Topic 3 NCM 106

3. CELLULAR ABERRATION The Biology Cancer Part 2

DIAGNOSIS

Imaging studies Excision or Fine Needle Aspiration Biopsy

with microscopic histologic examination Pap smear Blood tests – for example PSA for prostate

carcinoma, CEA or AFP for HCC or testicular, CEA for colorectal carcinoma, CA-125 for ovarian carcinoma, ALP for HCC or bone

Cytologic examination of blood cells – for leukemia

Urine with cancer cells (urine cytology

DIAGNOSTIC AIDS USED TO DETECT CANCER

Tumor markers – breast, colon, lung, ovarian, testicular, prostate cancers

MRI – neurologic, pelvic, abdominal, thoracic cancers

Fluoroscopy – neurologic, pelvic, skeletal, abdominal, thoracic cancers

UTZ – abdominal and pelvic cancers Endoscopy – bronchial, GIT cancers

MRI

Fluoroscopy

UTZ

DIAGNOSTIC AIDS USED TO DETECT CANCER

Nuclear medicine imaging – bone, liver, kidney, spleen, brain, thyroid cancers

PET – lung, colon, liver, pancreatic, head and neck cancers; Hodgkin and Non-Hodgkin lymphoma and melanoma

PET fusion – see PET Radioimmunoconjugates – colorectal, breast,

ovarian, head and neck cancers; lymphoma and melanoma

Nuclear Imaging

Nuclear Imaging

PET scan

Nomenclature

Tissue of origin

Benign Malignant

Ectoderm/endoderm

Epithelium Papilloma Carcinoma

Gland Adenoma Adenocarcinoma

Liver cells Adenoma HCC

Neuroglia Glioma Glioma

Melanocytes Malignant melanoma

Basal cells Basal cell carcinoma

Germ cells Mature teratoma Seminoma

Mesoderm Connective tissue

Adipose tissue Lipoma Liposarcoma

Fibrous Fibroma Fibrosarcoma

Bone Osteoma Osteosarcoma

Cartilage Chondroma Chondrosarcoma

Nomenclature

Tissue of origin Benign Malignant

Mesoderm Muscle

Smooth muscle Leiomyoma Leiomyosarcoma

Striated muscle Rhabdomyoma Rhabdomyosarcoma

Neural tissue

Nerve cells Ganglioneuroma Neuroblastoma

Endothelial tissue

Blood vessels Hemagioma AngiosarcomaKaposi sarcoma

Meninges Meningioma Malignant meningioma

Hematopioetic tissue

Granulocytes Leukemia

Plasma cells Multiple myelomaplasmacytoma

Lymphocytes Lymphoma

Site Gender Age Evaluation Frequency

Breast

Colon and rectum

F

F/M

20-39

>40

>50

Clinical breast examination (CBE)Self breast examination (SBE)CBESBEMammogram

Fecal occult blood and flexible sigmoidoscopy or colonoscopy or double-contrast barium enema

Every 3 years

Every month

Every yearEvery monthEvery year

Every 5 years

Every 10 years

Every 5 years

Site Gender Age Evaluation Frequency

Prostate

Cervix

Cancer-related check ups

M

F

M/F

>50 (or 40-45 if at high risk)

>21 or within 3 years after starting to have intercourse

>20-39

40+

PSA and DRE

Pap smear

Pelvic examinationExamination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity and skin as well as counseling about health practices and risk factorsSame as 20-39

Every year

Every year if regular Pap; every 2 years if liquid Pap test

Every year

Every 3 years

Every year

MANAGEMENT OF CANCER

Surgery surgical removal of the entire cancer remains the ideal and most frequently used treatment method

a. Diagnostic surgery – biopsyb. As primary treatmentc. Prophylactic treatmentd. Palliative treatmente. Reconstructive surgery


Nursing management in cancer surgerya. The nurse completes a thorough

preoperative assessment for factors that may affect the patient undergoing the surgical procedure

b. The patient and family require time and assistance to deal with the possible changes and the outcomes resulting from the surgery

c. The nurse provides education and emotional support by assessing the needs of the patient and family and by discussing their fear and coping mechanisms with them

MANAGEMENT OF CANCER Nursing management in cancer surgeryd. After surgery, the nurse assesses the patient’s

responses to the surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction

e. The nurse also provides for the patient’s comfort. Postoperative teaching addresses wound care, activity, nutrition, and medication information

f. Plans for discharge, follow-up and home care, and treatment are initiated as early as possible to ensure continuity of care from hospital to home or from a cancer referral center to the patient’s local hospital and health care provider.


