Leukemia

Introduction :-

• It is also known as blood cancer.
• It is the type of cancer of blood and bone marrow with excess WBC.
• It is unregulated proliferation of WBC in bone marrow.

Definition:-

• "A malignant progressive disease in which the bone marrow and other blood organs produce increase number of immature or abnormal WBC.these suppress the production of normal blood cells."

Etiology :-

• Exact cause is unknown.

Risk factor :-

• Genetic predisposition.
• Viral pathogenesis.
• Bone marrow damage from radiation exposure or chemicals such as benzene and alklyle agent.

Classification of leukemia :-

• According to involvement of stem cells -

1. Myeloid (myeloblastic, myelocytic)
2. Lymphoid (lymphoblastic, lymphocytic)

• Based on time -

1. Acute (sudden onset within few weeks)
2. Chronic (gradual onset take several weeks to months)

Myeloid leukemia :-

Definition:-

Myeloid leukemia is a cancer of myeloid cells (stem cells) characterized by rapid growth of a normal cells that build up in the bone marrow and blood and interfere with the normal blood cells.

Myeloid leukemia is progressive malignant disease in which there are too many immature blood forming cells in the blood and bone marrow. In this type of granulocyte and monocyte do not mature that fight against infection.

Introduce Acute Myeloid leukemia :-

It result from defect in the hematopoietic stem cell that differentiate into all stem cell . (monocyte, granulocyte, eosinophil,basophil, neutrophil).

Incidence of Acute Myeloid leukemia:-

• All age groups are affected.
• The peak incidence is at 60yrs.
• It is the most common type of leukemia.
• Fever.
• Infection (due to neutropenia).
• Weakness and fatigue due to anemia.
• Bleeding tendency due to thrombocytopenia.
• Abdominal pain due to hepatosplenomegaly.
• Bone pain (due to proliferation in bone marrow).

Diagnostic evaluation of Acute Myeloid leukemia :-

1. CBC.
2. Decrease RBC, platelets and neutrophils.
3. Bone marrow biopsy to confirm the type of cell involve.

Management of Acute Myeloid leukemia:-

1. Chemotherapy :- It include induction and consolidation chemotherapy.

• Induction chemotherapy :- It aims at eradicating all leukemic cells. It involve administration of high dose of chemotherapeutic agents such as cytorebine,deunorubicin,ideribicin,etoposide etc.
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Oral cancer

Introduction:-

• Oral cancer is also known as mouth cancer.
• Oral cancer is cancer that develops in tissue of the mouth or throat. It belongs to a large group of cancer called head and neck cancer. Most develop in squamous cell found in your mouth, tongue and lips. It can be fatal if not diagnosed in early stages.

Definition:-

• "Oral cancer is defined as uncontrolled growth or sore in mouth.that does not go away. "
• Oral cancer and high includes cancer of lips, tongue, cheeks,floor of mouth hard and soft palate, sinuses and pharynx (throat).
• Oral cancer is a type of head and neck cancer is any tissue growth located in oral cavity.
• It may arises as from distent site of origin or by extrusion from neighboring anatomic site such as nasal cavity.

Common sites of oral cancer :-

• Lower lips.
• Lateral or under surface of tongue.
• Buccal mucosa.
• Hard and soft palate.
• Pharyngeal wall.

Incidence:-

• More common after 45 yr of age - male : female is 2:1.
• Oral cancer accounts for 50% of 70% of total cancer mortality.

Clinical manifestation:-

1. Leukoplakia :- White patches on the mucosa of the mouth or tongue.
2. Hyperkeratosis :- Hard and lethargy White patches.
3. Erythroplakia :- Rad velvety patch on the mouth or tongue.

• Painful ulceration.
• Soreness of tongue.
• Increased salivation.
• Dysphagia.
• Slurred speech.
• Tooth ache.
• Ear ache.
• Difficulty in chewing/mastication.
• Mouth,lip,tongue,may be pale or dark color or disorder.

