Med-Surg Immune System, part 12: Integumentary and Hematologic Cancers

by Cathy Parkes October 09, 2020

In this article, we cover what you need to know about skin cancer and cancers of the blood, including lymphoma and myeloma. Learn about skin cancer prevention, the difference between Hodgkin's and non-Hodgkin's lymphoma, and important nursing care and patient teaching for these cancers.

These cancers, their pathophysiology, treatment, and important patient teaching are covered in our Medical-Surgical flashcards (Immune system), and Cathy’s videos follow along with the cards.

Skin cancers (integumentary system)

Prevention

There are some important steps you can teach all patients to help prevent skin cancer. Avoiding midday sun, wearing sunscreen, and wearing protective clothing are all ways to protect the skin from the harmful rays of the sun.

Even with precautions, skin cancers can't always be prevented. But if a patient does have a cancerous growth on their skin, it's important to catch it early. Patients should check their own skin for any abnormalities, as well as seeing a dermatologist about once a year to get a comprehensive skin check.

The three types of skin cancer

There are three main types of skin cancer you should know about for your Med-Surg and Critical Care exams as well as your nursing practice, and those are basal cell carcinoma, squamous cell carcinoma, and melanoma.

basal cell carcinoma

Basal cell carcinoma

Basal cell carcinoma of the skin is a type of cancer that originates in the basal layer of the epidermis. It's the most common type of skin cancer, and it presents as a waxy nodule with pearly borders.

squamous cell carcinoma

Squamous cell carcinoma

Squamous cell carcinoma of the skin is a type of cancer that originates in the upper (squamous) layer of the epidermis and presents as an oozing, crusting lesion.

It's important to note that the term "squamous cell carcinoma" is used often by itself and is referring to the cancer of the skin, but since it is only referring to the type of cell, it can occur in other types of cancer besides what is generally grouped as skin cancer. For example, a patient with lung cancer may have squamous cell carcinoma of the lungs. In our previous article on tumor classification, you can learn more about squamous cell carcinoma in general.

melanoma

Melanoma

Melanoma is a cancer that arises out of the melanocytes, which are the melanin-producing (color-producing) cells in the epidermis. Melanoma is the most deadly form of skin cancer, and it is highly metastatic, so it can spread to other areas of the body very rapidly. When you see a lesion that is highly irregular with color changes throughout the lesion, that is a red flag and indicative of a possible melanoma.

ABCDE assessment

The ABCDE is a handy assessment tool for checking for melanoma.

  • A is for asymmetry. If the mole or lesion is asymmetric, that is concerning.
  • B is for border. If the mole has irregular borders, then that is also suspect.
  • C is for color. If pigmentation varies across the mole or lesion, that is also suspicious.
  • D is for diameter. If the mole has a diameter greater than 6mm, about the width of a pencil eraser, then it should definitely be checked out by a dermatologist.
  • E is for evolving. If the mole has changed in appearance over time, or if it starts to bleed, then it should also be checked out by a dermatologist.

Treatment

There are multiple treatment options for skin cancer.

An excision is surgical removal of the skin cancer.

Certain skin cancers can be treated with topical chemotherapy, and this chemotherapy medication is called 5-fluorouracil.

Another treatment option for skin cancer is a procedure called Mohs surgery, in which one layer of the growth is removed at a time and analyzed while the patient waits. This is more time consuming but overall less invasive.

Cryosurgery is another option for skin cancer, where the lesion is frozen off.

Blood cancers (hematologic)

Blood cancers, or cancers of the hematologic system, are cancers that affect blood cells and bone marrow.

Leukemia

Leukemia is cancer of the bone marrow, which causes an overgrowth of cancerous white blood cells. In turn, this prevents the growth of red blood cells, platelets, and normal white blood cells. This causes immunodeficiency because because there are too many WBCs that are immature, not functioning correctly, and crowding out the platelets, RBCs, and functional WBCs

Leukemia is a little bit different than cancers marked by solid tumors, because there are not actual tumors. So you would not use TNM staging to measure leukemia.

Lymphoma (Hodgkin’s vs. Non-Hodgkins)

Lymphoma is marked by a solid tumor in the lymphoid tissue, like in the lymph nodes or the spleen. This causes the overgrowth of lymphocytes, a type of white blood cells. There are two types of lymphoma that you have likely heard of: Hodgkin's lymphoma and non-Hodgkin's lymphoma.

Hodgkin's lymphoma is marked by the presence of Reed-Sternberg cells, which are large cells with more than one nucleus. In non-Hodgkin's lymphoma, there are no Reed-Sternberg cells.

Multiple Myeloma

Multiple myeloma is a cancer that causes the overgrowth of plasma cells in the bone marrow. This results in excess secretion of cytokines and antibodies, which prevents the growth of red blood cells, platelets, and normal white blood cells.

Treatment

There are different treatment options for hematologic cancers depending on the type and severity, including chemotherapy, radiation, targeted therapy, and a stem cell transplant.

