
with
anato
xin
Alcoh
ol
Chem
ical
Carci
noge
ns
Miscel
laneo
us
agent
s
AsbestosLung CA
Vinyl
chlorideLiver
hemangiosarc
oma
Chromium,
nickel – Lung
CA
Arsenic – Skin
CA
Components
of
insecticides
c
el
l
C
A
a
n
d
m
el
a
n
o
c
ar
ci
n
o
m
a
of
th
e
sk
in
Diethylstilbes
trol
R
a
di
a
nt
C
ar
ci
n
o
g
e
n
s
Ultrav
iolet
rays
I
m
pl
ic
at
e
d
in
s
q
u
a
m
o
u
s
c
el
l
C
A,
b
a
s
al
D
e
p
e
n
d
s
o
n
th
e
ty
p
e,
in
te
n
si
ty
a
n
d
le
n
gt
h
of
e
x
p
o
s
ur
e,
a
n
d
q
u
a
nt
it
y
of
m
el
a
ni
n
o
n
sk
in
U
V
B
is
th
e
c
ar
ci
n
o
g
e
ni
c
ty
p
e
R
a
di
a
nt
C
ar
ci
n
o
g
e
n
s
Ionizi
ng
Radia
tion
formation
of free
radicals
which can
damage DNA
El
e
ct
ro
m
a
g
n
et
ic
ra
di
at
io
n(
xra
y
s,
g
a
m
m
a)
P
ar
ti
c
ul
at
e
ra
di
at
io
n
(a
lp
h
a
p
ar
ti
cl
e
s,
b
et
a
p
ar
ti
cl
e
s,
pr
ot
o
n
s,
n
e
ut
ro
n
s)
T
h
er
a
p
e
ut
ic
ra
di
at
io
n
Huma
n
Papill
omavi
rus
Anogenital,
cervical and
skin cancer
Viral
Carcinogens
Hepa
DNAvi
rus
Hepa B virus
(Hepatocellul
ar cancer)
Hepat
otropi
c
virus
Hepa C virus
(Hepatocellul
ar cancer)
Herpe
svirus
Epstein Barr
virus
(Hodgkin’s
lymphoma,
nasopharyng
eal CA)
Kapos
i’s
sarco
ma
Huma
n
immu
nodef
icienc
y
virus
Horm
ones
Estro
gen
Proge
stero
ne
Andro
gens
Warni
ng
Signs
of
Cance
r
From
the
Ameri
can
Cance
r
Societ
y
Healt
h
Histor
y
Change in
bowel or
bladder
habits
Thickening or
lump in
breast or
elsewhere
Indigestion or
difficulty
swallowing
Obvious
change in
wart or mole
Nagging
cough or
hoarseness
Asses
smen
t
Healt
h
Histor
y
Physi
cal
Exami
natio
n
Diagn
ostic
Proce
dures
Perso
nal
and
Social
Histor
y
Gener
al
infor
matio
n
A sore that
doesn’t heal
Unusual
bleeding or
discharge
hospitalizatio
ns / surgery
-
allergy
name
- diet
- age
- life-
-
style
- race
occupation
gender
Healt
h
Histor
y
- date
& place of
birth
marital status
Famil
y
Histor
y
Healt
h
Histor
y
OBGyne
Histor
y
Chief
Comp
laint
Past
Medic
al
Histor
y
previous
medical
disease
previous
menarche
menopause
- OCP
use
- GP
(TPAL)
Physi
cal
Exami
natio
n
h
e
al
)
Skin
L
o
ss
of
sk
in
m
ar
ki
n
g
s
P
er
si
st
e
nt
ul
c
er
(a
n
y
c
h
a
n
g
e
in
c
ol
or
,
si
z
e,
s
h
a
p
e,
el
e
Ir
re
g
ul
ar
h
y
p
er
k
er
at
ot
ic
ar
e
a
s
(r
o
u
g
h
ar
e
a
th
at
sc
a
b
s
o
v
er
,
re
sc
a
b
s
or
fa
ils
to
v
at
io
n,
s
ur
fa
c
e,
s
ur
ro
u
n
di
n
g
sk
in
,
s
e
n
s
at
io
n
or
c
o
n
si
st
e
n
c
y)
Pr
ur
it
u
s
(p
re
v
al
e
nt
in
H
o
d
g
ki
n’
s
di
s
e
a
s
e)
V
ar
ia
ti
o
n
in
pi
g
m
e
nt
at
io
n
P
h
y
si
c
al
E
x
a
m
in
at
io
n
Head
and
Neck
ul
ty
c
h
e
wi
n
g,
s
w
al
lo
wi
n
g,
or
m
o
vi
n
g
to
n
g
u
e
or
ja
w
Di
ffi
c
Fi
r
m
,
u
ni
la
te
ra
l
ly
m
p
h
n
o
d
e
s
in
n
e
c
k
P
er
si
st
e
nt
re
d
di
s
h
or
w
hi
ti
s
h
p
at
c
h
Oral
cavity
O
ta
lg
ia
S
w
el
li
n
g
or
ul
c
er
th
at
fa
ils
to
h
e
al
,
in
d
ur
at
e
d
ul
c
er
,
or
ip
sil
at
er
al
re
fe
rr
e
d
ul
c
er
Physi
cal
Exami
natio
n
Oroph
arynx
D
y
s
p
h
a
si
a,
lo
c
al
p
ai
n,
p
ai
n
o
n
s
w
al
lo
wi
n
g,
or
re
fe
rr
e
d
ot
al
gi
a
Laryn
x
P
er
si
st
e
nt
h
o
ar
s
e
n
e
ss
,
p
ai
n,
re
fe
rr
e
d
ot
al
gi
a,
or
n
e
c
k
m
a
ss
Naso
phary
nx
Bl
o
o
d
y
n
a
s
al
di
sc
h
ar
g
e,
o
b
st
ru
ct
e
d
n
o
st
ril
,
c
o
n
d
u
ct
iv
e
d
e
af
n
e
ss
P
h
y
si
c
al
E
x
a
m
in
at
io
n
Nose
and
sinus
es
Bl
o
o
d
y
n
a
s
al
di
sc
h
ar
g
e,
n
a
s
al
o
b
st
ru
ct
io
n,
fa
ci
al
p
ai
n,
fa
ci
al
s
w
el
li
n
g,
di
pl
o
pi
a
Paroti
d and
subm
andib
ular
gland
s
P
ai
nl
e
ss
lo
c
al
s
w
el
li
n
g
or
h
e
m
if
a
ci
al
p
ar
al
y
si
s
Physi
cal
Exami
natio
n
Chest
/Lung
s
Change in
pulmonary
habits
Cough
Hoarseness
Chest pain
Rust-streaked
or purulent
sputum
production
Hemoptysis
Dyspnea
P
h
y
si
c
al
E
x
a
m
in
at
io
n
Breas
t
Axilla
ry
lymp
hade
nopat
hy
Blood
y
disch
arge
Chan
ge in
conto
ur of
breas
t
Dimpl
ing of
skin
of
breas
t
Edem
a or
eryth
ema
of
breas
t skin
Fixati
on of
a
mass
to
pecto
ral
fascia
or
chest
wall
Nippl
e
retrac
tion
Painle
ss
lump
or
mass
Unilat
eral
nipple
disch
arge
s
of
a
p
p
et
it
e
Physi
cal
Exami
natio
n
Abdo
men
St
o
m
a
c
h
C
o
m
pl
ai
nt
s
of
in
di
g
es
ti
o
n
or
e
pi
g
as
tri
c
di
st
re
ss
L
os
U
ni
nt
e
nt
io
n
al
w
ei
g
ht
lo
ss
or
a
n
or
e
xi
a
D
ys
p
h
a
gi
a
M
as
s
in
a
b
d
o
m
e
n
Ul
c
er
ty
p
e
p
ai
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Ir
o
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d
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a
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e
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ia
P
h
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ic
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E
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at
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v
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ai
nf
ul
h
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p
at
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al
y
e
al
v
ar
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es
sc
it
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S
E
so
p
h
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g
Physi
cal
Exami
natio
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G
al
lb
la
d
d
er
Ja
u
n
di
c
e
GI
bl
e
e
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g
F
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er
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A
Li
v
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A
E
d
e
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a
A
b
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o
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al
p
ai
n
A
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or
e
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a
U
ni
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e
nt
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Ja
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a
N
a
u
se
a
V
o
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iti
n
g
Physi
cal
Exami
natio
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P
a
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cr
e
a
s
In
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o
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s
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A
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or
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C
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C
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di
ar
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al
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te
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m
u
s
Ir
o
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m
ia
Physi
cal
Exami
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n
Exami
natio
n
Genit
ourinar
y
Genit
ourinar
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Ki
d
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a
n
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ur
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ar
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tr
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F
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H
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Ol
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ia
Physi
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n
u
s
u
al
pi
g
m
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a
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pr
ur
it
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c
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at
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m
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u
er
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p
ai
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os
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te
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al
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os
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p
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e
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m
os
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E
n
d
o
m
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m
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p
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nt
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ar
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Physi
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Exami
natio
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Genit
ourinar
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F
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s
p
ai
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or
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p
el
vi
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m
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O
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p
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m
pl
ai
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s,
a
b
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V
a
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at
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F
al
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al
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Genit
ourinar
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M
al
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x
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at
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ai
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o
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h
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g
e
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lw
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ys
re
tr
a
ct
fo
re
sk
in
)
Pr
os
ta
te
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b
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e
p
ai
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n
d
c
o
nt
in
u
o
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s
p
ai
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in
lo
w
er
b
a
ck
,
p
el
vi
s,
or
u
p
p
er
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ig
h
s;
re
n
al
in
s
uf
fi
ci
e
n
cy
,
h
e
m
at
ur
ia
T
es
te
s
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p
ai
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s
e
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g
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m
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nt
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e
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e
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st
ic
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lu
m
p
or
n
o
d
ul
e,
fe
el
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g
of
h
e
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n
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s
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a
g
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n
g
in
lo
w
er
a
b
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h
a
n
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e
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pr
e
e
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h
y
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o
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el
e
P
os
si
bl
e
e
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a
m
in
at
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er
y
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y
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ar
s
Low
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and
asym
ptom
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client
s
A
g
e
s
2
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P
E
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th
h
e
al
th
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o
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n
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el
in
g
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v
O
v
er
a
g
e
4
0
–
a
n
n
u
al
P
E
M
ol
e
m
a
p
pi
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g
S
e
m
ia
n
n
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al
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e
nt
al
or
al
e
x
a
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at
io
n
High
risk
or
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ic
client
s
M
or
e
fr
e
q
u
e
nt
e
x
a
m
s
S
cr
e
e
ni
n
g
te
st
s
Possi
ble
exami
natio
ns for
the
Femal
e
Client
BSE
mont
hly
for
client
s
older
than
age
20
B
S
E
s
h
o
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d
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e
d
o
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e
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d
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y
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te
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m
e
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al
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d
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P
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st
m
e
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o
p
a
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s
al
or
h
y
st
er
e
ct
o
m
iz
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d
cli
e
nt
s
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p
er
fo
r
m
B
S
E
o
n
s
a
m
e
d
a
y
e
a
c
h
m
o
nt
h
Clinic
al
breas
t
exam
E
v
er
y
3
y
e
ar
s
fo
r
a
g
e
s
2
04
0
natio
ns for
the
Femal
e
Client
Mam
mogr
aphy
E
v
er
y
y
e
ar
fo
r
a
g
e
s
o
v
er
4
0
Possi
ble
exami
di
s
p
o
s
e
d
w
o
m
e
n
B
a
s
el
in
e
fo
r
a
g
e
s
3
53
9
B
a
s
el
in
e
at
a
g
e
2
5
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r
g
e
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ic
al
ly
pr
e
E
v
er
y
12
y
e
ar
s
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r
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g
e
s
4
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9
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v
er
y
y
e
ar
fo
r
5
0
a
n
d
a
b
o
v
e
e
wi
th
se
x
u
al
a
ct
iv
it
y
Possi
ble
exami
natio
ns for
the
Femal
e
Client
Colpo
scopy
for
wome
n with
histor
y of
HPV
Pelvic
exam
and
Pap
test
W
o
m
e
n
a
g
e
s
1
84
0
B
as
el
in
e
o
n
c
W
o
m
e
n
o
v
er
4
0
–
e
v
er
y
y
e
ar
Endo
metri
al
biops
y at
meno
pause
P
os
si
bl
e
e
x
a
m
in
at
io
n
s
fo
r
th
e
F
e
m
al
e
Cl
ie
nt
E
v
er
y
13
y
e
ar
s
Annu
al
fecal
occult
blood
test
for
client
s
older
than
50
Annu
al
DRE
for
client
s over
40
Sigm
oidos
copy
for
client
s
older
than
50
every
3-5
years
fecal
blood
test
Possi
ble
exami
natio
ns for
the
Male
Client
Prost
ate
exami
natio
n
E
v
er
y
y
e
ar
fo
r
cli
e
nt
s
ol
d
er
th
a
n
5
0
Occul
t
E
v
er
y
y
e
ar
fo
r
cli
e
nt
s
ol
d
er
th
a
n
5
0
DRE
E
v
er
y
y
e
ar
fo
r
cli
e
nt
s
ol
d
er
th
a
n
4
0
Sigm
oidos
copy
E
v
er
y
15
y
e
ar
s
fo
r
cli
e
nt
s
ol
d
er
th
a
n
5
0
Mont
hly
testic
ular
selfexami
natio
n
Fr
o
m
p
u
b
er
ty
to
a
g
e
4
0
Bronc
hosco
py
Di
a
g
n
o
st
ic
Pr
o
c
e
d
ur
e
s
XRay
Use
of
ionizi
ng
radiat
ion to
provi
de
imag
es of
tissue
&
bone
struct
ure
and
functi
on
X-Ray
Mam
mogr
aphy
CT
Scan
Contr
aindic
ated
in
pregn
ancy
MRI
Ultras
ound
Nursi
ng
care
Bone
Scan
Lumb
ar
Punct
ure
Thora
cente
sis
Pap
Smea
r
remove
metallic
objects,
jewelry, or
clothing
apply lead
shields
instruct
patient to
remain still
Mam
mogr
aphy
Diagn
ose
breas
t
cance
r
Contr
aindic
ated
in
pregn
ancy
Chara
cteris
tics of
cance
rous
lesion
Nursi
ng
care
explain that
compression
does not
harm the
breast
Comp
uted
Tomo
graph
y
Scan
Use
of
radiat
ion
beam
s to
produ
ce
crosssectio
nal
views
of
soft
tissue
anato
my
and
restru
cturin
g with
the
aid of
comp
uter
Contr
aindic
ations
:
allergy to dye
/ contrast
material
pregnancy
unstable vital
signs /
restlessness
renal failure
Imagi
ng
Use
of
electr
omag
netic
wave
s
acros
s the
body
in
differ
ent
plane
s
More
sensit
ive to
soft
tissue
s
Contr
aindic
ations
claustrophobi
a
unstable,
restless
patient
metallic
implants
claustrophobi
a
Ultras
ound
Magn
etic
Reson
ance
Use
of
highfrequ
ency
sound
wave
s
Highl
y
accur
ate in
distin
guishi
ng
betwe
en
cystic
and
solid
mass
es
Used
in
pelvis
,
abdo
men,
uteru
s
Bone
Scan
Involv
es IV
injecti
on of
radio
active
dye
mater
ial
which
is
detec
ted
by a
scann
ing
machi
ne
Areas
of
conce
ntrate
d
nucle
otide
uptak
e
may
repre
sent a
tumor
or
any
abnor
malit
y
Contr
aindic
ated
in
pregn
ancy
Lumb
ar
Punct
ure
A
spinal
needl
e is
insert
ed
into
the
subar
achno
id
space
to
exami
natio
n CSF
to
diagn
ose
brain
and
spinal
cord
tumor
s
Contr
aindic
ations
uncooperativ
e patient
increased ICP
infection at
the lumbar
puncture site
bleeding
disorders
Thora
cente
sis
Pleur
al tap
Insert
ing a
needl
e into
the
pleur
al
space
to
remo
ve
fluid
and
air
Nursi
ng
care
explain the
procedure
secure
informed
consent
instruct
patient not to
cough
make sure
CXR plates
are available
routine postprocedure
monitoring
(CXR)
Pap
Smea
r
Used
to
detec
t
cance
r cell
secret
ions
from
the
cervix
and
vagin
a
Can
detec
t
early
cellul
ar
chang
es in
prem
aligna
nt or
existi
ng
malig
nant
condit
ions
bleedi
ng,
tumor
s and
obtai
n
biops
y
sampl
es
Flexib
le
fibero
ptic
bronc
hosco
pe
Scree
ning:
yearly
for 2
negat
ive
exam
s,
then
repea
t
every
3 yrs
until
age
65
Bronc
hosco
py
Direct
visual
izatio
n of
laryn
x,
trach
ea,
and
bronc
hi to
locali
ze
Gener
al
anest
hesia
or IV
sedati
on
Nursi
ng
care
- NPO
6-8 hrs
secure
informed
consent
remove any
dental
prosthesis
routine postprocedure
monitoring
Upper
GI
Series
Bariu
m
swall
ow
Visual
ize
upper
GI
tract
“appl
e
core”
defor
mity
Endos
copy
Direct
visual
izatio
n of
UGIT
with a
flexibl
e
fibero
ptic
scope
ERCP
Endoscopic
Retrograde
CholangioPancreatogra
phy
detect tumors
in the
pancreaticobiliary tree
jaundiced
patients
Colon
oscop
y
Use
of
colon
oscop
e to
direct
ly
visual
ize
colon
and
obtai
n
biops
y
Contr
aindic
ations
unstable
medical
condition
profuse rectal
bleeding
bowel
distention
suspected
colon
perforation
Nursi
ng
care
informed
consent
bowel
preparation
Proct
osigm
oidos
copy
Use
of a
rigid
proct
oscop
e to
detec
t
lesion
s in
the
rectos
igmoi
d
colon
and
obtai
n
biops
y
Same
princi
ple in
colon
oscop
y
Diagn
ostic
Lapar
oscop
y
Insuffl
ation
of
abdo
minal
cavity
with
C02
- Fine
Needle
Aspiration
Biopsy
(FNAB)
Insert
ion of
came
ra
throu
gh
umbili
cal
port
incisi
ons to
visual
ize
the
intrab
domi
nal
organ
s
- Core
needle biopsy
Gener
al
anest
hesia
Biops
y
Acqui
sition
of
tissue
for
exact
histol
ogic
diagn
osis
Aspir
ation
biops
y
Incisi
on
biops
y
Excisi
on
biops
y
Biops
y
Bone
Marro
w
Brain
Liver
Lung
Pleur
al
Endo
metri
al
Thyro
id
Breas
t
Stere
otacti
c
Prost
ate
Tumo
r
Marke
rs
Carci
noEm
bryon
ic
Antig
en
(CEA)
- NV:
0 – 2.5 ng/mL
colorectal,
metastatic
breast, lung
cancer
Alpha
FetoProtei
n
(AFP)
- NV:
10 ng/mL
testicular,
liver cancer
Prost
ateSpecif
ic
Antig
en
(PSA)
- NV:
<4 ng/mL
primary &
metastatic
prostate
cancer
medullary
cancer of the
thyroid
Tumo
r
Marke
rs
Tumo
r
Marke
rs
Huma
n
Chori
onic
Gona
dotro
pin
(HCG)
- NV:
0-1 ng/mL
choriocarcino
ma, testicular
cancer
Cance
r
Antig
en
125
(CA
125)
- NV:
34 U/mL
ovarian
cancer
Calcit
onin
- NV:
M=0-14
pg/mL; F=028 pg/mL
Horm
ones
- ER /
PR
ACTH, Insulin,
PTH (“ectopic
hormones”)
Enzy
mes
Amylase
(lung &
ovarian
tumors)
SGPT, SGOT
(liver cancer)
Stagi
ng of
Cance
r
TNM
Stagi
ng
Syste
m
T:
exten
t of
prima
ry
tumor
based
on
size,
depth
of
penet
ration
,&
invasi
on of
adjac
ent
struct
ures
N:
Prese
nce,
exten
t, &
locati
on of
regio
nal
lymp
h
node
involv
emen
t
M:
Prese
nce
or
absen
ce of
distan
t
meta
stase
s&
degre
e of
disse
minat
ion
Stagi
ng of
Cance
r
Stage
1Malig
nant
cells
are
confin
ed to
the
tissue
of
origin
, with
no
signs
of
meta
stasis
.
