Objectives GI MALIGNANCIES -...
Transcript of Objectives GI MALIGNANCIES -...
3/5/2014
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GI
MALIGNANCIES
Trisha Marsolini RN, BS, OCN, CMSRN Overlake Hospital Medical Center March 2014
Objectives
Review pathophysiology of GI systems Esophagus Colon Pancreas
Discuss risk factors
Discuss presenting signs and symptoms
Discuss and Identify current treatment options
Review side effects and nursing management
2010 Estimated US Cancer Cases
3 Source: American Cancer Society, 2010
Men
789,620
Women
739,940
27% Breast
14% Lung & bronchus
9% Colon & rectum
6% Uterine corpus
4% Non-Hodgkin lymphoma
4% Melanoma of skin
4% Thyroid
3% Kidney & renal pelvis
3% Ovary
3% Pancreas
22% All Other Sites
Prostate 25%
Lung & bronchus 15%
Colon & rectum 9%
Urinary bladder 7%
Melanoma of skin 5%
Non-Hodgkin 5% lymphoma
Kidney & renal pelvis 5%
Leukemia 3%
Oral cavity 3%
Pancreas 3%
All Other Sites 19%
2010 Estimated US Cancer Deaths
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ONS=Other nervous system.
Source: American Cancer Society, 2010.
Men
299,200
Women
270,290
26% Lung & bronchus
15% Breast
9% Colon & rectum
7% Pancreas
5% Ovary
4% Non-Hodgkin lymphoma
3% Leukemia
3% Uterine corpus
2% Liver & intrahepatic bile duct
2% Brain/ONS
25% All other sites
Lung & bronchus 30%
Prostate 9%
Colon & rectum 9%
Pancreas 6%
Leukemia 4%
Liver & intrahepatic 4% bile duct
Esophagus 4%
Urinary bladder 3%
Non-Hodgkin 3% lymphoma
Kidney & renal pelvis 3%
All other sites 25%
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GI Malignancies Worldwide
Type Diagnosed Cases
Deaths US cases
Esophageal
482,300 406, 800 17, 460
Stomach
989,600 738,000 21,320
Pancreatic # fall under other
800,230 43, 920
Colorectal
1,167,020 602,958 143,460
Combined: 25% of all diagnosis and 32% of deaths
worldwide
•Numbers are based data collected by ACS in 2008
http://blogs.abcnews.com
Esophageal
Cancer
Anatomy and Function
Located behind the trachea, at the hypopharynx
Starts at thoracic inlet, ending at GE junction
muscular tube 10-13 inches long Facilitates swallowing and moves food and fluids
Movement controlled by sphincters and peristalsis
Esophageal Anatomy
Mucosa – two components
• Epithelial layer – squamous cells
• Lamina layer – connective tissue
Sub mucosa
• Glandular layer
Muscularis Propria
• Muscle layer
Adventia
• Connective tissue layer
Lymph Nodes
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•Types of Esophageal Cancer
Squamous cell carcinoma (SCC)
Originate from mucosal layer
Usually occurs from mid to upper esophagus
90% used to be SCC now < 30%
More common in black men
Types of Esophageal Cancer
• Adenocarcinoma
• Does anyone remember where this type originates from?
• Originate from glandular cells of sub mucosa
• Squamous cells are replaced by glandular cells
• Usually occurs near the stomach
• Increasing about 1% a year in white men
Incidence of Esophageal Cancer
2% of U.S. cancer deaths
17, 460 estimated new cases - 2012 US
15,070 estimated deaths – 2012 US
8th most common cancer Worldwide
7th most common cancer death Worldwide
3 to 4 higher in men than women
startoncology.net
• Stats from 2004
Highest incidence :
•South Africa
•China
•Malawi
•Mongolia
•These areas have 20
to 30 times higher
than US
Worldwide Incidence 2008
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Risk Factors for Esophageal Cancer
Age - most cases occur > 65
Male – 3 to 4x higher than women
Tobacco
44X risk more significant in SCC
Alcohol – heavy
Synergic relationship with smoking
Obesity/ High BMI
More significant in adenocarcinoma
Risk Factors for Esophageal Cancer
HPV – predisposes to adenocarcinoma
Diet Diet low in fruits and vegetables Drinking hot fluids frequently Diet high in processes meats (high salt), pickled
vegetables
Decline of h. pylori in esophagus In squamous cell
Presenting Signs & Symptoms
Asymptomatic in early stage Late Symptoms
• circumference of esophagus less than 13mm –Difficulty/painful swallowing –Weight loss – Chest or Epigastric Pain –Hoarse Voice –Hiccups –Hematemesis –Melena
No screening tests available in US
Risk Factors for Esophageal Cancer
Barrett’s Esophagus
10% of people with GERD have Barrett’s
GERD asst with high BMI
Squamous cells replaced with glandular cells
30-125 times increased risk of adenocarcinoma
Cancer risk higher when there is dysplasia
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Case Study
Jim a 67 yr old
Hx: HTN, Hyperlipidemia, DM, GERD, obese and Barrett’s
Progessive dyspaghia for last 4 to 6 weeks
Previous 2 weeks only eating soft food
50 pd weight loss last 6 mo.
