Week6 6671/6611 Flashcards
Modifiable risk factors for cancer
Alcohol Cancer-causing substances Chronic inflammation Diet Hormones Immunosuppression Infectious agents Obesity Radiation Sunlight Tobacco
Carcinogenic drivers
Proto-oncogene
Gene involved in normal cell growth
Mutations may cause it to become an oncogene- which can cause growth of ca cell
Oncogene
Mutated proto-oncogene
Tumor suppressor gene
Negative regulator of growth factor stimulation
Controls cell growth and division
Suppress or block the development of cancer
Anti-oncogene
Cellular or tumor characteristics of cancer
Abnormality
Uncontrollability
Invasiveness
Prevalence refers to?
Expressed by?
Pint prevalence?
Period prevalence?
Number of cases of disease divided by everyone at risk for the disease
Expressed per 1000 people
Point prevalence- counts only those alive at a particular date in time
Period prevalence- counts all cases, including new cases and all deaths between 2 dates (better measure of disease load)
When does a person become a cancer survivor?
At time of dx
Prevalence = survivorship
Incidence rates
New cases
Frequency of occurrence of new cases of disease or injury in a population over a specified period of time
Denominator(s)…
Summed person-years of observation
Average population (usually what literature uses)
Mortality rate
Frequency of death in defined population during a specified interval
Childhood cancer
Average age at dx : 6 y/o
ALL: Acute lymphocytic leukemia
Brain and other CNS tumors
Neuroblastoma
White and Hispanic children have higher incidence rates
1 in 330 dx by age 20
Everyone has a cancer risk, but certain populations are high-risk.
High risk populations?
Heavy alcohol use Older adults Frequent exposure to ca causing substances Obesity Frequent unprotected exposure to sunlight High inflammatory dietary habits Ca survivors Tx including hormones or radiation Persons w/ immunosuppression Exposure to tobacco or smoke
Median ca age
66 y/o
Skin ca lifestyle recommendations
Protect w/ sunscreen (products, clothing, hats and visors)
Minimize time in sun between 10am-4pm
Wear dark fabrics
Check skin regularly
Lung ca screening recommendations
Annual screening with low-dose CT (LDCT) in adults 55-80 who have a 30 pack year smoking history and currently smoke or have quit within past 15 years
Breast ca screening recommendations
Biennial mammogram aged 50-74
Prostate ca screening recommendations
55-69 y/o
Individual decision to do PSA (prostate-specific antigen)
Change in bowel or bladder habits
Action to be taken?
US and endoscopy
A sore that does not heal
Action to be taken?
Biopsy and oral and akin examination
High risk moles - occur after age ?
New moles after age 25
Unusual bleeding or discharge in stool
Action to be taken?
Rectal exam and colonoscopy
Unusual bleeding between periods
Gyno exam for cervix and biopsy
Thickening or lump in breast or testicles
Action to be taken?
US and FNAC if abnormal
Indigestion or difficulty swallowing
Action to be taken?
Endoscopy
Obvious change in size of mole or mouth sore
Action to be taken?
Biopsy
Nagging cough or hoarseness
Action to be taken?
ENT exam and chest X-ray
Pain warranting more investigation
Different tunes- Acute, Chronic/persistent, breakthrough
Different types- nerve, bone, soft tissue, phantom or referred
Nocturnal pain
Doesn’t respond to tx or position change
HA in morning that improves throughout day; may worsen w/ position changes or activity
Benign tumor
7 characteristics
- Typically slow growing
- Localized
- Not invasive
- Not cancerous
- Recurrence unlikely
- Encapsulated
- End with “oma”
Malignant tumor
11 characteristics
- Rapid or slow growing
- Invasive
- Encapsulated - abnormal cell membranes
- Cancerous
- Possible recurrence
- End in “oma” but has more description regarding pathology (organ or cell of origin) - ex: end in “sarcoma”
- No normal cell organization/differentiation
- Lack of control of cell division
- No contact inhibition
- Don’t adhere to each other- often break free from mass, invade other tissues
- Don’t undergo apoptosis
Cancer in skin or in tissues that line/cover internal organs
Carcinoma
Cancer of bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue
Sarcoma
Cancer blood-forming tissue
Leukemia
Cancer of immune system cells
Lymphoma and myeloma
Cancer of brain and spinal cord tissue
CNS cancer
Tumor behaviors- evasion strategies
Immune escape: Loss of immunogenicity Antigenic modulation Induction of immune suppression Prevention of NK and T cell activation
Most common primary ca sites
Skin Lung Breast (F) Colorectal Corpus uteri Prostate (M)
Grading ca
Cell/tissue appearance based on microscopic exam-
GX: Grade cannot be assessed
G1: well differentiated (low grade)
G2: moderately differentiated (intermediate grade)
G3: poorly differentiated (High grade)
G4: undifferentiated (high grade)
Ca staging - specific vs general
Tumor type specific staging takes precedence over general staging guidelines
Primary tumors are staged and graded