Stage
2Tumo
r is
larger
,
proba
bly
has
invad
ed
surro
undin
g
tissue
s, or
both
Stage
3Sprea
d of
the
cance
r is
limite
d to
the
local
area
Stage
4Cance
r has
meta
stasiz
ed to
other
parts
of the
body
TNM
Stagi
ng
Syste
m
T0:
no
evide
nce of
prima
ry
tumor
Tis:
carcin
omain-situ
T1,
T2,
T3,
T4:
indica
te
progr
essiv
e
degre
es of
tumor
size
and
involv
emen
t
Tx:
tumor
can
not
be
asses
sed
N0:
regio
nal
LN
not
demo
nstra
bly
abnor
mal
N1,
N2,
N3:
indica
te
regio
nal
lymp
h
nodes
involv
emen
t with
increa
sing
degre
e
Nx:
regio
nal
LN
can
not
be
asses
sed
clinic
ally
M0:
no
evide
nce of
meta
stasis
M1:
meta
stasis
prese
nt
G4:
very
poorl
y
differ
entiat
ed
Cance
r
Mana
geme
nt
Surge
ry
Gradi
ng of
Tumo
r
Radia
tion
thera
py
Gx:
grade
can
not
be
asses
sed
Chem
other
apy
G1:
welldiffer
entiat
ed
Biolog
ic
thera
py
Surgi
cal
Oncol
ogy
G2:
mode
rately
welldiffer
entiat
ed
Oldes
t
treat
ment
for
cance
r
G3:
poorl
y
differ
entiat
ed
Used
to be
the
only
treat
ment
that
could
cure
patie
nts
with
cance
r
Roles
for
surge
ry
Prevention of
cancer
Diagnosis of
cancer
Treatment of
cancer
Proph
ylacti
c
Surge
ry
Diagn
osis
Of
Cance
r
Acqui
sition
of
tissue
for
exact
histol
ogic
diagn
osis
Aspir
ation
biops
y
- Fine
Needle
Aspiration
Biopsy
(FNAB)
- Core
needle biopsy
genci
es
Palliat
ion
Recon
struct
ion
and
rehab
ilitati
on
Incisi
on
biops
y
Radia
tion
Thera
py
Excisi
on
biops
y
Electr
omag
netic
Radia
tion
Treat
ment
Of
Cance
r
Prima
ry
cance
r
Resid
ual
disea
se
Metas
tatic
Disea
se
Oncol
ogic
emer
Gamma
radiation
>
produced
intranuclearly
(decay of
radioactive
isotopes)
Roentgen
>
produced
extranuclearl
y
Photo
electr
ic
absor
ption
Radia
tion
Thera
py
Brach
yther
apy
radiation
device is
placed within
or close to
the target
volume
interstitial &
intracavitary
radiation
used in the
treatment of
gynecologic &
oral tumors
Radia
tion
Thera
py
Telet
herap
y
- uses
a device
located at a
distance from
the patient
Radia
tion
Thera
py
Rapid
death
by
apopt
osis
Death
while
trying
to
divide
May
produ
ce
unusu
al
forms
as a
result
of
aberr
ant
attem
pts at
divisi
on
Cells
may
stay
as it
is,
unabl
e to
divide
, but
physi
ologic
ally
functi
onal
for a
long
perio
d
May
under
go no
altera
tions
or
only
minor
ones
hy
cells
in the
area
Radia
tion
Thera
py
Eradi
cates
radioc
urabl
e
disea
se
such
as
earlystage
breas
t CA
follow
ing
lump
ecto
my
Energ
y
depos
ited
in
cells
cause
a
direct
hit to
the
DNA
causi
ng
DNA
stran
d
break
s
Tumo
r cells
lose
their
capac
ity to
repair
dama
ge
Affect
s
norm
al
healt
Radia
tion
Thera
py
Contr
ols
the
growt
h and
sprea
d of
disea
se,
such
as
adjuv
ant
thera
py for
latestage
chest
wall
recurr
ence
Acts
as
proph
ylacti
c
treat
ment
to
preve
nt
micro
scopi
c
disea
se,
such
as
whole
brain
irradi
ation
with
lung
CA
Impro
ves
qualit
y of
life in
advan
ced
disea
se,
such
as
pain
from
bone
meta
stasis
or
press
ure
from
spinal
cord
comp
ressio
n
The
client
under
going
exter
nal
radiat
ion
thera
py
(telet
herap
y)
T
h
e
ra
di
at
io
n
o
n
c
ol
o
gi
st
m
ar
ks
s
p
e
ci
fi
c
lo
c
at
io
n
s
fo
r
ra
di
at
io
n
tr
e
at
m
e
nt
u
si
n
g
a
s
e
m
ip
er
m
a
n
e
nt
ty
p
e
of
in
k
Tr
e
at
m
e
nt
is
u
s
u
al
ly
gi
v
e
n
1
5
to
3
0
m
in
ut
es
p
er
d
a
y,
5
d
a
ys
p
er
w
e
e
k,
fo
r
2
to
7
w
e
e
ks
T
h
e
cli
e
nt
d
o
es
n
ot
p
os
e
a
ri
sk
fo
r
ra
di
at
io
n
e
x
p
os
ur
e
to
ot
h
er
p
e
o
pl
e
The
client
under
going
exter
nal
radiat
ion
thera
py
(telet
herap
y)
Cl
ie
nt
e
d
u
c
at
io
n
fo
r
e
xt
er
n
al
ra
di
at
io
n
W
as
h
th
e
m
ar
k
e
d
ar
e
a
of
th
e
sk
in
wi
th
pl
ai
n
w
at
er
o
nl
y
a
n
d
p
at
sk
in
dr
y;
d
o
n
ot
u
se
so
a
p
s,
d
e
o
d
or
a
nt
s,
lo
ti
o
n
s,
p
er
fu
m
es
,
p
o
w
d
er
s
or
m
e
di
c
at
io
n
s
o
n
th
e
si
te
d
ur
in
g
th
e
d
ur
at
io
n
of
th
e
tr
e
at
m
e
nt
;
d
o
n
ot
w
as
of
f
th
e
tr
e
at
m
e
nt
si
te
m
ar
ks
A
v
oi
d
ru
b
bi
n
g,
sc
ra
tc
hi
n
g,
or
sc
ru
b
bi
n
g
th
e
tr
e
at
m
e
nt
si
te
;
d
o
n
ot
a
p
pl
y
e
xt
re
m
e
te
m
p
er
at
ur
es
(h
e
at
or
c
ol
d)
to
th
e
tr
e
at
m
e
nt
si
te
;
if
s
h
a
vi
n
g,
u
se
o
nl
y
a
n
el
e
ct
ri
c
ra
zo
r
The
client
under
going
exter
nal
radiat
ion
thera
py
(telet
herap
y)
W
e
ar
so
ft.
L
o
os
efit
ti
n
g
cl
ot
hi
n
g
o
v
er
th
e
tr
e
at
m
e
nt
ar
e
a
Pr
ot
e
ct
sk
in
fr
o
m
s
u
n
e
x
p
os
ur
e
d
ur
in
g
th
e
tr
e
at
m
e
nt
a
n
d
fo
r
at
le
as
t
1
y
e
ar
af
te
r
th
e
tr
e
at
m
e
nt
is
c
o
m
pl
et
e
d;
w
h
e
n
g
oi
n
g
o
ut
d
o
or
s,
u
se
s
u
n-
bl
o
ck
in
g
a
g
e
nt
s
wi
th
s
u
n
pr
ot
e
ct
io
n
fa
ct
or
(S
P
F)
of
at
le
as
t
1
5
M
ai
nt
ai
n
pr
o
p
er
re
st
,
di
et
,
a
n
d
fl
ui
d
in
ta
k
e
as
es
se
nt
ia
l
to
pr
o
m
ot
in
g
h
e
al
th
a
n
d
re
p
ai
r
of
n
or
m
al
ti
ss
u
es
H
ai
r
lo
ss
m
a
y
o
cc
ur
;
c
h
o
os
e
a
wi
g,
h
at
,
or
sc
ar
f
to
c
o
v
er
a
n
d
pr
ot
e
ct
H
e
a
d
(r
ef
er
to
c
ar
e
of
cli
e
nt
wi
th
al
o
p
e
ci
a
la
te
r
in
c
h
a
pt
er
)
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
S
o
ur
c
e
s
of
in
te
rn
al
ra
di
at
io
n
I
m
pl
a
nt
e
d
in
to
af
fe
ct
e
d
ti
ss
u
e
or
b
o
d
y
c
a
vi
ty
In
g
es
te
d
as
a
so
lu
ti
o
n
In
je
ct
e
d
as
a
so
lu
ti
o
n
in
to
th
e
bl
o
o
d
st
re
a
m
or
b
o
d
y
c
a
vi
ty
nal
radiat
ion)
Cl
ie
nt
e
d
u
c
at
io
n
The
client
under
going
brach
yther
apy
(inter
In
tr
o
d
u
c
e
d
th
ro
u
g
h
a
c
at
h
et
er
in
to
th
e
tu
m
or
A
v
oi
d
cl
os
e
c
o
nt
a
ct
wi
th
ot
h
er
s
u
nt
il
tr
e
at
m
e
nt
is
c
o
m
pl
et
e
d
M
ai
nt
ai
n
d
ai
ly
a
ct
iv
iti
es
u
nl
es
s
c
o
nt
ra
in
di
c
at
e
d,
al
lo
wi
n
g
fo
r
e
xt
ra
re
st
p
er
io
d
s
as
n
e
e
d
e
d
M
ai
nt
ai
n
b
al
a
n
c
e
d
di
et
;
m
a
y
to
le
ra
te
fo
o
d
b
et
te
r
if
c
o
n
s
u
m
es
s
m
al
l,
fr
e
q
u
e
nt
m
e
al
s
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
M
ai
nt
ai
n
fl
ui
d
in
ta
k
e
to
e
n
s
ur
e
a
d
e
q
u
at
e
h
y
dr
at
io
n
(2
-3
lit
er
s/
d
a
y)
If
i
m
pl
a
nt
is
te
m
p
or
ar
y,
m
ai
nt
ai
n
b
e
d
re
st
to
a
v
oi
d
di
sl
o
d
gi
n
g
th
e
i
m
pl
a
nt
E
xc
re
te
d
b
o
d
y
fl
ui
d
s
m
a
y
b
e
ra
di
o
a
ct
iv
e;
d
o
u
bl
efl
u
s
h
to
il
et
s
af
te
r
u
se
R
a
di
at
io
n
th
er
a
p
y
m
a
y
le
a
d
to
b
o
n
e
m
ar
ro
w
s
u
p
pr
es
si
o
n
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
N
ur
si
n
g
m
a
n
a
g
e
m
e
nt
of
cli
e
nt
re
c
ei
vi
n
g
in
te
rn
al
ra
di
at
io
n
E
x
p
os
ur
e
to
s
m
al
l
a
m
o
u
nt
s
of
ra
di
at
io
n
is
p
os
si
bl
e
d
ur
in
g
cl
os
e
c
o
nt
a
ct
wi
th
p
er
so
n
s
re
c
ei
vi
n
g
in
te
rn
al
ra
di
at
io
n;
u
n
d
er
st
a
n
d
th
e
pr
in
ci
pl
es
of
pr
ot
e
ct
io
n
fr
o
m
e
x
p
os
ur
e
to
ra
di
at
io
n:
ti
m
e,
di
st
a
n
c
e,
a
n
d
s
hi
el
di
n
g
Time:
minimize
time
spent in
close
proximity
to the
radiation
sources; a
common
standard
is to limit
contact
time to
30
minutes
total per
8-hour
shift;
minimum
distance
of 6 feet
used
when
possible
Distance:
maintain
the
maximum
distance
possible
from the
radiation
source
Shielding:
use lead
shields
and other
precautio
ns to
reduce
exposure
to
radiation
Pl
a
c
e
cli
e
nt
in
pr
iv
at
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
e
ro
o
m
In
st
ru
ct
vi
si
to
rs
to
m
ai
nt
ai
n
at
le
as
t
a
di
st
a
n
c
e
of
6
fe
et
fr
o
m
th
e
cli
e
nt
a
n
d
li
m
it
vi
si
ts
to
1
0
to
3
0
m
in
ut
es
E
n
s
ur
e
pr
o
p
er
h
a
n
dl
in
g
a
n
d
di
s
p
os
al
of
b
o
d
y
fl
ui
d
s,
as
s
ur
in
g
th
e
c
o
nt
ai
n
er
s
ar
e
m
ar
k
e
d
a
p
pr
o
pr
ia
te
ly
E
n
s
ur
e
pr
o
p
er
h
a
n
dl
in
g
of
b
e
d
li
n
e
n
s
a
n
d
cl
ot
hi
n
g
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
In
th
e
e
v
e
nt
of
a
di
sl
o
d
g
e
i
m
pl
a
nt
,
u
se
lo
n
gh
a
n
dl
e
d
fo
rc
e
p
s
a
n
d
pl
a
c
e
th
e
i
m
pl
a
nt
in
to
a
le
a
d
c
o
nt
ai
n
er
;
n
e
v
e
r
di
re
ct
ly
to
u
c
h
th
e
i
m
pl
a
nt
D
o
n
ot
al
lo
w
pr
e
g
n
a
nt
w
o
m
e
n
to
c
o
m
e
in
to
a
n
y
c
o
nt
a
ct
wi
th
ra
di
at
io
n
so
ur
c
es
;
sc
re
e
n
vi
si
to
rs
a
n
d
st
af
f
fo
r
pr
e
g
n
a
n
cy
If
w
or
ki
n
g
ro
ut
in
el
y
n
e
ar
ra
di
at
io
n
so
ur
c
es
,
w
e
ar
a
m
o
ni
to
ri
n
g
d
e
vi
c
e
to
m
e
as
ur
e
e
x
p
os
ur
e
Radia
tionprote
ction
meas
ures
Alpha
partic
les
E
d
u
c
at
e
cli
e
nt
in
al
l
sa
fe
ty
m
e
as
ur
es
Tr
a
v
el
at
gr
e
at
s
p
e
e
d,
p
o
or
p
e
n
et
ra
ti
o
n
Li
m
it
e
d
th
er
a
p
e
ut
ic
u
s
e
Beta
partic
les
P
h
o
s
p
h
or
u
s3
2
or
Yt
tri
u
m
9
0
C
a
n
b
e
s
hi
el
d
e
d
b
y
th
ic
k
pl
a
st
ic
or
b
y
th
e
b
o
d
y’
s
s
ur
fa
c
e
R
a
di
at
io
npr
ot
e
ct
io
n
m
e
a
s
ur
e
s
y,
th
e
th
ic
k
er
th
e
a
b
s
or
bi
n
g
m
at
er
ia
l
re
q
ui
re
d
Gam
ma
partic
les
U
n
st
a
bl
e
p
ar
ti
cl
e
s
T
h
e
hi
g
h
er
th
e
e
n
er
g
L
e
a
d
A
d
v
er
s
e
Ef
fe
ct
s
May
be
acute
or
imme
diate
–
after
6
mos.
