Lung Cancer f

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LungCancer


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INTRODUCTION

Cancer is the term used for diseases in whichabnormal cells divide (mitosis) without control.Cancer cells can invade nearby tissues andspread through the bloodstream and lymphaticsystem to other parts of the body (metastasis) .Cancer cells also avoid natural cell death(apoptosis).

The word originated from the Latin word forcrab, because the swollen veins around a surfacetumor appeared like the legs of a crab.


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Right lung=3 lobes

Left lung=2 lobes

Air enters lungsthrough trachea

Trachea divides intobronchi

Bronchi divide intobronchioles

Alveoli are the air sacsat the end of thebronchioles

Pleura = lining of the

lungs

ANATOMY OF LUNGS


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FUNCTIONS OF LUNGS

Every day one human being takes about 23,000 breaths,which bring almost 10,000 quarts of air into your lungs.

The air that breath in contains several gases, includingoxygen, that cells need to function.

With each breath, lungs add fresh oxygen to blood,which then carries it to cells. The lungs are the

essential respiration organ in humans.

Their principal function is to transport oxygen from theatmosphere into the bloodstream, and to release carbondioxide from the bloodstream into the atmosphere.


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Seven cardinal signs of cancer

C Change in bowel or bladderhabits could be a sign ofcolorectal cancer.

A sore that does not heal onthe skin or in the mouth could bea malignancy and should bechecked by a doctor.

U Unusual bleeding or dischargefrom the rectum, bladder orvagina could mean colorectal,

prostate, bladder or cervicalcancer.


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CONTDO Obvious changes to molesor warts could mean skincancer.

N Nagging cough orhoarseness that persists forfour to six weeks could be a

sign of lung or throat cancer.


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Lung Cancer: Defined

Uncontrolled growth of malignant cells inone or both lungs and tracheo-bronchialtree

A result of repeated carcinogenicirritation causing increased rates of cellreplication

Proliferation of abnormal cells leads tohyperplasia, dysplasia or carcinoma in

situ


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Picture of the CancerousLungs


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Most frequently diagnosed cancer

worldwide About 1.35 million new cases diagnosed

worldwide each year

Leading cause of cancer deaths inthe United States


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Incidence andmortality ratesbegin to increasebetween the agesof 45 and 54 andrise progressivelyuntil age 75

Median age atdiagnosis=70.07

Median age atdeath=71.07


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Males have a greater lifetime risk oflung cancer than females (7.81% vs.

5.8%)

Greater disparity in developing countrieswhere cigarette use by females is low


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Higher incidence and mortality ratesare reported among men from lower

SES groups


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Cigarette smoking is the most importantrisk factor for lung cancer

Causes approximately 90% of male and 75-80% of female lung cancer deaths

By the early 1950s, case control studiesin the US and Great Britain clearlyshowed an association between smokingand lung cancer

In 1964, the US Surgeon Generalreleased a report on the causal

relationship


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Smoking Facts

Tobacco use is theleading cause of lungcancer

87% of lung cancersare related to smoking

Risk related to:

age of smoking onset

amount smoked gender

product smoked

depth of inhalation


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More than 80carcinogens in cigarettesmoke according to theInternational Agencyfor Research on Cancer(IARC)

Polycyclic aromatic

hydrocarbons (PA

Hs) area well documented lungcarcinogen


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Secondhand smoke

Each year about 3,000 non-smoking

adults die of lung cancer as a result ofbreathing secondhand smoke.


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Whatabout

secondhand smoke?

Being in a nonsmoking section of arestaurant for 2 hours =

Being in a smoky home for one day =

Being in a smoky bar =

Mayo Clinic


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History of respiratory diseases such asasthma, bronchitis, emphysema, hayfever, or pneumonia may modify risk

When combined with smoking, there is acomplementary cycle of injury and repairthat may increase risk

Respiratory diseases may result in

chronic immune stimulation that causesrandom pro-oncogenic mutations thatincrease risk

Relationship is still speculative


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Animal models have indicated that dietaryfat can promote chemically induced

pulmonary tumors. Relationship may be confounded by the

association between smoking status and diet

Rates of lung cancer are highest incountries with greatest fat consumptionafter controlling for smoking.


