Oncology - For nursing students - tumors classification, cancer, differences between benign and malignant neoplasm,spread of cancer, pathophysiology with cancer cells, carcinogenesis, etiology, cancer screening, cancer prevention, management of cancer, radiation therapy, chemotherapy, bone marrow transplantation, oncologic emergencies

1. Oncology Nursing
Dr.puvaneswari.K
Professor
Narayana Hrudayalaya College of Nursing

2. Normal cell structure

3. • Oncology is the branch of medicine dealing with
tumors.
• Cancer is an uncontrolled proliferation of
cells
• Oncology nursing is also called cancer nursing
• Oncology: Onco—mass
• Neoplasm: Neo—new plasm—form

7. Terminologies / Cellular Adaptations
• Anaplasia: Cells that lack normal cellular
characteristics and differ in shape and
organization with respect to their cells of origin;
usually, anaplastic cells are malignant.
• Atrophy: Reduction of number and size of
parenchymal cells of an organ or its parts which
was once normal is called atrophy.

8. Terminology
• Neoplasia (New growth)
(Tumor) abnormal
proliferation of cells in a
tissue or organ.
• Dysplasia is any of various
types of abnormal growth or
development of cells
(microscopic scale) and/or
organs (macroscopic scale)

9. • Hyperplasia: Increase in the
number of cells of a tissue; most
often associated with periods of
rapid body growth.
• Hyperthrophy: Increased in cell
size, as in weight training and
steroid therapy

10. • Metaplasia: Conversion of one
type of mature cell into another
type of cell
• Metastasis: Spread of cancer cells
from the primary tumor to distant
sites

12. TUMORS CLASSIFICATION
It can be benign or malignant.
• Benign: Cells grow as a compact
mass and remain at their site of
origin
• Malignant:
 Growth of cells is uncontrolled
 Cells can spread into the
surrounding tissue and spread to
distant sites

13. Differences between benign and
malignant neoplasms
BENIGN MALIGNANT
Nuclear variation in size and shape
minimal
Nuclear variation in size and shape
minimal to marked, often variable
Diploid Range of ploidy
Low mitotic count,
normal mitosis
Low to high mitotic count,
abnormal mitosis
Retention of specialisation Loss of specialisation
Structural differentiation
retained
Structural differentiation shows wide range
of changes
Organised Not organised
Functional differentiation
usually
Functional differentiation often lost

14. • Carcinoma “in situ” “cancer in place”, cells have
lost their tissue identity, growth is rapid and
without regulation, however remains localized to a
specific area or organ
• Sarcoma : cancer that affects connective,
supportive and soft tissue (bone, cartilage, muscle
or fat)
• Osteosarcoma – bone
• Chondrosarcoma – cartilage
• Leiomyosarcoma – smooth muscle

15. • Adenoma- collection of growth(-oma) of
glandular origin, benign
• Adenocarcinomas- may become malignant
• Leukaemia – Malignancy of Lymphoid tissues
• Lymphoma- Malignancy of WBC

16. Pathophysiology with cancer cells
• Cancer is a disease process that begins when an
abnormal cell is transformed by the genetic
mutation of the cellular DNA. This abnormal cell
forms a clone and begins to proliferate
abnormally, ignoring growth-regulating signals in
the environment surrounding the cell. The cells
acquire invasive characteristics, and changes occur
in surrounding tissues. The cells infiltrate these
tissues and gain access to lymph and blood
vessels, which carry the cells to other areas of the
body. This phenomenon is called metastasis

18. Metastatic Mechanisms
• Lymph , Blood are key mechanisms by which
cancer cells spread.
• Angiogenesis, a mechanism by which the tumor
cells are ensured a blood supply, is another
important process.

19. • LYMPHATIC SPREAD The most common
mechanism of metastasis is lymphatic spread,
which is transport of tumor cells through the
lymphatic circulation.
• Malignant cells also may penetrate lymphatic
vessels by invasion. After entering the lymphatic
circulation, malignant cells either lodge in the
lymph nodes or pass between lymphatic and
venous circulation.
(Breast tumors frequently metastasize in this
manner through axillary, clavicular, and thoracic
lymph channels)

20. HEMATOGENOUS SPREAD
• Malignant cells are disseminated through the bloodstream.
• Hematogenous spread is directly related to the vascularity of
the tumor.
• Few malignant cells can survive the turbulence of arterial
circulation, insufficient oxygenation, or destruction by the
body’s immune system.
• Those malignant cells that do survive this hostile environment
are able to attach to endothelium and attract fibrin, platelets,
and clotting factors to seal themselves from immune system
surveillance.
• The endothelium retracts, allowing the malignant cells to
enter the basement membrane and secrete lysosomal
enzymes.
• These enzymes then destroy surrounding body tissues and
thereby allow implantation.

21. ANGIOGENESIS
• Malignant cells also have the ability to induce the
growth of new capillaries from the host tissue to
meet their needs for nutrients and oxygen. This
process is referred to as angiogenesis.
• It is through this vascular network that tumor
emboli can enter the systemic circulation and travel
to distant sites.
• Large tumor emboli that become trapped in the
microcirculation of distant sites may further
metastasize to other sites. Research into ways to
prevent angiogenesis is ongoing.

22. Carcinogenesis
• Malignant transformation, or carcinogenesis,
is thought to be at least a three-step cellular
process:
Initiation,
Promotion,
Progression.

23. Initiation, the first step, initiators (carcinogens), such
as chemicals, physical factors, and biologic agents,
escape normal enzymatic mechanisms and alter the
genetic structure of the cellular DNA.
• Normally, these alterations are reversed by DNA
repair mechanisms, or the changes initiate
programmed cellular suicide (apoptosis).
• Occasionally, cells escape these protective
mechanisms, and permanent cellular mutations
occur.

24. Promotion
• Repeated exposure to promoting agents (co-carcinogens)
causes the expression of abnormal or mutant genetic
information even after long latency periods.
• Cellular oncogenes, present in all mammalian systems, are
responsible for the vital cellular functions of growth and
differentiation.
• Cellular proto-oncogenes are present in cells and act as an
“on switch” for cellular growth. Similarly, cancer suppressor
genes “turn off” or regulate unneeded cellular
proliferation.
• When the suppressor genes (p53 gene ) become mutated,
rearranged, or amplified or lose their regulatory
capabilities, malignant cells are allowed to reproduce.

25. Progression
• The cellular changes formed during initiation and
promotion now exhibit increased malignant
behavior.
• These cells now show a propensity to invade
adjacent tissues and to metastasize. Agents that
initiate or promote cellular transformation are
referred to as carcinogens.