Diagnostic evaluation :-

• P.E.T.
• X-ray.
• CT scan.
• MRI.
• Biopsy.
• Oral exfoliative cytology.
• Toluidine blue test.

Management :-

Surgical management :-

• remove tumor.
• Removal of cancerous lymph node.
• Glossectomy (partial /complete).
• Removal of lower jaw.

Medical management:-

• Radiation therapy.
• Chemotherapy.
• Immunotherapies.
• Molecularly target therapy :- Targeted cancer therapies are drugs or other substances that block the growth and the spread of cancer by interfering with specific molecules that are involved in the growth progression and spread of cancer.

Management in case of metastatic cancer :-

• Radial neck desection:- It includes wide excision of involved area.
• Lesion with removal of regional lymph nodes the deep cervical lymph nodes and their lymphatic Channels (depending upon the extendiveness) the sternodomastoid muscle,internal jugular vein mendible,the sub maxillary gland.
• Modified neck desection:- It involves desection of major cervical lymphatic vessels and lateral cervical space with preservation of nerve blood vessels and jugular vein.

Palliative care :-

• It aims to treat symptoms and make patient more comfortable.
• Dysphagia - Gastrostomy
• Pain - Analgesic and narcotics.
• Increased salivary secretion :- Frequent suction of oral cavity .

Nursing management :-

• Risk for ineffective airway clearance related to oral surgery.
• Risk for imbalance nutrition less than body requirement related to oral surgery.
• Impaired verbal communication related to glossectomy.
• Disturbed body image related to surgical excision of tongue.

Breast cancer

Introduction :-

• Breast cancer is the cancer that forms in the cells of the breast.
• After skin cancer breast cancer is the most common cancer diagnosed in the women.

Definition :-

• "Breast cancer is a disease that occur when cells in breast tissue change or mutate and keep reproducing, these abnormal cells usually cluster together to form a tumor."
• A tumor is cancerous or malignant when these abnormal cells invade other parts of the breast.

Types :-

1. Ductal carcinoma in situ :- DCTS is a non-invasive condition.The cancer cells are confined to the ducts in the breast have not invade.
2. Lobular carcinoma in situ :- Lobular carcinoma in situ is cancer that grows in the milk producing glands of the breast , have not invade.
3. Invasive ductal carcinoma :- IDC is the most common type.This type of breast cancer begins in the breast milk duct and then invade nearby tissue in the breast.
4. Invasive Lobular carcinoma :- ILC first develops in breast lobules then invade near by tissue.

Etiology :-

• Breast cancer is caused by a genetic mutation in the DNA of breast cell.
• Inherited mutated genes known are breast cancer Gene 1 (BRCA 1), Breast cancer gene 2 (BRCA 2).

Risk factor :-

• Gender and Age :- the risk begin after 40 year in women.
• family history.
• Inherited genes :- the most well known gene mutation -BRCA 1,BRCA 2.
• Radiation therapy.
• Obesity.
• Beginning period at a younger age (before age 12).
• Beginning menopause at an older age.
• Have never been pregnant.
• Post menopausal hormone therapy (estrogen and progesterone).
• Alcohol Consumption.

Incidence :-

1. Most common malignancy in women.
2. Only 1% breast cancer occur in men.
3. 1/8 post menopausal women or at rest.
4. Occurrence of breast cancer according to the location.

Pathophysiology :-

• Majority of the breast cancer are adenocarcinomas.They are classified as ductal or lobular.

1. Intraductal.
2. Intralobular ( lobe or part or portion of an organ). 
3. Invasive ductal.
4. Invasive lobular.

Stages :-

• Stage 1 :-

1. tumor less than 2 cm.
2. Confined to breast.
3. No positive symptoms.
4. No metastasis present.