Radiation therapya. External radiationb. Internal radiation or brachytherapyc. Radiation dosage – dependent on the

sensitivity of the target tissue to radiation and on the tumor size

d. Toxicity – localized to the region being irradiated


Nursing Management in Radiation therapya. The nurse can explain the procedure for

delivering radiation and describe the equipment, the duration of the procedure (often minutes only), the possible need for immobilizing the patient during the procedure

b. The nurse informs the family about restrictions placed on visitors and health personnel and other radiation precautions, for radioactive implants

MANAGEMENT OF CANCER Chemotherapy a. Antineoplastic agents are used in an attempt

to destroy tumor cells by interfering with cellular functions, including replication

b. Used primarily to treat systemic disease rather than localized lesions that are amenable to surgery or radiation

c. May be combined with surgery, radiation therapy, or both, to reduce tumor size preoperatively, to destroy any remaining tumor cells postoperatively, or to treat some forms of leukemia

d. Goals: cure, control and palliation

ANTINEOPLASTIC DRUGS

UNDERSIRABLE EFFECTS

Undesirable Effects: Bone marrow depression Alopecia Retching-nausea/vomiting Fear and anxiety Stomatitis

GENERAL GUIDELINES FOR ANTINEOPLASTIC DRUGS

CBC, platelets - monitor Antiemetics before taking drug Nephrotoxicity - undesirable effect Counseling regarding reproduction issues Encourage handwashing, avoid crowds Recommend a wig for alopecia

PRIMARY GOALS OF CHEMOTHERAPY

Achieve a complete cure; permanent removal of all cancer cells from the body.

Control or manage the disease, cancer is not eliminated, preventing the growth and spread of the tumor may extend the patient’s life

Palliation - reduce the size of the tumor, easing the severity of pain and other tumor symptoms, thus improving the quality of life.

REASON FOR MULTIPLE DRUG USE AND SPECIAL SCHEDULING

Rapid cell division, Tumor cells express a high mutation rate Tumor changes its genetic make-up as it grows hundreds of different clones with different growth

rates and physiological properties Drugs affect cells in different ways and at

different times in their life cycle

Figure 27.3 Antineoplastic agents and the cell cycle

TYPES OF ANTINEOPLASTIC DRUGS

ALKYLATING AGENTS Action: Causes cell death or mutation of malignant growth

by changing the structure of malignant cell growth Indications: Palliative treatment of chronic lymphocytic

leukemia; malignant lymphomas; Hodgkin’s disease; breast, lung and ovarian cancers

Adverse Effects: Bone marrow depression (leukopenia, thrombocytopenia) Anorexia/alopecia Distressful nausea and vomiting Drugs: Busulfan, carboplatin, carmustine

Figure 27.4 Mechanism of action of alkylating agents

ANTIMETABOLITES Action: Interferes with the building blocks of DNA

synthesis Indications: Myelocytic leukemia; acute

lymphocytic leukemia; Cancer of the breast, cervix, colon, liver, ovary, pancreas, stomach and rectum

Adverse effects: GI disturbance, oral and anal inflammation, bone marrow depression, alopecia, renal dysfunction, thrombocytopenia

Drugs: Capecitabine; cytarabine

GENERAL GUIDELINES IN GIVING ANTIMETABOLITES Monitor CBC and platelets weekly Evaluate renal function test Temperature assessment q4-6 hours Asepsis (strict) Bleeding, anemia, infection, and nausea - report Oral hygiene - brush with soft toothbrush Lots of fluids (2-3 L/day) Intake and output, nutritional intake - monitor The protocols for handling and administering - follow Emphasize protective isolation

ANTITUMOR ANTIBIOTICS

Action: binding to DNA making it unable to separate (2) inhibiting ribonucleic acid (RNA), preventing enzyme synthesis.

