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Tis: Carcinoma in situ (site of origin).

Tt. TI, T3, T4: Progressive increase in tlllllor size and local involvcmcnr.

N: Regional lymph node involvemcnr

NX: Nodes cannor be assessed.

NO: No metastasis to local lymph nodes.

Nl, N2, N3: Progressive involvement of local lymph nodes.

M: Distant metastasis

MX: Presence of distam metastasis cannot be assessed.

MO: No disrant metastasis.

M1: Presence of distanr merastasis.

ONCOLOGY 339

Table 5-6. Grading of Neoplasms

Grade I

Tumor cells closely resemble original tissue.

Grades II and III

Tumor cells arc inrermediate in appearance,

moderately differentiated.

Grade IV

Tumor cells are so poorly differentiated (anaplastic) that the cell of origin is difficult or impossible to determine.

Additional treatments may include physical therapy, nutritional support, acupuncture, chiropractic treatment, alternative medicine, and hospice care.

Treatment protocols differ from physician to physician and from

cancer to cancer. Standard treatment includes some combination of

surgery, radiation, and chemotherapy.

Surgery

Surgical intervention is determined by the size, location, and type of

cancer, as well as the patient's age, general health, and functional status. The following are the types of general surgical procedures for resecting or excising a neoplasm:

•

Exploratory surgery is the removal of regions of the tumor to

explore for staging or discover the extent or invasion of the rumor.

• Excisiolla/ surgery is the removal of cancerous cells and the surrounding margin of normal tissue. Tissue cells are sent to pathology to determine the type of cancer cell and to determine whether the entire growth was removed.

• Debit/king is an incomplete resection used to reduce the size of a

large tumor to make the patient more comfortable or prevent the

tumor from impinging vital tissue. This surgery is usually used

when the cancer is considered "incurable."

• Mohs' surgery is a microscopically controlled surgery in which

layers of the tumor are removed and inspected microscopically

until all layers have been removed.s

•

Lymph node dissection involves rhe removal or resection of

malignant lymph nodes to help control the spread of cancer.

340 AClJrE CARE. HANDBOOK FOR PHYSICAl. TlI£RAI'ISTS

• Skin grafting may be indicated in large resections of tumors to

replace areas of skin removed during resection of a neoplasm with

donor skin (see Chaprer 7) .

•

Reconstructive surgery is the surgical repair of a region with a

flap of skin, fascia, muscle, and vessels. It aids in a more cosmetic

and funcrional resulr of surgical repair and prorects the underlying

resected a rea.

Clinical Tip

• Special care must be taken with skin grafts. Patients

usually remain on bed resr to allow the graft to begin to

adhere. (Lengrh of bed reSt is dependent on physician's

protocol, ranging from 0 to 36 days.9-1l) During bed rest,

therapeutic exercise may be performed with extremities

not involving the skin graft sire.

•

Muscle contraction in newly constructed muscle flaps

should be minimized or avoided.

Radiation

High-ionizing radiation is used to destroy or prevent cancer cells from

growing furrher, while minimizing the damage to surrounding healthy

tissues. Radiation therapy reduces the size of a tumor to allow for

resection surgically, to relieve compression on structures surrounding

the tumor, and to relieve pain (by relieving compression on pain-sensitive structures). Reducing the size of a tumor with radiation therapy may also help to reduce the need for a large resecrion, amputation, or

complete mastectomy.7

Radiarion may be delivered via supervolrage radiotherapy (teletherapy) or by planting radioactive marerial near the rumor (seeding or brachytherapy). Radiation destroys cells in its path; therefore, special consideration is given to irradiating as little normal tissue as possible. Teletherapy uses variolls methods, such as linear acceleration and modifying-beam wedges, to permit greater localization.' Seeding

may destroy all surrounding tissues, including healthy tissue. Radioactive seeds are implanted for several days, then removed.

ONCOLOGY 341

Common side effects of radiation therapy include skin reactions, slow healing of wounds, limb edema, conrracrures, fibrosis, alopecia, neuropathy, headaches, cerebral edema, seizures, visual

disturbances, bone marrow suppression, cough, pneumonitis,

fibrosis, esophagitis, nausea, vomiting, diarrhea, cystitis, and U[Inary frequency.6·7

Clinical Tip

• Physical therapy should be deferred while the person

has implanted radioactive seeds.

• Massage and heating modalities should be withheld for

1 year in an irradiated area.

• Persons undergoing irradiation by beam (teletherapy)

will have blue markings where the radiation is being delivered. Caution should be taken with the skin and underlying tissues in that area, because it will be very fragile.

Persons who have received the maximum allowable radiation in an area will have that area outlined in black. Special care should be taken with the skin and other tissues in that area, because it will be very fragile.

• A patient may be prescribed antiemetics (see Appendix

IV, Table TV-6) after radiation treatment to control nausea

and vomiting. Notify the physician if antiemetic therapy is

insufficient ro comrol the patient'S nausea or vomiting

during physical therapy sessions.