• Stage 2 :- Tumors less then 2cm with positive lymph-node.No metastasis evident. or tumor 2-5cm with or without positive lymphnode not metastasis evident or tumor greater then 5cm with lymphnodes ,not metastasis evident.
• Stage 3 :- Tumor >5cm with positive lymphnode,no metastasis present.
• Stage 4 :- Any distend metastasis to brain,lung,liver,or bone with or without positive lymphnode.

Sign and symptoms :-

• A breast lumps or tissue thickning that feel different than surrounding tissue.
• Breast pain.
• Red,pitted skin over entire breast.
• Swelling in all or part of breast.
• A nipple discharge other than breast milk.
• Blood discharge from nipple.
• A sudden change in the shape and size of breast.
• Inverted nipple.
• A lump or swelling in the arm.
• Peeling,scaling, or blaking of skin on nipple.  

Diagnostic evaluation:-

• Mammography :- It is the process of using low energy X-ray to examine the breast for diagnosis.during the procedure the breast is compressed using a dedicated mammogra[hy unit.Parallel plate compression evens out the thickness of breast tissue to increase image quality by reducing the thickness of tissue that X-ray penetrate.
• Breast biopsy :-During this test doctor will remove a tissue sample from the suspicious area to have it tested.The doctor uses a needle to take the tissue sample.then send to laboratory to test the sample.
• Ultrasound :- A breast ultra sound uses sound waves to create a picture of the tissue deep in the breast.A ultrasound distinguish between a solid mass or tumor.
• Breast self examination :- Breast self exam or regularly examining your breast on your own.there are following steps :-(done before warm bath)  

1. Step 1 :-Begin by looking at ypur breast in the mirror with your shoulders straight an arms on your hips.(breast that are their usual size,shape and color) (Dimpling ,bulging of skin,redness,rashes or swelling ,a nipple that has changed position or an inverted nipple)
2. Step 2 :-Now raise your arm and look for the same changes.
3. Step 3 :- While you are at the mirror look for any sign of fluid come out of one or both nipples.(this could be a watery,milky or yellow fluid or blood).
4. Step 4 :- Next fell your breast while lying down using your right hand to feel your left breast and then let hand to feel right breast.use a firm,smooth  touch with the first few fingers pads of your hand,keeping the fingers flat and together.Use a circular motion about the size of a qurter.
5. Finally feel breast while you are standing or sitting.

Management :-

Surgical management :-

• Lympectomy :-This procedure remove the tumor and surrounding tissue.
• Mastectomy :- In this procedure a surgeon remove an entire breast.
• Sentinal node biopsy :- This surgery remove a few of the lymph node.
• Contralateral prophylactic mastectomy :- Even though breast cancer may be present in only one breast this surgery remove healthy breast to reduce risk of developing breast cancer again.

Medical management :-

• Medication used after and in addition to surgery are adjuvant therapy.
• Hormone blocking therapy :- some breast cancers require estrogen to continue growing.they can be identified by the presence of estrogen receptors (ER+) and progesterone receptors (PR+) on their surface.these ER+ cancer can be treated with drugs that either block the receptors. Example :- Tamoxifen , Toremifene (Prvent estrogen from binding to estrogen receptors),Aromatase Inhibitor (stop estrogen production).
• Chemotherapy :- The chemotherapy medication are administered in combinations.Usually for periods of 3-6month. Example:- Cyclophosphamide with Doxorubin.
• Radiation therapy :-Radiation is given after surgery to the region of the tumor bed and regional lymphnode to destroy microscopic tumor cells.Radiation therapy can be delivered as external beam radiotherapy or as Brachytherapy (internal radiotherapy).

Nursing management :-

Pre-operative Nursing care :-

1. Knowledge deficit about breast cancer and treatment.
2. Anxiety related cancer diagnosis.
3. Fear related specific treatment ,body images change or possible death.
4. Decisional conflict related treatment option.
5. Risk for ineffective copping related diagnosis of breast cancer.