PLANT EXTRACTS

VINCA ALKALOIDS Inhibits mitotic division

TAXANES Inhibits mitotic division

TOPOISOMERASE INHIBITORS Breaks the DNA strands therefore altering the

integrity of the genome

Biologic Response Modifiers

Interferons (IFNs) Cytokines secreted by lymphocytes and

macrophages Slow the spread of viral infections Enhance the activity of existing leukocytes.

Biologic Response Modifiers

Interleukins Levamisole (Ergamisole) stimulate B cells, T

cells, and macrophages in patients with colon cancer

Bacille Calmette-Guéin (BCG) vaccine (TICE, TheraCys) is an attenuated strain of Mycobacterium tuberculosis, used for the pharmacotherapy of certain types of bladder cancer.

Table 27.6 (continued) Hormones and Hormone Antagonists


Nursing management in chemotherapya. Assess fluid and electrolyte imbalanceb. Modify risks for infection and bleedingc. Administering chemotherapyd. Protecting caregivers

Lab Values

Patients with cancer require regular monitoring of lab values by nurses who will anticipate their health care needs.

Nursing interventions can include prophylactic measures if abnormal lab values are noted and addressed quickly.

Leukopenia

Chemotherapy and radiation therapy can decrease a patient's white blood cell (WBC) count and lead to leukopenia .

Because neutrophils act as phagocytes, a significant decrease in the neutrophil count places a patient with cancer at high risk for infection.

Neutropenia

A measure used to assess a patient's risk for infection is the absolute neutrophil count (ANC).

ANC less than 500 places the patient at severe risk for infection, and a count less than 100 constitutes extreme risk.

The patient may receive medications on a daily basis to stimulate WBC production.

The nurse should know the ANC prior to medication administration and take appropriate measures to prevent infection

Anemia

Anemia occurs when the patient's red blood cells (RBC) are lost or the production rate is decreased; low hemoglobin and hematocrit result.

Any abnormal values should be discussed with the primary care provider because the patient with cancer may require blood transfusions before reaching critically low levels.

Critical values for hemoglobin and hematocrit are less than 5.0 g/dl.

Thrombocytopenia

Thrombocytopenia occurs when platelet counts fall below 100,000.

Spontaneous bleeding can occur when platelet levels fall below 20,000.

To avoid an emergent situation, the nurse should report platelet count at 40,000.

The patient with elevated platelets can also develop bleeding if the platelet function is abnormal.

Hematopoietic Growth Factors or Colony-stimulating factors

Medications that help improve these hematologic conditions are hematopoietic growth factors or colony-stimulating factors.

These agents stimulate red and/or white blood cell production and maturation.

The nurse should be aware of administration techniques, expected therapeutic outcomes, and potential adverse effects.

Colony Stimulating Factors

Filigastrim (Neupogen) and sargramostim (Leukine) are used to enhance the WBC count.

Pegfiligastrim (Neulasta) for patients with a decreased WBC.

These medications may be needed if the patient is receiving antineoplastic agents that suppress the bone marrow.

Epoetin alfa recombinant (Procrit) is administered to maintain or increase the patient's RBC level.

Positive results with this medication can decrease the need for blood transfusions.

Colony Stimulating Factors

Oprelvekin (Neumega), also known as interleukin 11, is a growth factor that is used to prevent thrombocytopenia following chemotherapy infusion.

This medication allows hematopoietic stem cells and the progenitor cells to proliferate, increasing platelet production.

As the plasma volume increases, the nurse may see decreased hemoglobin, decreased serum albumin, and decreased gamma globulins.

The nurse must review lab values and administration routes associated with the use of colony-stimulating factors prior to their administration.

Electrolyte Imbalance

Electrolytes, essential for normal physiologic function of nerves and muscles, are monitored closely in the patient with cancer.

