Download Alterations in Cell Differentiation/Neoplasia

Unit 4 Alterations in Cell Differentiation/Neoplasia
UNIT 4
(OPTION)
Alterations in Cell
Differentiation/Neoplasia
Originally developed by:
Patricia Halliday RN, MN
Former MN student and staff nurse in the Tom Baker Cancer
Centre Outpatient Clinic
Harry Plummer RN, MSc, MEd. PhD.
Former Director of Nursing, Tom Baker Cancer Centre
Revised (2000) by:
Marlene Reimer RN, PhD, CCN(C)
Professor, Faculty of Nursing, University of Calgary
&
Associate in Nursing, Calgary Health Region
1
Unit 4 Table of Contents
Overview ..............................................................................................................4
Aim .................................................................................................................... 4
Objectives ......................................................................................................... 4
Resources .......................................................................................................... 4
Web Links......................................................................................................... 5
Section 1: Alterations in Cell Differentiation/Neoplasia ............................6
Learning Activity #1—Interpretations of Statistical Tables ..................... 6
The Cell Cycle .................................................................................................. 7
Alterations in Cell Differentiation ................................................................ 8
Learning Activity #2—Crossword Puzzles ................................................. 9
Final Thoughts...................................................................................................13
References ..........................................................................................................14
Glossary ..............................................................................................................14
Acronyms ............................................................................................................14
Checklist of Requirements..............................................................................15
Answers to Learning Activities ......................................................................16
Learning Activity #1—Interpretation of Statistical Tables ..................... 16
Learning Activity #2—Answers to Crossword Puzzles.......................... 16
Unit 4 Alterations in Cell Differentiation/Neoplasia
3
UNIT 4
Alterations in Cell Differentiation/Neoplasia
Understanding the pathophysiology that occurs in the cancer patient’s
body is the first step required in understanding the disease process of
cancer. Knowledge of cancer pathophysiology provides the
groundwork that is required for understanding both the current
method of cancer treatment and the social/emotional impact of cancer
on the client and family. To enhance your learning on cell
differentiation/neoplasia, think of a cancer patient for whom you have
cared. Try to recall the signs, symptoms, laboratory and radiological
findings that your patient presented with and exhibited throughout the
treatment. As you are working through this unit, try to provide the
rationale for the physiological changes that could possibly account for
your findings.
4
Unit 4 Alterations in Cell Differentiation/Neoplasia
Overview
Aim
Upon completion of this unit you will be able to understand the nature
of cancer from a physiological perspective. Cancer is a group of
diseases, but the one constant is the importance of a defective growth
mechanism which is characteristic of cancer cells. We have included
information that spans both normal physiology and abnormal
pathophysiology to aid your learning.
Objectives
Upon completion of this unit you will be able to:
1. Differentiate among the terms neoplasm, cancer and tumour.
2. Identify the main classes of neoplastic growth.
3. Differentiate between benign and malignant neoplasms as to
structure, rate of growth, pattern of enlargement and spread.
4. Describe the possible cellular basis for formation of malignant
neoplasms.
5. Define metastasis and describe methods by which it might
occur.
6. Describe the principles for treating neoplastic conditions in
relation to rationale for selection and effects on normal body
functioning.
Resources
Requirements
Porth, C. M. (2005).Pathophysiology – Concepts of Altered
Health States (7th ed.). Philadelphia: Lippincott.
Groenwald, Frogge, Goodman & Yarbro (2005 ) Invasion and
mestastases (Ch. 4, pp. 59-69). Cancer Nursing (3rd ed.). Boston: Jones &
Bartlett: Note: You do not need to buy this text for this course but if
you intend to go into oncology nursing it is an excellent textbook.
Porth covers the concepts we will be discussing in sufficient depth to
understand the processes.