Previous EGD 2 yrs ago – WNL
3/26 Had EGD
Obstructing mass distal esophagus
Biopsy
High grade poorly differentiated adenocarcinoma
Diagnostic Work-up
Initial diagnostic exams
Baruim Swallow
Endoscopy and Biopsy
Staging exams
CT chest and abdomen
Bronchoscopy
PET scan
MRI
Bone scan
Laparoscopy
Diagnostic Work-up
Endoscopic Ultrasound
Identifies unseen
tumors and depth of
tumors
Can do biopsies
Even of lymph nodes
http://www.barrettsadvice.com
Case Study
4/4 CT/PET
Obstructing mass distal esophagus and junction
Enlarged perigastric node
Bulky upper R mediastinum/paratracheal node
No distant mets
Family Hx
Dad passed from esophageal ca
Brother passed from a brain tumor
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Metastatic Patterns
Local Spread through esophageal layers
Lymph Nodes
Surrounding organs
Distant Metastases
Liver
Lung & Pleura
Stomach
Peritoneum
NCCN Esophageal Staging
TNM used
Plus add Grade
Makes difference in early stages
Squamous Vs Adenocarcinoma
Squamous staging
adds location
TNM Staging - Squamous TNM staging - Adenocarcinoma
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Staging TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis High-grade dysplasia.c
T1 Tumor invades lamina propria, muscularis mucosae, or submucosa.
T1a Tumor invades lamina propria or muscularis mucosae.
T1b Tumor invades submucosa.
T2 Tumor invades muscularis propria.
T3 Tumor invades adventitia.
T4 Tumor invades adjacent structures.
T4a Resectable tumor invading pleura, pericardium, or diaphragm.
T4b Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.
Nodes
Nx = unable to
assess LN
N0 = no LN
N1= 1-2 LN
N2 = 3-6 LN
N3 = >7 LN
Esophageal tumor
5 Year Survival Rates
Localized disease survival rate is 37%
Regional staged is 19%
Distant metastasis 3%
Survival rates doubled last 40 years but remain poor
NCCN Treatment Guidelines
Surgery alone
Early Stage - rare
Chemotherapy
Pre and postoperative
Chemoradiation – Primary treatment
Used alone in locally advanced SCC
Combined with surgery in adenocarcinoma
Radiation –
Alone if tumor is locally advanced
Palliative for symptom management
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Case Study
Jim is not a surgical candidate
Why?
4/9 Port placed and chemo started
Carboplatinum, taxotere and 5-FU
4/14 admitted to onc unit
Dehydration, diarrhea and stomatitis/esophagitis
WBC 8.8
HCT 34.6
Crt 1.7
Stopped 5-FU 8 hrs early
Time frame in general early for SE
NCCN Treatment Guidelines Combination Chemotherapies most common
Xeloda or 5-FU paired with Cisplatin Irinotecan Oxaliplatin Carboplatin Pacilataxel Docetaxel
Herceptin in locally advanced or metastatic setting
2 drug regimens most common with Radiation 3 drug regimens most common when Radiation is not
indicated
Ongoing trials to find the best chemo and radiation combo
Trials ongoing with radiosensitizers
NCCN Treatment Guidelines
Surgery Esophago-gastrectomy
Less invasive approaches Thoracoscopy with limited laparotomy or laparoscopy & possible cervical incision
More invasive approaches Thoracotomy with laparotomy & possible cervical incision
NCCN Treatment Guidelines
Tumor can be unresectable – due to location
Close to cricopharyngeaus – cervical area
Extensive EGJ involved
Bulky tumor that involves surrounding organs
Bulky lymphadenopthy
Distant mets
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Nursing Management
Post Surgical care
Pneumonia Obstruction or paralytic ileus Bleeding Anastomosis Leakage Blood clots Infection Pain management Recurrent laryngeal nerve paralysis (cervical
sites)
Nursing Management
Later phase surgical issues
Slow emptying and chronic nausea/vomiting Strictures Heartburn
Patient are going to have to learn to eat different
Nutrition Consult
Case Study
Jim is not a surgical candidate
Why?