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Lowered risk associated with consumptionof fresh vegetables and fruits Risk in those with highest intake was about

one-half of those with lowest intake

Beneficial micronutrients in fruits andvegetables Carotenoids Isothiocyanates Folate Selenium


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Difficult to assess association betweenalcohol and lung cancer due to

confounding by smoking status


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IARC categorized several occupational

agents as known carcinogens Radon

x Well established lung carcinogen, responsible for 6.5%of lung cancer deaths in the United Kingdom in 1998

Asbestos

Arsenic

Bischloromthyl ether

Chromium Nickel

Polycyclic aromatic compounds

Vinyl chloride


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Only a fraction of long-term smokers willdevelop lung cancer

Likely impacted by genetic susceptibility Familial aggregation

Studies have reported an excess of lung cancermortality in relatives of lung cancer patients


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Polymorphisms in genes encoding forenzymes responsible for detoxification of

carcinogens affect the internal dose oftobacco carcinogens that lung tissue isexposed to

Many different polymorphisms

Cytochrome P-450


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Defective repair of genetic damage is animportant determinant of susceptibility to

lung cancer Hypersensitivity to carcinogenic exposure

Many studies have demonstrated that cancercases have a significant decrease in DNA

repair capacity compared to controls


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Where does it travel?

Lymph Nodes, Brain, Liver, Adrenal,Gland, Bones

40% of metastasis occurs in the

Adrenal Gland


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PATHOPHYSIOLOGYMore than 90% of lung cancer originate

from the epithelium of bronchus. Theyslowly & it takes 8 to 10 years, for atumor to reach 1cm in size.

Cancerous lung tissue cannot exchangeoxygen & carbon dioxide

It impairs the functioning of the lung


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Tumor cells grow & invade

surrounding lung tissue

Air way invaded & obstructing the

flow of the air

Cancerous cells invade local lymph

nodes & thoracic duct

Significant growth of the tumor


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Evolution of Intraepithelial Neoplasia

Mild/Moderate/Severe/CIS

Squamous

Adenomatous

Normal Hyperplasia/Metaplasia Dysplasia Cancer


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Types:

There are 4 major types :Non- small cell carcinoma:-

1- epidermiod [squamous] -35%

2- adeno carinema -30%

3- large cell carcinoma -15%

4- small cell lung cancer -20%


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Epidermiod carcinoma -35% :

Occurs most frequently in men and oldpeople

Usually starts on one breathing tubes. Tend to be localized in the chest longer

than other types of lung cancer.

Does not tend to metastasize early.

It is strongly associated with smoking.


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Adenocarcinnoma-30%:

Most common cancer amongwomen.

Usually started near the outer

edges of the lung. Invasion of pleura and

mediastinal lymph node is

common. May spread to other parts of thebody.

Can be seen in non smoker.


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Large cell carcinoma 15% :

Less well differentiated. May occur at any part of the

lung.

Tumors are large by the timethey are diagnosed.

Has greater possibility ofspreading to brain andmediastinum.


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Small cell lung cancer:

Small cell lung cancer also called oatcellbecause SCLC cells have oat grainappearance.

It arises from endocrine cells[kulchitisky cells] where many hormonesare secreted

Spread to lymph nodes and other organsmore quickly than NSCLC .


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Cntd.

Usually started in one larger breathing tube.

.Tend to grow rapidly .

Commonly has spread by the time and is

considered a systemic disease.

It is the only one of the bronchialcarcinomas that respond to chemotherapy


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NON SMALL CELL LUNG

CANCERIt is staged according to the sizeof the tumor, the level of lymphnode involvement and the extent

to which the cancer has spread.The stages include:STAGE 0:Cancer is limited to

the lining of the air passage andhasnt invaded lung tissue.STAGE1:Invaded to lung tissue

Hasnt invaded to lymph nodes


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CONTD

STAGEII: Spread to neighboringlymph nodes Invaded the chest wall

STAGEIIIA: Spread from the lung tolymph nodes.

STAGEIII B: Spread locally to areas .

STAGEIV :spread to other parts ofthe body.

NSCLC S i


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NSCLC StagingT 1: tumor < 3 cm

T2: tumor > 3 cm, >2 cm from carina, invading the

pleura, partial lung collapseT3:


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SCLC Limited StageDefined as tumor involvement of one lung,the mediastinum and ipsilateral and/orcontralateral supraclavicular lymph nodes

or disease that can be encompassed in asingle radiotherapy port.

Extensive Stage

Defined as tumor that has spread beyondone lung, mediastinum, and supraclavicularlymph nodes. Common distant sites ofmetastases are the adrenals, bone, liver,bone marrow, and brain.


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Presentations:

Lung cancer may present innumber of different ways :

Most commonly symptomsreflect local involvement of thebronchus.

May also arise from spread to

the chest wall or mediastinum orfrom distant blood-bornespread.


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Local effects of tumor withinthe bronchus :

1- cough ( in 80% of cases ) :

- It is the most common early symptoms.

- sputum is purulant if there is secondaryinfection.

- A change in the character of the (regular

cough) associated with other newrespiratory symptoms increase thepossibilityof B.C.


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2-Haemoptysis (in 70% of cases):

- Repeated episodes of scanty

cough hemoptysis or blood streaking of sputum in smokersare highly suggestive of B.C and

should be always investigated .


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Cntd.