26. ETIOLOGY
• Certain categories of agents or factors implicated
in carcinogenesis include viruses and bacteria,
physical agents, chemical agents, genetic or
familial factors, dietary factors, and hormonal
agents.

27. Viruses and Bacteria
• Viruses as a cause of human cancers are hard to
determine because viruses are difficult to isolate.
Epstein-Barr virus- Burkitt’s lymphoma,
nasopharyngeal cancers, non-Hodgkin’s
lymphoma,Hodgkin’s disease.
Hepatitis B virus -Cancer of the liver
Cytomegalovirus, and human papillomavirus- Cancer
of the cervix
• Bacteria
• Helicobacter pylori has been associated with an
increased incidence of gastric malignancy

28. Physical Agents
• Physical factors associated with carcinogenesis
includes
• Exposure to sunlight
• Chronic irritation or inflammation
• Excessive exposure to the ultraviolet rays of the
sun(fair-skinned, blue- or green-eyed people)
• Exposure to ionizing radiation, Radiation therapy

29. Chemical Agents(75% of all cancers)
• Tobacco smoke (30% of cancer deaths) - Lung, head
and neck, esophagus, pancreas, cervix and bladder.
• Suspected chemical substances - amines and aniline
dyes; pesticides and formaldehydes; arsenic, tars;
asbestos; benzene; betel nut and lime; cadmium;
chromium compounds; nickel and zinc ores; wood
dust; beryllium compounds; and polyvinyl chloride.

30. • Most hazardous chemicals - Altering DNA
structure (liver, lungs, and kidneys are the
organ systems) most often affected,
presumably because of their roles in
detoxifying chemicals.

31. Genetic and Familial Factors
• Genetic factors play a role in cancer cell
development.
• Abnormal chromosomal patterns (Extra
chromosomes, too few chromosomes, or
translocated chromosomes.)
• Approximately 5% to 10% of cancers of adulthood
and childhood display a familial predisposition.
(Burkitt’s lymphoma, chronic myelogenous leukemia,
meningiomas, acute leukemias, retinoblastomas,
Wilms’ tumor, and skin cancers, including malignant
melanoma)

32. Dietary Factors
• Dietary factors are thought to be related to 35% of
all environmental cancers
• Dietary substances can be proactive (protective),
carcinogenic, or co-carcinogenic.
• Obesity is associated with endometrial cancer,
postmenopausal breast cancers and risk for
cancers of the colon, kidney, and gallbladder.

33. Dietary Factors
Increased cancer risk
• Fats
• Alcohol
• Salt-cured or smoked meats
• Foods containing nitrates and
nitrites, and a high caloric
dietary intake
Reduce cancer risk
• High-fiber foods, cruciferous
vegetables (cabbage, broccoli,
cauliflower, Brussels sprouts,
kohlrabi), carotenoids
(carrots, tomatoes, spinach,
apricots, peaches, dark-green
and deep-yellow vegetables),
• possibly vitamins E and C, zinc,
and selenium.

34. Hormonal Agents
• Tumor growth may be promoted by disturbances in
hormonal balance either by the body’s own
(endogenous) hormone production or by
administration of exogenous hormones.
• Endogenous hormonal level- Cancers of the breast,
prostate, and uterus

35. • Diethylstilbestrol (DES)- Vaginal carcinomas
• Oral contraceptives and prolonged estrogen
replacement therapy - Increased incidence of
hepatocellular, endometrial, and breast cancers,
whereas they appear to decrease the risk for
ovarian and endometrial cancers.
• The combination of estrogen and progesterone
appears safest in decreasing the risk for
endometrial cancers.
• Increased numbers of pregnancies are associated
with a decreased incidence of breast,
endometrial, and ovarian cancers.

36. Detection and Prevention of Cancer
• Primary prevention is concerned with reducing
the risks of cancer in healthy people.
• Secondary prevention involves detection and
screening to achieve early diagnosis and prompt
intervention to halt the cancer process.
• Tertiary Prevention – Treating/ Managing the
illness

37. • PRIMARY PREVENTION
• Educate the community about cancer risk, nurses
in all settings play a key role in cancer prevention.
• Assisting patients to avoid known carcinogens is
one way to reduce the risk for cancer.
• Adopting dietary and various lifestyle changes
that epidemiologic and laboratory studies show
influence the risk for cancer.
• Nurses can use their teaching and counseling skills
to encourage patients to participate in cancer
prevention programs and to promote healthful
lifestyles.

38. • Limit alcohol Avoid alcohol drinking
• Avoid use of unnecessary drugs
• Physical activities
• Avoiding obesities
• Healthy dietary practices
• Reducing occupational and environmental
exposures
• Immunization against hepatitis B virus
• Safe sexual practices for avoiding cancer genesis
• Screening Tests ( Colon, Breast, Cervical ,Prostate )
• Self-exams (Testicular SE, BSE)

39. SECONDARY PREVENTION
• To provide individualized education and
recommendations for continued surveillance and
care in high-risk populations.
• Cancer Registration: It provides a baseline data
regarding magnitude of the cancer problem and
for planning and implementing the required
services they are of two types
• Hospital Based Registries: It includes all out
patient as well as in patients on treatment in the
hospital. It should be done as per “WHO
handbook for standardized cancer registers”

40. Secondary Prevention:
• Population Based Registries: It should include
situation in a given geographical area.
• Early Detection of cases:
• This is done by cancer screening at a stage where
the lesion is localized.
• Treatment: Treatment of cancer include the
following methods:
Surgery
Chemotherapy
 Radiotherapy
 Immunotherapy

41. Tertiary Prevention:
• Tertiary prevention aims at disability limitation and
rehabilitation
• Disability limitation: -This is done by intensive
treatment to prevent development of disability patient
may develop disability due to pain, decreased vitality,
loss of weight, fatigue, and discomfort in advance stage
of cancer.
• Rehabilitation:
• Patients who have undergone surgery are rehabilitated.
After amputation of leg they are given prostheses and
physiotherapy in order to train them to walk with
prostheses.
• Rehabilitation also includes management of
psychological problem of the patient and management
of the social spiritual and family problem.

42. Cancer screening
• Cancer screening aims to detect cancer before
symptoms appear.
• This may involve blood tests, urine tests, other
tests, or medical imaging.
• The benefits of screening in terms of cancer
prevention, early detection and subsequent
treatment must be weighed against any harms.
• Cancer screening is not indicated unless life
expectancy is greater than five years and the
benefit is uncertain over the age of 70.

43. Cancer screening
• Screening is not normally useful for rare cancers.
• Countries often focus their screening
recommendations on the major forms of treatable
cancer found in their population.
• Screening recommendations depend on the
individual's risk, with high-risk people receiving
earlier and more frequent screening than low risk
people.