4/9 Port placed and chemo started
Carboplatinum, taxotere and 5-FU
4/14 admitted to onc unit
Dehydration, diarrhea and stomatitis/esophagitis
WBC 8.8
HCT 34.6
Crt 1.7
Stopped 5-FU 8 hrs early
Time frame in general early for SE
Case Study
4/17 Labs
WBC 2.2
HCT 25.1
Treatment
2 units PRBCs
GCSF
Next treatment dosed reduced
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Palliative Therapy
Esophageal Dilatation
Esophageal Stents
PEG or PEJ placement
Photodynamic Therapy
Laser Endoscopy
Treatment
Photodynamic Therapy
Used on superficial and mucosal lesions Procedure Given photosensitizing agent
Wait a few days
Via endoscopy Special laser is pointed at cancer
cells causing cell death
Little harm to normal cells Patients need to stay inside for 4- 6 weeks
Case Study
5/22 CT showed
Mild improvement in obstructing mass
Dysphagia improved – Reg diet
Creatinine climbing 2.7
No more GCSF
Stopped chemo except 5-FU
6/1 palliative radiation started
Total 25 treatments
Case Study 6/9 admitted
increased confusion, dehydration, weakness
Mucositis/dysphagia
Currently on 5-FU CADD pump
Labs
Crt 2.06
K 3.1
BS 388
Finished 5-FU took a few days off Radiation TX
7/8 last dose of 5-FU
7/26 finished radiation
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Case Study
8/4 CT
T12 compression fx
New bulky distal esophageal adenopathy
8/9 started rad tx to new area
8/20 admitted LBP compression L-5 and constipation
IV narcotics for pain control
Kyphoplasty – pain not improved after
Relistor relieved constipation
Summary – Esophageal cancer
Overall 5 yrs survival is 11 to 18%
Males much higher risk than women
Tobacco significant risk in SCC
GERD significant risk in Adenocarcinoma
Healthy weight and active lifestyle best defense
Adenocarcinoma increasing in white men
SCC decreasing in US but still significant problem worldwide
Colorectal Cancer
Colon Anatomy •Primary Function is water and mineral absorption and stool formation.
•70% of tumor occurrences are in the colon and 30% are in the rectum.
•Colon is approx. 5 to 6 ft long
•Rectum is 10 to 12 inches long
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Normal to Adenoma to Carcinoma Human colon carcinogenesis
progresses by the dysplasia/adenoma to carcinoma pathway
•How long do you think this pathway takes?
Genetic Model of Colon Cancer
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p53
Late Adenoma
Optimum phase for early detection
Many
decades
APC
K-ras
Mutation
Courtesy of Barry M. Berger. MD, FCAP EXACT Sciences
Late Cancer
Early Cancer
Adenoma Norma l Epithelium
Dwell Time: 2-5
years
2-5
years
1 in 19 men and 1 in 20 women lifetime risk
143, 460 new cases - 2012 US
51,690 death – 2012 US
3rd leading cause of cancer death men and women
World-wide incidence similar in developed countries
African Americans have 20% higher incidence, 45% higher mortality
Colon cancer has decreased 15 years due to screening
1 million survivors of colorectal cancer in the US
Incidence of Colorectal Cancer
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World-wide Incidence 2008
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Risk Factors
Age over 50
Obesity - especially abdominal obesity
High fat and red meat
Type II Diabetes
Smoking
Inflammatory Bowel Disease: Crohns, Ulcerative colitis
Previous cancerous polyps
Family history – 20% of all CRC
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Risks Factors
Familial Adenomatous Polyposis (FAP)
1% of CRC
Adenomatous polyposis coli (APC) gene mutation
Hundreds of polyps by age 39
Not necessarily just located in colon and rectum
100% lifetime risk of CRC
Autosomal dominant
Risks Factors
Hereditary Nonpolyposis Colorectal Cancer (HNPCC)
• 3-5% of CRC
• Also known as Lynch Syndrome
• Mismatch repair gene mutation
• Average age of onset is 44
