Management of Patients with Oncologic Disorders - Lecture Notes

CHAPTER 15 Management of Patients with Oncologic Disorders CANCER  large group of disorders with different causes, manifestations, treatments, and prognoses  Because cancer can involve any organ system and treatment approaches have the potential for multisystem effects, cancer nursing practice overlaps with numerous nursing specialties  Cancer nursing practice covers all age groups and is carried out in various settings, including acute care institutions, outpatient centers, physician offices, rehabilitation facilities, the home, and long-term care facilities  scope, responsibilities, and goals of cancer nursing, also called oncology nursing, are as diverse and complex as those of any nursing specialty  Nursing management of the patient with oncologic disorders care of pts throughout the cancer trajectory from prevention through end-of-life care  Precision medicine- possible due to recent development of biologic databases (human genome sequencing), technological advances that can identify unique characteristics of individual persons (genomics, cellular assay tests), and computer-driven systems that can mine and analyze datasets o immediate goal focus on preventing and curing cancers  Affects males/females  Ageless  Presentation varies- severe/acute/chronic  Clinical features o Type o Staging o Molecular characteristics Can affect any one o Lung, Breast, Colorectal, Prostate Epidemiology  cancer is the second leading cause of death in the United States  one in four deaths is caused by cancer. leading causes of cancer death in the U.S. in order of frequency and location are lung, prostate, and colorectal cancer in men and lung, breast, and colorectal cancer in women  occurs in older adults  all cancer diagnoses are in people 55 years of age or older  prevalence of cancer is higher in men than in women  despite the rate of cancer deaths being declined, AA continue to have the higher cancer rates compared to Caucasia men & 2x of Hispanic men  despite AA women have. flower risk of cancer overall than white women, they still have higher cases of of deaths from cancer overall to women in general or white women racial dispraise is due to comorbid conditions such as CV disease & poverty in AA population  than in others  Cancer incidence and death rates also vary by geography PATHOPHYSIOLOGY OF THE MALIGNANT PROCESS  disease process that begins when a cell is transformed by genetic mutations of the cellular deoxyribonucleic acid (DNA)  Genetic mutations may be inherited and/or acquired, leading to abnormal cell behavior  initial genetically altered cell forms a clone and begins to proliferate abnormally, evading normal intracellular and extracellular growth-regulating processes or signals as well as the immune system defense mechanisms of the body  Genetic mutations may lead to abnormalities in cell signaling transduction processes (signals from outside and within cells that turn cell activities either on or off) that can in turn lead to cancer development  cells acquire numerous capabilities that causes them to invade surrounding tissues and/or gain access to the lymph & blood vessels carrying the cells to other areas of the body which results in metastasis [spread of the cancer]  Cancer characteristics o Uncontrolled cell growth o Lack contact inhibition o Do not undergo apoptosis o No anchorage dependence o Dysplasia- deranged cell growth o Neoplasia- uncontrolled cell proliferation o Anaplasia- cells lose regular structure (LOSES ITS FUNCTION) ex: skin cell Right picture: contact inhibition (cancer cells) get in there and proliferate and process no longer occurs Natural cell death: apoptosis Characteristics of Malignant Cells  Benign and malignant cells differ in many cellular growth characteristics like the method and rate of growth, ability to metastasize or spread, destruction of tissue, and ability to cause death  anaplasia [pattern of growth in which the cells do not have normal characteristics & are different in shape & organization with respect to their cells of origin] is related to an increased malignant potential BENIGN VS. MALIGNANT CELL CHARACTERISTICS [Know the difference between the cells **TABLE ACROSS Carcinogenic Agents/Factors of Malignant Cells Molecular Process  Malignant transformation/carcinogenesis o Three-step cellular process  Initiation: apoptosis  carcinogen such as chemicals, physical factors, or biological agents cause mutation in cellular DNA. These alterations are normally reversed by DNA repair mechanism/changes that cause apoptosis or cell senescence  Promotion: preneoplastic/benign lesions  repeated exposure to promoting agents (co-carcinogens) cause proliferation and expansion of imitated cells with increased expression or manifestations of abnormal genetic information, even after long latency periods – promotion phase leads to formation of