post
expos
ure
May
be
late
or
chron
ic –
after
1
year
post
expos
ure
Reflec
t cell
dama
ge
and
accu
mulat
ion of
toxic
effect
s of
tissue
destr
uction
indivi
dual
differ
ences
SiteSpecif
ic
Adver
se
Effect
s
Head
and
neck
Sitespecif
ic
Depe
ndent
on
volum
e,
dose
fracti
onati
on,
total
dose
and
St
o
m
at
iti
s
X
er
o
st
o
m
ia
T
o
ot
h
d
e
c
a
y
a
n
d
c
ar
ie
s
T
a
st
e
c
h
a
n
g
e
s
O
st
e
or
a
di
o
n
e
cr
o
si
s
(
m
a
n
di
bl
e)
H
y
p
o
pi
tu
it
ar
is
m
(r
ef
le
ct
d
e
cr
e
a
s
e
d
s
e
cr
et
io
n
s
of
c
or
ti
s
ol
,
th
yr
o
xi
n
e,
a
n
d
s
e
x
h
or
m
o
n
e
s)
SiteSpecif
ic
Adver
se
Effect
s
a
gi
ti
s
C
o
u
g
h
R
a
di
at
io
n
p
n
e
u
m
o
ni
ti
s
R
a
di
at
io
n
fi
br
o
si
s
Abdo
men
Chest
E
s
o
p
h
s
e
a
a
n
d
v
o
m
iti
n
g
G
a
st
rit
is
N
a
u
SiteSpecif
ic
Adver
se
Effect
s
gi
n
al
st
e
n
o
si
s
O
v
ar
ia
n
fa
il
ur
e
T
e
st
ic
ul
ar
d
y
sf
u
n
ct
io
n
Pelvis
Di
ar
rh
e
a
C
y
st
iti
s
Er
e
ct
il
e
d
y
sf
u
n
ct
io
n
V
a
SiteSpecif
ic
Adver
se
Effect
s
Brain
C
er
e
br
al
e
d
e
m
a
(s
te
ro
id
th
er
a
p
y
in
di
c
at
e
d)
Al
o
p
e
ci
a
C
h
a
n
g
e
s
in
h
ai
r
te
xt
ur
e
a
n
d
c
ol
or
S
c
al
p
pr
ur
it
u
s
Chem
other
apy
Chem
other
apy
Induc
tion
chem
other
apy
Adjuv
ant
chem
other
apy
Neoa
djuva
nt
chem
other
apy
Types
of
chem
other
apy
Adjuv
ant –
micro
meta
stase
s
Neoa
djuva
nt –
shrink
sa
tumor
prior
surgic
al
remo
val
syner
gizes
the
thera
peutic
action
s of
other
cytot
oxic
drugs
Prima
ry
thera
py –
treats
a
locali
zed
tumor
when
there’
s an
altern
ative,
less
effect
ive
Proph
ylacti
c – to
preve
nt
micro
meta
stase
s
Induc
tion –
treats
a
cance
r for
which
there
is no
altern
ative
treat
ment
Comb
inatio
n–
enha
nces
or
Prima
ry
Chem
other
apy
Neopl
asms
in w/c
CTX
is the
prima
ry
thera
peutic
moda
lity
for
locali
zed
tumor
s
Large cell
lymphoma
Lymphoblasti
c lymphoma
Hodgkin’s
disease
Wilm’s tumor
Embryonal
rhabdomyosa
rcoma
Small cell
lung cancer
- CNS
lymphomas
Neoa
djuva
nt
Chem
other
apy
Neopl
asms
in w/c
prima
ry
CTX
can
allow
less
mutil
ating
surge
ry
- Anal
carcinoma
Bladder
carcinoma
Breast cancer
Esophageal
cancer
Laryngeal
cancer
Osteogenic
sarcoma
- Soft
tissue
sarcoma
Basic
Conce
pts in
Chem
other
apy
Destr
oy
cance
r cells
by
interf
ering
with
their
repro
ductio
n
Act at
specif
ic
points
in the
cell
cycle
Affect
any
rapidl
y
dividi
ng
cell
within
the
body,
thus
havin
g the
poten
tial
for
toxicit
y
devel
opme
nt in
healt
hy,
functi
onal
tissue
(bone
marro
w,
hair
follicl
es, GI
muco
sa)
To
reduc
e
possi
bility
of
toxicit
y and
drug
resist
ance,
combi
natio
n
thera
py is
often
used
Availa
ble in
oral,
paren
teral
and
topica
l
prepa
ration
s
Basic
Conce
pts in
Chem
other
apy
Patter
n of
neutr
openi
a
after
chem
other
apy
M
in
i
m
al
n
e
ut
ro
p
e
ni
a
47
d
a
y
s
af
te
r
tr
e
at
m
e
nt
N
a
di
r
(p
er
io
d
of
m
a
xi
m
u
m
n
e
ut
ro
p
e
ni
a)
8
to
1
2
d
a
y
s
af
te
r
tr
e
at
m
e
nt
R
et
ur
n
of
n
or
m
al
n
u
m
b
er
of
n
e
ut
ro
p
hi
ls
1
4
to
1
8
d
a
y
s
af
te
r
tr
e
at
m
e
nt
Chem
other
apeut
ic
Drugs
Alkyla
ting
agent
s
- cell
cycle
nonspecific
Nitrogen
mustards
- form
highly
reactive
carbonium
ions which
react w/ DNA,
proteins, &
other
essential
cellular
substances
>
Chlorambucil
>
Cyclophospha
mide
>
Ifosfamide
replace
hydrogen
atoms w/
alkyl radicals,
causing
cross-linking
& abnormal
base pairing
in the DNA
molecule
renders DNA
molecule
defective &
unable to
carry on
normal
cellular
metabolic &
reproductive
functions
Chem
other
apy
Alkyla
ting
agent
s
>
Mechloretha
mine
>
Melphalan
Nitrosureas
>
Carmustine
>
Lomustine
>
Streptozocin
>
Busulfan
>
Carboplatin
>
Cisplatin
>
Thiotepa
Chem
other
apeut
ic
Drugs
Antibi
otics
- cell
cycle specific;
inhibit RNA &
protein
synthesis or
rapidly
dividing cells
Produ
ced
by
the
bacte
rial
speci
es
Strep
tomy
ces
Dacti
nomy
cin,
Daun
orubi
cin,
Doxor
ubicin
,&
Plica
mycin
- use
complex
mechanisms
to combine w/
DNA base
pairs, thus
interfering w/
DNA, RNA, &
protein
synthesis
Chem
other
apeut
ic
Drugs
Bleo
mycin
causes DNA
strand
scission and
fragmentatio
n
Mito
mycin
inhibits DNA
replication by
causing
cross-links to
form between
complementa
ry strands of
the molecule
Chem
other
apeut
ic
Drugs
Antim
etabo
lites
- cell
cycle specific
inhibition of S
phase
Folic
acid
analo
g
Blocks the
action of the
enzyme
dihydrofolate
reductase
which inhibits
production of
coenzyme
needed for
synthesis of
thymidylic
acid –
precursor for
nucleic acid
replication
Pyrim
idine
&
purin
e
analo
gs
block
enzymes
needed
during the
synthesis of
DNA & RNA
Chem
other
apeut
ic
Drugs
Antim
etabo
lites
Cytarabine
Floxuridine
Fluorouracil
Mercapturine
Methotrexate
Thioguanine
Chem
other
apeut
ic
Drugs
Natur
al or
semis
ynthe
tic
produ
cts
deriv
ed
from
differ
ent
plants
Etopo
side
semisynthetic
derivative of
podophylloto
xin, derived
from root of
May-apple
plant
affect G2
phase pf cell
cycle
causes cell
lysis at high
dose
prevents cells
from entering
mitosis stage
& inhibit DNA
synthesis
Chem
other
apeut
ic
Drugs
Vincri
stine
&
Vinbl
astine
Vinca
alkaloids from
periwinkle
plant
arrest cell
activity at the
M phase
(metaphase)
inhibiting
mitosis
Horm
ones
Inhibit RNA &
protein
synthesis that
are
dependent on
sex hormone
for
development
Side
effect
s of
chem
other
apeut
ic
agent
s
>.Bon
e
marro
w
suppr
essio
n
Decre
ased
WBC
count
(imm
unosu
ppres
sion)
Decre
ased platelet
count
(thrombocyto
penia)
Decre
ased
hemoglobin
and
hematocrit
(anemia)
Gastr
ointestinal
effects:
anorexia,
nausea,
vomiting, and
diarrhea
Side
effect
s of
chem
other
apeut
ic
agent
s
ss
)
St
o
m
at
iti
s
(i
nf
la
m
m
at
io
n
of
th
e
m
o
ut
h)
a
n
d
m
u
c
o
si
to
si
s
Al
o
p
e
ci
a
(h
ai
r
lo
F
at
ig
u
e
X
er
o
st
o
m
ia
(d
ry
m
o
ut
h)
O
th
er
si
d
e
ef
fe
ct
s
s
p
e
ci
fi
c
to
c
h
e
m
ot
h
er
a
p
e
ut
ic
a
g
e
nt
s,
peopl
e with
infecti
ons,
and
small
childr
en
when
WBC
is low
Immu
nosup
pressi
on
Cl
ie
nt
e
d
u
c
at
io
n
fo
r
i
m
m
u
n
o
s
u
p
pr
e
ss
io
n
Use
meticulous
personal
hygiene to
avoid
infection
Immu
nosup
pressi
on
Wash
hands before
and after
eating, after
toileting, and
after contact
with other
people and
pets
R
isk for
infecti
on is
high
when
WBC
count
is low
A
void
crowd
Consume a
low-bacteria
diet; avoid
undercooked
meat and raw
fruits and
vegetables
Be aware of
signs and
symptoms of
infection and
report them
immediately
to primary
care provider
Nursi
ng
mana
geme
nt of
immu
nosup
pressi
on
Nursi
ng
mana
geme
nt of
immu
nosup
pressi
on
Monit
or
labor
atory
value
s:
CBC
with
differ
ential
,
platel
ets,
BUN,
liver
enzy
mes
WBC
suppr
essio
n,
maln
utritio
n anf
prese
nce of
disea
se
increa
se the
risk of
infecti
on
Asses
s for
infecti
on;
monit
or
vital
signs
for
early
indica
tion
of
infecti
on:
fever,
tachy
cardia
, and
tachy
pnea
Utilize
neutr
openi
c
preca
utions
(lowbacte
ria
diet,
no
fresh
plants
or
flower
s in
room,
no
pets,
no
visitor
s with
infecti
ons)
when
WBC
level
falls
below
prede
termi
ned
level
(such
as
2,000
mm3)
o
p
e
n
i
a
•
Thro
mboc
ytope
nia
C
l
i
e
n
t
e
d
u
c
a
t
i
o
n
f
o
r
t
h
r
o
m
b
o
c
y
t
Mo
nit
or
sto
ols
an
d
uri
ne
for
ble
edi
ng
•
For
sh
avi
ng,
us
e
ele
ctri
c
raz
or
onl
y
•
Av
oid
co
nta
ct
sp
ort
s
an
d
oth
er
act
ivit
ies
tha
t
ma
y
ca
us
e
tra
um
a
•
If
tra
um
a
do
es
oc
cur
,
ap
ply
ice
to
are
a
an
d
se
ek
me
dic
al
as
sis
tan
ce
Thro
mboc
ytope
nia
•
A
v
o
i
d
d
e
n
t
a
l
w
o
r
k
o
r
o
t
h
e
r
i
n
v
a
s
i
v
e
p
r
o
c
e
d
u
r
e
s
•
I
n
f
o
r
m
a
l
l
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
s
o
f
c
h
e
m
o
t
h
e
r
a
p
y
a
n
d
/
o
r
r
a
d
i
a
t
i
o
n
t
r
e
a
t
m
e
n
t
s
•
A
v
o
i
d
o
d
u
c
t
s
•
t
o
o
t
h
b
r
u
s
h
e
s
S
a
f
e
t
y
a
s
p
i
r
i
n
p
r
e
c
a
u
t
i
o
n
s
a
n
d
f
o
r
a
s
p
i
r
i
n
c
o
n
t
a
i
n
i
n
g
o
r
a
l
p
r
t
h
y
g
i
e
n
e
;
u
s
e
s
o
f
a
n
d
d
o
n
o
t
f
l
o
s
s
Nursi
ng
mana
geme
nt of
throm
bocyt
openi
a
•
T
h
e
r
e
i
s
a
h
i
g
h
r
i
s
k
f
o
r
s
p
o
n
t
a
n
e
o
u
s
h
e
m
o
r
r
h
a
g
e
w
h
e
n
p
l
a
t
e
l
e
t
c
o
u
n
t
i
s
<
2
0
,
0
0
0
;
p
r
e
c
a
u
t
i
o
n
s
a
r
e
n
e
c
e
s
s
a
r
y
f
o
r
p
l
a
t
e
l
e
t
c
o
u
n
t
<
5
0
,
0
0
0
•
A
s
s
e
s
s
f
o
r
b
l
e
e
d
i
n
g
,
m
o
n
i
t
o
r
s
t
o
o
l
s
a
n
d
u
r
i
n
e
f
o
r
o
c
c
u
l
t
b
l
o
o
d
Nursi
ng
mana
geme
nt of
throm
bocyt
openi
a
•
A
s
s
e
s
s
s
k
i
n
f
o
r
e
c
c
h
y
m
o
s
e
s
,
p
e
t
e
c
h
i
a
e
,
a
n
d
t
r
a
u
m
a
•
E
d
u
c
a
t
e
c
li
e
n
t
a
b
o
u
t
b
l
e
e
d
i
n
g
s
a
f
e
t
y
p
r
e
c
a
u
t
i
o
n
s
•
Stom
atitis
A
v
o
i
d
i
n
t
r
a
m
u
s
c
u
l
a
r
i
n
j
e
c
t
i
o
n
s
a
n
d
li
m
i
t
v
e
n
i
p
u
n
c
t
u
r
e
s
and
muco
sitosi
s
i
s
•
C
l
i
e
n
t
e
d
u
c
a
t
i
o
n
f
o
r
s
t
o
m
a
t
i
t
i
s
a
n
d
m
u
c
o
s
i
t
o
s
•
U
se
a
so
ft
to
ot
h
br
u
s
h;
m
o
ut
h
s
w
a
b
s
m
a
y
b
e
n
e
e
d
e
d
d
ur
in
g
a
c
ut
e
e
pi
so
d
e
A
v
oi
d
m
o
ut
h
w
as
h
es
c
o
nt
ai
ni
n
g
al
c
o
h
ol
;
d
o
n
ot
u
se
le
m
o
n
gl
yc
er
in
s
w
a
b
s
or
d
e
nt
al
fl
os
s
Stom
atitis
and
muco
sitosi
s
•
C
o
n
s
i
d
e
r
u
s
i
n
g
c
h
l
o
r
h
e
x
i
d
i
n
e
m
o
u
t
h
w
a
s
h
(
P
e
r
i
d
e
x
)
t
o
d
e
c
r
e
a
s
e
r
i
s
k
o
f
h
e
m
o
r
r
h
a
g
e
a
n
d
p
r
o
t
e
c
t
g
u
m
s
f
r
o
m
t
r
a
u
m
a
•
A
s
s
e
s
s
d
a
il
y
f
o
r
l
e
s
i
o
n
s
,
i
n
f
e
c
t
i
o
n
,
b
l
e
e
d
i
n
g
,
o
r
i
r
r
i
t
a
t
i
o
n
Stom
atitis
and
muco
sitosi
s
•
F
or
x
er
o
st
o
m
ia
,
a
p
pl
y
lu
br
ic
at
in
g
a
n
d
m
oi
st
ur
izi
n
g
a
g
e
nt
s
to
pr
ot
e
ct
th
e
m
u
c
o
u
s
m
e
m
br
a
n
e
s
fr
o
m
tr
a
u
m
a
a
n
d
in
fe
ct
io
n
•
M
a
y
c
o
n
si
d
er
u
si
n
g
“
ar
tif
ici
al
s
al
iv
a
”
a
n
d
h
ar
d
c
a
n
d
y
or
m
in
ts
to
h
el
p
wi
th
dr
y
n
e
ss
Stom
atitis
and
muco
sitosi
s
•
s
y
m
p
t
o
m
s
o
f
o
r
a
l
i
n
f
e
c
t
i
o
n
a
n
d
t
o
.Avoid
smoking and
alcohol,
which can
further
irritate oral
mucosa
T
e
a
c
h
r
i
m
a
r
y
h
e
a
l
t
h
c
a
r
e
s
i
g
n
s
a
n
d
r
e
p
o
r
t
t
o
p
p
r
o
v
i
d
e
r
•
D
r
i
n
k
c
o
o
l
li
q
u
i
d
s
,
a
n
d
a
v
o
i
d
o
r
a
l
m
u
c
o
u
s
m
e
m
b
r
a
n
e
s
e
v
e
r
y
4
h
o
u
r
s
h
o
t
a
n
d
i
r
r
i
t
a
t
i
n
g
f
o
o
d
s
Stom
atitis
and
muco
sitosi
s
•
Nu
rsi
ng
ma
na
ge
me
nt
of
sto
ma
titi
s
•
A
s
s
e
s
s
T
e
a
c
h
a
n
d
i
m
p
l
e
m
e
n
t
p
r
o
p
e
r
o
r
a
l
c
a
r
e
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
Cl
ie
nt
e
d
u
c
at
io
n
fo
r
m
ai
nt
ai
ni
n
g
a
d
e
q
u
at
e
n
ut
rit
io
n,
fl
ui
d
a
n
d
el
e
ct
ro
ly
te
b
al
a
n
c
e
•
E
a
t
f
r
e
q
u
e
n
t
s
m
a
ll
,
l
o
w
f
a
t
m
e
a
l
s
•
A
v
o
i
d
s
p
i
c
y
a
n
d
f
a
t
t
y
f
o
o
d
s
•
A
v
o
i
d
e
x
t
r
e
m
e
l
y
h
o
t
f
o
o
d
s
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
•
•
cr
ib
e
d
•
P
er
fo
r
m
or
al
h
y
gi
e
n
e
b
ef
or
e
a
n
d
af
te
r
m
e
al
s
M
ai
nt
ai
n
fl
ui
d
in
ta
k
e
as
pr
es
•
T
a
k
e
n
ut
rit
io
n
al
s
u
p
pl
e
m
e
nt
s
as
pr
es
cr
ib
e
d
(v
it
a
m
in
s,
li
q
ui
d
n
ut
rit
io
n)
M
ai
nt
ai
n
a
d
ai
ly
jo
ur
n
al
of
fo
o
d
a
n
d
fl
ui
d
in
ta
k
e
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
N
u
r
s
i
n
g
m
a
n
a
g
e
m
e
n
t
t
e
i
m
b
a
l
a
n
c
e
s
o
f
i
n
a
d
e
q
u
a
t
e
n
u
t
r
i
t
i
o
n
a
n
d
f
l
u
i
d
a
n
d
e
l
e
c
t
r
o
l
y
•
As
se
ss
for
ad
eq
uat
e
hy
dr
ati
on;
for
du
rat
ion
of
tre
at
me
nt,
en
co
ur
ag
e
dai
ly
flui
d
int
ak
e
of
2
to
3
lite
rs
unl
es
s
co
ntr
ain
dic
ate
d
•
•
Ad
mi
nis
ter
ant
ie
me
tic
s
pri
or
to
ch
em
oth
era
py
We
igh
cli
ent
ro
uti
nel
y,
mo
nit
or
for
we
igh
t
los
s
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
•
M
o
ni
to
r
la
b
v
al
u
es
in
di
c
at
iv
e
of
n
ut
rit
io
n
al
st
at
u
s
(h
e
m
o
gl
o
bi
n,
h
e
m
at
o
cr
it,
al
b
u
m
in
,
pr
e
al
b
u
m
in
)
•
M
o
ni
to
r
fo
r
di
ar
rh
e
a
or
c
o
n
st
ip
at
io
n,
a
n
d
n
a
u
se
a
or
v
o
m
iti
n
g
•
E
n
c
o
ur
a
g
e
a
d
e
q
u
at
e
n
ut
rit
io
n
al
in
ta
k
e
wi
th
m
e
al
s
th
at
ar
e
se
rv
e
d
at
tr
a
ct
iv
el
y,
a
n
d
e
n
vi
ro
n
m
e
nt
fr
e
e
of
n
o
xi
o
u
s
st
i
m
ul
i
(b
e
d
p
a
n,
ur
in
al
,
o
d
or
s)
Fatig
ue
N
ur
si
n
g
m
a
n
a
g
e
m
e
nt
of
fa
ti
g
u
e
•
A
ss
ur
e
cli
e
nt
th
at
fa
ti
g
u
e
is
a
n
or
m
al
re
s
p
o
n
se
to
c
h
e
m
ot
h
er
a
p
y
a
n
d
th
at
it
d
o
es
n
ot
in
di
c
at
e
pr
o
gr
es
si
o
n
of
di
se
as
e
•
E
n
c
o
ur
a
g
e
cli
e
nt
to
c
o
nt
in
u
e
d
ai
ly
a
ct
iv
iti
es
as
m
u
c
h
as
p
os
si
bl
e,
al
lo
wi
n
g
fo
r
re
st
p
er
io
d
s
in
b
et
w
e
e
n
•
A
ss
is
t
cli
e
nt
in
se
lfc
ar
e
n
e
e
d
s
w
h
e
n
in
di
c
at
e
d
•
Al
lo
w
fo
r
p
er
io
d
s
of
re
st
;
cl
u
st
er
a
ct
iv
iti
es
Alope
cia
N
u
r
s
i
n
g
m
a
n
a
g
e
m
e
n
t
o
f
c
l
i
e
n
t
e
x
p
e
r
i
e
n
c
i
n
g
a
l
o
p
e
c
i
a
(
h
a
i
r
l
o
s
s
)
•
C
h
e
m
ot
h
er
a
p
y
a
n
d
ra
di
at
io
n
th
er
a
p
y
m
a
y
c
a
u
se
h
ai
r
lo
ss
;
th
e
h
ai
r
lo
ss
is
te
m
p
or
ar
y
a
n
d
wi
ll
gr
o
w
b
a
ck
,
u
s
u
al
ly
b
e
gi
n
ni
n
g
a
b
o
ut
a
m
o
nt
h
af
te
r
c
o
m
pl
et
io
n
of
th
e
c
h
e
m
ot
h
er
a
p
y;
th
e
cli
e
nt
s
h
o
ul
d
k
n
o
w
th
at
th
e
te
xt
ur
e
a
n
d
c
ol
or
of
th
e
n
e
w
h
ai
r
gr
o
w
th
m
a
y
b
e
di
ff
er
e
nt
;
h
ai
r
lo
ss
d
ur
in
g
ra
di
at
io
n
th
er
a
p
y
to
th
e
h
e
a
d
m
a
y
b
e
p
er
m
a
n
e
nt
Alope
cia
•
E
n
c
o
ur
a
g
e
th
e
cli
e
nt
to
c
h
o
os
e
a
wi
g
b
ef
or
e
h
ai
r
lo
ss
o
cc
ur
s
in
or
d
er
to
m
at
c
h
te
xt
ur
e
a
n
d
h
ai
r
c
ol
or
•
C
ar
e
of
h
ai
r
a
n
d
sc
al
p
in
cl
u
d
es
w
as
hi
n
g
h
ai
r
t
w
o
to
th
re
e
ti
m
es
a
w
e
e
k
wi
th
a
m
il
d
s
h
a
m
p
o
o;
p
at
h
ai
r
dr
y,
a
n
d
d
o
n
ot
u
se
a
bl
o
w
dr
y
er
•
Al
lo
w
cli
e
nt
to
e
x
pr
es
s
fe
el
in
g
s
c
o
n
c
er
ni
n
g
al
te
re
d
b
o
d
y
i
m
a
g
e
Nursi
ng
implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
In
tr
a
v
e
n
o
u
s
ro
ut
es
m
a
y
b
e
o
bt
ai
n
e
d
b
y
s
u
b
cl
a
vi
a
n
c
at
h
et
er
s,
i
m
pl
a
nt
e
d
p
or
ts
,
or
p
er
ip
h
er
al
ly
in
se
rt
e
d
c
at
h
et
er
s
E
xt
r
a
v
a
s
a
ti
o
n
th
e
le
a
ki
n
g
of
c
h
e
m
ot
h
er
a
p
e
ut
ic
a
g
e
nt
s
in
to
th
e
s
ur
ro
u
n
di
n
g
ti
ss
u
e,
is
th
e
m
oj
or
c
o
m
pl
ic
at
io
n
of
in
tr
a
v
e
n
o
u
s
c
h
e
m
ot
h
er
a
p
y;
e
xt
re
m
e
c
ar
e
m
u
st
b
e
u
se
d
w
h
e
n
a
d
m
in
is
te
ri
n
g
v
es
ic
a
nt
a
g
e
nt
s
(c
h
e
m
ic
al
s
c
a
u
si
n
g
d
a
m
a
g
e
to
ti
ss
u
e
o
n
c
o
nt
a
ct
)
Nursi
ng
implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
P
h
y
s
i
c
i
a
n
s
a
n
d
n
u
r
s
e
s
h
o
u
l
d
b
e
s
p
e
c
i
a
ll
y
t
r
a
i
n
e
d
t
i
c
a
g
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n
t
t
o
p
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t
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n
c
y
m
u
s
t
b
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h
a
n
d
l
e
a
n
d
a
d
m
i
n
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s
t
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r
c
h
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m
o
t
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r
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p
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V
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n
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s
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r
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r
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r
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c
h
e
m
o
t
h
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r
a
p
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t
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c
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g
e
n
t
s
W
a
r
n
i
n
g
:
n
e
v
e
r
t
e
s
t
v
e
i
n
p
a
t
e
n
c
y
w
i
t
h
c
h
e
m
o
t
h
e
r
a
p
e
u
t
i
c
a
g
e
n
t
s
Nursi
ng
implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
I
f
e
x
t
r
a
v
a
s
a
t
i
o
n
o
c
c
u
r
s
,
d
e
p
e
n
d
i
n
g
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t
h
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c
h
e
m
o
t
h
e
r
a
p
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t
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c
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g
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n
t
,
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n
t
e
r
v
e
n
t
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o
n
s
m
a
y
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n
c
l
u
d
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t
h
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i
n
j
e
c
t
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o
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a
n
a
n
t
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d
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e
,
t
h
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a
p
p
l
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c
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t
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f
a
c
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d
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o
m
p
r
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s
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a
p
p
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c
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t
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f
a
w
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r
m
c
o
m
p
r
e
s
s
Nursi
ng
implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
A
s
s
e
s
s
r
e
s
p
i
r
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t
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r
y
a
n
d
c
a
r
d
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a
c
E
K
G
,
g
n
s
a
s
s
e
s
s
f
o
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h
e
a
r
t
f
a
i
l
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r
e
,
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n
d
s
t
a
t
u
s
;
m
o
n
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t
o
r
m
o
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t
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v
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t
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l
s
i
M
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n
i
t
o
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t
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f
o
r
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n
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p
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l
a
c
t
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c
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a
