Certain Tumors

Certain Tumors 150 150 Tony Guo
  • Certain tumors are more susceptible to the effects of radiation than others
  • Simulation
    • A process by which radiation treatment fields are defined, filmed, and marked out on skin
    • Radiation oncologist specifies dose and volume of area to be treated
  • Immobilization device
    • The patient is positioned on a simulator, which is a diagnostic x-ray machine that recreates the actions of the linear accelerator and the radiation fields are marked on the patient’s skin.
    • Simulation uses immobilization devices to help the patient maintain a stable position.
    • In this example, a head holder and immobilization mask may be used to ensure accurate positioning for daily treatment of head and neck cancer.
  • Linear accelerator
    • A linear accelerator, which generates ionizing radiation from electricity and can have multiple energies, is the most commonly used machine for delivering external beam radiation.


  • Internal radiation
    • Patient is emitting radioactivity
    • Limit amount of time near patients being treated
      • Organize care
      • Use shielding
      • Wear film badge to monitor exposure


Obstructive Emergencies
Superior Vena Cava Syndrome (SVCS)
  • Results from obstruction of superior vena cava by tumor or thrombosis.
  • Common causes are lung cancer, non-Hodgkin’s lymphoma, and metastatic breast cancer.
  • Presence of central venous catheter and previous mediastinal radiation increase risk of development.
  • Facial edema, periorbital edema.
  • Distention of veins of head, neck, and chest
  • Headache, seizures.
  • Mediastinal mass on chest x-ray.
  • Considered a serious medical problem.
  • Radiation therapy to site of obstruction.
  • Chemotherapy for tumors more sensitive to this therapy.
Spinal Cord Compression
  • Neurologic emergency caused by cancer in epidural space of spinal cord.
  • Common causes are breast, lung, prostate, GI, and renal cancers and melanomas.
  • Lymphomas can also invade epidural space.
  • Intense, localized, and persistent back pain accompanied by vertebral tenderness.
  • Motor weakness, sensory paresthesia and loss.
  • Autonomic dysfunction (e.g., change in bowel or bladder function)
  • Radiation therapy and corticosteroids.
  • Surgical decompressive laminectomy.
  • Activity limitations and pain management.
Third Space Syndrome
  • Shifting of fluid from vascular space to interstitial space.
  • Occurs secondary to extensive surgical procedures, immunotherapy, or septic shock.
  • Signs of hypovolemia: hypotension, tachycardia, low central venous pressure, decreased urine output
  • Fluid, electrolyte, and plasma protein replacement.
  • During recovery hypervolemia can occur, resulting in hypertension, elevated central venous pressure, weight gain, and shortness of breath.
Metabolic Emergencies
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
  • Tumor cells can produce abnormal or sustained production of antidiuretic hormone (ADH).
  • Many chemotherapy agents may also contribute to ectopic ADH production or potentiate ADH effects
  • Water retention and hyponatremia (hypotonic hyponatremia).
  • Weight gain without edema, weakness, anorexia, nausea, vomiting, personality changes, seizures, oliguria, decrease in reflexes, and coma
  • Treat underlying malignancy.
  • Take measures to correct sodium-water imbalance, including fluid restriction, oral salt tablets or isotonic (0.9%) saline administration, and IV 3% sodium chloride solution (severe cases).
  • Furosemide (Lasix) used in initial phases.
  • Monitor sodium level because correcting SIADH rapidly may result in seizures or death.
  • Occurs in metastatic disease of bone or multiple myeloma, or when a parathyroid hormone–like substance is secreted by cancer cells.
  • Immobility and dehydration can contribute to or exacerbate hypercalcemia.
  • Serum calcium in excess of 12 mg/dL (3 mmol/L) often produces symptoms.
  • Apathy, depression, fatigue, muscle weakness, ECG changes, polyuria and nocturia, anorexia, nausea, and vomiting.
  • High calcium elevations can be life threatening.
  • Chronic hypercalcemia can result in nephrocalcinosis and irreversible renal failure.
  • Treat primary disease.
  • Hydration (3 L/day) and bisphosphonate therapy.
  • Diuretics (particularly loop diuretics) used to prevent heart failure or edema.
  • Infusion of bisphosphonate zoledronate (Zometa) or pamidronate (Aredia)
Tumor Lysis Syndrome (TLS)
  • Metabolic complication characterized by rapid release of intracellular components in response to chemotherapy and radiation therapy (less commonly).
  • Massive cell destruction releases intracellular components (potassium, phosphate, DNA, RNA) that are metabolized to uric acid by liver.
  • Hallmark signs: hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia.
  • Weakness, muscle cramps, diarrhea, nausea, and vomiting.
  • Occurs within first 24 to 48 hr. after initiation of chemotherapy.
  • May persist for about 5 to 7 days.
  • Metabolic abnormalities and concentrated uric acid (which crystallizes in distal tubules of kidneys) can lead to acute kidney injury.
  • Identify patients at risk.
  • Increase urine production using hydration therapy.
  • Decrease uric acid concentrations using allopurinol.
  • Use IV sodium bicarbonate to counter effects of acidic properties that are released
Infiltrative Emergencies
Cardiac Tamponade
  • Fluid accumulation in pericardium.
  • Caused by constriction of pericardium by tumor or pericarditis secondary to radiation therapy to the chest
  • Heavy feeling over chest, shortness of breath, tachycardia, cough, dysphagia, hiccups, hoarseness.
  • Nausea, vomiting, excessive perspiration.
  • Decreased level of consciousness, distant or muted heart sounds.
  • Extreme anxiety.
  • Decrease fluid around heart using (1) surgery to create a pericardial window or an (2) indwelling pericardial catheter.
  • Administer O2 therapy, IV hydration, and vasopressor therapy
Carotid Artery Rupture
  • Invasion of arterial wall by tumor or erosion following surgery or radiation therapy.
  • Occurs most frequently in patients with head and neck cancer
  • Bleeding: ranges from minor oozing to spurting of blood in the case of a “blowout” of artery.
  • Administer IV fluids and blood products.
  • Surgery: ligation of carotid artery above and below rupture site and reduction of local tumor