preneoplastic or benign (non-cancerous) lesion   Progression: angiogenesis  altered cells exhibit increasingly malignant behavior – cells acquire ability to stimulate angiogenesis (growth of new blood vessels that allow cancer cells to grow), invade adjacent tissues, metastasize  Cellular oncogenes; responsible for vital functions (proliferation/differentiation)  Cellular proto-oncogenes: epidermal growth factor receptor (EGFR), transcription factors c-Myc, cell signaling proteins Kirsten ras (KRAS) act as on switches for cellular growth o Amplification of these genes or epidermal growth factor (EGF) lead to uncontrolled cell proliferation o mutations that increase oncogenes activity deregulate cell proliferation as well  in the gene for KRAS, genetic alterations have been associated with  pancreatic, lung, & colorectal cancer  Just as proto-oncogenes turn on cellular growth, cancer suppressors turn off or regulate unneeded cellular proliferation Carcinogen agents that cause malignant transformation/substances that cause cancer Even though cells can escape from these protective mechanisms [apoptosis], the mutations are not as important to the cells until the 2nd step of carcinogenesis Angiogenesis- develop own blood supply Cancer cells don’t want to die Cancer cells are able to proliferate and have their own blood supply Telemerase will release PROLIFERATIVE PATTERNS  numerous body tissues normally go thru periods of rapid/proliferative growth that must be differentiated from malignant growth activity the several pattern that cell growth exist are hyperplasia, dysplasia, & metaplasia  Cancer cells: malignant neoplasms – uncontrolled cell growth that follows no physiologic demand (neoplasia)  Both benign & malignant growths are classified & named by tissue of origin  Etiology  causes indicated or known to cause carcinogenesis: viruses& bacteria, physical agents, chemicals, genetic or familial factors, lifestyle hormones. 1. Agents  Viruses, bacteria – infectious disease o DNA viruses infect part of own DNA near infected cell genes causing cell division – newly formed cells carry viral DNA lack normal control on growth  Exaples: human papillomavirus (HPV) - cervical and head and neck cancers, Hep B (HBV) - liver cancer, Epstein-Barr virus (EBV), - burkitt lymphoma and nasopharyngeal cancer  H. pylori – gastric cancer o little evidence to support the link of most bacteria to cancer, although chronic inflammatory reactions to bacteria and the production of carcinogenic metabolites are possible mechanisms o Helicobacter pylori is one bacterium identified as a significant cause of gastric cancer Classification of caner: Carcinoma: 80-90% of all cancers  Tissue of origin: epithelial (adenocardinoma) – glandular epithelium, – organs or glands capable of secretion o Ex: adenocarcinoma of breast, lung, prostate  squamous epithelium (squamous cell carcinoma) – covers/lines all external and internal body surfaces o Ex: squamous cell cancer of lung, skin, esophagus  Sarcoma: connective/supportive o Bone (osteosarcoma) most common form of cancer of bone  Example: osteosarcoma of femur, humerus o Cartilage (chondrosarcoma) - rare, arises from within bones  Ex: chondrosarcoma of femur, pelvis o Adipose (liposarcoma) - arises from deep soft tissue  Ex: liposarcoma of retroperitoneum, thigh o Smooth muscle (leiomyosarcoma) very rare  Ex: leiomyosarcoma of uterus, intestine, stomach o Skeletal muscle (rhabdpsarcoma) most common in young children  Ex: rhabdosarcoma of head and neck, limbs o Fibrous tissue (fibrosarcoma) often involves long/flat bones  Ex: fibrosarcoma of femur, tibia, mandible o Membranes lining body cavities (mesothelial sarcoma/mesothelioma) most often related to asbestos exposure  Ex: mesothelioma of pleura or peritoneum o Blood vessels: (angiosarcoma) with liver – involvement related to occupational exposure to vinyl chloride monomer  Ex: angiosarcoma of liver, heart  Myeloma o Plasma cells (N/A) - produced by B-cell lymphocytes; plasma cell produce antibodies  Lymphoma Lymphocytes - (non-Hodgkin lymphoma): 2main classifications; may involve lymph nodes and/or body organs  Ex: b-cell lymphoma, T-cell lymphoma Leukemia o Hematopoietic cells in bone marrow – may involve various cell lines produced in bone marrow o WBC (myelogenous) - acute myelogenous leukemia  Lymphocytes: (lymphocytic) - acute lymphocytic leukemia o RBC – erythremia – involves overproduction of RBC and associated with increased levels of WBC/platelets; risk of additional bone marrow disease  Ex: polycythemia vera o  1.        2.         3.     