44. Cancer screening
• A. Breast Cancer Screening
• B. Cervical Cancer Screening
• C. Colorectal Cancer Screening
• D. Genetic Screening
• E. Lung Cancer Screening
• F. Prostate Cancer Screening
• G. Head and Neck Cancer Screening

47. Cancer diagnosis
• A cancer diagnosis is based on assessment for
physiologic and functional changes and results of the
diagnostic evaluation. Patients with suspected cancer
undergo extensive testing to
• (1) determine the presence of tumor and its extent,
• (2) identify possible spread (metastasis) of disease
or invasion of other body tissues,
• (3) evaluate the function of involved and uninvolved
body systems and organs,
• (4) obtain tissue and cells for analysis, including
evaluation of tumor stage and grade.

48. What is cancer staging?
• Staging is a system that is used to classify the
extent of cancer
• This information is vital to decide what treatment is
appropriate
• Usually, the cancer is staged at the time of
diagnosis
• This may not be possible if patient present as an
emergency
• In general, the pathological stage is the most
important one in making treatment decisions

49. • Stage can be assesed by 3 ways –by clinical examination,
investigations and by pathologic examination of the
tissue removed.
• Types of staging-There are two types
• a) Clinical staging is based on physical examination,
radiographs, isotopic scans, CT scans, and other imaging
procedures;
• b)Pathologic staging takes into account information
obtained during a surgical procedure,
• 1.Intraoperative palpation,
• 2.Resection of regional lymph nodes and/or
• 3. Tissue adjacent to the tumor, and inspection and
biopsy of organs commonly involved in disease spread.

50. What is the system?
• TNM staging and AJC staging
TNM - Standard system for staging most cancer
•Based on the Tumour, lymph node, and
metastasis (TNM)

51. General rules of the TNM system
• TNM system is an expression of the anatomic
extent of the disease and is based on the
assessment of 3 components:
• T-The extent of primary tumor
• N-The absence or presence and extent of regional
lymph node metastasis.
• M-The absence or presence of distant metastasis.

52. Definitions of TNM
• Primary tumor-(T)-
• Tx-Primary tumor cannot be assessed.
• T0-No evidence of primary tumor.
• Tis-Carcinoma in situ.
• T1,T2,T3,T4-Increasing size and/or local extent
of primary tumor.

53. Definitions of TNM
• Regional lymph nodes-(N)
• Nx-Regional lymph nodes cannot be assesed.
• N0-No regional lymph node metastasis.
• N1,N2,N3-Increasig involvement of regional
lymph nodes.
• Direct extension of the primary tumor into a
lymph node is classified as lymph node
metastasis.
• Metastasis in any lymph node other than regional
is classified as distant metastasis.

54. Definitions of TNM
• Distant metastasis-(M)-
• Mx-Distant metastasis cannot be assesed.
• M0-No distant metastasis.
• M1-Distant metastasis. For pathologic Stage grouping ,
if sufficient tissue to evaluate the highest T and N
categories has been removed for pathological
examination ,M1 may be either clinical(cM1) or
pathologic(pM1).
• If only the metastasis has had microscopic
confirmation the classification is pathoilogic and the
stage is pathologic.

55. Significance of staging
• 1.Tumor burden increases and curability
decreases with increasing stage.
• 2.Staging serves to estimate the chances of
survival in the individual patient.
• 3.It helps to compare the results of treatment
in different institutions.

56. Other staging systems
• Dukes classification for colorectal cancers,
• FIGO(International Federation of
Gynecologists and Obstetricians ) classification
for gynecologic cancers,
• Ann Arbor classification for Hodgkin's
disease.

57. • C
• A
• U
• T
• I
• O
• N

58. Management of Cancer
• The range of possible treatment goals may include
complete eradication of malignant disease (cure),
prolonged survival and containment of cancer cell
growth (control), or relief of symptoms associated
with the disease (palliation).
• Surgery
• Radiation therapy,
• Chemotherapy
• Gene therapy
• Stem cell and Bone marrow transplantation
• Immunotherapy
• Biologic response modifier (BRM) therapy

59. SURGERY
• Surgical removal of the entire cancer remains the
ideal and most frequently used treatment
method.
• Surgery may be the primary method of
treatment, or it may be prophylactic, palliative,
or reconstructive.

60. Diagnostic Surgery- Diagnostic surgery, such as a
biopsy, is usually performed to obtain a tissue sample
from the actual tumor for analysis of cells suspected
to be malignant.
Common biopsy methods are the
• Excisional,
• Incisional, and
• Needle methods.

61. • Excisional biopsy is most frequently used for easily
accessible tumors of the skin, breast, upper and
lower gastrointestinal tract, and upper respiratory
tract.
• Incisional biopsy is performed if the tumor mass is
too large to be removed. In this case, a wedge of
tissue from the tumor is removed for analysis.
• Needle biopsies are performed to sample
suspicious masses that are easily accessible, such as
some growths in the breasts, thyroid, lung, liver,
and kidney..

62. Surgery as Primary Treatment
• When surgery is the primary approach in treating
cancer, the goal is to remove the entire tumor or as
much as is feasible (a procedure sometimes called
debulking) and any involved surrounding tissue,
including regional lymph nodes.

63. Surgery as Primary Treatment
• Two common surgical approaches used for treating
primary tumors are
local
wide excisions.
• Local excision is warranted when the mass is small.
• Wide or radical excisions (en bloc dissections)
include removal of the primary tumor, lymph
nodes, adjacent involved structures, and
surrounding tissues that may be at high risk for
tumor spread.

64. Prophylactic Surgery
• Prophylactic surgery involves removing nonvital
tissues or organs that are likely to develop cancer.
The following factors are considered
when electing prophylactic surgery:
• • Family history and genetic predisposition
• • Presence or absence of symptoms
• • Potential risks and benefits
• • Ability to detect cancer at an early stage
• • Patient’s acceptance of the postoperative
outcome
(Eg- Colectomy, mastectomy, and oophorectomy)

65. Palliative Surgery
• When cure is not possible, the goals of treatment are
to make the patient as comfortable as possible and
to promote a satisfying and productive life for as long
as possible.
• Whether the period is extremely brief or lengthy, the
major goal is a high quality of life
• Honest and informative communication with the
patient and family about the goal of surgery is
essential to avoid false hope and disappointment.
• Palliative surgery is performed in an attempt to
relieve complications of cancer, such as ulcerations,
obstructions, hemorrhage, pain, and malignant
effusions

66. Reconstructive Surgery
• Reconstructive surgery may follow curative or
radical surgery and is carried out in an attempt
to improve function or obtain a more
desirable cosmetic effect. It may be performed
in one operation

67. Radiation Therapy

69. Radiation Therapy
The type of radiation therapy that you may have
depends on many factors, including:
• Type of cancer, size of the tumor
• The tumor’s location in the body
• How close the tumor is to normal tissues that are
sensitive to radiation
• Patient’s general health and medical history
• Other factors, such as your age and other medical
conditions

70. Radiation Therapy
• Radiation may be used to cure the cancer, as in
Hodgkin’s disease, testicular seminomas, thyroid
carcinomas, localized cancers of the head and
neck, and cancers of the uterine cervix.
• Radiation therapy may also be used to control
malignant disease when a tumor cannot be
removed surgically or when local nodal
metastasis is present, or it can be used
prophylactically to prevent leukemic infiltration
to the brain or spinal cord.