• 70-80% lifetime risk of CRC
• Women have very high risk of endometrial cancer
• Increased risk of other cancers
Presenting Symptoms - Generalized
Persistent abdominal discomfort
Changes in bowel habits (over several weeks)
Rectal bleeding/Blood in the stool
A feeling that your bowel doesn't empty completely
Unexplained weight loss
Fatigue
Anemia
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Presenting Symptoms – Location
Ascending Descending
Large bulky tumor
Palpable mass uncommon
Dull pain
Tarry dark stool Late Symptoms:
Transverse Palpable mass
Occult blood in stool
Obstruction
Maroon colored in stool
Incomplete stool evacuation
Obstruction
Tenesmus
Sigmoid Constipation
Pencil-like stool
Tenesmus
Presenting Symptoms - Rectal
Mucous discharge/diarrhea
Bright red rectal bleeding (most common)
Tenesmus – spasmodic contraction
Sense of incomplete evacuation
Late Symptoms:
Feeling of rectal fullness
Constant ache
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Screening
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American Cancer Society-Screening Guidelines
Screening should begin at the age of 45 to 50 If there is no previous history of polyps or cancer
Tests that find polyps and cancer Flexible sigmoidoscopy every 5 years*, or Colonoscopy every 10 years, or Double-contrast barium enema every 5 years*, or CT colonography (virtual colonoscopy) every 5 years*
Tests that primarily find cancer Yearly fecal occult blood test (gFOBT)**, or Yearly fecal immunochemical test (FIT) every year**, or Stool DNA test (sDNA), interval uncertain** * If the test is positive, a colonoscopy should be done. ** The multiple stool take-home test should be used. One test done by the doctor in the office is
not adequate for testing. A colonoscopy should be done if the test is positive.
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Colon Polyps Colon Cancers
Diagnostic & Lab Procedures
Barium Enema
CAT Scan/PET Scan
Colonoscopy, Sigmoidoscopy, Protoscopy
MRI
Hematocrit
Liver Function Tests
Carcinoembryonic Antigen (CEA) Monitor for response to therapy and recurrence – not presence
of cancer
Case Study
Jane 33 weeks of pregnancy
CT showed large obstructing mass in rectum and liver mets.
Flex sig showed innumerable polyps.
She was to have a C-Section at 36 weeks
contractions at 35 weeks
C-section = healthy boy
Pathology from flex sig
Familial Adenomatous Polyposis (FAP)
She has 10 other children at home.
What are their risk of getting FAP?
50/50
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Case Study
CEA (Reference Range: 0-3 NG/ML)
Jan. 23 Result: 2126.94
Feb. 25 Result: 4176.6
After delivery sent home
Return to hospital 1 week later in terrible pain
After about a week had to have a debulking surgery Diverting ileostoy
TPN
PCA, frequent large boluses and pain consult
DC home about 2 weeks later
Metastatic Patterns
Local extension through penetration of layers of bowel
Invasion of submucosal layer: direct access to vascular and
lymphatic system
Distant metastasis
most frequent in liver, then the lungs Less frequent in brain, bone and adrenal glands
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Staging for Colon Cancer TNM – Staging
System
Tumor Nodes Metastasis 5 yr Survival
Stage 0 - Polyp Tis N0 M0
Stage I Tumor involves the inner lining of the intestine.
T1
T2
N0
N0
M0
M0 93%
Stage IIA Tumor invades muscle wall of the intestine but no LN.
T3 N0 M0 85%
Stage IIB T4 N0 M0 72%
Stage IIIA Lymph nodes are involved.
Any T N1 M0 83%
Stage IIIB Any T N2 M0 64%
Stage IIIC Any T N3 M0 44%
Stage IV Tumor spread to other organs.
Any T Any N M1
8%
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NCCN Treatment Guidelines
Recommendations for treatment by stage
Surgery
Primary treatment 75% of colorectal cancers goal being cure!