Physical agents: Sunlight sunscreen [radiation] o being expose in the sun excessively especially in fair skinned folks increases the risk of skin cancers o exposure to sunlight, radiation, chronic irritation or inflammation, tobacco carcinogens, industrial chemicals and asbestos being exposed to ionizing radiation can occur w/repeated diagnostic x-ray procedures/radiation therapy used to tx disease chronic irritation/inflammation Improved x-ray equipment minimizes the risk of extensive radiation exposure Radiation therapy used in cancer treatment and exposure to radioactive materials at nuclear weapon manufacturing sites or nuclear power plants associated with a higher incidence of leukemia, multiple myeloma, and cancers of the lung, bone, breast, thyroid, and other tissues Background radiation from the natural decay processes that produce radon has also been associated with lung cancer it is advised to utilized ventilators at home in which high levels of trapped radon can disperse into the atmosphere Chemical agents a. numerous cancers are linked to environmental factors b. Tobacco c. Asbestos hazardous chemicals produce their toxic effects by altering DNA structure-occur in body sites distant from that of initial chemical exposure Tobacco smoke o single most lethal chemical carcinogen, accounts for about one third of cancer deaths Smoking is strongly associated with cancers of the lung, head and neck, esophagus, stomach, pancreas, cervix, kidney, and bladder and with acute myeloblastic leukemia Passive smoke (i.e., secondhand smoke) has been linked to lung cancer & may be linked with childhood leukemia and cancers of the larynx, pharynx, brain, bladder, rectum, stomach, and breast combustible forms of tobacco such as cigars, pipes, roll-your-own products, and water pipes (or hookah)- associated with increased cancer risk electronic cigarettes- great concern about potential negative health effects Smokeless tobacco products, such as chewing tobacco and snuff- associated with an increased risk of oral, pancreatic, and esophageal cancer chemical substances found in the workplace are carcinogens or co-carcinogens o aromatic amines and aniline dyes; pesticides and formaldehydes; arsenic, soot, and tars; asbestos; benzene; cadmium; chromium compounds; nickel and zinc ores; wood dust; beryllium compounds; and polyvinyl chloride o Betel nut and lime- chewed as stimulants in some cultures Genetics &familial Factors genetics, shared environments, cultural or lifestyle factors Genetic factors play a role in cancer cell development Cancer has been associated with extra chromosomes, too few chromosomes, or translocated chromosomes Cancers with these underlying genetic abnormalities include chronic myelogenous leukemia, meningiomas, acute leukemia, retinoblastomas, and Wilms tumor       4.    certain syndromes represent a cluster of cancers identified by a specific genetic alteration that is inherited across generations In these families, the associated genetic mutation is found in all cells (it is germline and somatic) and represents an inherited susceptibility to cancer for all family members who carry the mutation. cancers in adults display a pattern of cancers suggestive of a familial predisposition families with a hereditary cancer syndrome include cancer in two or more first-degree relatives (the parent, sibling, or child of an individual), onset of cancer in family members younger than 50 years, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members evidence of an autosomal dominant inheritance pattern of cancers affecting several generations of a family advances in the recognition of inherited cancer susceptibility syndromes enabled the appropriate identification of families at risk for certain syndromes o Examples include hereditary breast and ovarian cancer syndrome (BRCA1 and BRCA2) and multiple endocrine neoplasia syndrome (MEN1 and MEN2)  nephroblastomas, pheochromocytomas, and colorectal, stomach, thyroid, renal, prostate, and lung cancers Lifestyle Factors diet, obesity, and insufficient physical activity. second only to tobacco use as major risk factors associated with cancer development risk of cancer increases with long-term ingestion of carcinogens or co-carcinogens or the absence of protective substances in the diet  Dietary substances that appear to increase the risk of cancer include fats, alcohol, salt-cured or smoked meats, nitrate- and nitrite-containing foods, and red and processed meats  Heavy alcohol use increases the risk of cancers of the mouth, pharynx, larynx, esophagus, liver, colon, rectum, and breast  Poor diet and obesity- contributing factors to the development of cancers of the breast (in postmenopausal women), colon, endometrium, esophagus, and kidney o Obesity - increased risk for cancers of the pancreas, gallbladder, thyroid, ovary, and cervix, and for multiple myeloma, Hodgkin lymphoma, and an aggressive form of prostate cancer  sedentary lifestyles and lack of regular exercise to cancer development 5. Hormonal agents  tumor growth has been linked to disturbances in hormonal balance either by the endogenous [own body's] hormone production or by the administration of exogenous hormones.  