71. Types of Radiation therapy
• External beam radiation therapy
• Brachytherapy

72. External beam radiation therapy
Externally applied radiation beams can be produced
by several approaches:
• Radioactive sources, such as Cobalt-60 that emit
gamma rays;
• High energy x-rays or photons produced by linear
accelerators; or particle beams—electrons, protons
or heavier ions—accelerated by other types of
accelerators.

73. • These machines are equipped with accessories
that are able to dynamically shape the radiation
beam according to beam direction, as well as
onboard imaging devices that can verify the
accuracy of treatment delivery.
• Linear accelerators are currently the backbone
of external beam radiation therapy

74. • https://www.youtube.com/watch?v=nyGROC2
dpqg&feature=emb_logo (Radiation )
• https://www.youtube.com/watch?v=g3aPjjhTj
Y0 (Brachy )
• https://www.youtube.com/watch?v=6g4X8hA
oFqM

75. Brachytherapy – Temporarily or permanently
placing radiation-emitting sources directly within
tissues or body cavities.
• Permanent sources decay rapidly, depositing the
dose and remaining in the body;
• Temporary placement uses higher activity sources
that are electromechanically guided to the tumor
within pre-placed interstitial or intra cavitary
catheters. The source and applicators are
removed after the prescribed dose of radiation
has been delivered.

76. • Internal radiation can be implanted by means of
needles, seeds, beads, or catheters into body
cavities (vagina, abdomen, pleura) or interstitial
compartments (breast).
• Brachytherapy may also be administered
• Orally as with the isotope I131, used to treat
thyroid carcinomas.
• Intracavitary radioisotopes are frequently used to
treat gynecologic cancers.
• Interstitial implants, used in treating such
malignancies as prostate, pancreatic, or breast
cancer, may be temporary or permanent,
depending on the radioisotopes used.

77. • https://scienceblog.cancerresearchuk.org/201
7/07/12/an-introduction-to-radiotherapy-
what-is-it-how-does-it-work-and-whats-it-for/

78. Process
• Prescription:
• Planning
• Treatment
• Prescription: The first step is completion of the
radiation prescription, which indicates
the exact part of the body to be treated
the dose/fractionation schedule, (total radiation
dose/ how many fractions/ what intervals, and in
what overall time period. )

79. • Planning:
• Patients are positioned on an x-ray imaging
machine that simulates the geometry of
treatment machine, or in more modern settings
on a specially adapted CT 7 scanner (CT-
simulator).
• A desired position is determined (supine, prone,
arms up or by the side of the body); if needed,
the patient is immobilized
• The set-up information is documented in the RT
chart or electronic medical record. Images of the
part of the body to be treated are obtained and
stored.

80. Treatment Plan
• The radiation oncologist outlines the tissues that must
be irradiated on images and a radiation technologist
/dosimetrist or a medical physicist develops the
treatment plan, using specialized planning software
that models the placement of radiation beams and the
dose contributed by each beam
• Treatment delivery:
• In each session, the patient is positioned exactly as
during simulation. After verifying the prescription,
treatment plan and patient’s position, the radiation
dose is delivered.
• Treatments are frequently given five days per week; in
curative settings, they may continue for four to six
weeks. Daily treatments are commonly delivered
during a session lasting 10-20 minutes.

81. Side effects and Nursing care of
patient of Radiation therapy
• Assignment BY STUDENTS

82. Chemotherapy
Antineoplastic agents are used in an attempt to
destroy tumor cells by interfering with cellular
functions and reproduction.
• Chemotherapy is used primarily to treat systemic
disease rather than lesions that are localized and
amenable to surgery or radiation.
• It may be combined with surgery or radiation
therapy, or both

83. Chemotherapy
• The goals of chemotherapy (cure, control,
palliation) must be realistic because they will
define the medications to be used and the
aggressiveness of the treatment plan.
• It can be used to reduce tumor size preoperatively,
to destroy any remaining tumor cells
postoperatively, or to treat some forms of
leukemia.

84. Concept of Chemotherapy
• Combination chemotherapy (use of cytotoxic
drugs in combination
• Adjuvant chemotherapy(along with surgery and
radiation)
• Neoadjuvant chemotherapy ( initial use of
chemotherapy to reduce the bulk and lower the
stage of tumor , making it amenable to cure with
subsequent local therapy )

85. Cell Kill and the Cell Cycle
Aimed at destroying all the malignant cells,
leaving none
This approach ensures
• Early recovery
• Prevents relapse
• Prolongs survival
• Pharmacological sancturies

86. Cell Kill and the Cell Cycle
• Each time a tumor is exposed to a
chemotherapeutic agent, a 20% to 99%,
percentage of tumor cells are destroyed.
• Repeated doses of chemotherapy are necessary
over a prolonged period to achieve regression of
the tumor.
• The goal of treatment is to eradicate enough of the
tumor so that the remaining tumor cells can be
destroyed by the body’s immune system.

87. Cell Kill and the Cell Cycle
• Actively proliferating cells within a tumor (growth
fraction) are the most sensitive to chemotherapeutic
agents.
• Non dividing cells capable of future proliferation are
the least sensitive to antineoplastic medications and
consequently are potentially dangerous.
• The non dividing cells must be destroyed, however, to
eradicate a cancer completely.
• Repeated cycles of chemotherapy are used to kill more
tumor cells by destroying these non dividing cells as
they begin active cell division.

