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What is Staging?
Staging describes the extent orseverity of an individuals cancer
It is base on the extent of the
original (primary) tumor and theextent of spread in the body.
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Staging is important:
Staging helps the doctor plan a personstreatment.
The stage can be used to estimate the
persons prognosis (likely outcome orcourse of the disease).
Knowing the stage is important inidentifying clinical trials (researchstudies) that may be suitable for aparticular patient.
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Elements of Staging
Systems Location of the primary tumor
Tumor size and number of tumors,
Lymph node involvement
Cell type and tumor grade
Presence or absence of metastasis
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TNM System:
The TNM system is based on :
the extent of the tumor (T)
the extent of spread to the lymph nodes(N)
the presence of metastasis (M).
A number is added to each letter to indicatethe size or extent of the tumor and theextent of spread.
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Primary Tumor (T)
TX - Primary tumor cannot beevaluated
T0 No evidence of primary tumor Tis - Carcinoma in situ (early cancer
that has not spread to neighboringtissue)
T1, T2, T3, T4 - Size and/or extent ofthe primary tumor
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Regional Lymph nodes
NX - Regional lymph nodes cannotbe evaluated
N0 - No regional lymph nodeinvolvement (no cancer found in thelymph nodes)
N1, N2, N3 - Involvement of regionallymph nodes (number and/or extentof spread)
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Distant Metastasis (M)
MX - Distant metastasis cannot beevaluated
M0 - No distant metastasis (cancerhas not spread to other parts of thebody)
M1 - Distant metastasis (cancer hasspread to distant parts of the body)
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Examples:
breast cancer T3 N2 M0 It refers to a large tumor that has spread
outside the breast to nearby lymph nodes,
but not to other parts of the body. Prostate cancer T2 N0 M0
It means that the tumor is located only in theprostate and has not spread to the lymph
nodes or any other part of the body.
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Stage I ( T1, N0, MO)- Early Stage
Stage II (T2, N1, M0) local Spread
Stage III ( T3, N2, M0)- extensivespread but no metastasis.
Stage IV (T4, N3, M+) Advanced
stage, with distant metastasis
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5 Main Categories of
Cancer In situ is early cancer that is presentonly in the layer of cells in which itbegan.
Localized is cancer that is limited to theorgan in which it began, withoutevidence of spread.
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Regional is cancer that has spread
beyond the original (primary) site tonearby lymph nodes or organs andtissues.
Distant is cancer that has spread fromthe primary site to distant organs ordistant lymph nodes.
Unknown is used to describe cases for
which there is not enough information toindicate a stage.
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Stages of Cancer
Stage DefinitionStage 0 Carcinoma in situ (early cancer that is
present only in the layer of cells in
which it began).
Stage I, Stage II,
and Stage III
Higher numbers indicate more
extensive disease: greater tumor size,
and/or spread of the cancer to nearby
lymph nodes and/or organs adjacent tothe primary tumor.
Stage IV The cancer has spread to another
organ.
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Why Cancer Detection and
Testing Important?
Detecting cancers early is an important
step in preventing significant healthproblems.
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Four Possible Outcomes. True Positive
False Positive
True Negative False Negative
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When a test is performed to detect a
disease, there are four possibleoutcomes:
True positive - test indicates that a patienthas a disease that the patient does indeedhave
False positive - test indicates that a patienthas a disease when they do not
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True negative - test indicates the patientis disease-free, and this is indeed thecase
False negative - test indicates thepatient is healthy when in fact thepatient has the disease
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Sensitivity refers to how accurately a testidentifies people who have the disease.
Specificity refers to how accurately a testidentifies people who do not have the disease
The best medical tests have high sensitivity and
high specificity.
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Non - Invasive Invasive Techniques Analysis of Biopsy
Complete Blood Count(CBC)UltrasoundMRI
PET ScanCT Scan
Fine Needle AspirationCore Needle Biopsy
Immunohistochemistry(IHC)Fluorescent In SituHybridization (FISH)
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Ultrasound uses reflection of sound waves to
create an image of a part of the body
MRI uses magnetic fields and radio waves toproduce images of the body.
PET scans use radioactive molecules to create adynamic image of internal tissues and organs.PET scans are able to measure the metabolicactivity of cells, not just their structure.