Patient teaching

As a nurse, it is important to remember that patients with leukemia, lymphoma (Hodgkins or non-Hodgkin's), or myeloma are at risk for anemia, neutropenia, and thrombocytopenia. These hematologic cancers inhibit the growth of normal red blood cells, normal platelets, and normal white blood cells, all of which are critical for normal immune function; so these cancers leave the patient in an immunocompromised state.

For neutropenia, patients should do their best to avoid illness. This can be by avoiding crowding areas, avoiding contact with people who are sick, eating no raw fruits or vegetables (only well-cooked), avoiding gardening, and eliminating fresh flowers or live plants from the home. Patients with anemia should follow a special diet to increase necessary iron. Those with thrombocytopenia should take special precautions to avoid bleeding.

Detailed patient teaching for these conditions is available in our previous article, Med-surg Immune System, Part 11: Neutropenia, Anemia, Thrombocytopenia.

Cathy’s teaching on hematologic cancers is intended to help prepare you for Medical-Surgical nursing exams. The Medical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.


Full transcript

Hi, I'm Cathy and in this video, I'm going to talk about cancers of the integumentary system, so that's the skin, as well as cancers associated with the hematologic system, or the blood. If you're following along with cards, I'm card number 27.

We're first going to talk about skin cancer and let's touch a bit on prevention. So you need to teach your patient to avoid midday sun. They should wear sunscreen and protective clothing and perform regular skin checks. They should also see a dermatologist about once a year to get a comprehensive skin check from a professional.

There are three main types of skin cancer that I'm going to talk about here in this video. Those include basal cell carcinoma, squamous cell carcinoma, and melanoma. So I'm going to bring up photos of each of these types of cancers so you can get a good feeling for what they look like.

This is an example of basal cell carcinoma which originates in the basal layer of the epidermis. It's the most common type of skin cancer, and you can see it kind of presents as a waxy type nodule with pearly borders. All right.

This is an example of squamous cell carcinoma. So this type of skin cancer originates in the upper layer of the epidermis and it presents as an oozing, crusting type of lesion.

Here's an example of melanoma, which this type of cancer arises out of the melanocytes, which are the melanin-producing cells in the epidermis. This is the most deadly form of skin cancer. And it is highly metastatic, meaning it will spread to other areas of the body very rapidly. So when you see a lesion like this that is highly irregular with color changes throughout the lesion, then that is definitely a red flag and indicative of possible melanoma.

Alright. Let's talk now about our ABCDE assessment of a patient's lesion or mole to check for melanoma.

A stands for asymmetry. So if the mole or lesion is asymmetric, that is concerning.

B stands for border. If the mole has irregular borders, then that is also suspect.

C stands for color. So if pigmentation kind of varies across the mole or lesion, that is also suspicious.

D stands for diameter. So if the mole is big like over 6 millimeters, which is the width of a pencil eraser, then it should definitely be checked out by a dermatologist.

And then E stands for evolving. So if the mole has changed in appearance over time, or there's new bleeding, then it should also be checked out by a dermatologist.

In terms of treatment of skin cancer, we can do an excision. So it's surgical removal of the skin cancer.

We can do topical chemotherapy. So this medication is called 5-fluorouracil.

Or we can do something called Mohs surgery. This is where they go in and take kind of a layer off at a time and send it to the laboratory. And when they're sure they've gotten all the cancer, then the surgery can be completed.

And then cryosurgery is also an option. This is basically freezing the lesion off.

Alright. Let's now turn our attention to hematologic cancers. I'm going to touch on leukemia, lymphoma, and multiple myeloma.

With leukemia, we have cancer of the bone marrow, which causes overgrowth of cancerous white blood cells. And this, in turn, prevents the growth of red blood cells, of platelets, and of normal white blood cells.

Then we have lymphoma. This is where we have a solid tumor in the lymphoid tissue. So it may be in a lymph node or in the spleen, and it causes the overgrowth of lymphocytes.

There are two types of lymphoma. We have Hodgkin's and non-Hodgkin's.

With Hodgkin's, we have the presence of Reed-Sternberg cells, which are these really large cells with more than one nucleus.

With non-Hodgkin's lymphoma, there are no Reed-Sternberg cells.

Then we have multiple myeloma. This is a cancer that causes the overgrowth of plasma cells in the bone marrow. And this in turn results in excess secretion of cytokines as well as antibodies. And this prevents the growth of red blood cells, platelets, and normal white blood cells.

So in terms of treatment options for hematologic cancers, we can use chemotherapy, radiation, targeted therapy, as well as a stem cell transplant.

As a nurse, it's going to be important to remember that when any of these blood cancers, the patient's going to be at risk for anemia, neutropenia, and thrombocytopenia because these blood cancers inhibit the growth of normal red blood cells, normal platelets, and normal white blood cells.

So you're definitely going to want to implement precautions and do some patient teaching because of these risk factors. And I did go over that teaching in my previous video. So if you haven't watched that then definitely go back and watch that so you know those important nursing care items and important teaching that you need to provide to keep your patients safe. So that's it for this video. I will pick it up with more cancers in my next video. Thank you so much for watching.

[BLOOPER:] Cancers of the blood...Psh...I don't know what I'm saying?? Sorry!


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