Elevated or decreased electrolyte levels can have life-threatening effects.

The nurse must anticipate problems such as cardiac dysrhythmias or uncontrolled bleeding and intervene quickly.

Intravenous fluids, oral electrolyte supplements, and/or total parenteral nutrition (TPN) can influence electrolyte balances.

The nurse must be able to report current lab values and all sources of ingested or parenteral electrolytes to oncology specialists.

Neutropenia Precautions

Neutropenia could be related to the cancer pathology or the result of receiving chemotherapeutic agents.

Individuals with an absolute neutrophil count of less than 1,000 cells are considered neutropenic and are at moderate risk for infection.

ANC less than 500 creates a severe risk for the patient, and ANC less than 100 places the patient in an extreme risk category.

Nadir

The term nadir represents that period of time when blood levels are at their lowest point.

The nadir period varies for each antineoplastic agent.

Most nadir periods occur approximately 10 to 14 days after the beginning of chemotherapy treatment or several weeks following radiation therapy, depending on the treatment agent and life span of the particular blood cells

Reversed Isolation Precautions

An immunocompromised state makes it difficult for the patient with cancer to combat even minor colds; sepsis can result.

When assigned to care for a patient who is neutropenic, the nurse must review guidelines regarding care of an immunocompromised patient.

Common Adverse Effects of Chemotherapy and Radiation

Fatigue Nausea Pain Vomiting Oral stomatitis Bone/Joint Pain Anorexia Constipation Diarrhea Impaired skin integrity Alopecia

All patients do not experience these adverse effects; however, the nurse should be aware of assessment criteria and early intervention strategies

Fatigue: Nursing Intervention

Occurs greater than 70% It can occur when the patient reaches the

nadir period. Clustering patient care activities can reduce

fatigue and provide uninterrupted rest periods.

A sign on the patient's room door can prompt visitors to check with the nurse before entering.

Nausea and Vomiting: Nursing Intervention

Nausea and vomiting occur frequently with the use of chemotherapeutic agents.

Some chemotherapy drug regimens include antiemetics prior to administration to promote patient tolerance of the treatment.

Specific food choices such as gelatin, popsicles, and soft bland food may minimize queasiness

The patient should be encouraged to experiment with his or her diet to increase calories.

The patient must consume an adequate number of calories to maintain nutrition balance and enhance quality of life.

A dietary consult may be helpful in identifying the patient's caloric needs and identifying which foods would be best.

Oral Stomatitis: Nursing Intervention

Rapidly dividing cells in the mouth are affected by chemotherapy and radiation treatments, leading to painful mouth sores and chapped lips.

Candida albicans (yeast) may occur on the tongue and oral mucosa. Often, excess oral secretions make it difficult for the patient to speak clearly or to eat a substantial amount of food.

The patient may find relief from sucking on ice chips or popsicles. Several combinations of mouth rinses are available, depending on the

patient's need - excess secretions may require diphenhydramine (Benadry) in a mouth rinse, for increased pain may need lidocaine or water and baking soda rinses.

Frequent oral care is vital to preserve mucosal integrity. Individual needs and the extent of the stomatitis should be discussed

with the primary care provider to determine the best intervention.

Bone/Joint Pain: Nursing Interventions

Bone and joint pain increases as cancer advances and as an adverse effect of colony-stimulating factors.

Analgesics and anti-inflammatory medications, as well as alternative pain relief measures, can be used.

Alternative pain relief measures can include guided imagery, music therapy, relaxation exercises, and massage, if appropriate.

Constipation and Diarrhea: Nursing Interventions

The disease process, lack of activity, and frequent use of opioids may result in constipation.

High fiber food choices, adequate fluid intake, and stool softeners are used to promote regular elimination and help prevent bloating.

Diarrhea can result from frequent use of antibiotics and antiemetics.

Dehydration and the loss of electrolytes, minerals, and nutrients can result. Stool specimens may he collected to determine if an infection has occurred. If no infection is detected, antidiarrheal medications may be ordered.

It is important to replace lost fluids, maintain electrolyte levels, and prevent sepsis.