cancers of the great, prostate, & uterus depend on endogenous hormonal levels of growth  prenatal exposure to diethylstilbestrol [synthetic form of female hormone estrogen] is a RISK AFCTOR for clear cell adenocarcinoma of the lower genital tract  Hormonal changes related to the female reproductive cycle- associated with cancer incidence  Early onset of menses before age 12 and delayed onset of menopause after age 55, null parity (never giving birth), and delayed childbirth after age 30 are all associated with an increased risk of breast cancer. Increased numbers of pregnancies are associated with a decreased incidence of breast, endometrial, and ovarian cancers.  Women who take estrogen after menopause appear to have an increased risk of ovarian cancer. Combination estrogen and progesterone therapy is linked to a higher risk of breast cancer  longer the combined therapy is used, the higher the risk. However, within 3 years of stopping the hormones, the risk returns to that of a woman who never used this therapy  Women who have taken hormonal therapy appear to have a lower risk of getting colorectal cancer, but when cancers are found it may be more advanced (more likely to have spread to lymph nodes or distant sites) than the cancers found in women not taking hormones Role of Immune System  transformed cells arise on a regular basis, but are recognized by surveillance cells of the immune system that destroy them before cell growth becomes uncontrolled (immune surveillance  immune system fails to identify and stop the growth of transformed cells, a tumor can develop and progress Folks who have an increased incidence of cancer: immunocompromised pts & transplant recipients who received immunosuppressive therapy to prevent rejection of the transplanted organ  AIDS pts have an increased risk of Kaposi sarcoma & other cancers  folks treated for one cancer are at high risk for other [secondary] cancers 1. Normal immune response Intact immune system ability to recognize and combat cancer cells – innate, humoral, cellular components of immune system  Tumor associated antigens (TAA) found on membranes of many cancer cells  TAAs processed by antigen-presenting cells (APCS) - (macrophages, dendritic cells that present t and b lymphocytes) presented to T lymphocytes that recognize antigen-bearing cells as foreign o TAAs identified: found in many types of cancer, some exist in normal tissue of origin as well as cancer cells, some exist in both normal and cancer cells but overexpressed in cancer cells, some specific to cancer cell types o In response to recognizing TAAs as foreign o t lymphocytes release cytokines that elicit various immune system actions including:  1) proliferation of cytotoxic (cell killing T lymphocytes capable of direct destruction of cancer cells  2) induction of cancer cell apoptosis  3) recruitment of additional immune system cells (B-cell lymphocytes that produce antibodies, natural killer cells, macrophages) contribute to destruction and degradation of cancer cells  2. Immune system evasion  If body fails to recognize TAAs on cancer cells or function of APCs is impaired, immune system is not stimulated: cancer cells been found to have altered cell membranes that interfere with APC binding and presentation to T lymphocytes  cancer cells release cytokines that inhibit APC’s and other cells in immune system, when tumors do not possess TAAs that label as foreign, immune response not alerted and tumor grows  Immunogenicity (immunologic appearance) of cancer cells can be alerted through genetic mutations allowing cells to evade immune cell recognition o Tumor antigens may combine with antibodies produced by immune system and hide themselves to normal immune defense mechanisms o tumor antigen-antibody complex creates message to decrease antibodies and other immune system complexes  Overexpression (abnormally high concentrations) of host suppressor T lymphocytes induced through the release of cytokines by malignant cells down regulates immune system  permitting uncontrolled cell growth  proliferation of T lymphocytes (promote immune response) impaired by cytokines produced by cancer cells  without helper T lymphocytes immune response is limited and cancer cells proliferate Influencing factors  environmental  Genetic/familial  Lifestyle  nutrition  Medications  Immune status  Advanced age Virus- HPV (cervical, head, and neck); Hep B (liver cancer) – liver inflammation and cells are destroyed Radiation exposure on a high level used in cancer treatments can lead to a higher incidence (leukemia or the breast) Tobacco (starting); vaping Hormonal agents: endogenous hormone production (breast, uterus) Lifestyle: obesity* Genetics: predisposition (1st degree relatives) PREVENTION Primary prevention: reducing the risks of disease through health promotion and risk reduction strategies o Use of immunization to reduce the risk of cancer through prevention of infections associated with cancer