Print Companion: Alterations in Cell Differentiation/Neoplasia
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary
Unit 4 Alterations in Cell Differentiation/Neoplasia
5
Learning Activities


Learning Activity #1—Interpretation of Statistical Tables
Learning Activity #2—Crossword Puzzle #1 and #2
Supplemental Readings

See
US National Cancer Institute Website
www.nci.nih.gov

Leading causes of death and related cancer statistics are
available from
Statistics Canada
www.statcan.ca/english/Pgdb/People/Health
Web Links
All web links in this unit can be accessed through the Web CT system.
6
Unit 4 Alterations in Cell Differentiation/Neoplasia
Section 1: Alterations in Cell
Differentiation/Neoplasia
Learning Activity #1—Interpretations of
Statistical Tables
Use the following statistical tables, available from Statistics Canada
and the National Cancer Institute of Canada to answer the following
questions (answers at the end of this unit). Note also Figure 8-1 on page
156.
1. What is the leading cause of death in Canada for males and
females?
2. What percentage of females currently aged 30 to 50 years have a
lifetime probability of dying from some type of cancer?
3. Which types of cancer, once developed, are most likely to result
in death, in both male and female adults according to 1999
statistics:
4. Which type of cancer had the highest incidence among adult
males in the period 1990 to 2005?
5. Which type of cancer was most likely to cause death among
adult males and females according to 2005 statistics?
6. What type of cancer continues to have the highest incidence
among females?
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary
Unit 4 Alterations in Cell Differentiation/Neoplasia
7
The Cell Cycle
Note:
 all cells whether normal or abnormal proceed through the cell
cycle
 growth rates tend to vary for both normal and malignant cells
Figure 4.1 The Cell Cycle
Adapted from Carter, S. K., Bakowski, M. T., & Hellmann, K. (1981).
Chemotherapy of cancer (2nd ed.). Toronto: John Wiley & Sons.
Please note Figure 8-2 on page 157 for another description of the cell
cycle.
The concept of the cell cycle has important ramifications in
chemotherapy. Certain drugs are cell cycle specific or non cycle
specific. You will notice in your clinical practice that certain
chemotherapy drugs work in specific parts of the cell cycle and that
patients often receive more than one drug in order to take advantage
of cell cycling.
8
Unit 4 Alterations in Cell Differentiation/Neoplasia
Alterations in Cell Differentiation











Cell morphology/differentiation.
Tumor classification and nomenclature (e.g. a cancer of
connective tissue is called a sarcoma. What is a cancer of
epithelial tissue and glandular tissue called?).
Cell cycle - see Figure 4.1 in this unit and p. 157
Characteristics of: normal cells, cancer cells
Tumor development
Tumor cell markers
Ectopic hormone production
Metastasis
Clinical manifestations
Evaluation and treatment modalities
Oncological emergencies
After completing the readings, test your knowledge by completing the
following Crossword Puzzles. Answers are at the back of this unit.
Cell proliferation (pp.157-8).
The vast majority of normal cells, which have a nucleus, will undergo
proliferation.
Please read cell differentiation on p.158 and make sure you
understand what a stem cell is, and does, as it is an important concept
in understanding carcinogenesis and potentially treatment.
Page 159 – 161 compares and contrasts the differences between a
benign and a malignant tumour. Can a benign tumour be fatal? Can
you think of an example where this may be the case?
Cancer cell characteristics (pp. 161-2).
The term anaplasia means the tumour has no defining characteristics.
In other words, you could not say the sample came from a particular
tissue because it has none of the characteristics of any tissue (special
‘markers may be useful in trying to do this). Tumours are described as
being well differentiated (meaning they closely resemble the tissue of
origin), moderately differentiated, and poorly differentiated.
Porth describes cell surface antigens on page 162. These antigens
may be useful to indicate the presence of cancer although they do not
have the specificity to use for screening. For example, carcinoembryonic
antigen is usually elevated in colon cancer (and other conditions as
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary
Unit 4 Alterations in Cell Differentiation/Neoplasia
9
well). The physician will measure the pre treatment level and the post
treatment level (often 3-4 months after treatment). The level is then
measured approximately twice a year. If the level stays down it is a
fairly good indicator that the colon cancer is under control. If the level
begins to rise it usually indicates a return of the cancer (of course,
other reasons for the increase will need to be ruled out). Can you think
of other tumour antigens that are used in this regard?