In either constipation or diarrhea, the nurse should anticipate the patient's needs and initiate preventive measures.

Delirium: Nursing Intervention Agitated behavior requiring sedation, also described as delirium,

terminal restlessness, mental anguish and agitation, are common problems in cancer patients.

Factors such as cachexia, hypoalbuminemia, advanced age, and prior dementia can contribute to this condition.

Identification and treatment of delirium may involve such interventions as discontinuation or dose reduction of psychoactive medications, adjustments in fluid administration, or treatment of infections, dehydration, or electrolyte imbalances.

Ongoing monitoring and reassessment are critical especially when sedatives, opioids, or other psychoactive medications are required to control patient's symptoms.

Changes in the patient's health and mental status, in laboratory values, and symptoms that suggest drug toxicity should be reported promptly to the oncology specialist.

A psychosocial intervention for family caregivers of patients with advanced cancer may be beneficial.

Skin Integrity: Nursing Intervention

Maintaining skin integrity is a priority during the treatment and healing process of cancer.

Irradiated tissue, at risk for skin breakdown and delayed wound healing, should be assessed at least every shift.

Chemotherapy and radiation injure the rapidly dividing cells of the skin.

A patient with cancer may remain in bed for long periods of time due to fatigue and pain.

The underlying effects to the skin may not be visible immediately, and recovery will depend on the patient's response to treatment

Adequate nutrition is also an important component in maintaining skin integrity.

Cancer-associated cachexia, related to inadequate caloric needs and decreased protein intake, can delay wound healing

A skin assessment instrument, such as the Braden Scale, should be used to evaluate the patient each shift and determine specific interventions.

Anorexia: Nursing Intervention

Chemotherapy and radiation treatments affect rapidly dividing cells and can alter taste sensation.

Mouth rinses with baking soda and water can be used to soothe the mucosa prior to meals.

Megestrol acetate (Megace) has been used for appetite enhancement in the patient with advanced cancer.

Liquid nutritional supplements, such as health shakes, can also be offered.

The use of TPN may be necessary if other means for nutritional support are exhausted.

Chemotherapy Precautions

The nurse needs to be familiar with chemotherapy precautions, which are followed for a period of 48 hours after the patient's last dose of an antineoplastic agent.

Antineoplastic agents are excreted from the body through fluids such as sweat, vomitus, stool, and urine.

The nurse should use personal protective equipment (PPE) for each patient contact.

PPE includes masks with face shields or goggles, chemotherapy gloves, and a fluid-resistant gown.

Handwashing before and after working with the patient is essential. The nurse should cover the commode or toilet with a disposable drape

to prevent fluids from splashing while flushing twice. Specified receptacles for linen and trash disposal must be used. Family members must be instructed on and follow the necessary

precautions. The facility should have a policy that stipulates precautions and

supplies used to protect the staff, patient, and visitors.


Bone Marrow Transplantationa. Allogenic (from a donor other than the

patient); either a related donor or a matched unrelated donor

b. Autologous (from patient)c. Syngeneic (from an identical twin)


Nursing Management in Bone Marrow Transplantation

a. Implementing pretransplantation careb. Providing care during treatmentc. Providing posttransplantation care


Hyperthermia Targeted therapiesa. BRMb. Gene therapyc. Growth factors Photodynamic therapy Cancer rehabilitation

SQUAMOUS CELL CARCINOMA

SCC The second most common tumor arising on

sun-exposed sites in older people, exceeded only by basal cell carcinoma

Except for lesions on the lower legs, these tumors have a higher incidence in men than in women

The most important cause of cutaneous SCC is DNA damage induced by exposure to UV light

Is invasive, can recur and metastasize


Other Risk Factors1. Age older than 50 years2. Light skin; blonde or light brown hair; green,

blue, or gray eyes3. Skin that sunburns easily (Fitzpatrick skin

types I and II)4. Geography (closer to the equator)(http://emedicine.medscape.com/article/1101535-

overview)


Immunosuppression may contribute to carcinogenesis by reducing host surveillance and increasing the susceptibility of keratinocytes to infection and transformation by oncogenic viruses, particularly HPV subtypes 5 and 8