Post -operative nursing diagnosis :-

1. Pain related to surgical incision and manifestation of tissue.
2. Impaired skin integrity due to surgical incision.
3. Risk for infection related presence of surgical drain.
4. Body image disturbance related loss or alteration of the breast related surgical procedure.
5. risk for sexual dysfunction related loss of body part ,change in self image.
6. Self care deficit related partial immobility of upper extremity on operative side.

Lung Cancer

Introduction :-

• Lung cancer is cancer that start in the cells that make up the lungs.many other types of cancer such as breast or kidney can spread to the lungs.
• lung cancer are the fourth most common cancer reportedly in the Indian males.It account for 6.8% of all malignancies in india.
• The incidence is estimated to be about 6.6 per 100000 in males and 1.7 per 100000 in females.
• Commonly occur in individual more than 50yrs of age who have a long history of  cigrate smoking.

Definition :

• "Lung cnacer also known as lung carcinoma is a malignant lung tumor characterized by uncontrolled cell growth in tissue of the lung."
• "Lung cancer is neoplasm of the lung."

Etiology :-

• Exact cause is unknown.

Risk factor :-

• Genetic (transformation from one generation to another generation.)
• Age (mostly in older age, 65 or older age, average age is 70 year)
  
• Past lung disease ( can cause inflammation and scarring in the lung, eg: Tuberculosis, COPD)
• Radiation therapy to the chest (eg. breast therapy,Non-hodgkin's lymphoma)
• Second Hand Smoking
• Smoking
• Diet (low intake of vitamin-A, unbalanced diet)
• Environmental factor :- Asbestosis,Radon,Tar,Arsenic,Vinyl chloride) 
  
     

Types of Lung cancer :-

Non-Small cell Lung Cancer (NSCLC) :-

•  NSCLC is any type of epithelial lung cancer other than small cell lung carcinoma.
• NSCLC is accounts for about 85% of all lung cancer.
• NSCLC are relatively insensitive to chemotherapy compared to small cell lung cancer.
• When possible they are primarily treated by surgical resection with curative intent ,although chemotherapy has been used increasingly both pre-operative and post operative.

The most common type of NSCLC are :-

• Squamous cell carcinoma
• Adenocarcinoma
• Large cell carcinoma

1. Squamous cell carcinoma :- Arrives from bronchial epithelium & is more centrally located and its growth rate is slow.

Characteristics :- 

• Accounts for 20-30% of lung cancers.
• more common in men. Centrally located producing early symptoms of non productive cough and hemoptysis.
• do not have strong tendency to metastasis.

Response to therapy :-

• Surgically resection may be attempted.
• Adjuvant chemotherapy and radiation .

      2. Adenocarcinoma :- It arrives from the perifery of the lung and looks like nodules often metastasizes.Its growth rate is moderate.

Characteristics :-

• Accounts for 30-40% of lung cancer.
• Most common lung cancer in people.who have not smoked more common in women.
• Peripherally located often has no clinical manifestation until widespread metastasis is present.

Response to therapy :-

• Surgical resection may be attempted depending on the staging.
• Does not respond well to chemotherapy.

      3. Large cell carcinoma (undifferentiated) :- It is the fast growing carcinoma that arrive from the periphery branches of bronchi.

characteristics:- 

• Accounts for 10% of lung cancers.
• Composed of large cell that are anaplastic and often arise in the bronchi.
• It is highly metastatic via lymphatics and blood.

Response to therapy :-

• Surgery is not usually attempted.because of high rate of metastasis.
• Tumor may be radio sensitive but often recurs.

Small cell lung cancer (SCLC):-

1. Small cell carcinoma (SCC):- Arrives from the major bronchi & spread by infiltration along with bronchial walls.Growth rate is very rapid.

Characteristics :-

• Accounts for about 20% of lung cancers.
• Most malignant form of lung.
• Spread early via lymphatics & blood stream,frequent metastasis to brain.
• Associated with endocrine disturbances.