c
t
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o
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s
o
r
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r
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o
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s
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d
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f
f
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t
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;
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i
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c
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c
c
u
r
Nursi
ng
implic
ations
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M
o
n
i
t
o
r
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n
t
r
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v
e
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o
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s
s
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t
e
c
l
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y
d
u
r
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a
d
m
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n
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s
t
r
a
t
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;
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b
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p
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f
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l
t
r
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t
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P
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c
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r
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r
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d
m
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t
r
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t
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o
n
Nursi
ng
implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
U
s
e
c
a
ut
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n
w
h
e
n
pr
e
p
ar
in
g,
a
d
m
in
is
te
ri
n
g,
or
di
s
p
o
si
n
g
of
c
h
e
m
ot
h
er
a
p
e
ut
ic
a
g
e
nt
s;
fo
ll
o
w
pr
a
ct
ic
e
g
ui
d
el
in
e
s
a
n
d
pr
ot
e
ct
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e
st
a
n
d
ar
d
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fo
r
s
af
e
h
a
n
dl
in
g
of
c
h
e
m
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er
a
p
e
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ic
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g
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nt
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d
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d
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e
O
cc
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p
at
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S
af
et
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n
d
H
e
al
th
A
d
m
in
is
tr
at
io
n
(
O
S
H
A)
a
n
d
O
n
c
ol
o
g
y
N
ur
si
n
g
S
o
ci
et
y
The
client
under
going
a
bone
marro
w
trans
plant
(BMT)
B
M
T
is
u
s
e
d
in
th
e
tr
e
at
m
e
nt
of
le
u
k
e
m
ia
s,
u
s
u
al
ly
in
c
o
nj
u
n
ct
io
n
wi
th
ra
di
at
io
n
or
c
h
e
m
ot
h
er
a
p
y
Au
tol
og
ou
s
BM
T:
the
cli
ent
is
inf
us
ed
wit
h
ow
n
bo
ne
ma
rro
w
ha
rve
ste
d
du
rin
g
re
mi
ssi
on
of
dis
ea
se
All
og
eni
c
BM
T:
the
cli
ent
is
inf
us
ed
wit
h
do
no
r
bo
ne
ma
rro
w
ha
rve
ste
d
fro
m
a
he
alt
hy
ind
ivi
du
al
The
client
under
going
a
bone
marro
w
trans
plant
(BMT)
T
h
e
b
o
n
e
m
ar
ro
w
is
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s
u
al
ly
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ar
v
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st
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d
fr
o
m
th
e
ili
a
c
cr
e
st
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th
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n
fr
o
z
e
n
a
n
d
st
or
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nt
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tr
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n
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si
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ef
or
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re
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ei
vi
n
g
th
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M
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cli
e
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m
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p
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er
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p
y
to
d
e
st
ro
y
th
e
i
m
m
u
n
e
s
y
st
e
m
;
in
fe
ct
io
n,
bl
e
e
di
n
g,
a
n
d
d
e
at
h
ar
e
m
aj
or
c
o
m
pl
ic
at
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s
th
at
c
a
n
o
cc
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d
ur
in
g
th
is
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o
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di
ti
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ni
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g
p
h
a
s
e
b
o
n
e
m
ar
ro
w
is
tr
a
n
sf
u
s
e
d
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tr
a
v
e
n
o
u
sl
y
th
ro
u
g
h
a
c
e
nt
ra
l
li
n
e
The
client
under
going
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bone
marro
w
trans
plant
(BMT)
Af
te
r
i
m
m
u
n
o
s
u
p
pr
e
ss
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n,
th
e
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d
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ef
fe
ct
s
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b
o
n
e
m
ar
ro
w
tr
a
n
s
pl
a
nt
:
di
n
g
re
la
te
d
to
th
ro
m
b
o
cy
to
p
e
ni
a
M
al
n
ut
rit
io
n
Bl
e
e
The
client
under
going
a
bone
marro
w
trans
plant
(BMT)
In
fe
ct
io
n
re
la
te
d
to
i
m
m
u
n
os
u
p
pr
es
si
o
n
nt
(BM
T)
Nur
sing
ma
nag
em
ent
of
clie
nt
und
erg
oin
ga
bon
e
mar
row
tran
spla
M
o
n
i
t
o
r
f
o
r
g
r
a
f
t
v
e
r
s
u
s
h
o
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t
t
h
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P
r
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v
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p
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b
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o
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p
i
t
a
l
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z
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d
r
o
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f
o
r
d
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s
e
a
s
e
r
i
v
a
t
e
h
o
s
p
i
t
a
l
i
z
e
d
c
l
i
e
n
t
;
c
l
i
e
n
t
w
i
l
6
t
o
t
h
s
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g
n
i
f
i
c
a
n
t
o
t
h
e
r
s
8
b
y
w
e
e
k
s
u
s
i
n
g
E
n
c
o
u
r
a
g
e
t
e
l
e
p
h
o
n
e
,
c
o
n
t
a
c
t
w
i
c
o
m
p
u
t
e
r
,
s
a
n
d
o
t
h
e
r
m
e
a
n
s
o
f
c
o
m
m
u
n
i
c
a
t
i
o
n
t
o
r
e
d
u
c
e
f
e
e
l
i
n
g
o
f
i
s
o
l
a
t
i
o
n
Biolog
ic
Thera
py
Cance
r
treat
ment
that
produ
ces
antitumor
effect
s
prima
rily
throu
gh
the
action
of
natur
al
host
defen
se
mech
anism
s or
the
admi
nistra
tion
of
natur
al
mam
malia
n
subst
ances
Biolog
ic
Thera
py
Stimu
late
immu
ne
defen
se
mech
anism
s
Cause
the
tumor
to
appe
ar
more
“forei
gn”
comp
ared
to
norm
al
tissue
s
Immu
ne
cells
secret
e two
major
classe
s of
solubl
e
protei
n
Antibody
Cytokines
Antib
ody
Two
pairs
of
differ
ent
polyp
eptid
e
chain
s
(heav
y&
light
chain
s)
Two
recog
nition
sites
capab
le of
combi
ning
with
the
immu
nizing
antig
en
Media
te cell
destr
uction
by
phag
ocyto
sis
ing
cells
Cytot
oxic T
Lymp
hocyt
e
(CTL)
Interf
erons
Natur
al
Killer
cells
(NK)
Cytok
ines
Produ
ced
by
lymp
hocyt
es
(lymp
hokin
es) or
mono
cytes
(mon
okine
s)
acting
as
true
horm
ones
–
acting
on
other
cells
at a
distan
ce
from
the
secret
Tumo
r
Necro
sis
Facto
r
(TNF)
Interl
eukin
s118
Oncol
ogic
Emer
genci
es:
Diagn
osis
and
Mana
geme
nt
Spinal
cord
comp
ressio
n
O
c
c
u
r
s
s
e
c
o
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d
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r
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p
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m
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E
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r
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m
p
t
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s
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n
c
l
u
d
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b
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k
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n
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g
p
a
i
n
,
c
o
l
d
n
e
s
s
,
n
u
m
b
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s
,
t
i
n
g
li
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,
p
a
r
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s
t
h
e
s
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a
;
p
r
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s
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i
o
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l
e
a
d
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t
o
b
o
w
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l
a
n
d
b
l
a
d
d
e
r
d
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f
u
n
c
t
i
o
n
,
w
e
a
k
n
e
s
s
,
a
n
d
p
a
r
a
l
y
s
i
s
E
a
r
l
y
d
e
t
e
c
t
i
o
n
i
s
e
s
s
e
n
t
i
a
l
:
i
n
v
e
s
t
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g
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t
e
a
ll
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o
m
p
l
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n
t
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p
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r
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c
a
l
c
h
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n
g
e
s
sio
n
an
d
pr
ev
en
t
irr
ev
ers
ibl
e
pa
ra
ple
gia
;
ma
y
rec
eiv
e
cor
tic
ost
er
oid
to
re
du
ce
cor
d
ed
em
a
Spinal
cord
comp
ressio
n
Tr
ea
tm
en
t is
ai
me
d
at
re
du
cin
g
tu
mo
r
siz
e
by
ra
dia
tio
n
an
d/o
r
sur
ge
ry
to
reli
ev
e
co
mp
res
Nu
rsi
ng
int
er
ve
nti
on
s
inc
lud
e
ea
rly
rec
og
niti
on
of
sy
mp
to
ms
,
mo
nit
ori
ng
vit
al
sig
ns,
ne
ur
olo
gic
al
ch
ec
ks,
an
d
me
dic
ati
on
ad
mi
nis
tra
tio
n
Super
ior
vena
cava
syndr
ome
C
o
m
pr
e
ss
io
n
or
o
b
st
ru
ct
io
n
of
th
e
s
u
p
er
io
r
v
e
n
a
c
a
v
a
(S
V
C)
U
s
u
al
ly
a
ss
o
ci
at
e
d
wi
th
c
a
n
c
er
of
lu
n
g
s
a
n
d
ly
m
p
h
o
m
a
s
Si
g
n
s
a
n
d
s
y
m
pt
o
m
s
ar
e
th
e
re
s
ul
t
of
bl
o
c
k
a
g
e
of
v
e
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o
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s
ci
rc
ul
at
io
n
of
h
e
a
d,
n
e
c
k,
a
n
d
u
p
p
er
tr
u
n
k
Super
ior
vena
cava
syndr
ome
E
ar
ly
si
g
n
s
a
n
d
s
y
m
pt
o
m
s
ar
e
p
er
io
rb
it
al
e
d
e
m
a
a
n
d
fa
ci
al
e
d
e
m
a
S
y
m
pt
o
m
s
pr
o
gr
e
ss
to
e
d
e
m
a
of
n
e
c
k,
ar
m
s,
a
n
d
h
a
n
d
s;
di
ffi
c
ul
ty
s
w
al
lo
wi
n
g;
s
h
or
tn
e
ss
of
br
e
at
h
L
at
e
si
g
n
s
a
n
d
s
y
m
pt
o
m
s
ar
e
c
y
a
n
o
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s,
al
te
re
d
m
e
nt
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st
at
u
s,
h
e
a
d
a
c
h
e,
a
n
d
h
y
p
ot
e
n
si
o
n
Super
ior
vena
cava
syndr
ome
D
e
at
h
m
a
y
o
cc
ur
if
c
o
m
pr
e
ss
io
n
is
n
ot
re
li
e
v
e
d
Tr
e
at
m
e
nt
in
cl
u
d
e
s
hi
g
hd
o
s
e
ra
di
at
io
n
to
s
hr
in
k
tu
m
or
a
n
d
re
li
e
v
e
s
y
m
pt
o
m
s
N
ur
si
n
g
in
te
rv
e
nt
io
n
s
in
cl
u
d
e
m
o
ni
to
ri
n
g
vi
ta
l
si
g
n
s,
pr
o
vi
di
n
g
o
x
y
g
e
n
s
u
p
p
or
t,
pr
e
p
ar
in
g
fo
r
tr
a
c
h
e
o
st
o
m
y
if
n
e
c
e
ss
ar
y,
in
iti
at
in
g
s
ei
z
ur
e
pr
e
c
a
ut
io
n
s,
a
n
d
a
d
m
in
is
te
ri
n
g
c
or
ti
c
o
st
er
oi
d
s
to
re
d
u
c
e
e
d
e
m
a
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
S
e
v
er
e
di
s
or
d
er
of
c
o
a
g
ul
at
io
n,
of
te
n
tri
g
g
er
e
d
b
y
s
e
p
si
s,
w
h
er
e
b
y
a
b
n
or
m
al
cl
ot
fo
r
m
at
io
n
o
cc
ur
s
in
th
e
m
ic
ro
v
a
sc
ul
at
ur
e;
th
is
pr
o
c
e
ss
d
e
pl
et
e
s
th
e
cl
ot
ti
n
g
fa
ct
or
s
a
n
d
pl
at
el
et
s,
al
lo
wi
n
g
e
xt
e
n
si
v
e
bl
e
e
di
n
g
to
o
cc
ur
;
ti
ss
u
e
h
y
p
o
xi
a
o
cc
ur
s
a
s
a
re
s
ul
t
of
th
e
bl
o
c
k
a
g
e
of
bl
o
o
d
v
e
ss
el
s
fr
o
m
th
e
cl
ot
s
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
Si
g
n
s
a
n
d
s
y
m
pt
o
m
s
ar
e
re
la
te
d
to
d
e
cr
e
a
s
e
d
bl
o
o
d
fl
o
w
to
m
aj
or
or
g
a
n
s
(t
a
c
h
y
c
ar
di
a,
ol
ig
ur
ia
,
d
y
s
p
n
e
a)
a
n
d
d
e
pl
et
e
d
cl
ot
ti
n
g
fa
ct
or
s
(a
b
n
or
m
al
bl
e
e
di
n
g
a
n
d
h
e
m
or
rh
a
g
e)
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
Tr
e
at
m
e
nt
in
cl
u
d
e
s
a
nt
ic
o
a
g
ul
a
nt
s
to
d
e
cr
e
a
s
e
st
i
m
ul
at
io
n
of
c
o
a
g
ul
at
io
n
a
n
d
tr
a
n
sf
u
si
o
n
of
o
n
e
or
m
or
e
of
th
e
fo
ll
o
wi
n
g:
fr
e
s
h
fr
o
z
e
n
pl
a
s
m
a
(F
F
P)
,
cr
y
o
pr
e
ci
pi
ta
te
,
pl
at
el
et
s,
a
n
d
p
a
c
k
e
d
re
d
bl
o
o
d
c
el
ls
(R
B
C
s)
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
N
ur
si
n
g
in
te
rv
e
nt
io
n
s
in
cl
u
d
e
a
ss
e
ss
in
g
cli
e
nt
,
m
o
ni
to
ri
n
g
fo
r
bl
e
e
di
n
g,
a
p
pl
yi
n
g
pr
e
ss
ur
e
dr
e
ss
in
g
s
to
v
e
ni
p
u
n
ct
ur
e
si
te
s,
a
n
d
pr
e
v
e
nt
in
g
ri
sk
of
s
e
p
si
s
M
or
ta
lit
y
fo
r
cli
e
nt
s
e
x
p
er
ie
n
ci
n
g
DI
C
is
gr
e
at
er
th
a
n
7
0
p
er
c
e
nt
d
e
s
pi
te
a
g
gr
e
ss
iv
e
tr
e
at
m
e
nt
Cardi
ac
tamp
onade
Perica
rdial
effusi
on
secon
dary
to
meta
stase
s or
esoph
ageal
cance
r can
lead
to
comp
ressio
n of
heart,
restri
cting
heart
move
ment
and
result
ing in
cardia
c
tamp
onade
Cardi
ac
tamp
onade
Signs
and
symp
toms
are
relate
d to
cardio
genic
shock
or
circul
atory
collap
se:
anxie
ty,
cyano
sis,
dyspn
ea,
hypot
ensio
n,
tachy
cardia
,
tachy
pnea,
impai
red
level
of
consc
iousn
ess,
and
increa
sed
centr
al
venou
s
press
ure
Cardi
ac
tamp
onade
Perica
rdioce
ntesis
is
perfor
med
to
remo
ve
fluid
from
perica
rdial
sa
Nursi
ng
interv
entio
ns
includ
e
admi
nister
ing
oxyge
n,
maint
aining
intrav
enous
line,
monit
oring
vital
signs,
hemo
dyna
mic
monit
oring,
and
the
admi
nistra
tion
of
vasop
ressor
agent
s
Neoplasm
“Cancer adheres to any part that it seizes
upon in an obstinate manner like the crab.”
product of new growth
abnormal mass of tissue
The crab depicts the manner of growth of
the disease.
exceeds and is uncoordinated with
that of the normal tissues
persists in the same excessive
manner after cessation of the stimuli
which evoked that change
Cancer
More than 100 neoplastic diseases that
involve all body organs
Uncontrolled growth of one of more cells
Progression from normal tissue to invasive
cancer is 5 – 20 years
Driven by a series of accumulative genetic
changes
Terminologies
Neoplasia – “new growth”
Tumor – swelling originally due to
inflammation
Oncology – study of tumors or neoplasms
purposeless, preys on the host,
autonomous
1.2 million in US are diagnosed with cancer
every year
Greatest increase seen in lung CA
Number of CA deaths increased by 11%
during past 40 years
Epidemiology
Geographic and Environmental Factors
Gastric CA in Japan
Racial differences due to
environmental influences
Epidemiology
Second leading cause of death in the US
after heart disease
Ranks fourth for males and first for females
as leading cause of death
Ranks second for children as cause of death,
after accidents
Epidemiology
Age
Late age
Cancers of certain age groups
Heredity
Inherited cancer syndromes
(Rhabdomyosarcoma)
Familial cancers (Breast, colon, ovary
and brain)
Terminologies
Do not invade adjacent structures
- grows to a large size
Benign - designated by the suffix
Do not spread to distant sites
- it obstructs important channels in the body
“-oma”
Usually not lethal
- it ulcerates or bleeds
Malignant – “sarcomas, carcinomas”
Life-threatening
- it produces endocrine disturbances
Benign Tumors
- if it forms in a critical location
Tissue of Origin
Benign
Malignant
Tissue of Origin
Benign
Malignant
Composed of
More Than One
Neoplastic Cell
Type (Mixed
Tissue of Tumors)
Origin
Benign
Composed
One
1. of
Salivary
Parenchymal Cell
glands
Type
A. Mesenchymal
Tumors 2. Breast
1.
Lipoma
3.
Pleomor
Malignant mixed tumor of
phic
adenoma
salivary gland
Fibroade
Fibrosarcoma
Malignant cystosarcoma
noma
phyllodes
Liposarcoma
Connective
tissue and
Chondroma
3.
Renal Anlage
derivatives
Osteoma
2. Endothelial and
related tissues
3.
Fibroma
Malignant
Angiosarcoma
Lymphangioma
Lymphangiosarcoma
Muscle
Benign
2.
Basal cell
3.
Glands or ducts
4.
Respiratory passages
5.
Malignant
Tumors
Neuroectoderm
Basal cell carcinoma
Adenoma
Leiomyosarcoma
Rhabdomyoma
Rhabdomyosarcoma
Adenocarcinoma
Bronchogenic
carcinoma
Nevus
Malignant melanoma
6.
Renal epithelium
Renal tubular adenoma
Renal cell carcinoma
7.
Liver cells
Liver cell adenoma
Hepatocellular
carcinoma
8.
Urinary tract epithelium
Transitional cell papilloma
Transitional cell
carcinoma
Leukemias
Leiomyoma
Malignant
Composed of One Parenchymal Cell Type
1. Totipotential cells in
Mature teratoma, dermoid
Immature teratoma,
gonads
or in embryonic
cyst
B. Epithelial
Tumors
Squamous cellteratocarcinoma
papilloma
Squamous cell
rests
carcinoma
1. Stratified squamous
Chondrosarcoma
Wilms’ tumor
Osteosarcoma
Hemangioma
Blood cells
Benign
vs.
Composed of More Than
One Neoplastic Cell Type
From More Than One
Germ Layer Tissue of Origin
Teratogenous
Tumor Progression
Cancer is a
multistep
process
Initiation
Carcinogen
Cell
Tumor
Abnormal Cell
Promotion
Carcinogen
The
Switc
h
from
Norm
al to
Abnor
mal
Growt
h
Activa
tion
of
Onco
genes
Oncogenes
encode
proteins that
promote cell
growth
Inhibi
tion
of
Tumo
r
Suppr
essor
Gene
s
Tumor
Suppressor
Genes apply
brakes to cell
proliferation
The
Switc
h
from
Norm
al to
Abnor
mal
Growt
h
Altera
tion
in cell
cycle
Dereg
ulatio
n of
cell
cycle
contr
ol
Apopt
osis
Growth
Local
Invasion
What
cause
s the
switc
h?