3- Dyspnea ( 60% of cases ):- reflect occulusion of a largebronchus resulting in collapse of a

lobe of the lung or development ofplearal effusion.4- Pleural pain :- reflect malignant invasion of thepleura or reflect infection distalto a tumuor (wich is recurrentand fail to resolve).


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Direct spread:

Involvement of pleura and ribs .

-Pancoasts tumour: involvement of lower

part of the brachial plexus ( C8 , T1,T2)causing severe pain of the shoulder anddown inner surface of the arm.

-Horner syndrom: due to involvement of the

sympathetic ganglion.


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Contd.

-Recurrent laryngeal nerve palsy :causing unilateral vocal cord paresiswith hoarsness of voice and a bovine

cough..Invation of phrenic nerve ,

causing paralysis of thediaghragm.


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.Involvement of esophagus ,causing dysphagia.

.Cardiovascular: atrial fibrillation,temponade ,pericarditis,pericardial effusion .


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Contd..

. Superior vena cava obstructioncausing early morning headache,facial congestion and edema

involving the upper limb,distention of jugular vein andveins of the chest.


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Nonmetastatic extrapulmonary manifistation:1- Endocrine manifestation:12% of tumors ,in particular small

cell tumors present withSIADH, ACTH secretion(SCLC),hypercalcemia (sq.cellcarcinoma),bone metastasis

gynaecomastia(LCLC) .


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Contd.

2- Neurological manifetation:e.g: sensory polyneuropathy

,myelopathy, cerebellardegeneration.


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Cntd.

3- Others: Digital clubbing ,

Hypertrophic pulmenary osteo-

arthropathy (sq.cell cancer) , Nephrotic syndrome,

Hypercoagulopathy (adenocarcinoma),

Thrombophelibitis migricans.


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Blood borne metastasis:

.Bony metastasis giving severe bony painand pathalogical fractures.

.liver metastasis (Jundice)

.Brain metastasis (change in personality,epilpsy,focal neurological symptoms).


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DIAGNOSTIC STUDIES


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Physical signs:

Examination is usually normalunless there is significantbronchial obstruction or tumor

has spread to pleura ormediastinum.


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Cntd.

1- physical signs of collapse (in largeobstructing tumor) which may rise topneumonia.

2- monophonic or unilateral wheeze (fixedbronchial obstruction).

3- stridor (obstruction at or above thelevel of main carina.


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Contd..

4- hoarsness of voice associated withbovine cough (recurrent laryngeal nervepalsy).

5- dullness percussion and absent breathsounds at the lung base (unilateraldiaphragmatic palsy due to involvement

of phrenic nerve)


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Contd.

6- physical signs of pleursy or pleuraleffusion (involvement of pleura).

7- bilateral engorgement of the jangularvein and later edema affecting face,neck, arms.

8- tenderness and pain of long bone andjoints .


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Investigation:

Sputum cytology: high yield for

endobronchial tumors such assquamous cell and small cellcarcinoma.


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chest x-ray:common radiologicalpresentation of bronchialcarcinoma.

1- unilateral hilar-enlagement.

2- peripheral pulmonary opacity.3- lung, lobe or segmental

collapse.


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. Bronchoscopy : gives high yield inexcess of 90% (allows biopsy andbronchial brush samples) if fail

precautious fine needle aspiration underCT.


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.CT thorax and upper abdomen.

.Head CT scan.

.Radio nuclide bone scanning.

.liver US.

.bone marrow biopsy.


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MANAGEMENT


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MANAGEMENT

Medical management :1. Radiation therapy

2. Chemotherapy

3. Bronchoscopic laser therapy

4. Photodynamic therapy

5. Airway stentingSurgical management :

1. Surgical resection

RADIATION THERAPY


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RADIATION THERAPY Radiation therapy uses high-energy radiation

to shrink tumors and kill cancer cells . X-rays, gamma rays, and charged particles aretypes of radiation used for cancertreatment.

The radiation may be delivered by a machineoutside the body (external-beam radiationtherapy), or it may come from radioactivematerial placed in the body near cancer cells

(internal radiation therapy, also calledbrachytherapy).

About half of all cancer patients receivesome type of radiation therapy sometime

during the course of their treatment.

H d d h


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How does radiation therapykill cancer cells?

Radiation therapy kills cancer cells bydamaging their DNA (the molecules inside cellsthat carry genetic information and pass itfrom one generation to the next) .

Radiation therapy can either damage DNAdirectly or create charged particles (freeradicals) within the cells that can in turndamage the DNA.

Cancer cells whose DNA is damaged beyondrepair stop dividing or die. When the damagedcells die, they are broken down and eliminatedby the bodys natural processes.