Nursing Implications

  • Bone marrow suppression
    • Myelosuppression: most common side effect of chemotherapy
    • Treatment-induced reductions in RBCs and WBCs can result in
      • Infection
      • Hemorrhage
      • Overwhelming fatigue
  • Fatigue
    • Encourage conservation strategies
      • Rest before activity
      • Get assistance with activity
      • Remain active during periods of time patients feel better
    • Maintain nutritional and hydration status
    • Assess for reversible causes of fatigue
  • Gastrointestinal (GI) effects 
    • Prophylactic administration of antiemetics
    • Assess for signs and symptoms of 
      • Alkalosis, dehydration, and I and O
    • Nonirritating, low-fiber, high-calorie, high-protein diet
    • Antidiarrheal, antimotility, and antispasmodic medications
    • Anorexia
      • Monitor carefully to avoid weight loss
        • Weigh twice weekly
      • Recommend small, frequent, high-protein, high-calorie meals
      • Involve dietitian before treatment begins
  • Skin reactions
    • Occur in radiation treatment field
    • Acute or chronic
      • Develop 1 to 24 hours after treatment
      • Generally progressive as treatment dose accumulates
    • Dry desquamation
      • Erythema is an acute response followed by dry desquamation. 
      • Dry reactions are uncomfortable and result in pruritus. Lubricate the dry skin with a nonirritating lotion emollient (such as aloe vera) that contains no metal, alcohol, perfume, or additives that can be irritating to the skin.
    • Wet desquamation
      • If the rate of cell sloughing is faster than the ability of the new epidermal cells to replace dead cells, a wet desquamation occurs with exposure of the dermis and weeping of serous fluid.
      • Wet reaction must be kept clean and protected from further damage.
      • Wet desquamation of tissues generally produces pain, drainage, and increased risk of infection.
    • Prevent infection
    • Facilitate wound healing
    • Protect irritated skin temperature extremes
    • Avoid constricting garments, harsh chemicals, and deodorants
    • Help patients deal with hair loss (alopecia)
  • Reproductive effects
    • Inform patient of expected sexual side effects
    • Use appropriate shielding
    • Encourage discussion of issues related to reproduction and sexuality
    • Refer to counseling if needed