Other risk fatcors include industrial carcinogens (tars and oils), chronic ulcers and draining osteomyelitis, old burn scars, ingestion of arsenicals, ionizing radiation, and (in the oral cavity) tobacco and betel nut chewing

SQUAMOUS CELL CARCINOMA History A new and enlarging lesion that concerns the

patient Most lesions are slow growing, while others rapidly

enlarges Symptoms such as bleeding, weeping, pain, or

tenderness may be noted, especially with larger tumors

Numbness, tingling, or muscle weakness may reflect underlying perineural involvement, and this history finding is important to elicit because it adversely impacts prognosis.

May be asymptomatic(http://emedicine.medscape.com/article/

1101535-overview)


Imaging studies like CT scan are done for patients with neurologic symptoms and with (+) lymphadenopathy

FNAB or excision biopsy of palpable lymph nodes

Small biopsies of the lesion suspected to be SCC(http://emedicine.medscape.com/article/

1101535-overview)


Nonsurgical treatment options:1. topical chemotherapy - 5-FU2. topical immune response modifiers –

sirolimus, prednisone, cyclosporine, azathioprine, and mycophenolate

3. photodynamic therapy (PDT)4. Radiotherapy5. Systemic chemotherapy – 5-FU and

cetuximab (EGFR antagonist)(http://emedicine.medscape.com/article/

1101535-overview)


Surgical treatment options:1. Cryotherapy – for in-situ lesions; makes use

of liquid nitrogen2. Electrodesiccation and curettage – for low-

risk carcinomas of the trunk and extremities3. Excision with conventional margins(http://emedicine.medscape.com/article/

1101535-overview)

Electrodesiccation

Excision biopsy

BASAL CELL CARCINOMA

BCC The most common invasive cancer in

humans Slow-growing tumors that rarely metastasize Have a tendency to occur in sun-exposed

areas and in lightly pigmented people Incidence rises sharply with

immunosuppression and in people with inherited defects in DNA repair


Tumors present clinically as pearly papules often containing prominent dilated subepidermal blood vessels

Advanced lesion may ulcerate, and extensive local invasion of bone and facial sinuses may occur after many years of neglect (rodent ulcers)

BASAL CELL CARCINOMA Treatment1. Electrodessication and curettage involves

destroying the tumor with an electrocautery device then scraping the area with a curette

2. Surgical excision of the lesion including a margin of normal skin. This method is preferred for larger lesions (>2cm) on the cheek, forehead, trunk, and legs

3. Radiation therapy - may also be used where tumors are difficult to excise or where it is important to preserve surrounding tissue such as the lip. Its use is declining.

4. Cryotherapy - involves destroying the tissue by freezing it with liquid nitrogen. This may be effective for small, well-defined superficial tumors


Prevention 1. Avoid UVB radiation from sun exposure

especially midday sun 2. Use protective clothing 3. Use sunscreen with an SPF of at least 15.

This is especially important for children. 4. Have suspicious lesions checked out - If you

have a question, get it checked out. Treating premalignant lesions prevents their transformation to potentially metastatic cancers.

MELANOMA

A relatively common neoplasm that remains deadly if not caught at its earliest stages

Can occur in the oral and anogenital mucosal surfaces, esophagus, meninges, and the eye

Melanomas evolve over time from localized skin lesions to aggressive tumors that metastatize and are resistant to therapy

Early recognition and complete excision are critical

MELANOMA

Usually asymptomatic Itching or pain may be an early manifestation Majority of lesions are greater than 10 mm in

diameter at diagnosis Most consistent clinical signs (in pigmented

lesions):1. Changes in color2. Changes in size3. Changes in shape

MELANOMA

Unlike benign tumors, these tumors show variations in color (shades of black, brown, red, dark blue, and gray)

There may be areas of hypopigmentation Borders are irregular and often notched, not

smooth, round, and uniform Important warning signs (ABCs):1. Asymmetry2. Irregular borders3. Variegated color