Invasion and Metastasis (pp.162-3). Tumours may spread by
local invasion, e.g. breast cancer may invade the chest wall.
By seeding – for example, an ovarian cancersheds tumour cells into
the peritoneal cavity.
The final method is metastasis and is the most common form seen in
clinical practice. Metastasis occurs more frequently by lymph spread
than by the blood spread. It is hypothesized that blood is relatively toxic
to cancer cells and the majority of cancer cells die in the bloodstream
(although some will survive. It has been hypothesized that only 4% of
cancer cells in the blood will survive).
Tumour growth (Page 164) discusses the rate of growth in a
normal and cancer cell. On a theoretical basis cancer cells have the
potential to grow exponentially but rather they grow more or less
in a Gompertzian manner. Cancer cells do die often because their
blood supply has tortuous blood vessels which collapse quite easily
and the development of a necrotic core.
Etiology of Cancer (pp. 165-6).
It is not an expectation for this course for you to know the molecular basis
of carcinogenesis. Be aware,though, of growth promoting oncogenes
and growth suppressing oncogenes. See figure 8-8 for a brief
illustration of how they may be a cause of cancer.
Porth also discusses the host and environmental factors for cacinogenesis
on pp.167-170. These are ‘hot’ topics in research and the popular press.
The role of the BRCA-1 and BRCA-2 gene mutations in cancer risk were
probably the first to be used in evaluating ‘at risk’ families.
Clinical Manifestations (PP. 171-73).
No doubt many of you have seen the consequences of cancer as the
disease progresses. Your text refers to tissue integrity and how this may
manifested by bleeding; a sore that won’t heal; or pain. Some early signs
of cancer may be dismissed as being ‘normal’. For example, bloating may
be dismissed, but in fact, it may be an early warning for ovarian cancer.
10
Unit 4 Alterations in Cell Differentiation/Neoplasia
Another example, is cachexia. As your text mentions there are probably a
number of factors that contribute to it. Tumour necrosis factor was the
first factor to be identified as a cause for cachexia followed by certain
interleukins.
The paraneoplastic syndrome also called inappropriate hormone
production or ectopic hormone production is a fascinating biological
phenomena. In effect, certain cancers will produce hormones or factors
which are inappropriate for that particular tissue. This hormone, or factor
production may have important clinical consequences. Please see Figure
8-3 on page 172 for a list of common paraneoplastic syndromes.
Learning Activity #2—Crossword Puzzles
Crossword #1
Clues:
Across
Down
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary
Unit 4 Alterations in Cell Differentiation/Neoplasia
2. Cancer causing viruses
4. Evaluation of the tumor’s degree of
malignancy
7. New growth of blood vessels to vascularize
tissues
11. Increase in size of cell
12. A broad group of malignant neoplasms
divided into two groups, carcinomas and
sarcomas.
15. Lack of cell differentiation.
16. Conversion of one cell into another kind.
11
1. A spontaneous new growth of tissue
forming an abnormal mass
3. Production of cancer
5. Can be elevated in persons with hepatic,
pancreatic and embryonal carcinomas
6. Process by which a normal cell becomes a
cancer cell
8. Many shapes, a variety of cell types
9. Process of classifying tumors
10. Increase in number of cells
13. Cancers of connective tissue
14. Not recurrent or progressive
12
Unit 4 Alterations in Cell Differentiation/Neoplasia
Crossword #2
Clues:
Across
Down
1. To invade, grow
9. Cancers of epithelial tissue
11. Glial cells of the central nervous system
12. Substances produced by cancer cells found
on tumor plasma membranes or in
blood/urine
2.
3.
4.
5.