Recurrent lesions are NOT restaged
TNM system
T: primary tumor
N: regional lymph nodes
M: distant metastasis
For each:
X: cannot be evaluated
0: NO evidence/involvement/metastasis
1-4: size/extent/degree or M1: metastasis
Staging ca
0: carcinoma in situ
1: early stage, localized to primary organ
2: increased risk of regional spread
3: local ca spread regionally
4: metastasis
Spread of malignant tumors
Invasion
Local spread
Tumor cells grow into adjacent tissues and destroy then
Ex: uterine carcinoma invades vagina
Spread of malignant tumors
Metastasis
Spread to distant sites
Via blood or lymph
Ex: carcinoma of colon spreads to liver
Spread of malignant tumors
Seeding
Implantation
Another form of metastasis
Spread to distant sites via body fluids or along membranes
Ex: ovarian ca spreads through peritoneal cavity
Main sites of metastasis
Cancer type: bladder
Bone
Liver
Lung
Main sites of metastasis
Cancer type: breast
Bone
Brain
Liver
Lung
Main sites of metastasis
Cancer type: colorectal
Liver
Lung
Peritoneum
Main sites of metastasis
Cancer type: kidney
Adrenal gland Bone Brain Liver Lung
Main sites of metastasis
Cancer type: lung
Adrenal gland Bone Brain Liver Other lung
Main sites of metastasis
Cancer type: melanoma
Bone Brain Liver Lung Skin/muscle
Main sites of metastasis
Cancer type: ovary
Liver
Lung
Peritoneum
Main sites of metastasis
Cancer type: pancreas
Liver
Lung
Peritoneum
Main sites of metastasis
Cancer type: prostate
Adrenal gland
Bone
Liver
Lung
Main sites of metastasis
Cancer type: stomach
Liver
Lung
Peritoneum
Main sites of metastasis
Cancer type: thyroid
Bone
Liver
Lung
Main sites of metastasis
Cancer type: uterus
Bone Liver Lung Peritoneum Vagina
1 site of metastasis
Bone
Radiation therapy
Goal, timing and methods
Curative or palliative
Timing: Neoadjuvant, intraoperative (IORT), adjuvant
External beam, teletherapy
Internal radiation, brachytherapy
Systemic
Radiation planning process
External beam
Simulation:
Temp skin marks/tattoos
Positioning
Tx:
5-10 min
Daily 4-6 weeks
Measured in Grays (Gy)
Radiation therapy
Total dosage effects
40 Gy +
Skin effects, hair loss can occur w/ >1 Gy, dryness of glands
50 Gy+
Bone effects
60 Gy+
Soft tissue effects
70 Gy+
Muscle and tendon effects
The glycocalyx layer
Semi-permeable membrane which keeps fluid in the interstitial tissues and unable to re-enter the venous system
If the glycocalyx is intact, when fluid leaves a vessel it NEVER re-enters it.
Venous system is NOT primary mover of interstitial fluid back to the heart
Lymphatics return ___% of whatever is leaked into the tissues.
100%
Technically all edema in skin is lymphedema
The lymph system is a(n) ___ system. Performs ___ not ____.
Open system
Performs lymph transport not lymph circulation
Flow is created with low pressure dynamics (osmotic/tissue pressures, peristaltic muscle and local physiologic conditions)
2 networks of lymph system
Deep and superficial
Deep cannot be treated
We work with superficial
(People don’t live long with deep network problems)
Superficial lymph system
Dx and tx performed ONLY in this level
Flow of lymph arranges into 6 zones
Each have a grouped bed of lymph nodes
Each region independent
Each region marked by a functional landmark called a WATERSHED
All lymph from watershed borders flows towards it’s lymph node bed
Lymph node -
Pressures that drive flow
Return to heart:
Normal BP
Good muscle contraction and tissue pressure
Blood protein concentrations (Normal osmotic pressures)
Retained in tissue:
Gravity
Poor tissue pressure
Lymphedema often occurs as a result of
Systemic and biomechanical malfunctions
Primary lymphedema
Lymphedema from genetic miscoding and anomalies
Hyperplasia or Hypoplasia of venous-lymphatic networks
Transport of loads become poor as management demands increase
Absence of lymphatic structures (aplasia)
Primary Lymphedema onset
0-2 years old : congenital lymphedema
2-35 years old: lymphedema praecox
> 35 years old: lymphedema tarda
Well known genetic syndromes (primary lymphedema)
Milroy syndrome Klinefelter syndrome Turner syndrome Meige’s syndrome Lymphedema-distichiasis syndrome
Secondary causes of lymphatic disease
Venous insufficiency Cancer (and related tx) Trauma and injury Obesity Diseases of other systems: renal, CV, hepatic
Non-western countries (warmer climates):
Filariasis (parasite)
Phlebo-lymphedema
Combined insufficiency
Most common encounter
Lymphatic failure due to chronic venous congestion
Common following orthopedic injury or surgery
Chronic or morbid overload of lymphatics from severe venous congestion
Darkened color
Differentiate between types of lymphedema
Venous
Darkened skin- hemosiderin staining Hx of major organ failure Improves w/ rest or sleep Low protein edema Wounds Thin shiny skin
Differentiate between types of lymphedema
Lymphatic
Milky white skin tone Hx of lymph nodes removed Minimally reduces w/ sleep High protein edema Wounds or hyperkeratosis
Differentiate between types of lymphedema