o HPV vaccine recommended to prevent cervical, head, neck cancer o vaccine to prevent HBV infection reduce risk of Hep B and development of liver cancer o Risk factor modification, Immunization, Chemoprevention Risk factor modification: sunscreen smoking, smoking, immunizations (HPV, HEP vaccine Secondary prevention: screening and early detection activities that seek to identify precancerous lesions and early stage cancer in individuals who lack signs and symptoms of cancer o ACS screening for many types of cancer o Reduce costs, use of resources and morbidity associated with advanced stages of cancer o Genetics have contributed to screening and prevention efforts – in depth assessment, screening, education, and counseling as well as follow-up monitoring for people at high risk for cancer o Noninvasive screening tests o Evaluation of family history for genetic syndromes   Tertiary prevention: efforts focus on monitoring for and preventing recurrence of the primary cancer as well as screening for development of secondary malignancies in cancer survivors o Improved screening, diagnosis, and treatment approaches have led to estimated 14.5 million survivors o Monitoring for and preventing recurrence of primary cancer as well as screening for development of second malignancies to cancer survivors o Second malignancies: lymphoma/leukemia (associated with chemotherapy agents and use of radiation therapy) o second malignancies can also be related to: inherited cancer syndromes, environmental exposures, lifestyle factors o Reducing morbidity and mortality o Treatment and management of side effects o Refer in table 15.3 Want to reduce illness and death through treatment Focus on monitoring and recurrences of primary cancers and screen for secondary malignancy r/t metastasis TYPES OF CANCER  Divided into 2 main categories o Solid tumors o Hematological malignancies  3 Subcategories of hematological malignancies  Further classified by tissue of origin.  Epithelial  Connective/Supportive Solid tumors- rise from body organs and destroy body tissue as the grow Hematological- rise from hemopoietic (lymph nodes or spleen); affecting blood line (platelets, EBC, RBC) - LEUKEMIA LYMPHOMA MULTIPLE MYELOMA DIAGNOSIS CANCER BASED ON assessment of physiologic and functional changes and results in diagnostic evaluation  Undergo extensive testing o to determine presence and extent of cancer  identify possible metastasis o evaluate function of involved and uninvolved body systems and organs o obtain tissue and cells for analysis, including evaluation of tumor stage and grade  Diagnostic evaluation: review of systems, physical examination, imaging studies, lab tests of blood, urine, and other body fluids; procedures, pathologic analysis  Nurse Role: o Help address pt fear/anxiety by explaining tests performed, sensations likely to be experienced, pt role in test procedures, encourages family member and pt to voice fears about test results, o support pt / family through diagnostic evaluation, reinforces/clarifies information conveyed by dr  Diagnostic evaluation dependent upon o Suspected cancer subtype, possible disease location, and expected extensiveness of the disease  Laboratory tests  Imaging  Diagnostic surgery  Endoscopic procedures Diagnostic Tests Diagnosis of cancer Undergo extensive testing 1. Determine presence and extent of the tumor 2. Identify possible disease metasis or spread 3. Evaluate function of the involved and uninvolved body system and organs 4. Obtain and tissue and cells for analysis Tumor Staging and Grading  Considers the size of the tumor, burden of the disease, and extent of disease spread  Used to plan patient assessment, clinical management, and treatment strategies  Solid malignancy staging o Tumor size (T) o Number of lymph nodes involved (N) o Presence of metastases (M) Complete diagnostic evaluation includes identifying stage and grade of tumor prior to tx to provide baseline for evaluating outcomes of therapy tx and prognosis based on tumor stage/grade  Staging: o determines the size of tumor, existence of local invasion, lymph node involvement, distant metastasis – tumor, nodes o metastasis (TNM) system – used to describe many solid tumors o  Grading: pathologic classification of tumor cells – define type of tissue from which tumor originated and degree to which tumor cells retain the functional and histologic characteristics of the tissue of origin (differentiation) o Obtained from tissue scrapings, body fluids, secretions, washings, biopsy, surgical excision o helps predict prognosis of tumors o numeric value ranging from I to IV  Grade I tumor (well differentiated tumors) resemble tissue of origin in structure/function - tumors that do not resemble tissue of origin in structure or function assigned grade IV (more aggressive, less responsive to treatment, associated with poorer prognosis as compared to well-differentiated, grade