  • Immunotherapy uses the immune system to fight cancer
  • Some types called biologic therapy
  • Boost or manipulate the immune system and create an environment not conducive for cancer cells to grow
  • Attack cancer cells directly

Target therapy

  • Interferes with cancer growth by targeting specific cell receptors and pathways that are important in tumor growth
    • Does less damage to normal cells
    • Agents that target specific oncogenes are being developed

Hormone therapy

  • Sex hormones
    • Can stop the growth of cancer cells
  • Corticosteroids
    • Used in combination with drug regimens to help curb side effects

Hematopoietic Stem Cell Transplantation (HSCT)

  • Bone marrow transplant (BMT) 
  • Peripheral stem cell transplantation (PSCT) 
  • Allows high doses for treatment 
    • Failing to respond to standard doses of chemotherapy or radiation
    • Develop resistance (refractory)
  • Procedure with many risks, including death
  • Highly toxic
  • Overall cure rates are steadily increasing
  • Tumor cells are eradicated and bone marrow is rescued by infusing healthy cells

Gene Therapy

  • Experimental therapy
    • Genetic material is introduced into cells to fight disease
    • Investigational


Complications of cancer

  • Patients with cancer may develop complications from 
    • Continual growth of the cancer into normal tissue
    • Side effects of treatment

Nutritional problems

  • Malnutrition
  • Altered taste sensation (dysgeusia)
    • Physiologic basis of altered taste is unknown
  • Wasting syndrome (Cancer cachexia)
    • Upper gastrointestinal and pancreatic cancer patient are at great risk
  • Infections
    • Usual sites of infection include the lungs, GU system, mouth, rectum, peritoneal cavity, and blood (septicemia).
    • Infection occurs as a result of the ulceration and necrosis caused by the tumor, compression of vital organs by the tumor, and neutropenia caused by the disease process or the cancer treatment.

Cancer pain

  • Patient report should always be believed and accepted as primary source for pain assessment data
  • Drug therapy should be used to control pain
  • Inadequate pain assessment is single greatest barrier to effective cancer pain management
    • Management of cancer pain
      • Fear of addiction is unwarranted
      • Numerous drug options for pain management
      • Nonpharmacologic interventions, including relaxation therapy and imagery, can be used effectively
    • Moderate to severe pain occurs in approximately 50% of patients who are receiving active treatment for their cancer and in 80% to 90% of patients with advanced cancer.
    • It is essential to perform a comprehensive pain assessment on an ongoing basis and to enact a pain management plan that addresses both components of pain if they are present.


Coping with cancer and treatment

  • Nursing assessment and support are key
    • Pervasive anxiety and fear
      • Fears of dependency
      • Loss of control
      • Family relationship stress
      • Financial burden
      • Fear of death
        • Be available, especially during difficult times
        • Exhibit caring
        • Actively listen
        • Provide symptom relief
        • Provide accurate information
        • Build trust
        • Use touch
        • Assist setting realistic goals
        • Support usual lifestyle patterns
        • Maintain hope
        • Reassure of ongoing support
        • Offer support from survivors
          • Improvement in early detection and treatment
          • > 14.5 million in the United States

Summary of cancer

  • Initiation, the first stage, is a mutation in the cell’s DNA structure following exposure to a chemical, radiation, or viral agent. The mutation may also be inherited.
  • Promotion, the second stage in the development of cancer, is characterized by the reversible proliferation of the altered cells.
  • Progression, the final stage, is characterized by increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site (metastasis).

Factors that may influence ability to cope

  • Ability to cope with stressful events in the past, availability of significant others, ability to express feelings and concerns, age at the time of diagnosis, extent of disease, disruption of body image, presence of symptoms, past experience with cancer, and attitude associated with cancer.


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