Cancers of lymphatic tissue
New, and abnormal formation of tissue
Cancers of the blood-forming organs
Causes an acceleration of the rate at which
the cell has a chance of becoming malignant
6. Spread of cancer cells from a primary site of
origin to a distant site
7. Antigens expressed by cells during certain
stages of embryonic development
8. Process of cells dividing in an
uncoordinated fashion, invading and
destroying neighboring tissue
10. Development of cancer after exposure to
the carcinogen
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary
Unit 4 Alterations in Cell Differentiation/Neoplasia
13
Final Thoughts
In this unit, we have tried to enhance your understanding of the key
concepts that lead to changes in cell morphology in the human body,
culminating in the complex pathological process of cancer. I have not
attempted to provide an in-depth explanation of all cancers but rather
provide you with some of the core knowledge so that you can research
cancers you have an interest in. Porth does a very good job of
explaining these core concepts.
The word “cancer” still strikes fear into the hearts of people. In order to
understand and appreciate the full extent of what is happening to the
person with cancer, it is our belief that nurses must understand the
underpinnings of the pathophysiology as well as the psychosocial
processes involved.
We have focused primarily on neoplasias in adults. However, it would
be inappropriate to close this unit without some attention to differences
in the types and mechanisms involved with children and older adults.
Leukemia is the most common malignancy diagnosed in children under
15 years of age. Over 80% of leukemias in children are of the acute
lymphoblastic (ALL) or acute undifferentiated (AUL) types .
The article by Crawford and Cohen (1987) on “Relationship of cancer
and aging” in Clinics in Geriatric Medicine, pp. 419-432, provides an indepth look at the interaction between cancer and aging. You may find it
a bit technical, but might skim it for a general appreciation. If you had
some difficulty understanding the stages of carcinogenesis you may
find Figure 6 on p. 424 of this article a useful review.
The Tom Baker Cancer Centre Library has an extensive collection of
books, articles and audiovisual materials covering every aspect related
to cancer.
14
Unit 4 Alterations in Cell Differentiation/Neoplasia
References
Crawford, J., & Cohen, H. (1987). Relationship of cancer and
aging. Clinics in Geriatric Medicine, 3(3), 419-432.
(3rd
Groenwald, Frogge, Goodman, & Yarbro (1993). Cancer nursing
ed.). Boston: Jones & Bartlett.
Porth, C. M. (2205). Pathophysiology- Concepts of Altered
Health States (7th ed.). Philadelphia: Lippincott.
Glossary
No separate glossary is provided in this unit but you are encouraged to
review the answers to the crossword puzzles to check your grasp of
terminology.
Acronyms
ALL
acute lymphoblastic leukemia
AUL
acute undifferentiated leukemia
DNA deoxyribonucleic acid
RNA ribonucleic acid
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary
Unit 4 Alterations in Cell Differentiation/Neoplasia
Checklist of Requirements
Porth (2005)
 Chapter 8

Groenwold, Frogge, Goodman & Yarbro (2005)
 Invasion and metastases
 Ectopic hormone production
 Print Companion
 Alterations in Cell Differentiation/Neoplasia
Learning Activities
 Learning Activity #1—Interpretation of Statistical Tables
 Learning Activity #2—Crossword Puzzles #1 and #2
15
16
Unit 4 Alterations in Cell Differentiation/Neoplasia
Answers to Learning Activities
Learning Activity #1—Interpretation of Statistical
Tables
1.
2.
3.
4.
5.
6.
cancer
22.8%
lung pancreas leukemia stomach
cancer of the prostate
cancer of the lung
cancer of the breast
Learning Activity #2—Answers to Crossword
Puzzles
Crossword #1 Word List
A-fetoprotein
angiogenesis
anaplasia
benign
cancer
carcinogenesis
grading
hypertrophy
hyperplasia
metaplasia
oncogenic viruses
pleomorphism
sarcomas
staging
transformation
tumor
Crossword #2 Word List
carcinomas
gliomas
initiation
leukemias
lymphomas
malignant
metastasis
neoplasm
oncofetal
promotion
progression
tumor cell markers
Rankin, Reimer & Then. © 2000 revised edition. NURS 461 Pathophysiology, University of Calgary