I tumors)  Cancer generally staged along a continuum (Ⅰ-Ⅳ)  Stage Ⅰ— Small tumor without obvious spread outside the organ Stage Ⅱ — Invasion of tissues or involvement of local lymph nodes   Stage Ⅲ — Large or locally invasive tumors  Stage Ⅳ — cancers that have metastasized TNM system Tumor size Number of lymph nodes Presence of metastases Anatomic Stage Group  Diagnosis, clinical stage, histologic grade has been determined, anatomic stage group, designated by I through IV (representing increasing severity of disease)  assigned to facilitate communication, tx decisions, estimation of prognosis (useful for comparing clinical outcomes) Clinical presentation  Types of symptoms o CAUTION symptoms o Constitutional signs o Malignancy-specific signs and symptoms Prognosis- course of disease is going to go; refers to likely course of the disease Concerns: anxiety, early detection Palliation – treatment of quality of life Caution symptoms: change in bowel/bladder habits, unusual bleeding or discharge, thickening/lumping in parts of the body, indigestion or difficulty swallowing, change in wort and mole, nagging cough or hoarseness, sore threat that won’t go away Constitutional signs: may think they have another illness Nursing management  Care of patients with cancer crosses all subspecialties of medical-surgical nursing and ambulatory primary care  The disease can affect any organ system and can be managed in a variety of clinical settings Treatment  3 Broad treatment modalities o Surgical procedures o Radiation therapies o chemotherapies  Single therapy or multimodality  Neoadjuvant therapy  Adjuvant therapy Can cut it out, radiate it, drug it Mix therapies – multimodality Shrinking a tumor Adjuvant therapy- used in remission or disease free but high risk for relapse (microscopic malignant cells that can come back with symptoms)  Biopsy: excisional, incisional  Tumor removal: wide excision, local excision  Prophylactic surgery  Palliative surgery  Reconstructive Prophylactic- preventative (Angelina Jolie) Palliative surgery- we can’t remove cancer but might do surgery to relieve symptoms Ex: benign can grow really big so you remove portions at a time Reconstructive surgery- ex: Angelina Jolie- double mastectomy and then get breast implants Nursing Care of Patients with Cancer  Maintaining tissue integrity o Stomatitis o Radiation-associated impairment of skin integrity o Alopecia o Malignant skin lesions (see chart 15-7) Alopecia- loss of hair Mindful when caring for the patient’s skin  Promoting nutrition o Nutritional impairment o Anorexia o Malabsorption o Cancer-related anorexia-cachexia syndrome  Relieving pain  Decreasing fatigue Improving body self-image Relieving pain- medications, distraction, other therapies Monitoring and managing Potential Complications  Infection  Septic shock  Bleeding, hemorrhage Reduce platelet count hemorrhage Monitor for signs and symptoms Management of Cancer/Treatment Treatment goals are based on specific type, stage, grade of cancer  Possible treatment goals: o complete eradication of malignant disease (cure) o prolonged survival and containment of cancer cell growth (control relief of symptoms associated with disease o improvement of quality of life (palliation)  Palliation- quality of life treatment not initiated until diagnosis of cancer confirmed and grading/staging completed   Multiple modalities: surgery, radiation therapy, chemotherapy, hematopoietic stem cell transplantation (HSCT) o Used together or at different times throughout tx  Cure – cure to the cancer (procedure or medication) Controlthrough treatment  Surgery  Surgical removal of entire cancer remains ideal and most frequently used tx method – primary tx, prophylactic, palliative, reconstructive  Diagnostic surgery- definitive method for obtaining tissue to identify the cellular characteristics that influence all treatment decisions. Diagnostic surgery  Aka Biopsy – used to obtain tissue sample for histologic analysis of cells suspected to be malignant (biopsy can be taken from actual tumor or lymph nodes near suspicious tumor)  Many cancers can metastasize from the primary site to other areas of the body through the lymphatic circulation. o Knowing whether adjacent lymph nodes contain tumor cells helps the health care team plan the best therapeutic approach to combat cancer that has spread beyond the primary tumor site  some cancer metastasizes through lymphatic circulation  use of injectable dyes and nuclear medicine imaging to help identify sentinel lymph node or initial lymph node to which primary tumor and surrounding tissue drain  Sentinel lymph node biopsy (SLNB), sentinel lymph node mapping (minimally invasive surgical approach has replaced more invasive lymph node dissections (lymphadenectomy) associated complications such as lymphedema and delayed healing  SLNB adopted for reginal lymph node staging in melanoma and breast cancer