89. According to activity on cell
Cell cycle phase specific
•G1 phase :Bleomycin, Corticosteroids, Hormones
•G2 phase: Bleomycin, Etoposide, Topotecan, Taxol
etc.
•S phase: Cytarabin, 5-fluorocil, Methotrexate •M
phase : Vinblastin, Vincristine, Paclitaxel
Cell cycle phase non-specific
• Busulfan • Cisplatin • Cyclophosphamide

90. Cancer chemotherapy
curative
• Acute Leukemias
• Wilm’s Tumour
• Ewing’s Sarcoma
• Choriocarcinoma
• Hodgkin’s Disease
• Lymphosarcoma
• Burkitts lymphoma
• Testicular Teratomas
• Seminomas
Palliative effect
• Breast Cancer
Ovarian Cancer
• Endometrial Cancer
• Prostatic Cancer
• Chronic Lymphatic
Leukemia
• Chronic Myeloid Leukemia
• Head & Neck Cancer
• Lung (small cell) Cancer

91. Depending on mechanism at cell level
Directly acting cytotoxic drugs:
• Alkylating agent
• Antimetabolites
• Natural products
 Antibiotics
 Vinca alkaloids
 Taxanes
 Epipodophyllotoxins
 Camptothecin analogs
 Enzymes
 Biological response
modifiers – Miscellaneous:
Cisplatin, carboplatin
Indirectly acting- by altering the
hormonal mileau :
• Corticosteroids
• Estrogens & ERMs
• 5 alpha reductase inhibitors
• Gnrh agonists
• Progestins

92. Antineoplastic Agents
Drugs Mechanisms of action COMMON SIDE EFFECTS
Alkylating Agents
Busulfan, carboplatin,
chlorambucil,
cisplatin, cyclophosphamide,
dacarbazine,
hexamethyl melamine,
ifosfamide,
melphalan, nitrogen
mustard, thiotepa
initiating
breaks in the DNA molecule,
cross-linking DNA strands
Bone marrow suppression,
nausea, vomiting, cystitis
(cyclophosphamide,
ifosfamide),
stomatitis, alopecia,
gonadal suppression, renal
toxicity (cisplatin)
Nitrosureas
carmustine (BCNU), lomustine
(CCNU), semustine (methyl
CCNU), streptozocin
Similar to the alkylating
agents;
cross the blood–brain barrier
Delayed and cumulative
myelosuppression,
especially
thrombocytopenia;
nausea, vomiting
Topoisomerase I Inhibitors
irinotecan, topotecan
Induce breaks in the DNA
strand by binding to enzyme
topoisomerase I, preventing
cells from dividing
Bone marrow suppression,
diarrhea, nausea, vomiting,
hepatotoxicity

93. Antineoplastic Agents
Drugs Mechanisms of action COMMON SIDE EFFECTS
Antimetabolites
5-azacytadine, cytarabine,
edatrexate fludarabine,
5-fluorouracil (5-FU), FUDR,
gemcitabine, hydroxyurea,
leustatin, 6-mercaptopurine,
methotrexate, pentostatin,
Interfere with the biosynthesis
of
metabolites or nucleic acids
necessary for RNA and DNA
synthesis
Nausea, vomiting, diarrhea,
bone marrow suppression,
proctitis, stomatitis, renal
toxicity
(methotrexate),
hepatotoxicity
Antitumor Antibiotics
bleomycin, dactinomycin,
daunorubicin, doxorubicin
(Adriamycin), idarubicin,
mitomycin, mitoxantrone,
plicamycin
Interfere with DNA synthesis
by binding DNA; prevent RNA
synthesis
Bone marrow suppression,
nausea, vomiting, alopecia,
anorexia, cardiac toxicity
(daunorubicin, doxorubicin)
Mitotic Spindle Poisons
Plant alkaloids: etoposide,
teniposide,
vinblastine, vincristine
(VCR), vindesine, vinorelbine
Taxanes: paclitaxel, docetaxel
Arrest metaphase by inhibiting
mitotic tubular formation
(spindle); inhibit DNA and
protein synthesis
Arrest metaphase by inhibiting
tubulin depolymerization
Bone marrow suppression
(neuropathies
(VCR), stomatitis
Bradycardia, hypersensitivity
reactions,
bone marrow suppression,
alopecia, neuropathies

94. Antineoplastic Agents
Drugs Mechanisms of action COMMON SIDE EFFECTS
Hormonal Agents
androgens and
antiandrogens,
estrogens and antiestrogens,
progestins and
antiprogestins,
aromatase inhibitors,
luteinizing
hormone–releasing
hormone analogs, steroids
Bind to hormone receptor
sites
that alter cellular growth;
block binding of estrogens to
receptor sites
(antiestrogens);
inhibit RNA synthesis;
suppress
aromatase of P450 system,
which decreases estrogen
level
Hypercalcemia, jaundice,
increased
appetite, masculinization,
feminization, sodium
and fluid retention, nausea,
vomiting, hot flashes,
vaginal
dryness
Miscellaneous Agents
asparaginase, procarbazine
Unknown or too complex to
categorize
Anorexia, nausea, vomiting,
bone marrow suppression,
hepatotoxicity, anaphylaxis,
hypotension, altered glucose
metabolism

95. Administration of Chemotherapeutic
Agents
Chemotherapeutic agents may be administered in
the hospital, clinic, or home setting by
• Topical, oral, intravenous, intramuscular,
subcutaneous, arterial, intracavitary, and
intrathecal routes.

96. • The administration route usually depends on
the type of agent, the required dose, and the
type, location, and extent of tumor
being treated.

97. Safe preparation, handling and
disposal
• Aseptic preparation of parenteral products should be
followed
• Only properly trained personnel should handle cytotoxic
drugs
• • Safe preparation has been divided into 3 sections
• – Steps A,B,C
• – Steps D,E,F,G
• – Steps H,I,J,K,L
Step A
• All procedures involved in the preparation of cytotoxic
• drugs should be performed in a class 2 ,type A or type B
• Laminar flow biological safety cabinet

98. Step B
• The work surface of the cabinet should be covered
with plasticbacked absorbent paper
Step C
• Personnel preparing the drugs should wear PPE
(Gloves ,gown , facial protection respiratory
protection apparatus, caps and shoe covers)
• Gloves should be changed regularly and
immediately if torn or punctured
• Skin contact : Thoroughly wash the area with soap
and water do not abrade. Flush eye(s),while
holding back the eyelid(s) with copious amount of
water for at least 15 minutes. Then seek medical
evaluation

99. Safe preparation, handling and
disposal
Step D
• Reconstitution should be done with a venting
device using a 0.22 micron hydrophobic filter
(reduce the probability of spraying and spillages)
Step E
• If a chemotherapy dispensing pin is not used ,a
sterile alcohol pad should be carefully placed
around the needle and vial top during withdrawal
from the septum

100. Safe preparation, handling and
disposal
Step F
• The external surface contaminated with a drug should
be wiped clean with an alcohol swab prior to transfer
or transport
Step G
• for glass ampule, wrap it and then snap it at the break
point using an alcohol pad to reduce the possibility of
injury and to contain aerosol produced
Step H
• syringes and I.V bottles containing cytotoxic drug
should be labeled and dated

101. Safe preparation, handling and
disposal
Step K
• Hand should be washed between glove
changes and after glove removal
Step L
• Cytotoxic drugs are categorized regulated
wastes and therefore, should be disposed of
according to National, state and local
requirements

102. Side effects and Nursing care of
patient with Chemotherapy
Assignment

103. Bone Marrow transplantion
• Bone Marrow transplant is a procedure used to
treat patients with life-threatening blood,
immune or genetic disorders.
• This includes leukaemia and bone marrow
cancers.
• A bone Marrow transplant replaces the
unhealthy blood- forming cells with healthy ones.
Healthy bone marrow stem cells are harvested
from matching bone marrow donors.