Response to therapy :-

• Chemotherapy main stay of treatment but over all poor prognosis.
• Radiation is used as adjuvant therapy and palliative measure.

Pathophysiology :-

• The carcinogens binds to the DNA
• Damage it.
• Cellular changes and abnormal growth
• Malignant cells.

As the damaged DNA is passed on to daughter cells,the DNA under goes further changes and become unstable with the accumulation of genetic changes the pulmonary epithelium under goes malignant transformation.

Stages of cancer :-

1. T o :- No evidence of tumor.
2. T x :- Tumor proved by cytologic studies ,but visualize by radiography.
3. T is :- Carcinoma in situ.
4. T 1 :- Tumor 3cm or less.
5. T 2 :- Tumor grater than 3cm.
6. T 3 :- Direct extension of chest wall.
7. T 4 :- Tumor invading mediastinal.
8. N o :- No nodule metastasis.
9. N 1-3 :- According to the progress of nodule involvement.
10. M o :- NO known metastasis.
11. M 1 :- Presence of distant metastasis.  

Enlist clinical manifestation :-

• Asymptomatic till diagnosis.
• Persistent.
• Non productive cough at earlier and in later productive cough.
• Blood tinged sputum.
• Chest pain.
• Dyspnoea.
• Wheezes.
• Palpable lymphnodes in neck or axilla.
• Unilateral paralysis of diaphragm.
• Superior venacava obstruction.(Due to intx. thorasic spread of malignancy )
• Pericardial effusion and dysrrhythemia. (if media stinum is involved)
• Annorexia.
• Fatigue.
• Weight loss.
• Fever.
• Nausea,Vomitting.

Diagnostic evaluation :-

• Chest x-ray :- shows presence of tumor or evidence of metastasis to ribs or vertebrae.
• CT-Scan and MRI :- shows the location and extent of masses.
• PET :- Helps in early detection of cancer staging and monitoring effects of treatment.
• Sputum specimen for cellular studies.
• Bronchoscopy :-Helps in direct visualization ,allows to take biopsy specimen.
• Mediastenoscopy :- Involve insertion of scope through a small anterior chest incision into the mediastinum.It is done to examine metastasis in the anterior mediastinum or in the chest extrapluraly.
• Biopsy.
• Pulmonary Angiography.
• Lungs scan.
• Fine needle aspiration.

Management of Lung cancer :-

Surgical management :-

1. lobectomy
2. wedge resection
3. Pneumonectomy
   
   

Medical management :-

1. Radiation therapy 
2. Chemotherapy
3. Laser surgery
   

Complication :-

• Airway obstruction
• Atelectosis
• Plural effusion
• Pulmonary Abscess
• Pneumonia
• Paraneoplastic syndrome

Prognosis :- 

Prognosis is generally poor ,13%of patients with lung cancer survive.

Nursing management :-

1. Ineffective breathing pattern resulting from compression of lung tissue.
2. Impaired gas exchange resulting from retained secretion and occluded bronchial.
3. Acute pain related to surgical incision tissue trauma and disruption of inter-coastal nerves ,presence of chest tube.
4. Fear and anxiety related to situational crises, change in health status and perceived threat of death.     

Hodgkin's Lymphoma

Introduction :-

• Hodgkin's lymphoma (HL) also known as Hodgkin's disease is a cancer of lymphatic system.
• It was first discovered by Thomas Hodgkin's in 1832.
• HL is a type of lymphoma in which cancer originates from a specific type of WBC called Lymphocytes.
• Lymphoma is a group of blood cancer that develop from lymphocytes.

Definition:-

• "Hodgkin's Lymphoma is also known the cancer of the lymphatic system in which the lymphocytes (WBC cells)grow abnormally and spread beyond the lymphatic system."
• "Hodgkin's lymphoma is a chronic disease the growth of tumor cells take place mainly in the lymphatic node."
• "Hodgkin's lymphoma is a type of lymphoma in which cancer originate from specific type of WBC called lymphocytes."