Linear Accelerator Used for


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Linear Accelerator Used forExternal-beam Radiation

Therapy

SIDE EFFECTS OF


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SIDEEFFECTS OFRADIATION THERAPY

Acute side effects of radiation therapyare:-

Cough

Pharyngitis

Esophagitis

Anorexia

Weight loss

Fatigue

Skin reactions

CONTD


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CONTD. Late side effects of radiation therapy

may or may not occur. Depending on thearea of the body treated, late sideeffects can include :

Fibrosis (the replacement of normal tissue

with scar tissue, leading to restrictedmovement of the affected area).

Damage to the bowels, causing diarrhea andbleeding.

Memory loss. Infertility (inability to have a child).

DRUG AMINOFOSTINE IS GIVEN TOLESSEN THE SIDEEFFECTS OF

RADIATION THERAPY.

CHEMOTHERAPY


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CHEMOTHERAPY Chemotherapy (also called chemo) is a

type of cancer treatment that uses drugsto destroy cancer cells.

Chemotherapy works by stopping orslowing the growth of cancer cells, which

grow and divide quickly. But it can also harm healthy cells that

divide quickly, such as those that line yourmouth and intestines or cause your hair to

grow. Damage to healthy cells may cause side

effects. Often, side effects get better

or go away after chemotherapy is over.

DRUGS USED FOR


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DRUGS USED FORCHEMOTHERAPY

Cisplantin

Vincristine

Palcitaxel

Cyclophosphamide

Doxorubicin

SIDE EFFECTS OF CHEMOTHERAPY


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SIDEEFFECTS OFCHEMOTHERAPY

NephrotoxicityNausea

Vomiting

MyelosupressionPulmonary toxicity


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PHOTODYNAMIC THERAPY

Photodynamic therapy (PDT) is atreatment that uses a drug, called aphotosensitizer or photosensitizingagent, and a particular type of light.

When photosensitizers are exposed to aspecific wavelength of light, they

produce a form of oxygen that killsnearby cells.

How is PDT used to treat


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How is PDT used to treatcancer?

In the first step of PDT for cancer treatment,a photosensitizing agent is injected into thebloodstream.

The agent is absorbed by cells all over the body

but stays in cancer cells longer than it does innormal cells.

Approximately 24 to 72 hours after injection,when most of the agent has left normal cells

but remains in cancer cells, the tumor isexposed to light.

The photosensitizer in the tumor absorbs thelight and produces an active form of oxygenthat destroys nearby cancer cells.


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AIRWAY STUNT


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Surgery


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NURSING MANAGEMENT


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NSG ASSESSMENT

Determine the understanding ofpatient & the family concerning thediagnostic tests.

Assess the level of anxiety. Determine onset & duration of

coughing, sputum production, &degree of dyspnea.


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CONTD Auscultate for breath

sounds.

Observe symmetry of chestduring respiration.

Ask about pain, its location,

intensity & factorsinfluencing pain.


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NSG DIAGNOSES Ineffective breathing pattern

related to obstructiverespiratory processes

associated with lung cancer

Imbalanced nutrition: less than

body requirements related tohyper metabolic state, tasteaversion, anorexia


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CONTD Acute or chronic pain related to

tumor effects, invasion ofadjacent structures, toxicities

associated with radiotherapy/chemotherapy

Anxiety related to uncertain

outcomes & fear recurrence

NSG INTERVENTIONS


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NSG INTERVENTIONS

Improving breathingpatterns Elevate head of bed to promote

gravity drainage.

Teach breathing retrainingexercises.

Give prescribed treatment such as

antimicrobial agents. Augment the patients ability to

cough.


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CONTD Adminster oxygen if prescribed. Allow patient to sleep in reclining

chair or with head of bed elevated

if severely dyspneic.Improvingnutritionalstatus :

Encourage small amounts of highcalroie & high protein foods.

Ensure adequate protein intake :milk, eggs, chicken, fish, cheese etc.

CONTD


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CONTD Adminster or encourage prescribed

vitamin supplement . Change consistency of diet to soft or

liquid.

Give enteral or total parenteralnutrition for malnourished patientswho is unable to eat.

Controlling pain :

Assess condition of the patient.

Give analgesics to the patient.


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CONTD Evaluate problems of insomnia,

depression, anxiety etc.

Initiate bowel training program.

Minimizinganxiety : Try to have the patient exress

concerns ; share these concerns.

Expect some feelings of anxiety.

Encourage the patient to

communicate feelings.

HEALTH EDUCATION


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HEALTH EDUCATION

QUIT SMOKING,

IF PATIENTQUIT SMOKINGTHEN


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HEALTH EDUCATION


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HEALTH EDUCATION Help the patient Teach the

patient to to realize that everypain & ache is caused by lungcancer.

Take NSAIDS or otherprescribed medication.

Tell the patient abouttreatment.

Advise the patient to report

new or persistent pain.


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Lung Cancer f