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CT scans use x-rays to take multipleimage slices in order to create a 3Dimage.
X-rays utilized high energy beams tocreate an image.
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Non- Invasive: CBC
It provides information about the number,parts, shape, and structure of the differentcell types found in blood.
3 main types of blood cells: WBC
RBC
Platelets
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MRIWhen contrast agent is not
used an MRI can show:
When contrast agent is used
MRI can show:
contrast agent is not used an MRIcan show:
The shape, size, appearance, andlocation of organs, bones, andjointsThe presence of abnormal growthsSigns of inflammation or infection
size and location of benign ormalignant growths
enlarged lymph nodeschanges in blood flowextracellular volume
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Positron Emission
Tomography (PET) Is an imaging technique that uses radioactive
molecules to create a dynamic image ofinternal tissues and organs.
It produce images that reveal the activity ofliving tissue.
PET scans use radioactively labeled tracers(radiotracers) that are injected into the
bloodstream
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Computed Tomography
It uses x-rays in the same way as aconventional x-ray but instead oftaking one image a CT scanner takesmultiple images, or slices.
It can provide a 3 dimensional imageof an internal structure, it can detect
differences in tissue density.
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Fine Needle Aspiration (FNA) Core Needle Biopsy(CNB)
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Biopsy
Is the removal of cells, tissue, or fluidfor examination.
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Invasive Techniques
Fine needle aspiration (FNA) uses a
small needle to collect small samplesof a lesion.
Core needle biopsy (BPA) uses alarger needle to collect samples of alesion
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Fine Needle Aspiration Core Needle Biopsy
Sample Removed Removes only a very small portion of the lesion Removes a small portion in most
cases, occasionally removes the
entire lesionNeedle Size 22-27 gauge 11-18 gauge
Pathology Type Cytopathology Histopathology
Interpretation Time Immediately Delayed
Diagnostic Abilities Limited ability to specifically diagnose benign
lesions
No ability to differentiate between in situ and
invasive breast cancer
Strong ability to specifically
diagnose benign lesions.
Some ability to differentiate
between in situ and invasive breast
cancer.
Disadvantages Cannot be used for additional study More invasive, time consuming,
expensive
Advantages Inexpensive, quick, readily available, and very
safe
Can be used for additional study
and has more specific diagnosticabilities than FNA
Effectiveness Sensitivity: 75.8-98.7%
Specificity: 60-100%
Positive Predictive Value: 93.5-100%
Sensitivity: 91-99.6%%
Specificity: 98-100%
Positive Predictive Value: 10
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Analysis of FNA
Benign - the mass is not of much concern and willnot cause any significant problems as long as itremains unchanged.
Atypically indeterminate - a diagnosis cannot beobtained from the sample. Other tests are neededto determine the nature of the lesion.
Suspicious/probably malignant- not a diagnosis ofcancer. This type of diagnosis requires additional
investigation because the sample has abnormalcharacteristics. This lesion should be biopsiedwith a more complete method to determinewhether a malignancy (cancer) is present.
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Malignant- a diagnosis of cancer;should be biopsied and tested for exacttumor makeup to prepare for
treatment. Unsatisfactory- a diagnosis cannot be
determined from the sample because
of insufficient sample size, processingor other machine or human errors.
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Examination of TissueSamples Immunohistochemistry (IHC)
Fluorescence in SituHybridization (FISH)
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Immunohistochemistry (IHC)
Is a technique used to determine thepresence and level of specific cellularproteins.
An example: Three proteins of particularinterest in breast cancer are HER2, theestrogen receptor (ER) and the progesterone
receptor (PR).
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Fluorescence in SituHybridization (FISH)
Is a cytogenetic technique used to detectand localize the presence or absence of
specific DNA sequences on chromosomes.
FISH uses fluorescent probes that bind toonly those parts of the chromosome with
which they show a high degree of sequencesimilarity.
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Cancer Specific Techniques
Mammography uses low dose x-rayto create an image of a breast.
Sigmoidoscopy uses a small tubecontaining viewing equipment toview the colon.
Virtual Colonoscopy uses an MRI or
CT scan to create an image of theinside of the colon.
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Pap smears use a sample of cells from thecervix to detect cervical cancer. Pap smearsmay also detect ovarian and uterine cancers
that have migrated to the cervix.