Chemotherapy
Monoclonal antibodies/Targeted Agents
Radiation – Rectal cancer mostly
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Treatment: Chemotherapy
Used in combination with surgery in colon cancer
Can be adjuvant or neoadjuvant
Fluorouracil (5-FU)/Xeloda and Leucovorin remains mainstay
Other agents:
Irinotecan (Camptosar)
oxaliplatin (Eloxatin),
Cisplatin
Targeted therapy
Avastin – k-ras mutation
Erbitux
Vectibix
Treatment- Radiation
Used in combination with chemo in rectal cancer
Endocavitary radiation
• Early rectal cancers in low-rectal and mid-rectal regions
• Early anal cancers
External Beam radiation
• Can be before or after surgery in rectal cancer
• Limited use in colon cancer
• Not used in metastatic setting
• Palliative – symptom management
Treatment: Surgery Colon
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Right Hemicolectomy Left Hemicolectomy
•Laproscopic-assited colectomy – early stage colon cancer
•Hemicolectomy - sometimes many need temporary colostomy -rarely are
the permanent
•Debulking – pallative/symptom management – often ends up with
colostomy
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Treatment: Surgery Rectum
Early stage surgeries
Transanal endoscopic microsurgery
Local Transanal Resection
Surgical procedure determined by location
Lower Anterior Resection – lesion in upper third of the rectum
temporary ileostomy may be neccessary
Treatment: Surgery Rectum
Colo-anal Anastomosis – lesion in the middle and lower third of the rectum
J-pouch and temporary ileostomy
Abdominoperineal (AP) Resection – lesion in the middle and lower third of the rectum, large and bulky
Permanent colostomy
Nursing Management – Post Op
Post Surgical care
Pneumonia
Obstruction or paralytic ileus
Bleeding
Anastomosis Leakage
Stoma complications
TPN
Discharge teaching
Ostomy Care
Self image
New and Exciting Treatments
Immunotherapy Using patients T-cells to attack antigens on the surface
of the colorectal cancer cells
Her-2/neu expression in GI
Malignancies
Vit D is being studied in recurrent
disease
An Aspirin a day may decrease risk of developing
recurrent colorectal cancer
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Case study
Jane started chemo 4 weeks after surgery
5Fu. Leucovorin and oxaliplatin
Tolerated treatment for many months
CEA started to rise in November
Added Avastin
Early on too much bleeding worry
April following year tumor began to progress
Passed way in August
Summary – Colon cancer
3rd leading cause of cancer death
Most significant risk age & smoking!
Early detection SO IMPORTANT!
Get your colonoscopy
Stage is most significant prognostic indicator
Surgery is primary treatment
Cure is the goal!
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Pancreatic Cancer Anatomy of Pancreas
Pear shaped dual-function gland
6 in long/about 15 cm
Located between stomach and
spine
3 Parts
• Head
• Body
• Tail
Approximately 75%of tumors occur in the head
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Function of the Pancreas
Endocrine Function Islets of Langerhans –
produce insulin and glucagon
Neuroendocrine tumors originate here
1% of pancreatic cancers
Exocrine Function Comprised of ducts and acini
Enzymes help in digestion
95% pancreas
95% are adenocarcinomas
Incidence of Pancreatic Cancer
10th most common cancer
4th leading cause of cancer deaths
43, 920 new cases – 2012 US
37,330 deaths – 2012 US
Lifetime risk 1 in 72
Higher incidence in African Americans
At time of diagnosis > 50% have distant mets
Incidence the same worldwide – developed countries
World-wide incidence Risk Factors
Age – 55 and greater
Smoking – 2 to 3x greater risk Obesity Type 2 diabetes
Cirrhosis of the Liver Chronic pancreatitis – often related to smoking Helicobacter pylori (H. pylori) infection Genetic Syndromes
10% of pancreatic cancers
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Presenting Signs & Symptoms
Abdominal and back pain
• Dull and constant
• Radiates to mid or upper back
• Worse while supine
Weight Loss and Poor Appetite
Blockage of digestive enzymes
• Pale, bulky, greasy stool that may float
Nausea and vomiting
Presenting Signs & Symptoms
Jaundice – usually painless
DVT/PE – paraneoplastic syndrome
Fatigue
Depression
Ascites ♦ Once there are signs and symptoms the disease is already
advanced!!!