Point
mutat
ions
Transl
ocatio
ns
Gene
ampli
ficatio
n
Loss
of
heter
ozygo
zity
Damage to
the DNA
Stage
s of
Tumo
r
Growt
h
Transformatio
n
Metastases
Angio
genes
is
Conti
nued
tumor
growt
h
requir
es
persis
tent
new
blood
vesse
l
growt
h
Shed
ding
of
malig
nant
cells
into
the
venou
s
drain
age
Tumo
r cells
releas
e
solubl
e
factor
s that
requir
e
angio
genic
respo
nse
(angi
ogen
esis
factor
s)
Metas
tasis
Metas
tasis
Detac
hmen
t of
the
tumor
cells
from
each
other
Attac
hmen
t to
matri
x
comp
onent
s
Degra
datio
n of
extra
cellul
ar
matri
x
b
et
w
e
e
n
v
e
n
o
u
s
a
n
d
ly
m
p
h
at
ic
ci
rc
ul
at
io
n
Migra
tion
of
tumor
cells
Mech
anism
s of
Metas
tasis
Via
the
lymp
hatic
syste
m
C
a
n
c
er
c
el
ls
re
si
d
e
in
ly
m
p
h
n
o
d
e
s
or
p
a
ss
Ar
e
a
s
of
b
o
d
y
wi
th
e
xt
e
n
si
v
e
ly
m
p
h
at
ic
ci
rc
ul
at
io
n
(e
.g
.
br
e
a
st
)
M
e
c
h
a
ni
s
m
s
of
M
et
a
st
a
si
s
Via
the
circul
atory
syste
m
H
e
m
at
o
g
e
n
o
u
s
ro
ut
e:
bl
o
o
d
c
ar
ri
e
s
c
a
n
c
er
c
el
l
fr
o
m
o
n
e
si
te
to
a
n
ot
h
er
R
el
at
e
d
to
th
e
d
e
gr
e
e
of
v
a
sc
ul
ar
it
y
or
a
n
gi
o
g
e
n
e
si
s
in
th
e
tu
m
or
M
e
c
h
a
ni
s
m
s
of
M
et
a
st
a
si
s
Via
direct
sprea
d of
cance
r cells
(seedi
ng)
where
there
are
no
boun
daries
to
stop
growt
h
(e.g.
ovary,
stomach)
C
ar
ci
n
o
g
e
ni
c
A
g
e
nt
s
Chem
ical
carcin
ogens
Radia
nt
energ
y
Onco
genic
viruse
s
Horm
ones
Genet
ic
Immu
nodef
icienc
y
immune
effector cells
can eliminate
cells that
undergo
malignant
transformatio
n
development
of tumor is a
failure of
immune
surveillance
in
maintaining
tissue
homeostasis
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Organ
specif
ic
Genot
oxic
(caus
e
genet
ic
dama
ge)
Envir
onme
ntal
expos
ures
Activa
tion
of
endo
geno
us
muta
genic
pathw
ays
(nitric
oxide
& oxy
radica
ls)
Requi
res
accu
mulat
ed
expos
ure
Gross
chro
moso
mal
chang
es
Chem
ical
Carci
noge
ns
Two
stage
s of
chemi
cal
carcin
ogen
esis
e
ni
c
a
g
e
nt
Initiation
R
e
s
ul
ts
fr
o
m
e
x
p
o
s
ur
e
of
c
el
ls
to
a
n
a
p
pr
o
pr
ia
te
d
o
s
e
of
a
c
ar
ci
n
o
g
n
in
d
u
c
e
tu
m
or
s
in
in
iti
at
e
d
c
el
ls
b
ut
ar
e
n
o
nt
u
m
or
ig
e
ni
c
b
y
th
e
m
s
el
v
e
s
C
a
u
s
e
s
p
er
m
a
n
e
nt
D
N
A
d
a
m
a
g
e
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Promotion
C
a
Pr
o
d
u
c
e
re
v
er
si
bl
e
d
a
m
a
g
e
to
D
N
A
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Direct
Actin
g
Alkyla
ting
Agent
s
- use
as anticancer
drugs
cyclophospha
mide,
chlorambucil,
busulfan,
melphalan
and others
Polyc
yclic
Arom
atic
Hydro
carbo
ns
some of the
most potent
carcinogens
Pr
o
d
u
c
e
d
in
th
e
c
o
m
b
u
st
io
n
of
to
b
a
cc
o
a
s
in
ci
g
ar
et
te
s
m
o
ki
n
g
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Arom
atic
Amin
es
and
Azo
Dyes
E
x
er
ts
it
s
ef
fe
ct
s
in
th
e
li
v
er
“
T
h
e
ul
ti
m
at
e
c
ar
ci
n
o
g
e
n
”
In
te
r
m
e
di
at
e
s
wi
th
th
e
c
yt
o
c
hr
o
m
e
P4
5
0
o
x
y
g
e
n
a
s
e
s
y
st
e
m
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
Natur
ally
occur
ring
carcin
ogens
Aflatoxin B1
Produced by
certain
strains of
Aspergillus
flavus
Found on
improperly
stored grains
and peanuts
Nitros
amin
es
and
amid
es
In the
gastrointestin
al tract
C
h
e
m
ic
al
C
ar
ci
n
o
g
e
n
s
in
th
e
Di
et
Chem
ical
Carci
noge
ns in
the
Diet
High
fat,
low
fiber
conte
nt
Food
additi
ves
such
as
cycla
mides
,
nitrite
s and
sacch
arin
Heav
y
food
seaso
ning
Smok
ed or
salted
foods
Foods
conta
minat
ed
with
anato
xin
Alcoh
ol
Chem
ical
Carci
noge
ns
Miscel
laneo
us
agent
s
AsbestosLung CA
Vinyl
chlorideLiver
hemangiosarc
oma
Chromium,
nickel – Lung
CA
Arsenic – Skin
CA
Components
of
insecticides
c
el
l
C
A
a
n
d
m
el
a
n
o
c
ar
ci
n
o
m
a
of
th
e
sk
in
Diethylstilbes
trol
R
a
di
a
nt
C
ar
ci
n
o
g
e
n
s
Ultrav
iolet
rays
I
m
pl
ic
at
e
d
in
s
q
u
a
m
o
u
s
c
el
l
C
A,
b
a
s
al
D
e
p
e
n
d
s
o
n
th
e
ty
p
e,
in
te
n
si
ty
a
n
d
le
n
gt
h
of
e
x
p
o
s
ur
e,
a
n
d
q
u
a
nt
it
y
of
m
el
a
ni
n
o
n
sk
in
U
V
B
is
th
e
c
ar
ci
n
o
g
e
ni
c
ty
p
e
R
a
di
a
nt
C
ar
ci
n
o
g
e
n
s
Ionizi
ng
Radia
tion
formation
of free
radicals
which can
damage DNA
El
e
ct
ro
m
a
g
n
et
ic
ra
di
at
io
n(
xra
y
s,
g
a
m
m
a)
P
ar
ti
c
ul
at
e
ra
di
at
io
n
(a
lp
h
a
p
ar
ti
cl
e
s,
b
et
a
p
ar
ti
cl
e
s,
pr
ot
o
n
s,
n
e
ut
ro
n
s)
T
h
er
a
p
e
ut
ic
ra
di
at
io
n
Huma
n
Papill
omavi
rus
Anogenital,
cervical and
skin cancer
Viral
Carcinogens
Hepa
DNAvi
rus
Hepa B virus
(Hepatocellul
ar cancer)
Hepat
otropi
c
virus
Hepa C virus
(Hepatocellul
ar cancer)
Herpe
svirus
Epstein Barr
virus
(Hodgkin’s
lymphoma,
nasopharyng
eal CA)
Kapos
i’s
sarco
ma
Huma
n
immu
nodef
icienc
y
virus
Horm
ones
Estro
gen
Proge
stero
ne
Andro
gens
Warni
ng
Signs
of
Cance
r
From
the
Ameri
can
Cance
r
Societ
y
Healt
h
Histor
y
Change in
bowel or
bladder
habits
Thickening or
lump in
breast or
elsewhere
Indigestion or
difficulty
swallowing
Obvious
change in
wart or mole
Nagging
cough or
hoarseness
Asses
smen
t
Healt
h
Histor
y
Physi
cal
Exami
natio
n
Diagn
ostic
Proce
dures
Perso
nal
and
Social
Histor
y
Gener
al
infor
matio
n
A sore that
doesn’t heal
Unusual
bleeding or
discharge
hospitalizatio
ns / surgery
-
allergy
name
- diet
- age
- life-
-
style
- race
occupation
gender
Healt
h
Histor
y
- date
& place of
birth
marital status
Famil
y
Histor
y
Healt
h
Histor
y
OBGyne
Histor
y
Chief
Comp
laint
Past
Medic
al
Histor
y
previous
medical
disease
previous
menarche
menopause
- OCP
use
- GP
(TPAL)
Physi
cal
Exami
natio
n
h
e
al
)
Skin
L
o
ss
of
sk
in
m
ar
ki
n
g
s
P
er
si
st
e
nt
ul
c
er
(a
n
y
c
h
a
n
g
e
in
c
ol
or
,
si
z
e,
s
h
a
p
e,
el
e
Ir
re
g
ul
ar
h
y
p
er
k
er
at
ot
ic
ar
e
a
s
(r
o
u
g
h
ar
e
a
th
at
sc
a
b
s
o
v
er
,
re
sc
a
b
s
or
fa
ils
to
v
at
io
n,
s
ur
fa
c
e,
s
ur
ro
u
n
di
n
g
sk
in
,
s
e
n
s
at
io
n
or
c
o
n
si
st
e
n
c
y)
Pr
ur
it
u
s
(p
re
v
al
e
nt
in
H
o
d
g
ki
n’
s
di
s
e
a
s
e)
V
ar
ia
ti
o
n
in
pi
g
m
e
nt
at
io
n
P
h
y
si
c
al
E
x
a
m
in
at
io
n
Head
and
Neck
ul
ty
c
h
e
wi
n
g,
s
w
al
lo
wi
n
g,
or
m
o
vi
n
g
to
n
g
u
e
or
ja
w
Di
ffi
c
Fi
r
m
,
u
ni
la
te
ra
l
ly
m
p
h
n
o
d
e
s
in
n
e
c
k
P
er
si
st
e
nt
re
d
di
s
h
or
w
hi
ti
s
h
p
at
c
h
Oral
cavity
O
ta
lg
ia
S
w
el
li
n
g
or
ul
c
er
th
at
fa
ils
to
h
e
al
,
in
d
ur
at
e
d
ul
c
er
,
or
ip
sil
at
er
al
re
fe
rr
e
d
ul
c
er
Physi
cal
Exami
natio
n
Oroph
arynx
D
y
s
p
h
a
si
a,
lo
c
al
p
ai
n,
p
ai
n
o
n
s
w
al
lo
wi
n
g,
or
re
fe
rr
e
d
ot
al
gi
a
Laryn
x
P
er
si
st
e
nt
h
o
ar
s
e
n
e
ss
,
p
ai
n,
re
fe
rr
e
d
ot
al
gi
a,
or
n
e
c
k
m
a
ss
Naso
phary
nx
Bl
o
o
d
y
n
a
s
al
di
sc
h
ar
g
e,
o
b
st
ru
ct
e
d
n
o
st
ril
,
c
o
n
d
u
ct
iv
e
d
e
af
n
e
ss
P
h
y
si
c
al
E
x
a
m
in
at
io
n
Nose
and
sinus
es
Bl
o
o
d
y
n
a
s
al
di
sc
h
ar
g
e,
n
a
s
al
o
b
st
ru
ct
io
n,
fa
ci
al
p
ai
n,
fa
ci
al
s
w
el
li
n
g,
di
pl
o
pi
a
Paroti
d and
subm
andib
ular
gland
s
P
ai
nl
e
ss
lo
c
al
s
w
el
li
n
g
or
h
e
m
if
a
ci
al
p
ar
al
y
si
s
Physi
cal
Exami
natio
n
Chest
/Lung
s
Change in
pulmonary
habits
Cough
Hoarseness
Chest pain
Rust-streaked
or purulent
sputum
production
Hemoptysis
Dyspnea
P
h
y
si
c
al
E
x
a
m
in
at
io
n
Breas
t
Axilla
ry
lymp
hade
nopat
hy
Blood
y
disch
arge
Chan
ge in
conto
ur of
breas
t
Dimpl
ing of
skin
of
breas
t
Edem
a or
eryth
ema
of
breas
t skin
Fixati
on of
a
mass
to
pecto
ral
fascia
or
chest
wall
Nippl
e
retrac
tion
Painle
ss
lump
or
mass
Unilat
eral
nipple
disch
arge
s
of
a
p
p
et
it
e
Physi
cal
Exami
natio
n
Abdo
men
St
o
m
a
c
h
C
o
m
pl
ai
nt
s
of
in
di
g
es
ti
o
n
or
e
pi
g
as
tri
c
di
st
re
ss
L
os
U
ni
nt
e
nt
io
n
al
w
ei
g
ht
lo
ss
or
a
n
or
e
xi
a
D
ys
p
h
a
gi
a
M
as
s
in
a
b
d
o
m
e
n
Ul
c
er
ty
p
e
p
ai
n
Ir
o
n
d
ef
ici
e
n
cy
a
n
e
m
ia
P
h
ys
ic
al
E
x
a
m
in
at
io
n
Li
v
er
P
ai
nf
ul
h
e
p
at
o
m
e
g
al
y
e
al
v
ar
ic
es
sc
it
es
S
E
so
p
h
a
g
Physi
cal
Exami
natio
n
G
al
lb
la
d
d
er
Ja
u
n
di
c
e
GI
bl
e
e
di
n
g
F
e
v
er
c
ut
e
or
c
hr
o
ni
c
c
h
ol
e
cy
st
iti
s
A
Li
v
er
te
n
d
er
n
es
s
wi
th
n
o
d
ul
ar
e
nl
ar
g
e
m
e
nt
pl
e
n
o
m
e
g
al
y
A
E
d
e
m
a
A
b
d
o
m
in
al
p
ai
n
A
n
or
e
xi
a
U
ni
nt
e
nt
io
n
al
w
ei
g
ht
lo
ss
Ja
u
n
di
c
e
ni
a
N
a
u
se
a
V
o
m
iti
n
g
Physi
cal
Exami
natio
n
P
a
n
cr
e
a
s
In
si
d
u
o
u
s
o
n
se
t
of
as
th
e
A
n
or
e
xi
a
W
ei
g
ht
lo
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G
as
e
o
u
s
n
es
s
N
a
u
se
a
C
ol
o
n
a
n
d
re
ct
u
m
C
h
a
n
g
e
in
b
o
w
el
h
a
bi
ts
(o
b
st
ru
ct
io
n,
di
ar
rh
e
a,
re
ct
al
bl
e
e
di
n
g,
te
n
es
m
u
s
Ir
o
nd
ef
ici
e
n
cy
a
n
e
m
ia
Physi
cal
Exami
natio
n
Exami
natio
n
Genit
ourinar
y
Genit
ourinar
y
Ki
d
n
e
y
s
a
n
d
ur
in
ar
y
tr
a
ct
F
e
m
al
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g
e
ni
ta
li
a
C
V
O
b
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ct
io
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H
e
m
at
ur
ia
Ol
ig
ur
ia
Physi
cal
n
u
s
u
al
pi
g
m
e
nt
at
io
n
ul
v
a
–
pr
ur
it
u
s
bl
e
e
di
n
g,
ul
c
er
at
e
d
le
si
o
n,
m
as
s,
u
er
vi
x
–
p
ai
nf
ul
in
te
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o
ur
se
,
p
os
tc
oi
ta
l
c
oi
ta
l
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in
te
r
m
e
n
st
ru
al
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e
e
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n
g,
or
w
at
er
y
fo
ul
s
m
el
li
n
g
di
sc
h
ar
g
e
n
st
ru
al
bl
e
e
di
n
g
or
p
os
t
m
e
n
o
p
a
u
sa
l
bl
e
e
di
n
g
(6
m
os
.)