Types and stages of Hodgkin's disease:-

1. Classical Hodgkin's lymphoma :-(more common type) In this lymphoma people is diagnosed with this disease have large ,abnormal cells called Reed-sternberg cells in their lymph node.
2. Nodular lymphocyte -predominant Hodgkin's lymphoma :-(have better chance of cure) This much rare type of hodgkin's lymphoma involve large ,abnormal cells that are sometimes called Popcorn cells lymphoma.

Staging describe the extent and severity of the disease:-

• Stage 1 (Early stage):- Means that cancer is found in one lymph node region on the cancer is found in only one area of a single organ.
• Stage 2 (locally advanced disease) :- Means that cancer is found in two lymph node region on one side of diaphragm which is the muscle beneath your lung or that cancer was found in one lymph node region as well as in a near by organ.
• Stage 3 (Advanced disease) :- Means that cancer is found in lymph node region both above and below your diaphragm or that cancer was found in one lymphnode area and in one organ on opposite side of your diaphragm.
• Stage 4 (wide spread disease) :- means that cancer was found outside the lymph node and has spread widely to other parts of your body,such as your bone marrow liver or lung.

Causes or etiology of Hodgkin's disease :-

• The main cuase of HL is unknown.
• Disease ha sbeen linked to DNA or genetic mutation. [ Mutation tell the cell to multiply rapidly ,causing many diseased cells that continue multiplying.] 

Risk factor of Disease :-

Factors that can increase the risk of HL :-

• Age :- HL is most often diagnosed in people between 15 to 40 year and these over 55.
• A family History of Lymphoma :- Having a blood relative with lymphoma, increase the risk of developing disease .
• Gender :- male are slightly more likely to develop Hodgkin's lymphoma than are female.
• Epstein Bar Infection :- People who have illness causes by Epstein bar virus such as mononucleosis are more likely to develop HL.
• Weak Immune System.

Sign and Symptoms of Hodgkin's disease :-

• The most common symptoms -swelling of the lymph nodes.
• Night sweats
• Itchy skin 
• fever
• fatigue
• unintended weight loss
• persistent cough,trouble breathing 
• chest pain
• pain in lymph-node after consuming alcohol 
• Enlarged sp;een
• severe Dyspnoea

Diagnostic Evaluation or Investigation:-

• Family history
• physical examination
• Imaging test such as x-ray or CT scan
• Lymph node biopsy for abnormal cells 
• blood test (CBC) to measure of ,RBC,WBC and platelets
• Bone marrow biopsy (to see cancer spread)
• Immunophenotyping to determine the type of lymphoma cells are present.
• lung function test (to determine how well your lungs are working)
• Echocardiogram (to determine how well your heart are working)

Management :-

Hodgkin's lymphoma treatment are right for you depends on the type and stage of your disease and health.

• Chemotherapy :- Chemotherapy is a drug treatment that uses chemicals to kill lymphoma cells (belomycin).Chemotherapy is often combined with radiation therapy in people with eatrly -stage classical type Hodgkin's lymphoma.
• Radiation therapy :- Radiation therapy uses high-energy beams such as x-ray and protons to kill cancer cells.
• Bone marrow transplantation :- also known as stem cell transplant is a treatment to replace with healthy stem cells.
• Other drug therapy :- Drugs used to treat H.D. such as immunotherapy that works to activate your immune system to kill lymphoma cells.  

Nursing Diagnosis:-

1. Risk of infection related to immunodeficiency.
2. Ineffective therapeutic regimen management related to insufficient knowledge.
3. Imbalance nutrition less than body requirement related to malabsorption or pain.
4. Activity intolerance related to weakness.
5. Disturbed body image due to swelling of lymph node or disease condition .
6. Risk for impaired skin integrity due to weakness or immunodeficiency.