104. TYPES - BONE MARROW
TRANSPLANTATION
• 1. Allogeneic (from a donor other than the patient):
either a related donor (ie, family member) or a
matched unrelated donor (national bone marrow
registry, cord blood registry)
• 2. Autologous (from patient)
• 3. Syngeneic (from an identical twin)

106. • Stem cell transplants do not usually work
against cancer directly. Instead, they help to
recover the ability to produce stem cells after
treatment with very high doses of radiation
therapy, chemotherapy, or both.

108. Transplant Process (5 steps)
(1) Conditioning,
(2) Stem cell infusion,
(3) Neutropenic phase,
(4) Engraftment phase
(5) Post-engraftment period.

109. Conditioning Phase
 The conditioning period typically lasts 7-10 days.
 The purposes are (by delivery of chemotherapy
and/or radiation)
• to eliminate malignancy
• to provide immune suppression to prevent rejection of new
stem cells
• create space for the new cells
 Radiation and chemotherapy agents differ in their
abilities to achieve these goals.

110. Stem c e l l processing and infusion
 Infusion - 20 minutes to an hour, varies depending on the
volume infused.
 The stem cells may be processed before infusion, if indicated.
 Depletion of T cells can be performed to decrease GVHD.
 Premedication with acetaminophen and diphenhydramine to
prevent reaction
 Infused through a CVL, much like a blood transfusion.
 Anaphylaxis, volume overload, and a (rare) transient GVHD are
the major potential complications involved.
 Stem cell products that have been cryopreserved contain
dimethyl sulfoxide (DMSO) as a preservative and potentially can
cause renal failure, in addition to the unpleasant smell and
taste.

111. Neutropenic Phase
 During this period (2-4 wk), the patient
essentially has no effective immune system.
 Healing is poor, and the patient is very
susceptible to infection.
 Supportive care and empiric antibiotic therapy
are the mainstays of successful passage through
this phase.

112. Engraftment Phase
 During this period (several weeks), the healing
process begins with resolution of mucositis and
other lesions acquired.
 In addition, fever begins to subside, and infections
often begin to clear.
 The greatest challenges at this time are
management of GVHD and prevention of viral
infections (especially CMV).

113. Post-engraftment Phase
 This period lasts for months to years. Hallmarks
of this phase include the gradual development
of tolerance, weaning off of
immunosuppression, management of chronic
GVHD, and documentation of immune
reconstitution.

114. Acute side effects
• include alopecia, hemorrhagic cystitis, nausea,
vomiting, diarrhea, and severe stomatitis.
Chronic side effects include sterility,
• Pulmonary dysfunction, cardiac dysfunction, and
liver disease

115. G ra f t Verses Host Disease
(GVHD)
• GVHD sometimes occurs with allogeneic
transplantation.
• Lymphocytes from the donor graft attack the cells of
the host
• GVHD can usually be treated with steroids or other
immunosuppressive agents.
• Acute GVHD occurs before day 100 post-transplant
Chronic GVHD occurs beyond day 100

116. BONEMARROW
TRANSPLANTATIONCARE
 A two- to four-week waiting period follows the marrow
transplant before its success can begin to be judged.
 The marrow recipient is kept in isolation during this time to
minimize potential infections.
 The recipient also receives intravenous antibiotic, antiviral,
and antifungal medications, as well as blood and platelet
transfusions to help fight off infection and prevent excessive
bleeding.

117. BONEMARROW
TRANSPLANTATIONCARE
 Blood tests are performed
 daily to monitor the patient's kidney and liver function, as
well as nutritional status.
 Other tests are performed as necessary.
 Further side effects, such as nausea and vomiting, can be
treated with other medications.

118. CARING FOR THE DONORS
• Donors commonly experience mood alterations,
decreased self esteem, and guilt from feelings of
failure if the transplantation fails.
• Family members must be educated and supported to
reduce anxiety and promote coping during this
difficult time. Family members must also be assisted
to maintain realistic expectations of themselves as
well as of the patient.
• As BMT becomes more prevalent, many moral and
ethical issues become apparent, including those
related to informed consent, allocation of resources,
and quality of life.

119. Gene therapy
• Gene therapy includes approaches that correct
genetic defects or manipulate genes to induce
tumor cell destruction in the hope of preventing
or combating disease.
• Gene therapy is a technique for introducing the
genetic material of a gene in a patient that lacks
that gene because of a mutation.

120. Gene therapy
• An example of one such trial involves inserting the
p53 tumor suppressor gene into cancer cells.
Normally this gene is responsible for repairing
damaged cells or causing cell death when the cell
cannot be repaired.
• Many types of cancer cells have mutated p53 genes
that then lead to uncontrolled cell growth. Insertion
of normal p53 genes can lead to either cancer cell
death or slowing of tumor growth. This approach
has been tested in lung, head and neck, and colon
cancers

121. » Main Types
1. Immunotherapy
2. Oncolytic Virotherapy
3. Gene Transfer

122.  Uses GM cells and viral particles to stimulate
the immune system to destroy cancer cells;
e.g. lung cancer.
Immunotherapy

123.  Uses viral particles that replicate within the
cancer cell to cause cell death; e.g.
metastatic cancers.
Oncolytic Virotherapy

124.  Introduces new genes into a cancerous cell or
the surrounding tissue to cause cell death or
slow the growth of cancer; e.g. in solid
tumours.
Gene Transfer

125. Cancer Type Commercial
Name
Approach Type of Therapy
Prostate Cancer Prostvac TRICOM vector
vaccine
Immunotherapy
Soft Tissue
Sarcoma
TNFerade Adenoviral
vector
Gene Transfer
Pancreatic
Cancer
Rexin-G Retroviral vector Gene Transfer

126. PHOTODYNAMIC THERAPY
• Photodynamic therapy, or phototherapy, is an
investigational cancer treatment that uses
photosensitizing agents, such as porfimer
(Photofrin).
• When administered intravenously, these agents are
retained in higher concentrations in malignant
tissue than in normal tissue.
• They are then activated by a light source, usually
laser light, which penetrates body tissue. The light
activated agent then creates activated singlet
oxygen molecules that are cytotoxic or harmful to
body tissue cells.