E
n
d
o
m
et
ri
u
m
–
p
er
si
st
e
nt
irr
e
g
ul
ar
pr
e
m
e
Physi
cal
Exami
natio
n
Genit
ourinar
y
F
e
m
al
e
g
e
ni
ta
li
a
e
ar
ly
sa
ti
et
y,
or
m
il
d
a
n
or
e
xi
a,
as
ci
te
s
p
ai
n,
or
a
p
el
vi
c
m
as
s
O
v
ar
ie
s
–
p
er
si
st
e
nt
v
a
g
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e
GI
c
o
m
pl
ai
nt
s,
a
b
d
o
m
in
al
di
sc
o
m
fo
rt,
in
di
g
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ti
o
n,
V
a
gi
n
a
–
bl
e
e
di
n
g,
c
h
a
n
g
es
in
ur
in
at
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p
at
te
rn
s,
fo
ul
s
m
el
li
n
g
di
sc
h
ar
g
e
F
al
lo
pi
a
n
tu
b
es
–
a
b
n
or
m
al
bl
e
e
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n
g,
a
b
d
o
m
in
al
p
ai
n,
v
a
gi
n
al
di
sc
h
ar
g
e
Genit
ourinar
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M
al
e
g
e
ni
ta
li
a
P
h
ys
ic
al
E
x
a
m
in
at
io
n
P
e
ni
s
–
p
ai
nl
es
s
ul
c
er
or
gr
o
w
th
or
p
er
si
st
e
nt
di
sc
h
ar
g
e
(a
lw
a
ys
re
tr
a
ct
fo
re
sk
in
)
Pr
os
ta
te
–
b
o
n
e
p
ai
n
a
n
d
c
o
nt
in
u
o
u
s
p
ai
n
in
lo
w
er
b
a
ck
,
p
el
vi
s,
or
u
p
p
er
th
ig
h
s;
re
n
al
in
s
uf
fi
ci
e
n
cy
,
h
e
m
at
ur
ia
T
es
te
s
–
p
ai
nl
es
s
e
nl
ar
g
e
m
e
nt
of
o
n
e
te
st
icl
e
or
a
te
st
ic
ul
ar
lu
m
p
or
n
o
d
ul
e,
fe
el
in
g
of
h
e
a
vi
n
es
s
or
dr
a
g
gi
n
g
in
lo
w
er
a
b
d
o
m
e
n,
c
h
a
n
g
e
in
pr
e
e
xi
st
in
g
h
y
dr
o
c
el
e
P
os
si
bl
e
e
x
a
m
in
at
io
n
s
er
y
3
y
e
ar
s
Low
risk
and
asym
ptom
atic
client
s
A
g
e
s
2
04
0
–
P
E
wi
th
h
e
al
th
c
o
u
n
s
el
in
g
e
v
O
v
er
a
g
e
4
0
–
a
n
n
u
al
P
E
M
ol
e
m
a
p
pi
n
g
S
e
m
ia
n
n
u
al
d
e
nt
al
or
al
e
x
a
m
in
at
io
n
High
risk
or
symp
tomat
ic
client
s
M
or
e
fr
e
q
u
e
nt
e
x
a
m
s
S
cr
e
e
ni
n
g
te
st
s
Possi
ble
exami
natio
ns for
the
Femal
e
Client
BSE
mont
hly
for
client
s
older
than
age
20
B
S
E
s
h
o
ul
d
b
e
d
o
n
e
35
d
a
y
s
af
te
r
m
e
n
st
ru
al
p
er
io
d
e
n
d
s
P
o
st
m
e
n
o
p
a
u
s
al
or
h
y
st
er
e
ct
o
m
iz
e
d
cli
e
nt
s
–
p
er
fo
r
m
B
S
E
o
n
s
a
m
e
d
a
y
e
a
c
h
m
o
nt
h
Clinic
al
breas
t
exam
E
v
er
y
3
y
e
ar
s
fo
r
a
g
e
s
2
04
0
natio
ns for
the
Femal
e
Client
Mam
mogr
aphy
E
v
er
y
y
e
ar
fo
r
a
g
e
s
o
v
er
4
0
Possi
ble
exami
di
s
p
o
s
e
d
w
o
m
e
n
B
a
s
el
in
e
fo
r
a
g
e
s
3
53
9
B
a
s
el
in
e
at
a
g
e
2
5
fo
r
g
e
n
et
ic
al
ly
pr
e
E
v
er
y
12
y
e
ar
s
fo
r
a
g
e
s
4
04
9
E
v
er
y
y
e
ar
fo
r
5
0
a
n
d
a
b
o
v
e
e
wi
th
se
x
u
al
a
ct
iv
it
y
Possi
ble
exami
natio
ns for
the
Femal
e
Client
Colpo
scopy
for
wome
n with
histor
y of
HPV
Pelvic
exam
and
Pap
test
W
o
m
e
n
a
g
e
s
1
84
0
B
as
el
in
e
o
n
c
W
o
m
e
n
o
v
er
4
0
–
e
v
er
y
y
e
ar
Endo
metri
al
biops
y at
meno
pause
P
os
si
bl
e
e
x
a
m
in
at
io
n
s
fo
r
th
e
F
e
m
al
e
Cl
ie
nt
E
v
er
y
13
y
e
ar
s
Annu
al
fecal
occult
blood
test
for
client
s
older
than
50
Annu
al
DRE
for
client
s over
40
Sigm
oidos
copy
for
client
s
older
than
50
every
3-5
years
fecal
blood
test
Possi
ble
exami
natio
ns for
the
Male
Client
Prost
ate
exami
natio
n
E
v
er
y
y
e
ar
fo
r
cli
e
nt
s
ol
d
er
th
a
n
5
0
Occul
t
E
v
er
y
y
e
ar
fo
r
cli
e
nt
s
ol
d
er
th
a
n
5
0
DRE
E
v
er
y
y
e
ar
fo
r
cli
e
nt
s
ol
d
er
th
a
n
4
0
Sigm
oidos
copy
E
v
er
y
15
y
e
ar
s
fo
r
cli
e
nt
s
ol
d
er
th
a
n
5
0
Mont
hly
testic
ular
selfexami
natio
n
Fr
o
m
p
u
b
er
ty
to
a
g
e
4
0
Bronc
hosco
py
Di
a
g
n
o
st
ic
Pr
o
c
e
d
ur
e
s
XRay
Use
of
ionizi
ng
radiat
ion to
provi
de
imag
es of
tissue
&
bone
struct
ure
and
functi
on
X-Ray
Mam
mogr
aphy
CT
Scan
Contr
aindic
ated
in
pregn
ancy
MRI
Ultras
ound
Nursi
ng
care
Bone
Scan
Lumb
ar
Punct
ure
Thora
cente
sis
Pap
Smea
r
remove
metallic
objects,
jewelry, or
clothing
apply lead
shields
instruct
patient to
remain still
Mam
mogr
aphy
Diagn
ose
breas
t
cance
r
Contr
aindic
ated
in
pregn
ancy
Chara
cteris
tics of
cance
rous
lesion
Nursi
ng
care
explain that
compression
does not
harm the
breast
Comp
uted
Tomo
graph
y
Scan
Use
of
radiat
ion
beam
s to
produ
ce
crosssectio
nal
views
of
soft
tissue
anato
my
and
restru
cturin
g with
the
aid of
comp
uter
Contr
aindic
ations
:
allergy to dye
/ contrast
material
pregnancy
unstable vital
signs /
restlessness
renal failure
Imagi
ng
Use
of
electr
omag
netic
wave
s
acros
s the
body
in
differ
ent
plane
s
More
sensit
ive to
soft
tissue
s
Contr
aindic
ations
claustrophobi
a
unstable,
restless
patient
metallic
implants
claustrophobi
a
Ultras
ound
Magn
etic
Reson
ance
Use
of
highfrequ
ency
sound
wave
s
Highl
y
accur
ate in
distin
guishi
ng
betwe
en
cystic
and
solid
mass
es
Used
in
pelvis
,
abdo
men,
uteru
s
Bone
Scan
Involv
es IV
injecti
on of
radio
active
dye
mater
ial
which
is
detec
ted
by a
scann
ing
machi
ne
Areas
of
conce
ntrate
d
nucle
otide
uptak
e
may
repre
sent a
tumor
or
any
abnor
malit
y
Contr
aindic
ated
in
pregn
ancy
Lumb
ar
Punct
ure
A
spinal
needl
e is
insert
ed
into
the
subar
achno
id
space
to
exami
natio
n CSF
to
diagn
ose
brain
and
spinal
cord
tumor
s
Contr
aindic
ations
uncooperativ
e patient
increased ICP
infection at
the lumbar
puncture site
bleeding
disorders
Thora
cente
sis
Pleur
al tap
Insert
ing a
needl
e into
the
pleur
al
space
to
remo
ve
fluid
and
air
Nursi
ng
care
explain the
procedure
secure
informed
consent
instruct
patient not to
cough
make sure
CXR plates
are available
routine postprocedure
monitoring
(CXR)
Pap
Smea
r
Used
to
detec
t
cance
r cell
secret
ions
from
the
cervix
and
vagin
a
Can
detec
t
early
cellul
ar
chang
es in
prem
aligna
nt or
existi
ng
malig
nant
condit
ions
bleedi
ng,
tumor
s and
obtai
n
biops
y
sampl
es
Flexib
le
fibero
ptic
bronc
hosco
pe
Scree
ning:
yearly
for 2
negat
ive
exam
s,
then
repea
t
every
3 yrs
until
age
65
Bronc
hosco
py
Direct
visual
izatio
n of
laryn
x,
trach
ea,
and
bronc
hi to
locali
ze
Gener
al
anest
hesia
or IV
sedati
on
Nursi
ng
care
- NPO
6-8 hrs
secure
informed
consent
remove any
dental
prosthesis
routine postprocedure
monitoring
Upper
GI
Series
Bariu
m
swall
ow
Visual
ize
upper
GI
tract
“appl
e
core”
defor
mity
Endos
copy
Direct
visual
izatio
n of
UGIT
with a
flexibl
e
fibero
ptic
scope
ERCP
Endoscopic
Retrograde
CholangioPancreatogra
phy
detect tumors
in the
pancreaticobiliary tree
jaundiced
patients
Colon
oscop
y
Use
of
colon
oscop
e to
direct
ly
visual
ize
colon
and
obtai
n
biops
y
Contr
aindic
ations
unstable
medical
condition
profuse rectal
bleeding
bowel
distention
suspected
colon
perforation
Nursi
ng
care
informed
consent
bowel
preparation
Proct
osigm
oidos
copy
Use
of a
rigid
proct
oscop
e to
detec
t
lesion
s in
the
rectos
igmoi
d
colon
and
obtai
n
biops
y
Same
princi
ple in
colon
oscop
y
Diagn
ostic
Lapar
oscop
y
Insuffl
ation
of
abdo
minal
cavity
with
C02
- Fine
Needle
Aspiration
Biopsy
(FNAB)
Insert
ion of
came
ra
throu
gh
umbili
cal
port
incisi
ons to
visual
ize
the
intrab
domi
nal
organ
s
- Core
needle biopsy
Gener
al
anest
hesia
Biops
y
Acqui
sition
of
tissue
for
exact
histol
ogic
diagn
osis
Aspir
ation
biops
y
Incisi
on
biops
y
Excisi
on
biops
y
Biops
y
Bone
Marro
w
Brain
Liver
Lung
Pleur
al
Endo
metri
al
Thyro
id
Breas
t
Stere
otacti
c
Prost
ate
Tumo
r
Marke
rs
Carci
noEm
bryon
ic
Antig
en
(CEA)
- NV:
0 – 2.5 ng/mL
colorectal,
metastatic
breast, lung
cancer
Alpha
FetoProtei
n
(AFP)
- NV:
10 ng/mL
testicular,
liver cancer
Prost
ateSpecif
ic
Antig
en
(PSA)
- NV:
<4 ng/mL
primary &
metastatic
prostate
cancer
medullary
cancer of the
thyroid
Tumo
r
Marke
rs
Tumo
r
Marke
rs
Huma
n
Chori
onic
Gona
dotro
pin
(HCG)
- NV:
0-1 ng/mL
choriocarcino
ma, testicular
cancer
Cance
r
Antig
en
125
(CA
125)
- NV:
34 U/mL
ovarian
cancer
Calcit
onin
- NV:
M=0-14
pg/mL; F=028 pg/mL
Horm
ones
- ER /
PR
ACTH, Insulin,
PTH (“ectopic
hormones”)
Enzy
mes
Amylase
(lung &
ovarian
tumors)
SGPT, SGOT
(liver cancer)
Stagi
ng of
Cance
r
TNM
Stagi
ng
Syste
m
T:
exten
t of
prima
ry
tumor
based
on
size,
depth
of
penet
ration
,&
invasi
on of
adjac
ent
struct
ures
N:
Prese
nce,
exten
t, &
locati
on of
regio
nal
lymp
h
node
involv
emen
t
M:
Prese
nce
or
absen
ce of
distan
t
meta
stase
s&
degre
e of
disse
minat
ion
Stagi
ng of
Cance
r
Stage
1Malig
nant
cells
are
confin
ed to
the
tissue
of
origin
, with
no
signs
of
meta
stasis
.
Stage
2Tumo
r is
larger
,
proba
bly
has
invad
ed
surro
undin
g
tissue
s, or
both
Stage
3Sprea
d of
the
cance
r is
limite
d to
the
local
area
Stage
4Cance
r has
meta
stasiz
ed to
other
parts
of the
body
TNM
Stagi
ng
Syste
m
T0:
no
evide
nce of
prima
ry
tumor
Tis:
carcin
omain-situ
T1,
T2,
T3,
T4:
indica
te
progr
essiv
e
degre
es of
tumor
size
and
involv
emen
t
Tx:
tumor
can
not
be
asses
sed
N0:
regio
nal
LN
not
demo
nstra
bly
abnor
mal
N1,
N2,
N3:
indica
te
regio
nal
lymp
h
nodes
involv
emen
t with
increa
sing
degre
e
Nx:
regio
nal
LN
can
not
be
asses
sed
clinic
ally
M0:
no
evide
nce of
meta
stasis
M1:
meta
stasis
prese
nt
G4:
very
poorl
y
differ
entiat
ed
Cance
r
Mana
geme
nt
Surge
ry
Gradi
ng of
Tumo
r
Radia
tion
thera
py
Gx:
grade
can
not
be
asses
sed
Chem
other
apy
G1:
welldiffer
entiat
ed
Biolog
ic
thera
py
Surgi
cal
Oncol
ogy
G2:
mode
rately
welldiffer
entiat
ed
Oldes
t
treat
ment
for
cance
r
G3:
poorl
y
differ
entiat
ed
Used
to be
the
only
treat
ment
that
could
cure
patie
nts
with
cance
r
Roles
for
surge
ry
Prevention of
cancer
Diagnosis of
cancer
Treatment of
cancer
Proph
ylacti
c
Surge
ry
Diagn
osis
Of
Cance
r
Acqui
sition
of
tissue
for
exact
histol
ogic
diagn
osis
Aspir
ation
biops
y
- Fine
Needle
Aspiration
Biopsy
(FNAB)
- Core
needle biopsy
genci
es
Palliat
ion
Recon
struct
ion
and
rehab
ilitati
on
Incisi
on
biops
y
Radia
tion
Thera
py
Excisi
on
biops
y
Electr
omag
netic
Radia
tion
Treat
ment
Of
Cance
r
Prima
ry
cance
r
Resid
ual
disea
se
Metas
tatic
Disea
se
Oncol
ogic
emer
Gamma
radiation
>
produced
intranuclearly
(decay of
radioactive
isotopes)
Roentgen
>
produced
extranuclearl
y
Photo
electr
ic
absor
ption
Radia
tion
Thera
py
Brach
yther
apy
radiation
device is
placed within
or close to
the target
volume
interstitial &
intracavitary
radiation
used in the
treatment of
gynecologic &
oral tumors
Radia
tion
Thera
py
Telet
herap
y
- uses
a device
located at a
distance from
the patient
Radia
tion
Thera
py
Rapid
death
by
apopt
osis
Death
while
trying
to
divide
May
produ
ce
unusu
al
forms
as a
result
of
aberr
ant
attem
pts at
divisi
on
Cells
may
stay
as it
is,
unabl
e to
divide
, but
physi
ologic
ally
functi
onal
for a
long
perio
d
May
under
go no
altera
tions
or
only
minor
ones
hy
cells
in the
area
Radia
tion
Thera
py
Eradi
cates
radioc
urabl
e
disea
se
such
as
earlystage
breas
t CA
follow
ing
lump
ecto
my
Energ
y
depos
ited
in
cells
cause
a
direct
hit to
the
DNA
causi
ng
DNA
stran
d
break
s
Tumo
r cells
lose
their
capac
ity to
repair
dama
ge
Affect
s
norm
al
healt
Radia
tion
Thera
py
Contr
ols
the
growt
h and
sprea
d of
disea
se,
such
as
adjuv
ant
thera
py for
latestage
chest
wall
recurr
ence
Acts
as
proph
ylacti
c
treat
ment
to
preve
nt
micro
scopi
c
disea
se,
such
as
whole
brain
irradi
ation
with
lung
CA
Impro
ves
qualit
y of
life in
advan
ced
disea
se,
such
as
pain
from
bone
meta
stasis
or
press
ure
from
spinal
cord
comp
ressio
n
The
client
under
going
exter
nal
radiat
ion
thera
py
(telet
herap
y)
T
h
e
ra
di
at
io
n
o
n
c
ol
o
gi
st
m
ar
ks
s
p
e
ci
fi
c
lo
c
at
io
n
s
fo
r
ra
di
at
io
n
tr
e
at
m
e
nt
u
si
n
g
a
s
e
m
ip
er
m
a
n
e
nt
ty
p
e
of
in
k
Tr
e
at
m
e
nt
is
u
s
u
al
ly
gi
v
e
n
1
5
to
3
0
m
in
ut
es
p
er
d
a
y,
5
d
a
ys
p
er
w
e
e
k,
fo
r
2
to
7
w
e
e
ks
T
h
e
cli
e
nt
d
o
es
n
ot
p
os
e
a
ri
sk
fo
r
ra
di
at
io
n
e
x
p
os
ur
e
to
ot
h
er
p
e
o
pl
e
The
client
under
going
exter
nal
radiat
ion
thera
py
(telet
herap
y)
Cl
ie
nt
e
d
u
c
at
io
n
fo
r
e
xt
er
n
al
ra
di
at
io
n
W
as
h
th
e
m
ar
k
e
d
ar
e
a
of
th
e
sk
in
wi
th
pl
ai
n
w
at
er
o
nl
y
a
n
d
p
at
sk
in
dr
y;
d
o
n
ot
u
se
so
a
p
s,
d
e
o
d
or
a
nt
s,
lo
ti
o
n
s,
p
er
fu
m
es
,
p
o
w
d
er
s
or
m
e
di
c
at
io
n
s
o
n
th
e
si
te
d
ur
in
g
th
e
d
ur
at
io
n
of
th
e
tr
e
at
m
e
nt
;
d
o
n
ot
w
as
of
f
th
e
tr
e
at
m
e
nt
si
te
m
ar
ks
A
v
oi
d
ru
b
bi
n
g,
sc
ra
tc
hi
n
g,
or
sc
ru
b
bi
n
g
th
e
tr
e
at
m
e
nt
si
te
;
d
o
n
ot
a
p
pl
y
e
xt
re
m
e
te
m
p
er
at
ur
es
(h
e
at
or
c
ol
d)
to
th
e
tr
e
at
m
e
nt
si
te
;
if
s
h
a
vi
n
g,
u
se
o
nl
y
a
n
el
e
ct
ri
c
ra
zo
r
The
client
under
going
exter
nal
radiat
ion
thera
py
(telet
herap
y)
W
e
ar
so
ft.
L
o
os
efit
ti
n
g
cl
ot
hi
n
g
o
v
er
th
e
tr
e
at
m
e
nt
ar
e
a
Pr
ot
e
ct
sk
in
fr
o
m
s
u
n
e
x
p
os
ur
e
d
ur
in
g
th
e
tr
e
at
m
e
nt
a
n
d
fo
r
at
le
as
t
1
y
e
ar
af
te
r
th
e
tr
e
at
m
e
nt
is
c
o
m
pl
et
e
d;
w
h
e
n
g
oi
n
g
o
ut
d
o
or
s,
u
se
s
u
n-
bl
o
ck
in
g
a
g
e
nt
s
wi
th
s
u
n
pr
ot
e
ct
io
n
fa
ct
or
(S
P
F)
of
at
le
as
t
1
5
M
ai
nt
ai
n
pr
o
p
er
re
st
,
di
et
,
a
n
d
fl
ui
d
in
ta
k
e
as
es
se
nt
ia
l
to
pr
o
m
ot
in
g
h
e
al
th
a
n
d
re
p
ai
r
of
n
or
m
al
ti
ss
u
es
H
ai
r
lo
ss
m
a
y
o
cc
ur
;
c
h
o
os
e
a
wi
g,
h
at
,
or
sc
ar
f
to
c
o
v
er
a
n
d
pr
ot
e
ct
H
e
a
d
(r
ef
er
to
c
ar
e
of
cli
e
nt
wi
th
al
o
p
e
ci
a
la
te
r
in
c
h
a
pt
er
)
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
S
o
ur
c
e
s
of
in
te
rn
al
ra
di
at
io
n
I
m
pl
a
nt
e
d
in
to
af
fe
ct
e
d
ti
ss
u
e
or
b
o
d
y
c
a
vi
ty
In
g
es
te
d
as
a
so
lu
ti
o
n
In
je
ct
e
d
as
a
so
lu
ti
o
n
in
to
th
e
bl
o
o
d
st
re
a
m
or
b
o
d
y
c
a
vi
ty
nal
radiat
ion)
Cl
ie
nt
e
d
u
c
at
io
n
The
client
under
going
brach
yther
apy
(inter
In
tr
o
d
u
c
e
d
th
ro
u
g
h
a
c
at
h
et
er
in
to
th
e
tu
m
or
A
v
oi
d
cl
os
e
c
o
nt
a
ct
wi
th
ot
h
er
s
u
nt
il
tr
e
at
m
e
nt
is
c
o
m
pl
et
e
d
M
ai
nt
ai
n
d
ai
ly
a
ct
iv
iti
es
u
nl
es
s
c
o
nt
ra
in
di
c
at
e
d,
al
lo
wi
n
g
fo
r
e
xt
ra
re
st
p
er
io
d
s
as
n
e
e
d
e
d
M
ai
nt
ai
n
b
al
a
n
c
e
d
di
et
;
m
a
y
to
le
ra
te
fo
o
d
b
et
te
r
if
c
o
n
s
u
m
es
s
m
al
l,
fr
e
q
u
e
nt
m
e
al
s
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
M
ai
nt
ai
n
fl
ui
d
in
ta
k
e
to
e
n
s
ur
e
a
d
e
q
u
at
e
h
y
dr
at
io
n
(2
-3
lit
er
s/
d
a
y)
If
i
m
pl
a
nt
is
te
m
p
or
ar
y,
m
ai
nt
ai
n
b
e
d
re
st
to
a
v
oi
d
di
sl
o
d
gi
n
g
th
e
i
m
pl
a
nt
E
xc
re
te
d
b
o
d
y
fl
ui
d
s
m
a
y
b
e
ra
di
o
a
ct
iv
e;
d
o
u
bl
efl
u
s
h
to
il
et
s
af
te
r
u
se
R
a
di
at
io
n
th
er
a
p
y
m
a
y
le
a
d
to
b
o
n
e
m
ar
ro
w
s
u
p
pr
es
si
o
n
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
N
ur
si
n
g
m
a
n
a
g
e
m
e
nt
of
cli
e
nt
re
c
ei
vi
n
g
in
te
rn
al
ra
di
at
io
n
E
x
p
os
ur
e
to
s
m
al
l
a
m
o
u
nt
s
of
ra
di
at
io
n
is
p
os
si
bl
e
d
ur
in
g
cl
os
e
c
o
nt
a
ct
wi
th
p
er
so
n
s
re
c
ei
vi
n
g
in
te
rn
al
ra
di
at
io
n;
u
n
d
er
st
a
n
d
th
e
pr
in
ci
pl
es
of
pr
ot
e
ct
io
n
fr
o
m
e
x
p
os
ur
e
to
ra
di
at
io
n:
ti
m
e,
di
st
a
n
c
e,
a
n
d
s
hi
el
di
n
g
Time:
minimize
time
spent in
close
proximity
to the
radiation
sources; a
common
standard
is to limit
contact
time to
30
minutes
total per
8-hour
shift;
minimum
distance
of 6 feet
used
when
possible
Distance:
maintain
the
maximum
distance
possible
from the
radiation
source
Shielding:
use lead
shields
and other
precautio
ns to
reduce
exposure
to
radiation
Pl
a
c
e
cli
e
nt
in
pr
iv
at
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
e
ro
o
m
In
st
ru
ct
vi
si
to
rs
to
m
ai
nt
ai
n
at
le
as
t
a
di
st
a
n
c
e
of
6
fe
et
fr
o
m
th
e
cli
e
nt
a
n
d
li
m
it
vi
si
ts
to
1
0
to
3
0
m
in
ut
es
E
n
s
ur
e
pr
o
p
er
h
a
n
dl
in
g
a
n
d
di
s
p
os
al
of
b
o
d
y
fl
ui
d
s,
as
s
ur
in
g
th
e
c
o
nt
ai
n
er
s
ar
e
m
ar
k
e
d
a
p
pr
o
pr
ia
te
ly
E
n
s
ur
e
pr
o
p
er
h
a
n
dl
in
g
of
b
e
d
li
n
e
n
s
a
n
d
cl
ot
hi
n
g
The
client
under
going
brach
yther
apy
(inter
nal
radiat
ion)
In
th
e
e
v
e
nt
of
a
di
sl
o
d
g
e
i
m
pl
a
nt
,
u
se
lo
n
gh
a
n
dl
e
d
fo
rc
e
p
s
a
n
d
pl
a
c
e
th
e
i
m
pl
a
nt
in
to
a
le
a
d
c
o
nt
ai
n
er
;
n
e
v
e
r
di
re
ct
ly
to
u
c
h
th
e
i
m
pl
a
nt
D
o
n
ot
al
lo
w
pr
e
g
n
a
nt
w
o
m
e
n
to
c
o
m
e
in
to
a
n
y
c
o
nt
a
ct
wi
th
ra
di
at
io
n
so
ur
c
es
;
sc
re
e
n
vi
si
to
rs
a
n
d
st
af
f
fo
r
pr
e
g
n
a
n
cy
If
w
or
ki
n
g
ro
ut
in
el
y
n
e
ar
ra
di
at
io
n
so
ur
c
es
,
w
e
ar
a
m
o
ni
to
ri
n
g
d
e
vi
c
e
to
m
e
as
ur
e
e
x
p
os
ur
e
Radia
tionprote
ction
meas
ures
Alpha
partic
les
E
d
u
c
at
e
cli
e
nt
in
al
l
sa
fe
ty
m
e
as
ur
es
Tr
a
v
el
at
gr
e
at
s
p
e
e
d,
p
o
or
p
e
n
et
ra
ti
o
n
Li
m
it
e
d
th
er
a
p
e
ut
ic
u
s
e
Beta
partic
les
P
h
o
s
p
h
or
u
s3
2
or
Yt
tri
u
m
9
0
C
a
n
b
e
s
hi
el
d
e
d
b
y
th
ic
k
pl
a
st
ic
or
b
y
th
e
b
o
d
y’
s
s
ur
fa
c
e
R
a
di
at
io
npr
ot
e
ct
io
n
m
e
a
s
ur
e
s
y,
th
e
th
ic
k
er
th
e
a
b
s
or
bi
n
g
m
at
er
ia
l
re
q
ui
re
d
Gam
ma
partic
les
U
n
st
a
bl
e
p
ar
ti
cl
e
s
T
h
e
hi
g
h
er
th
e
e
n
er
g
L
e
a
d
A
d
v
er
s
e
Ef
fe
ct
s
May
be
acute
or
imme
diate
–
after
6
mos.