Prostate specific antigen (PSA) testmeasures levels of a glycoprotein in the
blood. Elevated levels of PSA are associatedwith prostate cancer
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Sentinel Lymph Node
Biopsy (SLN) is used to detect metastasis.
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THANK YOU!
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Treatment Goal
Is to cure the client eradicate thetumor.
When cure is not possible, controllingor arresting a tumor growth becomesthe goal to prolong the survival.
Palliation or alleviation of symptoms.
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Treatments
Surgery
Radiation Therapy
Hormonal Therapy
Targeted Therapy Antibodies
Cancer Vaccines
Complimentary and AlternativeMedicines
Chemotherapy
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Surgery
The first line of treatment for manysolid tumors.
May be sufficient to cure the patientby removing all cancerous cells.
Surgery is often used in combinationwith radiation and/or chemotherapy
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Types of Treatment
Local Excision- simple surgery with smallmargin of normal tissue surrounding tumor.
En bloc Dissection- removal of tumor, tissues,and any contiguous structures.
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Surgery on Cancer in Situ
Electrosurgery- application ofelectrical current to cancerous cells
Cryosurgery- deep freezing withliquid nitrogen
Chemosurgery- appliedchemotherapeutic agents layer by
layer with surgical incision. Co2 laser- use of laser for laser
excision.
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Radiation
May be used in conjunction withsurgery and/or drug treatments.
The goal of radiation is to kill thecancer cells directly by damagingthem with high energy beams
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Radiation Therapy
Radiation treatments utilize high-energywaves to kill cancer cells.
Use of high energy moving throughspace or medium to treat disease.
It can be used alone or in conjunctionwith other treatments (e.g.chemotherapy and surgery) to cure orstabilize cancer.
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Objectives:
This treatment seeks to relievesymptoms of the cancer and toprolong survival, making life more
comfortable.
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Indications
Used to treat tumors- ionizingradiation transfers energy tomolecules present in cancer cells.
Different tissues have different radiosensitivities rapidly dividing tissues
(testes, ovaries, lymphoid tissues,and bone marrows) are moresensitive.
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Types of Radiation
Electromagnetic- radiation in wave form
Xrays- linear accelerators
Electrons- delivered by machines
Gamma- rays delivered by machines thatcontain radioactive sources (Cobalt 60), orradioactive substances ( seeds, threads)
Particulate radiation in the form of heavy
particles. (beta particles- High speedelectrons)
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Postoperative Radiation
It can destroy cancer cells stillpresent around the margins after atumor has been surgically removed.
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Internal Radiation
Is the process of implantingradioactive material onto or near thetumor or placing radioactive sources
into the body.
Implantation of radioactivesubstance within a client.
It can be temporary or permanent. Also called brachytherapy
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Types of Internal
Radiation Unsealed sources: Isotopes Liquid and administered orally.
Sealed Sources: Radium needles andradon seeds. Radioactive substance encased in metal
capsule placed in body cavity.
Delivers radiation directly to tumor
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External Radiation
It utilizes a machine to deliver radiationto the tumor.
This therapy is primarily an outpatient
treatment. Most protocols last approximately 4-7
weeks with treatments given 5 days perweek
Also called as Teletherapy- externalsource of radiation. ( machine is adistance from client)
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2 Types of External
Radiation Natural Radioactive Source - gammarays delivered via machine to lesion.
Machine is the linear accelerator-high voltage electric current deliverselectrons to client.
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Photon Radiation
It uses high energy rays composed ofparticles of energy called photons.
Photon radiation acts by disrupting the molecules of the target cells, interfering with normal cell functions.There are several types of photon radiation:
Gamma rays: are produced by thebreakdown of radioactive isotopes ofelements such as Cobalt-60 andradium
X-rays: originate from machines thatexcite electrons using cathode raytubes or linear accelerators.
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Administration of RadiationTherapy Internal
Seed implants Brachytherapy
External External Beam Radiation Therapy
3-D Conformal Therapy and IntensityModulated Radiation Therapy (IMRT)
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Benefits
Destroys quickly dividing cells at themargins of tumors. Surgery may miss thesecells leading to recurrence of disease.
Can successfully eradicate growth without
permanently damaging the adjacent normaltissue. If these tumors can be treated early beforemetastasis, there is a very high rate of curability.