MELANOMA

Other features:1. Diameter greater than 6 mm2. Any change in appearance3. New onset of itching4. Or new onset of pain

MELANOMA

Prognostic factors:1. Tumor depth - <1.7mm (favorable)2. Number of mitoses – no or few mitoses

(favorable)3. Evidence of tumor regression – absence

(favorable)4. The presence and number of tumor

infiltrating lymphocytes – brisk (favorable)5. Gender – female (favorable)6. Location – location on an extremity

(favorable)

MELANOMA

The two most important predisposing factors are inherited genes and sun exposure

Treatment is by stage

Stage 0 melanoma. Abnormal melanocytes are in the epidermis (outer layer of the skin).

Stage I melanoma. In stage IA, the tumor is not more than 1 millimeter thick, with no ulceration (break in the skin). In stage IB, the tumor is either not more than 1 millimeter thick, with ulceration, OR more than 1 but not more than 2 millimeters thick, with no ulceration. Skin thickness is different on different parts of the body.

Stage II melanoma. In stage IIA, the tumor is either more than 1 but not more than 2 millimeters thick, with ulceration (break in the skin), OR it is more than 2 but not more than 4 millimeters thick, with no ulceration. In stage IIB, the tumor is either more than 2 but not more than 4 millimeters thick, with ulceration, OR it is more than 4 millimeters thick, with no ulceration. In stage IIC, the tumor is more than 4 millimeters thick, with ulceration. Skin thickness is different on different parts of the body.

Stage III melanoma. The tumor may be any thickness with or without ulceration. It has spread either (a) into a nearby lymph vessel and may have spread to nearby lymph nodes; OR (b) to 1 or more lymph nodes, which may be matted (not moveable). Skin thickness is different on different parts of the body.

Stage IV melanoma. The tumor has spread to other parts of the body.

MELANOMA Stage 0 (Melanoma in Situ) - Treatment of stage 0

is usually surgery to remove the area of abnormal cells and a small amount of normal tissue around it.

Stage I Melanoma

1. Surgery to remove the tumor and some of the normal tissue around it.

2. A clinical trial of surgery to remove the tumor and some of the normal tissue around it, with or without lymph node mapping and lymphadenectomy.

3. A clinical trial of new techniques to detect cancer cells in the lymph nodes.

4. A clinical trial of lymphadenectomy with or without adjuvant therapy.

MELANOMA Stage II Melanoma1. Surgery to remove the tumor and some of the

normal tissue around it, followed by removal of nearby lymph nodes.

2. Lymph node mapping and sentinel lymph node biopsy, followed by surgery to remove the tumor and some of the normal tissue around it. If cancer is found in the sentinel lymph node, a second surgery may be done to remove more nearby lymph nodes.

3. Surgery followed by high- dose biologic therapy.4. A clinical trial of adjuvant chemotherapy and/or

biologic therapy.5. A clinical trial of new techniques to detect

cancer cells in the lymph nodes.

MELANOMA Stage III Melanoma

1. Surgery to remove the tumor and some of the normal tissue around it.

2. Surgery to remove the tumor with skin grafting to cover the wound caused by surgery.

3. Surgery followed by biologic therapy.

4. A clinical trial of surgery followed by chemotherapy and/or biologic therapy.

5. A clinical trial of biologic therapy.

6. A clinical trial comparing surgery alone to surgery with biologic therapy.

7. A clinical trial of chemoimmunotherapy or biologic therapy.

8. A clinical trial of hyperthermic isolated limb perfusion using chemotherapy and biologic therapy.

9. A clinical trial of biologic therapy and radiation therapy.

MELANOMA

Stage IV Melanoma1. Surgery or radiation therapy as palliative

therapy to relieve symptoms and improve quality of life.

2. Chemotherapy and/or biologic therapy.3. A clinical trial of new chemotherapy, biologic

therapy, and/or targeted therapy with monoclonal antibodies, or vaccine therapy.

4. A clinical trial of radiation therapy as palliative therapy to relieve symptoms and improve quality of life.

5. A clinical trial of surgery to remove all known cancer.

Health & Medicine

Topic 3 NCM 106