post
expos
ure
May
be
late
or
chron
ic –
after
1
year
post
expos
ure
Reflec
t cell
dama
ge
and
accu
mulat
ion of
toxic
effect
s of
tissue
destr
uction
indivi
dual
differ
ences
SiteSpecif
ic
Adver
se
Effect
s
Head
and
neck
Sitespecif
ic
Depe
ndent
on
volum
e,
dose
fracti
onati
on,
total
dose
and
St
o
m
at
iti
s
X
er
o
st
o
m
ia
T
o
ot
h
d
e
c
a
y
a
n
d
c
ar
ie
s
T
a
st
e
c
h
a
n
g
e
s
O
st
e
or
a
di
o
n
e
cr
o
si
s
(
m
a
n
di
bl
e)
H
y
p
o
pi
tu
it
ar
is
m
(r
ef
le
ct
d
e
cr
e
a
s
e
d
s
e
cr
et
io
n
s
of
c
or
ti
s
ol
,
th
yr
o
xi
n
e,
a
n
d
s
e
x
h
or
m
o
n
e
s)
SiteSpecif
ic
Adver
se
Effect
s
a
gi
ti
s
C
o
u
g
h
R
a
di
at
io
n
p
n
e
u
m
o
ni
ti
s
R
a
di
at
io
n
fi
br
o
si
s
Abdo
men
Chest
E
s
o
p
h
s
e
a
a
n
d
v
o
m
iti
n
g
G
a
st
rit
is
N
a
u
SiteSpecif
ic
Adver
se
Effect
s
gi
n
al
st
e
n
o
si
s
O
v
ar
ia
n
fa
il
ur
e
T
e
st
ic
ul
ar
d
y
sf
u
n
ct
io
n
Pelvis
Di
ar
rh
e
a
C
y
st
iti
s
Er
e
ct
il
e
d
y
sf
u
n
ct
io
n
V
a
SiteSpecif
ic
Adver
se
Effect
s
Brain
C
er
e
br
al
e
d
e
m
a
(s
te
ro
id
th
er
a
p
y
in
di
c
at
e
d)
Al
o
p
e
ci
a
C
h
a
n
g
e
s
in
h
ai
r
te
xt
ur
e
a
n
d
c
ol
or
S
c
al
p
pr
ur
it
u
s
Chem
other
apy
Chem
other
apy
Induc
tion
chem
other
apy
Adjuv
ant
chem
other
apy
Neoa
djuva
nt
chem
other
apy
Types
of
chem
other
apy
Adjuv
ant –
micro
meta
stase
s
Neoa
djuva
nt –
shrink
sa
tumor
prior
surgic
al
remo
val
syner
gizes
the
thera
peutic
action
s of
other
cytot
oxic
drugs
Prima
ry
thera
py –
treats
a
locali
zed
tumor
when
there’
s an
altern
ative,
less
effect
ive
Proph
ylacti
c – to
preve
nt
micro
meta
stase
s
Induc
tion –
treats
a
cance
r for
which
there
is no
altern
ative
treat
ment
Comb
inatio
n–
enha
nces
or
Prima
ry
Chem
other
apy
Neopl
asms
in w/c
CTX
is the
prima
ry
thera
peutic
moda
lity
for
locali
zed
tumor
s
Large cell
lymphoma
Lymphoblasti
c lymphoma
Hodgkin’s
disease
Wilm’s tumor
Embryonal
rhabdomyosa
rcoma
Small cell
lung cancer
- CNS
lymphomas
Neoa
djuva
nt
Chem
other
apy
Neopl
asms
in w/c
prima
ry
CTX
can
allow
less
mutil
ating
surge
ry
- Anal
carcinoma
Bladder
carcinoma
Breast cancer
Esophageal
cancer
Laryngeal
cancer
Osteogenic
sarcoma
- Soft
tissue
sarcoma
Basic
Conce
pts in
Chem
other
apy
Destr
oy
cance
r cells
by
interf
ering
with
their
repro
ductio
n
Act at
specif
ic
points
in the
cell
cycle
Affect
any
rapidl
y
dividi
ng
cell
within
the
body,
thus
havin
g the
poten
tial
for
toxicit
y
devel
opme
nt in
healt
hy,
functi
onal
tissue
(bone
marro
w,
hair
follicl
es, GI
muco
sa)
To
reduc
e
possi
bility
of
toxicit
y and
drug
resist
ance,
combi
natio
n
thera
py is
often
used
Availa
ble in
oral,
paren
teral
and
topica
l
prepa
ration
s
Basic
Conce
pts in
Chem
other
apy
Patter
n of
neutr
openi
a
after
chem
other
apy
M
in
i
m
al
n
e
ut
ro
p
e
ni
a
47
d
a
y
s
af
te
r
tr
e
at
m
e
nt
N
a
di
r
(p
er
io
d
of
m
a
xi
m
u
m
n
e
ut
ro
p
e
ni
a)
8
to
1
2
d
a
y
s
af
te
r
tr
e
at
m
e
nt
R
et
ur
n
of
n
or
m
al
n
u
m
b
er
of
n
e
ut
ro
p
hi
ls
1
4
to
1
8
d
a
y
s
af
te
r
tr
e
at
m
e
nt
Chem
other
apeut
ic
Drugs
Alkyla
ting
agent
s
- cell
cycle
nonspecific
Nitrogen
mustards
- form
highly
reactive
carbonium
ions which
react w/ DNA,
proteins, &
other
essential
cellular
substances
>
Chlorambucil
>
Cyclophospha
mide
>
Ifosfamide
replace
hydrogen
atoms w/
alkyl radicals,
causing
cross-linking
& abnormal
base pairing
in the DNA
molecule
renders DNA
molecule
defective &
unable to
carry on
normal
cellular
metabolic &
reproductive
functions
Chem
other
apy
Alkyla
ting
agent
s
>
Mechloretha
mine
>
Melphalan
Nitrosureas
>
Carmustine
>
Lomustine
>
Streptozocin
>
Busulfan
>
Carboplatin
>
Cisplatin
>
Thiotepa
Chem
other
apeut
ic
Drugs
Antibi
otics
- cell
cycle specific;
inhibit RNA &
protein
synthesis or
rapidly
dividing cells
Produ
ced
by
the
bacte
rial
speci
es
Strep
tomy
ces
Dacti
nomy
cin,
Daun
orubi
cin,
Doxor
ubicin
,&
Plica
mycin
- use
complex
mechanisms
to combine w/
DNA base
pairs, thus
interfering w/
DNA, RNA, &
protein
synthesis
Chem
other
apeut
ic
Drugs
Bleo
mycin
causes DNA
strand
scission and
fragmentatio
n
Mito
mycin
inhibits DNA
replication by
causing
cross-links to
form between
complementa
ry strands of
the molecule
Chem
other
apeut
ic
Drugs
Antim
etabo
lites
- cell
cycle specific
inhibition of S
phase
Folic
acid
analo
g
Blocks the
action of the
enzyme
dihydrofolate
reductase
which inhibits
production of
coenzyme
needed for
synthesis of
thymidylic
acid –
precursor for
nucleic acid
replication
Pyrim
idine
&
purin
e
analo
gs
block
enzymes
needed
during the
synthesis of
DNA & RNA
Chem
other
apeut
ic
Drugs
Antim
etabo
lites
Cytarabine
Floxuridine
Fluorouracil
Mercapturine
Methotrexate
Thioguanine
Chem
other
apeut
ic
Drugs
Natur
al or
semis
ynthe
tic
produ
cts
deriv
ed
from
differ
ent
plants
Etopo
side
semisynthetic
derivative of
podophylloto
xin, derived
from root of
May-apple
plant
affect G2
phase pf cell
cycle
causes cell
lysis at high
dose
prevents cells
from entering
mitosis stage
& inhibit DNA
synthesis
Chem
other
apeut
ic
Drugs
Vincri
stine
&
Vinbl
astine
Vinca
alkaloids from
periwinkle
plant
arrest cell
activity at the
M phase
(metaphase)
inhibiting
mitosis
Horm
ones
Inhibit RNA &
protein
synthesis that
are
dependent on
sex hormone
for
development
Side
effect
s of
chem
other
apeut
ic
agent
s
>.Bon
e
marro
w
suppr
essio
n
Decre
ased
WBC
count
(imm
unosu
ppres
sion)
Decre
ased platelet
count
(thrombocyto
penia)
Decre
ased
hemoglobin
and
hematocrit
(anemia)
Gastr
ointestinal
effects:
anorexia,
nausea,
vomiting, and
diarrhea
Side
effect
s of
chem
other
apeut
ic
agent
s
ss
)
St
o
m
at
iti
s
(i
nf
la
m
m
at
io
n
of
th
e
m
o
ut
h)
a
n
d
m
u
c
o
si
to
si
s
Al
o
p
e
ci
a
(h
ai
r
lo
F
at
ig
u
e
X
er
o
st
o
m
ia
(d
ry
m
o
ut
h)
O
th
er
si
d
e
ef
fe
ct
s
s
p
e
ci
fi
c
to
c
h
e
m
ot
h
er
a
p
e
ut
ic
a
g
e
nt
s,
peopl
e with
infecti
ons,
and
small
childr
en
when
WBC
is low
Immu
nosup
pressi
on
Cl
ie
nt
e
d
u
c
at
io
n
fo
r
i
m
m
u
n
o
s
u
p
pr
e
ss
io
n
Use
meticulous
personal
hygiene to
avoid
infection
Immu
nosup
pressi
on
Wash
hands before
and after
eating, after
toileting, and
after contact
with other
people and
pets
R
isk for
infecti
on is
high
when
WBC
count
is low
A
void
crowd
Consume a
low-bacteria
diet; avoid
undercooked
meat and raw
fruits and
vegetables
Be aware of
signs and
symptoms of
infection and
report them
immediately
to primary
care provider
Nursi
ng
mana
geme
nt of
immu
nosup
pressi
on
Nursi
ng
mana
geme
nt of
immu
nosup
pressi
on
Monit
or
labor
atory
value
s:
CBC
with
differ
ential
,
platel
ets,
BUN,
liver
enzy
mes
WBC
suppr
essio
n,
maln
utritio
n anf
prese
nce of
disea
se
increa
se the
risk of
infecti
on
Asses
s for
infecti
on;
monit
or
vital
signs
for
early
indica
tion
of
infecti
on:
fever,
tachy
cardia
, and
tachy
pnea
Utilize
neutr
openi
c
preca
utions
(lowbacte
ria
diet,
no
fresh
plants
or
flower
s in
room,
no
pets,
no
visitor
s with
infecti
ons)
when
WBC
level
falls
below
prede
termi
ned
level
(such
as
2,000
mm3)
o
p
e
n
i
a
•
Thro
mboc
ytope
nia
C
l
i
e
n
t
e
d
u
c
a
t
i
o
n
f
o
r
t
h
r
o
m
b
o
c
y
t
Mo
nit
or
sto
ols
an
d
uri
ne
for
ble
edi
ng
•
For
sh
avi
ng,
us
e
ele
ctri
c
raz
or
onl
y
•
Av
oid
co
nta
ct
sp
ort
s
an
d
oth
er
act
ivit
ies
tha
t
ma
y
ca
us
e
tra
um
a
•
If
tra
um
a
do
es
oc
cur
,
ap
ply
ice
to
are
a
an
d
se
ek
me
dic
al
as
sis
tan
ce
Thro
mboc
ytope
nia
•
A
v
o
i
d
d
e
n
t
a
l
w
o
r
k
o
r
o
t
h
e
r
i
n
v
a
s
i
v
e
p
r
o
c
e
d
u
r
e
s
•
I
n
f
o
r
m
a
l
l
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
s
o
f
c
h
e
m
o
t
h
e
r
a
p
y
a
n
d
/
o
r
r
a
d
i
a
t
i
o
n
t
r
e
a
t
m
e
n
t
s
•
A
v
o
i
d
o
d
u
c
t
s
•
t
o
o
t
h
b
r
u
s
h
e
s
S
a
f
e
t
y
a
s
p
i
r
i
n
p
r
e
c
a
u
t
i
o
n
s
a
n
d
f
o
r
a
s
p
i
r
i
n
c
o
n
t
a
i
n
i
n
g
o
r
a
l
p
r
t
h
y
g
i
e
n
e
;
u
s
e
s
o
f
a
n
d
d
o
n
o
t
f
l
o
s
s
Nursi
ng
mana
geme
nt of
throm
bocyt
openi
a
•
T
h
e
r
e
i
s
a
h
i
g
h
r
i
s
k
f
o
r
s
p
o
n
t
a
n
e
o
u
s
h
e
m
o
r
r
h
a
g
e
w
h
e
n
p
l
a
t
e
l
e
t
c
o
u
n
t
i
s
<
2
0
,
0
0
0
;
p
r
e
c
a
u
t
i
o
n
s
a
r
e
n
e
c
e
s
s
a
r
y
f
o
r
p
l
a
t
e
l
e
t
c
o
u
n
t
<
5
0
,
0
0
0
•
A
s
s
e
s
s
f
o
r
b
l
e
e
d
i
n
g
,
m
o
n
i
t
o
r
s
t
o
o
l
s
a
n
d
u
r
i
n
e
f
o
r
o
c
c
u
l
t
b
l
o
o
d
Nursi
ng
mana
geme
nt of
throm
bocyt
openi
a
•
A
s
s
e
s
s
s
k
i
n
f
o
r
e
c
c
h
y
m
o
s
e
s
,
p
e
t
e
c
h
i
a
e
,
a
n
d
t
r
a
u
m
a
•
E
d
u
c
a
t
e
c
li
e
n
t
a
b
o
u
t
b
l
e
e
d
i
n
g
s
a
f
e
t
y
p
r
e
c
a
u
t
i
o
n
s
•
Stom
atitis
A
v
o
i
d
i
n
t
r
a
m
u
s
c
u
l
a
r
i
n
j
e
c
t
i
o
n
s
a
n
d
li
m
i
t
v
e
n
i
p
u
n
c
t
u
r
e
s
and
muco
sitosi
s
i
s
•
C
l
i
e
n
t
e
d
u
c
a
t
i
o
n
f
o
r
s
t
o
m
a
t
i
t
i
s
a
n
d
m
u
c
o
s
i
t
o
s
•
U
se
a
so
ft
to
ot
h
br
u
s
h;
m
o
ut
h
s
w
a
b
s
m
a
y
b
e
n
e
e
d
e
d
d
ur
in
g
a
c
ut
e
e
pi
so
d
e
A
v
oi
d
m
o
ut
h
w
as
h
es
c
o
nt
ai
ni
n
g
al
c
o
h
ol
;
d
o
n
ot
u
se
le
m
o
n
gl
yc
er
in
s
w
a
b
s
or
d
e
nt
al
fl
os
s
Stom
atitis
and
muco
sitosi
s
•
C
o
n
s
i
d
e
r
u
s
i
n
g
c
h
l
o
r
h
e
x
i
d
i
n
e
m
o
u
t
h
w
a
s
h
(
P
e
r
i
d
e
x
)
t
o
d
e
c
r
e
a
s
e
r
i
s
k
o
f
h
e
m
o
r
r
h
a
g
e
a
n
d
p
r
o
t
e
c
t
g
u
m
s
f
r
o
m
t
r
a
u
m
a
•
A
s
s
e
s
s
d
a
il
y
f
o
r
l
e
s
i
o
n
s
,
i
n
f
e
c
t
i
o
n
,
b
l
e
e
d
i
n
g
,
o
r
i
r
r
i
t
a
t
i
o
n
Stom
atitis
and
muco
sitosi
s
•
F
or
x
er
o
st
o
m
ia
,
a
p
pl
y
lu
br
ic
at
in
g
a
n
d
m
oi
st
ur
izi
n
g
a
g
e
nt
s
to
pr
ot
e
ct
th
e
m
u
c
o
u
s
m
e
m
br
a
n
e
s
fr
o
m
tr
a
u
m
a
a
n
d
in
fe
ct
io
n
•
M
a
y
c
o
n
si
d
er
u
si
n
g
“
ar
tif
ici
al
s
al
iv
a
”
a
n
d
h
ar
d
c
a
n
d
y
or
m
in
ts
to
h
el
p
wi
th
dr
y
n
e
ss
Stom
atitis
and
muco
sitosi
s
•
s
y
m
p
t
o
m
s
o
f
o
r
a
l
i
n
f
e
c
t
i
o
n
a
n
d
t
o
.Avoid
smoking and
alcohol,
which can
further
irritate oral
mucosa
T
e
a
c
h
r
i
m
a
r
y
h
e
a
l
t
h
c
a
r
e
s
i
g
n
s
a
n
d
r
e
p
o
r
t
t
o
p
p
r
o
v
i
d
e
r
•
D
r
i
n
k
c
o
o
l
li
q
u
i
d
s
,
a
n
d
a
v
o
i
d
o
r
a
l
m
u
c
o
u
s
m
e
m
b
r
a
n
e
s
e
v
e
r
y
4
h
o
u
r
s
h
o
t
a
n
d
i
r
r
i
t
a
t
i
n
g
f
o
o
d
s
Stom
atitis
and
muco
sitosi
s
•
Nu
rsi
ng
ma
na
ge
me
nt
of
sto
ma
titi
s
•
A
s
s
e
s
s
T
e
a
c
h
a
n
d
i
m
p
l
e
m
e
n
t
p
r
o
p
e
r
o
r
a
l
c
a
r
e
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
Cl
ie
nt
e
d
u
c
at
io
n
fo
r
m
ai
nt
ai
ni
n
g
a
d
e
q
u
at
e
n
ut
rit
io
n,
fl
ui
d
a
n
d
el
e
ct
ro
ly
te
b
al
a
n
c
e
•
E
a
t
f
r
e
q
u
e
n
t
s
m
a
ll
,
l
o
w
f
a
t
m
e
a
l
s
•
A
v
o
i
d
s
p
i
c
y
a
n
d
f
a
t
t
y
f
o
o
d
s
•
A
v
o
i
d
e
x
t
r
e
m
e
l
y
h
o
t
f
o
o
d
s
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
•
•
cr
ib
e
d
•
P
er
fo
r
m
or
al
h
y
gi
e
n
e
b
ef
or
e
a
n
d
af
te
r
m
e
al
s
M
ai
nt
ai
n
fl
ui
d
in
ta
k
e
as
pr
es
•
T
a
k
e
n
ut
rit
io
n
al
s
u
p
pl
e
m
e
nt
s
as
pr
es
cr
ib
e
d
(v
it
a
m
in
s,
li
q
ui
d
n
ut
rit
io
n)
M
ai
nt
ai
n
a
d
ai
ly
jo
ur
n
al
of
fo
o
d
a
n
d
fl
ui
d
in
ta
k
e
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
N
u
r
s
i
n
g
m
a
n
a
g
e
m
e
n
t
t
e
i
m
b
a
l
a
n
c
e
s
o
f
i
n
a
d
e
q
u
a
t
e
n
u
t
r
i
t
i
o
n
a
n
d
f
l
u
i
d
a
n
d
e
l
e
c
t
r
o
l
y
•
As
se
ss
for
ad
eq
uat
e
hy
dr
ati
on;
for
du
rat
ion
of
tre
at
me
nt,
en
co
ur
ag
e
dai
ly
flui
d
int
ak
e
of
2
to
3
lite
rs
unl
es
s
co
ntr
ain
dic
ate
d
•
•
Ad
mi
nis
ter
ant
ie
me
tic
s
pri
or
to
ch
em
oth
era
py
We
igh
cli
ent
ro
uti
nel
y,
mo
nit
or
for
we
igh
t
los
s
Inade
quate
nutriti
on
and
fluid
and
electr
olyte
imbal
ance
•
M
o
ni
to
r
la
b
v
al
u
es
in
di
c
at
iv
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of
n
ut
rit
io
n
al
st
at
u
s
(h
e
m
o
gl
o
bi
n,
h
e
m
at
o
cr
it,
al
b
u
m
in
,
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e
al
b
u
m
in
)
•
M
o
ni
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r
fo
r
di
ar
rh
e
a
or
c
o
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st
ip
at
io
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a
n
d
n
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u
se
a
or
v
o
m
iti
n
g
•
E
n
c
o
ur
a
g
e
a
d
e
q
u
at
e
n
ut
rit
io
n
al
in
ta
k
e
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th
m
e
al
s
th
at
ar
e
se
rv
e
d
at
tr
a
ct
iv
el
y,
a
n
d
e
n
vi
ro
n
m
e
nt
fr
e
e
of
n
o
xi
o
u
s
st
i
m
ul
i
(b
e
d
p
a
n,
ur
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al
,
o
d
or
s)
Fatig
ue
N
ur
si
n
g
m
a
n
a
g
e
m
e
nt
of
fa
ti
g
u
e
•
A
ss
ur
e
cli
e
nt
th
at
fa
ti
g
u
e
is
a
n
or
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al
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s
p
o
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se
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h
e
m
ot
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p
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n
d
th
at
it
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o
es
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ot
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di
c
at
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pr
o
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o
n
of
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se
as
e
•
E
n
c
o
ur
a
g
e
cli
e
nt
to
c
o
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in
u
e
d
ai
ly
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ct
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as
m
u
c
h
as
p
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bl
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lo
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n
g
fo
r
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er
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d
s
in
b
et
w
e
e
n
•
A
ss
is
t
cli
e
nt
in
se
lfc
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e
n
e
e
d
s
w
h
e
n
in
di
c
at
e
d
•
Al
lo
w
fo
r
p
er
io
d
s
of
re
st
;
cl
u
st
er
a
ct
iv
iti
es
Alope
cia
N
u
r
s
i
n
g
m
a
n
a
g
e
m
e
n
t
o
f
c
l
i
e
n
t
e
x
p
e
r
i
e
n
c
i
n
g
a
l
o
p
e
c
i
a
(
h
a
i
r
l
o
s
s
)
•
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h
e
m
ot
h
er
a
p
y
a
n
d
ra
di
at
io
n
th
er
a
p
y
m
a
y
c
a
u
se
h
ai
r
lo
ss
;
th
e
h
ai
r
lo
ss
is
te
m
p
or
ar
y
a
n
d
wi
ll
gr
o
w
b
a
ck
,
u
s
u
al
ly
b
e
gi
n
ni
n
g
a
b
o
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a
m
o
nt
h
af
te
r
c
o
m
pl
et
io
n
of
th
e
c
h
e
m
ot
h
er
a
p
y;
th
e
cli
e
nt
s
h
o
ul
d
k
n
o
w
th
at
th
e
te
xt
ur
e
a
n
d
c
ol
or
of
th
e
n
e
w
h
ai
r
gr
o
w
th
m
a
y
b
e
di
ff
er
e
nt
;
h
ai
r
lo
ss
d
ur
in
g
ra
di
at
io
n
th
er
a
p
y
to
th
e
h
e
a
d
m
a
y
b
e
p
er
m
a
n
e
nt
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cia
•
E
n
c
o
ur
a
g
e
th
e
cli
e
nt
to
c
h
o
os
e
a
wi
g
b
ef
or
e
h
ai
r
lo
ss
o
cc
ur
s
in
or
d
er
to
m
at
c
h
te
xt
ur
e
a
n
d
h
ai
r
c
ol
or
•
C
ar
e
of
h
ai
r
a
n
d
sc
al
p
in
cl
u
d
es
w
as
hi
n
g
h
ai
r
t
w
o
to
th
re
e
ti
m
es
a
w
e
e
k
wi
th
a
m
il
d
s
h
a
m
p
o
o;
p
at
h
ai
r
dr
y,
a
n
d
d
o
n
ot
u
se
a
bl
o
w
dr
y
er
•
Al
lo
w
cli
e
nt
to
e
x
pr
es
s
fe
el
in
g
s
c
o
n
c
er
ni
n
g
al
te
re
d
b
o
d
y
i
m
a
g
e
Nursi
ng
implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
In
tr
a
v
e
n
o
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s
ro
ut
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m
a
y
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d
b
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n
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s,
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m
pl
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,
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p
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ly
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at
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xt
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v
a
s
a
ti
o
n
th
e
le
a
ki
n
g
of
c
h
e
m
ot
h
er
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p
e
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ic
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g
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nt
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in
to
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e
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ur
ro
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n
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n
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e,
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th
e
m
oj
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o
m
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of
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tr
a
v
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s