Systemic failure/Generalized edema
Recent weight gain
Enlarged abdomen, fullness in face, arms and neck
Recent increase in trouble breathing
Reports “feels bad”
Energy level is less functional than previous week
Lymphedema that may indicate recurrence
Sudden, noticeable increase in volume in an area or region
Discomfort or pain in the region or noticeable change in color
Area seems or feels “different” (heavy, achy, tight)
May have other “new” symptoms: bone/joint pain, HA, bloating, etc
Stemmers sign
Pinch between two fingers
Base of 2nd finger/toe (dorsum)
W/ true lymphedema can’t pinch bc too thick
PT without certification
Lymphedema can treat
General outpatient:
Venous insufficiency based lymphedema
MILD presentation, systemic issues are not present or are controlled
No cancer hx, no acute signs of symptoms
Onset correlates to injury or surgery
Area of swelling is in one body region of the extremities
Swelling < 1 month
(Cannot treat any in acute or skilled inpatient without being a Certified lymphedema therapist)
Non-complex edema
General outpatient or subacute facility- certification is not needed
Newly presenting, venous insufficiency based edema
MILD presentation, systemic issues are NOT present or are controlled
No cancer hx, no acute s/s
Onset correlates to recent injury or surgery
Area of swelling is in ONE area of extremities
Swelling present <1 month
Complex edema
Outpatient, Acute care or Skilled facility- CERTIFIED lymphedema therapists
Venous, lymphedema or combined/systemic failure
Moderate-Severe presentation
Onset from any cause
Lymphedema in more than 1 region or body part
Pt has active cancer or in remission
Edema- any symptoms found that may be correlated to infection, cellulitis, DVT, or cancer metastasis/recurrence- patients must be?
Sent back to physician ASAP
If provider can’t see pt right away emergency dept may be needed
Non complex edema mgmt goals
Reduce edema w/o further damage to the skin from excessively tight compression, blood flow reduction or pain
Restore tissue laxity enabling greater ROM, ease of movement, less discomfort/pain
Improve functional movement due to decrease pain, tightness/stiffness and improved proprioceptive input
Facilitate healing and recovery time due to decreased accumulation of cellular waste, increased perfusion and improved therapy performance
Independent self mgmt of variations in swelling
Teach pt symptoms of complex edema and where to get help
Non complex edema -tx options
Elevation is ok for a reasonable period of rest but is not functional for any therapy progress
Simple massage
(Lower leg) simple compression bandaging
Compressive wear: should be worn when up against gravity
Velcro on garments, sports compression wear
Less than 20 mmHg
Be sure compression is ___.
____ is always less than ___.
Gradient
Proximal is always less than distal
Non complex edema -tx options
AVOID vs use
Avoid heat- Use cooling agents
(But avoid cooling to the point is producing hyperemic effects)
Avoid wrapping with bandages that have “low working pressure” - NO ACE, NO TED HOSE
Complex edema and lymphedema- to refer to lymphedema therapist
Presentation
2 pitting or more
Does not return to 100% normal even on waking or with prolonged elevation
Persistent color changes
More than 1 body area involved (ex: lower AND upper leg)
Oncology based patients (active or remission)
If non-pitting, the area is more than 3-4 cm larger than unaffected side
Even if think is going to pass…Once persists longer than 3-4 weeks it can damage structures and become chronic
Complete decongestive therapy
Certified lymphedema therapists
Manual lymph drainage
Multi-layer compression bandaging w/ low elastic properties
Daily use of compression garments
Exercises for improved lymphatic return
Excellent skin care and hygiene
Manual lymph drainage
(Certified lymphedema therapist)
Phase 1: reduction
(complete decongestive therapy)
Stimulates lymphatic vessels to uptake proteins and transport them to regional lymph nodes
Empties lymph nodes and increases their lymph processing
Re-routes lymph flow across watersheds when a lymph region is damaged and cannot receive lymph
Multi-layered compression bandaging
(Certified lymphedema therapist)
Phase 1: reduction
(complete decongestive therapy)
Creates palpable compression gradient from distal to proximal end of affected body area, promoting fluid and proteins transport towards receiving lymph node beds
When done well, bandaging creates functional, effective, comfortable and durable compression environment
Manual lymph drainage
(Certified lymphedema therapist)
Phase 2: containment, independent maintenance, self care, and compression garments
(complete decongestive therapy)
Successful containment of lymph and venous return requires high quality, gradient compression garments that can can comfortably worn throughout the day and often at night
Daily self lymph clearing
Low impact exercise
Stress reduction
Flexitouch- pneumatic compression