127. PHOTODYNAMIC THERAPY
• Because most of the photosensitizing agent has
been retained in malignant tissue, a selective
cytotoxicity can be achieved with minimal
destruction to normal tissues.
• Cancers treated with phototherapy include
esophageal cancers, endobronchial tumors, skin
cancers, breast cancers, intraperitoneal tumors,
and malignant central nervous system disease. The
major side effect of therapy is photosensitivity for 4
to 6 weeks after treatment.

128. PHOTODYNAMIC THERAPY
• Patients must protect themselves from direct and
indirect sunlight to prevent skin burns. In
addition, local reactions are observed in the area
treated.
• Liver and renal function should also be monitored
for transient abnormalities.
• As with any investigational treatment, emotional
support and education are vital to assist the
patient and family.

129. BIOLOGIC RESPONSE MODIFIERS
• It involves the use of naturally occurring or
recombinant agents or treatment methods that can
alter the immunologic relationship between the
tumor and the cancer patient(host) to provide a
therapeutic benefit.
• Goal is to destroy or stop the malignant growth.
• The basis of BRM treatment lies in the restoration,
modification, stimulation, or augmentation of the
body’s natural immune defenses against cancer.

130. BIOLOGIC RESPONSE MODIFIERS
• Nonspecific Biologic Response Modifiers
• Monoclonal Antibodies
• Cytokines
• Tumor Necrosis Factor
• Retinoids

131. 1. Nonspecific Biologic Response Modifiers
• Some of the early investigations of the stimulation
of the immune system involved nonspecific agents
such as Bacille Calmette- Guérin (BCG) and
Corynebacterium parvum.
• When injected into the patient, these agents serve
as antigens that stimulate an immune response.
• Malignant melanoma.
• localized bladder cancer.

132. 2.Monoclonal Antibodies
• Monoclonal antibodies (MoAbs)available through
technological advances, enabling investigators to grow and
produce specific antibodies for specific malignant cells.
• Theoretically, this type of specificity allows the MoAb to
destroy the cancer cells and spare normal cells.
(The production of MoAbs involves injecting tumor cells that
act as antigens into mice. Antibodies made in response to
injected antigens can be found in the spleen of the mouse)

133. Monoclonal Antibodies
• The combination of spleen cells and the cancer cells is
referred to as a hybridoma. From hybridomas that continue
to grow in the culture medium, the desired antibodies are
harvested, purified, and prepared for diagnostic or
therapeutic use
• Alternative methods of producing MoAbs using human or
genetically engineered sources are under investigation.

134. 3.Cytokines
• Cytokines, substances produced by cells of the
immune system to enhance the production and
functioning of components of the immune
system, are also the focus of cancer treatment
research.
• Cytokines are grouped into families, such as
interferons,
interleukins

135. • Interferons (IFNs) has both antiviral and antitumor
properties. When stimulated, all nucleated cells are
capable of producing these glycoproteins, which
are classified according to their biologic and
chemical properties: IFN-α (leukocytes), IFN-β(
fibroblasts), and IFN-γ (lymphocytes).
• Interleukins are a subgroup of cytokines known as
lymphokines and monokines because they are
primarily produced by lymphocytes and
monocytes. They act by signaling and coordinating
other cells of the immune system.

136. 4.TUMOR NECROSIS FACTOR(TNF)
• TNF is a cytokine naturally produced by
macrophages, lymphocytes, astrocytes, and
microglial cells of the brain. The exact role of TNF is
still under investigation
5.RETINOIDS
• Retinoids are vitamin A derivatives (retinol, all-
trans-retinoic acid, and 13-cis-retinoic acid) that
play a role in growth, reproduction, epithelial cell
differentiation, and immune function

137. Cancer Rehabilitation
• The cancer patients may encounter a variety
of problems, including changes in their
functional abilities and in the attitudes of
employers,co-workers, and family members
who still view cancer as a terminal,
debilitating disease
• Nurses play an important role in the
Rehabilitation

138. • Both the patient and family are included as
part of any rehabilitation effort because
cancer affects not only the patient but also
the family members

139. Assessing Patient Needs
for Cancer Rehabilitation
Area of need
• Functional
• Activities of daily living
• Physiologic
• Nutrition
Factors to assess
• Mobility
• Cognitive impairment
• Sensory impairments
• Communication barriers
• Need for enteral or
parenteral
• nutrition

140. Assessing Patient Needs
for Cancer Rehabilitation
Area of need
• Elimination
• Symptoms related to
disease or treatment
Factors to assess
• Alterations in bowel and
bladder Function
• Pain
• Nausea, vomiting, diarrhea
• Dyspnea, fatigue
• Skin impairment, alopecia

141. Assessing Patient Needs
for Cancer Rehabilitation
Area of need
• Psychosocial Resources
• Family
Factors to assess
• Availability of caregiver,
home physical environment
• Availability of private
transportation; affordability
of transportation

142. Assessing Patient Needs
for Cancer Rehabilitation
Area of need
• Community
Factors to assess
• Availability of public
transportation;
• affordability of
transportation
• Availability and access to
community
• organizations for assistance
and
• support

143. Assessing Patient Needs
for Cancer Rehabilitation
Area of need
• Personal
• Financial
Factors to assess
• Spiritual concerns
• Family relationships
• Body image
• Coping abilities
• Sexuality
• Job security for patient and
family
• members
• Need for vocational training

144. Cancer Rehabilitation
• Assessment for body image changes as a result of disfiguring
treatments is necessary to facilitate the patient’s adjustment to
changes in appearance or functional abilities. The nurse can
refer the patient and family to a variety of support groups
sponsored
• Patients often experience distress (eg, pain, nausea) related to
the underlying cancer or treatments. These symptoms may
interfere with work and quality of life. Nurses assess for these
problems and assist the patient in identifying strategies for
coping with them.

145. • Nurses collaborate with dietitians to help patients plan
meals that will be acceptable and meet nutritional
requirements. Nurses are also involved in the ongoing
assessment of patients to detect any long-term
consequences of cancer treatment
• Unfair practices and discrimination in the workplace.
Attitudes of co-workers can be a problem when the patient
has a communication impairment, as may occur in some
head and neck cancers. The patient may benefit from
vocational rehabilitation services

146. HOSPICE
For many years, society was unable to cope appropriately with patients
in the most advanced stages of cancer, and patients died in acute care
settings rather than at home or in facilities designed to meet their
needs.
The needs of patients with terminal illnesses are best met by a
comprehensive multidisciplinary program that focus on quality of life,
palliation of symptoms, and provision of psychosocial and spiritual
support for the patient and family when cure and control of the disease
are no longer possible.