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e
m
ot
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er
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p
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xt
re
m
e
c
ar
e
m
u
st
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e
u
se
d
w
h
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n
a
d
m
in
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g
v
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nt
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g
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s
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h
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m
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s
c
a
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d
a
m
a
g
e
to
ti
ss
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e
o
n
c
o
nt
a
ct
)
Nursi
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implic
ations
for
the
admi
nistra
tion
of
chem
other
apy
P
h
y
s
i
c
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a
n
s
a
n
d
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r
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r
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V
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W
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r
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r
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p
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t
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c
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g
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t
s
Nursi
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implic
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for
the
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chem
other
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I
f
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x
t
r
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v
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s
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t
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c
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r
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p
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c
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s
Nursi
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other
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A
s
s
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s
s
r
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s
p
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r
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;
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M
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Nursi
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U
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of
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h
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m
ot
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ll
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A
d
m
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at
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O
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N
ur
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o
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The
client
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plant
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B
M
T
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s
e
d
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e
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e
nt
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k
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al
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at
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e
m
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er
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Au
tol
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s
BM
T:
the
cli
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us
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h
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All
og
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c
BM
T:
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cli
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is
inf
us
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h
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bo
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alt
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al
The
client
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(BMT)
T
h
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m
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s
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al
ly
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o
m
th
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B
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T,
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h
a
s
e
of
i
m
m
u
n
o
s
u
p
pr
e
ss
iv
e
th
er
a
p
y
to
d
e
st
ro
y
th
e
i
m
m
u
n
e
s
y
st
e
m
;
in
fe
ct
io
n,
bl
e
e
di
n
g,
a
n
d
d
e
at
h
ar
e
m
aj
or
c
o
m
pl
ic
at
io
n
s
th
at
c
a
n
o
cc
ur
d
ur
in
g
th
is
c
o
n
di
ti
o
ni
n
g
p
h
a
s
e
b
o
n
e
m
ar
ro
w
is
tr
a
n
sf
u
s
e
d
in
tr
a
v
e
n
o
u
sl
y
th
ro
u
g
h
a
c
e
nt
ra
l
li
n
e
The
client
under
going
a
bone
marro
w
trans
plant
(BMT)
Af
te
r
i
m
m
u
n
o
s
u
p
pr
e
ss
io
n,
th
e
Si
d
e
ef
fe
ct
s
of
b
o
n
e
m
ar
ro
w
tr
a
n
s
pl
a
nt
:
di
n
g
re
la
te
d
to
th
ro
m
b
o
cy
to
p
e
ni
a
M
al
n
ut
rit
io
n
Bl
e
e
The
client
under
going
a
bone
marro
w
trans
plant
(BMT)
In
fe
ct
io
n
re
la
te
d
to
i
m
m
u
n
os
u
p
pr
es
si
o
n
nt
(BM
T)
Nur
sing
ma
nag
em
ent
of
clie
nt
und
erg
oin
ga
bon
e
mar
row
tran
spla
M
o
n
i
t
o
r
f
o
r
g
r
a
f
t
v
e
r
s
u
s
h
o
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t
t
h
e
P
r
o
v
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d
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p
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b
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h
o
s
p
i
t
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l
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z
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d
r
o
o
m
f
o
r
d
i
s
e
a
s
e
r
i
v
a
t
e
h
o
s
p
i
t
a
l
i
z
e
d
c
l
i
e
n
t
;
c
l
i
e
n
t
w
i
l
6
t
o
t
h
s
i
g
n
i
f
i
c
a
n
t
o
t
h
e
r
s
8
b
y
w
e
e
k
s
u
s
i
n
g
E
n
c
o
u
r
a
g
e
t
e
l
e
p
h
o
n
e
,
c
o
n
t
a
c
t
w
i
c
o
m
p
u
t
e
r
,
s
a
n
d
o
t
h
e
r
m
e
a
n
s
o
f
c
o
m
m
u
n
i
c
a
t
i
o
n
t
o
r
e
d
u
c
e
f
e
e
l
i
n
g
o
f
i
s
o
l
a
t
i
o
n
Biolog
ic
Thera
py
Cance
r
treat
ment
that
produ
ces
antitumor
effect
s
prima
rily
throu
gh
the
action
of
natur
al
host
defen
se
mech
anism
s or
the
admi
nistra
tion
of
natur
al
mam
malia
n
subst
ances
Biolog
ic
Thera
py
Stimu
late
immu
ne
defen
se
mech
anism
s
Cause
the
tumor
to
appe
ar
more
“forei
gn”
comp
ared
to
norm
al
tissue
s
Immu
ne
cells
secret
e two
major
classe
s of
solubl
e
protei
n
Antibody
Cytokines
Antib
ody
Two
pairs
of
differ
ent
polyp
eptid
e
chain
s
(heav
y&
light
chain
s)
Two
recog
nition
sites
capab
le of
combi
ning
with
the
immu
nizing
antig
en
Media
te cell
destr
uction
by
phag
ocyto
sis
ing
cells
Cytot
oxic T
Lymp
hocyt
e
(CTL)
Interf
erons
Natur
al
Killer
cells
(NK)
Cytok
ines
Produ
ced
by
lymp
hocyt
es
(lymp
hokin
es) or
mono
cytes
(mon
okine
s)
acting
as
true
horm
ones
–
acting
on
other
cells
at a
distan
ce
from
the
secret
Tumo
r
Necro
sis
Facto
r
(TNF)
Interl
eukin
s118
Oncol
ogic
Emer
genci
es:
Diagn
osis
and
Mana
geme
nt
Spinal
cord
comp
ressio
n
O
c
c
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r
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m
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t
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l
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,
c
o
l
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e
s
s
,
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u
m
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s
,
t
i
n
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p
a
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t
h
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a
;
p
r
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e
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d
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t
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b
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w
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l
a
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d
b
l
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d
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f
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n
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t
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o
n
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w
e
a
k
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s
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a
n
d
p
a
r
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l
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s
E
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r
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y
d
e
t
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c
t
i
o
n
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s
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s
e
n
t
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l
:
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n
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g
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ll
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p
l
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c
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l
c
h
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n
g
e
s
sio
n
an
d
pr
ev
en
t
irr
ev
ers
ibl
e
pa
ra
ple
gia
;
ma
y
rec
eiv
e
cor
tic
ost
er
oid
to
re
du
ce
cor
d
ed
em
a
Spinal
cord
comp
ressio
n
Tr
ea
tm
en
t is
ai
me
d
at
re
du
cin
g
tu
mo
r
siz
e
by
ra
dia
tio
n
an
d/o
r
sur
ge
ry
to
reli
ev
e
co
mp
res
Nu
rsi
ng
int
er
ve
nti
on
s
inc
lud
e
ea
rly
rec
og
niti
on
of
sy
mp
to
ms
,
mo
nit
ori
ng
vit
al
sig
ns,
ne
ur
olo
gic
al
ch
ec
ks,
an
d
me
dic
ati
on
ad
mi
nis
tra
tio
n
Super
ior
vena
cava
syndr
ome
C
o
m
pr
e
ss
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n
or
o
b
st
ru
ct
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n
of
th
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p
er
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n
a
c
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v
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V
C)
U
s
u
al
ly
a
ss
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ci
at
e
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wi
th
c
a
n
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er
of
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s
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n
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ly
m
p
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m
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s
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g
n
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d
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m
pt
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m
s
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s
ul
t
of
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k
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g
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at
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of
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n
d
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p
p
er
tr
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n
k
Super
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vena
cava
syndr
ome
E
ar
ly
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m
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it
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m
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n
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ci
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m
a
S
y
m
pt
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m
s
pr
o
gr
e
ss
to
e
d
e
m
a
of
n
e
c
k,
ar
m
s,
a
n
d
h
a
n
d
s;
di
ffi
c
ul
ty
s
w
al
lo
wi
n
g;
s
h
or
tn
e
ss
of
br
e
at
h
L
at
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si
g
n
s
a
n
d
s
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m
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s,
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e,
a
n
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y
p
ot
e
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si
o
n
Super
ior
vena
cava
syndr
ome
D
e
at
h
m
a
y
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cc
ur
if
c
o
m
pr
e
ss
io
n
is
n
ot
re
li
e
v
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d
Tr
e
at
m
e
nt
in
cl
u
d
e
s
hi
g
hd
o
s
e
ra
di
at
io
n
to
s
hr
in
k
tu
m
or
a
n
d
re
li
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m
pt
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m
s
N
ur
si
n
g
in
te
rv
e
nt
io
n
s
in
cl
u
d
e
m
o
ni
to
ri
n
g
vi
ta
l
si
g
n
s,
pr
o
vi
di
n
g
o
x
y
g
e
n
s
u
p
p
or
t,
pr
e
p
ar
in
g
fo
r
tr
a
c
h
e
o
st
o
m
y
if
n
e
c
e
ss
ar
y,
in
iti
at
in
g
s
ei
z
ur
e
pr
e
c
a
ut
io
n
s,
a
n
d
a
d
m
in
is
te
ri
n
g
c
or
ti
c
o
st
er
oi
d
s
to
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d
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c
e
e
d
e
m
a
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
S
e
v
er
e
di
s
or
d
er
of
c
o
a
g
ul
at
io
n,
of
te
n
tri
g
g
er
e
d
b
y
s
e
p
si
s,
w
h
er
e
b
y
a
b
n
or
m
al
cl
ot
fo
r
m
at
io
n
o
cc
ur
s
in
th
e
m
ic
ro
v
a
sc
ul
at
ur
e;
th
is
pr
o
c
e
ss
d
e
pl
et
e
s
th
e
cl
ot
ti
n
g
fa
ct
or
s
a
n
d
pl
at
el
et
s,
al
lo
wi
n
g
e
xt
e
n
si
v
e
bl
e
e
di
n
g
to
o
cc
ur
;
ti
ss
u
e
h
y
p
o
xi
a
o
cc
ur
s
a
s
a
re
s
ul
t
of
th
e
bl
o
c
k
a
g
e
of
bl
o
o
d
v
e
ss
el
s
fr
o
m
th
e
cl
ot
s
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
Si
g
n
s
a
n
d
s
y
m
pt
o
m
s
ar
e
re
la
te
d
to
d
e
cr
e
a
s
e
d
bl
o
o
d
fl
o
w
to
m
aj
or
or
g
a
n
s
(t
a
c
h
y
c
ar
di
a,
ol
ig
ur
ia
,
d
y
s
p
n
e
a)
a
n
d
d
e
pl
et
e
d
cl
ot
ti
n
g
fa
ct
or
s
(a
b
n
or
m
al
bl
e
e
di
n
g
a
n
d
h
e
m
or
rh
a
g
e)
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
Tr
e
at
m
e
nt
in
cl
u
d
e
s
a
nt
ic
o
a
g
ul
a
nt
s
to
d
e
cr
e
a
s
e
st
i
m
ul
at
io
n
of
c
o
a
g
ul
at
io
n
a
n
d
tr
a
n
sf
u
si
o
n
of
o
n
e
or
m
or
e
of
th
e
fo
ll
o
wi
n
g:
fr
e
s
h
fr
o
z
e
n
pl
a
s
m
a
(F
F
P)
,
cr
y
o
pr
e
ci
pi
ta
te
,
pl
at
el
et
s,
a
n
d
p
a
c
k
e
d
re
d
bl
o
o
d
c
el
ls
(R
B
C
s)
Disse
minat
ed
intrav
ascul
ar
coagu
lopat
hy
(DIC)
N
ur
si
n
g
in
te
rv
e
nt
io
n
s
in
cl
u
d
e
a
ss
e
ss
in
g
cli
e
nt
,
m
o
ni
to
ri
n
g
fo
r
bl
e
e
di
n
g,
a
p
pl
yi
n
g
pr
e
ss
ur
e
dr
e
ss
in
g
s
to
v
e
ni
p
u
n
ct
ur
e
si
te
s,
a
n
d
pr
e
v
e
nt
in
g
ri
sk
of
s
e
p
si
s
M
or
ta
lit
y
fo
r
cli
e
nt
s
e
x
p
er
ie
n
ci
n
g
DI
C
is
gr
e
at
er
th
a
n
7
0
p
er
c
e
nt
d
e
s
pi
te
a
g
gr
e
ss
iv
e
tr
e
at
m
e
nt
Cardi
ac
tamp
onade
Perica
rdial
effusi
on
secon
dary
to
meta
stase
s or
esoph
ageal
cance
r can
lead
to
comp
ressio
n of
heart,
restri
cting
heart
move
ment
and
result
ing in
cardia
c
tamp
onade
Cardi
ac
tamp
onade
Signs
and
symp
toms
are
relate
d to
cardio
genic
shock
or
circul
atory
collap
se:
anxie
ty,
cyano
sis,
dyspn
ea,
hypot
ensio
n,
tachy
cardia
,
tachy
pnea,
impai
red
level
of
consc
iousn
ess,
and
increa
sed
centr
al
venou
s
press
ure
Cardi
ac
tamp
onade
Perica
rdioce
ntesis
is
perfor
med
to
remo
ve
fluid
from
perica
rdial
sa
Nursi
ng
interv
entio
ns
includ
e
admi
nister
ing
oxyge
n,
maint
aining
intrav
enous
line,
monit
oring
vital
signs,
hemo
dyna
mic
monit
oring,
and
the
admi
nistra
tion
of
vasop
ressor
agent
s