In conjunction with other treatments, may
cure tumors that are not responsive to anysingle agent.
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Hormonal Treatments
It prevent cancer cell growth bypreventing the cells from receivingsignals necessary for their continued
growth and division
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Targeted Therapy
They work by targeting specificproteins and processes that arelimited primarily to cancer cells or
that are much more prevalent incancer cells.
Inhibition of these processes
prevents cancer cell growth anddivision.
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Antibodies
This treatment involves the use ofantibodies to target cancer cells.
The antibodies may work by several
different mechanisms, either depriving thecancer cells of necessary signals or causingthe direct death of the cells.
Because of their specificity, antibodies may
be thought of as a type of specific inhibitor.
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Biological Response
Modifiers These treatments involve the use ofnaturally occurring, normal, proteinsto stimulate the body's own defenses
against cancer.
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Cancer Vaccines
It stimulate the body's defensesagainst cancer.
The treatment aims to increase theresponse of the body against thecancer cells.
Vaccines usually contain proteins found onor produced by cancer cells. Byadministering these proteins,
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Chemotherapy
It refers to a wide range of drugsused to treat cancer.
These drugs generally work by killingdividing cells.
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Goal of Chemotherapy
Is to cure malignancy
Control maybe the goal when cure isnot realistic; the aim is to extendsurvival and improve the quality oflife.
Palliation may be the goal when
neither cure nor control maybeachieved; this goal is directed towardclient comfort.
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Types of Chemotherapy
Drugs Antimetabolites Genotoxic Drugs
Spindle Inhibitors Other Chemotherapy Agents
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Anti- Metabolites
Drugs that interfere with theformation of key bio-moleculeswithin the cell including nucleotides,
the building blocks of DNA. These drugs ultimately interfere with
DNA replication and therefore cell
division.
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Types of Anti-
metabolites Folate Antagonists
Purine Antagonists
Pyrimidine Antagonists
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Folate Antagonist
also known as antifolates
It inhibit dihydrofolate reductase (DHFR),an enzyme involved in the formation of
nucleotides. When this enzyme is blocked,
nucleotides are not formed, disruptingDNA replication and cell division
Methotrexate and Pemetrexed
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Pyrimidine Antagonists act to block the synthesis of pyrimidinecontaining nucleotides (C and T in DNA; Cand U in RNA).
The drugs used to block the construction ofthese nucleotide have structures that are
similar to the natural compound. By acting as 'decoys', these drugs can
prevent the production of the finishednucleotides. They may exert their effects at
different steps in that pathway and maydirectly inhibit crucial enzymes.
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5-fluorouracil
Arabinosylcytosine
Capecitabine Gemcitabine
Decitabine
G t i D
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Genotoxic Drugs
Drugs that damage DNA. By causingDNA damage, these agents interferewith DNA replication, and cell
division 3 Treatments:
Alkylating Agents
Intercalating Agents Enzyme Inhibitors
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The genotoxic chemotherapytreatments include:Alkylating agents: The first class of chemotherapy
agents used. These drugs modify thebases of DNA, interfering with DNAreplication and transcription andleading to mutations
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Intercalating agents
These drugs wedge themselves into the
spaces between the nucleotides in theDNA double helix. They interfere withtranscription, replication and inducemutations.
Enzyme inhibitors
These drugs inhibit key enzymes, such as
topoisomerases, involved in DNAreplication inducing DNA damage.
S i dl I hibit
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Spindle Inhibitors
These agents prevent proper celldivision by interfering with thecytoskeletal components that enable
one cell to divide into two.
Vinca AlkaloidsPaclitaxel (Taxol)Docetaxel (Taxotere)Ixabepilone (Ixempra)
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Additional Chemotherapy
Agents While many of the commonly used
chemotherapy agents fit into one of thethree previously described groupings(Genotoxic, Cytoskeletal, and Anti-metabolite), some of them work throughmechanisms that do not neatly fit into one ofthese categories.
Arsenic trioxide (Trisenox)
BleomycinHydroxyureaStreptozocin
Ch th ti
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Chemotherapeutic
Administration Oral IM/ SQ
IV
Central Venous Catheter
Venous Access Devices (VAD)
Intraarterial Route Intraperitoneal Route