147. HOSPICE
 The concept of hospice, which originated in Great Britain, best
addresses the needs. Most important, the focus of care is on the
family, not just the patient.
 Hospice care can be provided in several settings: freestanding,
hospital-based, and community or home-based settings.
 Although physicians, social workers, clergy, dietitians,
pharmacists, physical therapists, and volunteers are involved in
patient care, nurses are most often the coordinators of all
hospice activities.

148. HOSPICE
• It is essential that home care and hospice nurses possess
advanced skills in assessing and managing pain,
nutrition, dyspnea, bowel dysfunction, and skin
impairments.
• In addition, hospice programs facilitate clear
communication among family members and health care
providers. Most patients and families are informed of the
prognosis and are encouraged to participate in decisions
regarding pursuing or terminating cancer treatment.
• Through collaboration with other support disciplines,
nurses assist patients and families to cope with changes in
role identity, family structure, grief, and loss. Hospice
nurses are actively involved in bereavement counseling.

149. Oncological Emergencies
• Superior Vena Cava Syndrome
• Spinal Cord Compression
• Hypercalcemia
• Tumor lysis syndrome
• Disseminated intravascular coagulation
• Syndrome of Inappropriate Secretion of Antidiuretic
Hormone (SIADH)
• Pericardial Effusion and Cardiac Tamponade

150. Oncological Emergencies
1.Superior Vena Cava Syndrome (SVCS) -
Compression or invasion of the superior vena cava by
tumor, enlarged lymph nodes, intraluminal thrombus
that obstructs venous circulation, or drainage of the
head, neck, arms, and thorax.
I can be associated with lung cancer, lymphoma and
metastases.
If untreated, SVCS may lead to cerebral anoxia
(because
not enough oxygen reaches the brain), laryngeal
edema, bronchial obstruction, and death.

151. Superior Vena Cava Syndrome
Signs and Symptoms
• Swelling of face & neck , Dry cough ,Dyspnea
Hoarseness of voice , Nasal congestion , Headache,
Cyanosis, Confusion ,Stupor
Management
• Radiation therapy to shrink tumor size and relieve symptoms
• Chemotherapy for radiation-resistant tumor
• Anticoagulant or thrombolytic therapy for intraluminal
• thrombosis
• Surgery (less common), eg, vena cava bypass graft (synthetic
or autologous) to redirect blood flow around the obstruction
• Supportive measures such as oxygen therapy, corticosteroids,
and diuretics

152. 2.Spinal Cord Compression
• Potentially leading to permanent neurologic impairment and
associated morbidity and mortality, compression of the cord
and its nerve roots may result from tumor, lymphomas, or
intervertebral collapse
• Signs and Symptoms
• Local inflammation, edema, venous stasis, and impaired
blood supply to nervous tissues
• Local or radicular pain .Pain exacerbated by movement,
coughing, sneezing, or the Valsalva maneuver
• Neurologic dysfunction, and related motor and sensory
deficits (numbness, tingling, feelings of coldness in the
affected area, inability to detect vibration, loss of positional
sense)
• Motor loss ranging from subtle weakness to flaccid paralysis
• Bladder and/or bowel dysfunction depending on level of
compression

153. 2.Spinal Cord Compression
• Management
• Radiation therapy to reduce tumor size to halt
progression and corticosteroid therapy to
decrease inflammation and swelling at the
compression site
• Surgery only if symptoms progress despite
radiation therapy or if vertebral fracture leads to
additional nerve damage
• Chemotherapy as adjuvant to radiation therapy
for patients with lymphoma or small cell lung
cancer

154. 3.Hypercalcemia
Potentially life-threatening metabolic abnormality resulting
when the calcium released from the bones is more than the
kidneys can excrete or the bones can reabsorb.
It may result from:
• Bone destruction by tumor cells and subsequent release of
calcium
• Production of prostaglandins and osteoclast-activating
factor, which stimulate bone breakdown and calcium release
• Tumors that produce parathyroid-like substances that
promote calcium release
• Excessive use of vitamins and minerals and conditions
unrelated to cancer, such as dehydration, renal impairment,
primary hyperparathyroidism, thyrotoxicosis, thiazide
diuretics, and hormone therapy

155. 3.Hypercalcemia
• Signs and Symptoms
• Fatigue, weakness, confusion, decreased level of
responsiveness, hyporeflexia, nausea, vomiting,
constipation, polyuria (excessive urination),
polydipsia (excessive thirst), dehydration, and
dysrhythmias

156. 3.Hypercalcemia
• Management
• Treating the underlying cause (eg, chemotherapy for
a malignancy or partial parathyroidectomy for
hyperparathyroidism) is essential.
• Administering fluids to dilute serum calcium and
promote its excretion by the kidneys, mobilizing the
patient, and restricting dietary calcium intake.
• IV administration of 0.9% sodium chloride solution
temporarily dilutes the serum calcium level.
• Administering IV phosphate can cause a reciprocal
drop in serum calcium.
• Furosemide (Lasix) is often used in conjunction with
administration of a saline solution

157. 4. Tumor lysis syndrome
• Tumor lysis syndrome is a group of metabolic
abnormalities that can occur as a complication during
the treatment of cancer, where large amounts of tumor
cells are killed off (lysed) at the same time by the
treatment, releasing their contents into the
bloodstream.
• Signs and Symptoms
• Hyperuricaemia & hyperphosphatemia produce
nausea, vomiting & muscle cramps, cardiac
arrhythmia & tetany flaccid paralysis. acute renal
failure

159. 4. Tumor lysis syndrome
Mangement
• IV Fluid, normal or half normal saline around 3000ml per
day.
• Correction of electrolytes and acid-base
abnormality & IV sodium bicarbonate to maintain
an alkaline urine pH.
• Oral allopurinol is given 300-600mg in divided doses
Monitoring serum uric acid, serum creatitine, serum
electrolytes and electrocardiogram after every few hours.
• IV calcium gluconate is given for
hypocalcaemia.

160. 5. Disseminated intravascular coagulation
• It is a condition in which blood clots form throughout
the body, blocking small blood vessels.
Signs and Symptoms
• Bleeding, from many sites in the body.
• Blood clots.
• Bruising.
• Drop in blood pressure.
• Shortness of breath.
• Confusion, memory loss or change of behavior.
• Fever.

161. 5. Disseminated intravascular
coagulation
Mangement
• Treatment includes correction of the cause and
replacement of platelets, coagulation factors (in fresh
frozen plasma), and fibrinogen (in cryoprecipitate) to
control severe bleeding.
• Heparin is used as therapy (or prophylaxis) in patients with
slowly evolving DIC who have (or are at risk of) venous
thromboembolism.