Diagnostic Procedures
CT
ERCP -No mass on CT
Stent obstruction
biopsies
Endoscopic Ultrasound (EUS)
• MRCP- If ERCP can’t be done
• Total Bilirubin
• CA 19-9 – not pancreas specific
• Liver Enzymes
• PET scan
• Laparotomy
• Jill healthy 60 yr old was admitted Nov. 2011 with painless jaundice
• HCT 24.2
• Total Bilirubin 8.8 (0.1-1.5)
• Alkaline Phosphate 444 (20-140)
• CA 19-9 = 125, 328
• EGD -showed bleeding duodenal mass
ERCP not possible D/T mass
• CT – mass at head of pancreas obstructing of biliary system and mets to the liver
• IR – biopsy done with biliary stent placement
Case Study
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Metastatic Pattern
Local spread/invasion to surrounding tissue and organ
• Small bowel, CBD, Stomach
Most common distant metastatic sites
• Liver
• Lungs
• Peritoneum/abdominal cavity
Staging/TNM Classification
TNM Tumor Nodes Metastasi
s
5 YR Survival
Stage 0 Tis N0 M0
Stage IA T1 N0 M0 37%
Stage IB T2 N0 M0 21%
Stage IIA T3 N0 M0 12%
Stage IIB T1 N1 M0 6%
T2 N1 M0
T3 N1 M0
Stage III T4 Any N M0 2%
Stage IV Any T Any N M1 1%
Staging •T1 is a tumor < 2cm
•T2 is a tumor > 2cm
•T3 tumor beyond pancreas, major arteries or veins
not involved
•T4 tumor involves major arteries and veins
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NCCN Treatment Guidelines
Chemotherapy – usually at all stages
• Gemcitabine and 5FU/Xeloda– Gold standard • proven to be chemo-resistant
Others you may see Xeloda, cisplatin, irinotecan,CPT-11, Taxol,
docetaxol, oxaliplatin
Targeted Therapy
• Erlotinib
Radiation – limited use
• After surgery to help prevent recurrence
• Tumor too large for surgery
Intra-operative Radiation
Clinical trials
Surgery
– Whipple Procedure (Pancreaticoduodenectomy) – Cancer much be contained with in the pancreas –Only potential cure and only 1 and 10 case
A series of three anastomoses are created Gastrojejunostomy tube
5 year survival even with surgery is 20%
Surgery
Gastrojejunostomy
Bypass tumor and attach stomach
to jejunum
Second anastomoses done
from biliary systemt to if possible
A palliative procedure for symptom management
Nursing Management Post operative care
Pneumonia
Bleeding
Infection
Anastomotic leaking
Blood sugar and electrolyte imbalances
TPN
Ileus
Dumping Syndrome
• Pain control
• Insulin Dependence – surgically induced
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Nursing Management
Malnourishment/Malabsorption
• Anorexia
• Nausea
• Pancreatic insufficiency
• Blockage
Interventions
• Pancreatic enzyme tablets
• Nutritional consult
• Feeding tube
Palliation treatment
Biliary obstruction – in IR or by ERCP
• Permanent biliary stent
• Percutaneous biliary
stent with drain
Gastric outlet obstruction
• Enteral stent
• PEG/PEJ tube
• Gastrojejunostomy
Case Study
• Jill was admitted in January for N/V and weakness
• Current Treatment
• Gemcitabine and Xeloda
CA 19-9 = 513,626 (125, 328)
Received bowel rest and IV hydration
• After several day N/V started again
Upper GI series showed gastric outlet obstruction
Laprascopic Gastrojejunostomy with Moss tube placement and cholecystectomy
Summary – Pancreatic cancer
Overall 5 yr survival is 3%
Smoking increases risk 3 to 4 fold
One of the most lethal cancers – in US
Median survival is 9-12 months
After resection 15-19 months
Treatment for majority pain and symptom management
Pancreatic cancer has proven to be fairly chemo resistant
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Chemotherapy Side Effects
Side effect Management Drug
Mucositis Good Oral Care Magic Mouthwash
5 –Fu
Diarrhea Anti-diarrheal Hydration
Irinetecan 5-FU
Hand Foot Syndrome Monitor Patient education
5-FU/Xeloda Targeted therapies
Acne like rash Monitor Creams/antibotics
Erlotinib Oxaliplatin
Thrombocytopenia Patient Education on risk and signs and symptoms
Gemcitabine
Neurotoxicity (tingling/numbness)
Monitor Patient education
Oxaliplatin
Cold Sensitivity No cold food Scarf in cold weather
Oxaliplatin
Patient Education -Chemotherapy
Nausea & Vomiting
• Antiemetic, keeping hydrated and when to call
Myelosuppression
• Growth factors, blood transfusion, hand hygiene
Fatigue
> than 99% of patients complaining of fatigue
• Encourage mild exercise and energy conservation
Decreased libido
Patient Education - Radiation
Inflammation of bowel or bladder
Blood in stool or urine
Ulceration of GI mucosa – pain
Necrosis of GI tract
Skin irritation/burns
Changes in sexual activity
Please refer to your handouts for nursing and patients resources.
Thankyou!
Q & A