Adult Medical-Surgical Adult Medical-Surgical Nursing Nursing

Respiratory Module:Respiratory Module:

Lung CancerLung Cancer

Bronchogenic Carcinoma Bronchogenic Carcinoma (Lung Cancer): Description(Lung Cancer): Description

Bronchogenic carcinoma is a major cancer Bronchogenic carcinoma is a major cancer killer for both men and womenkiller for both men and women

Often by the time of diagnosis malignancy Often by the time of diagnosis malignancy has spread to regional lymphaticshas spread to regional lymphatics

Therefore the long-term survival rate for Therefore the long-term survival rate for lung cancer even with treatment is lowlung cancer even with treatment is low

Lung CancerLung Cancer

Lung cancer comprises:Lung cancer comprises:

Primary bronchial carcinomaPrimary bronchial carcinoma

Lung metastases secondary to a primary Lung metastases secondary to a primary malignancy elsewhere in the body eg the malignancy elsewhere in the body eg the breast breast

Lung Cancer and SmokingLung Cancer and Smoking

85% of lung cancer is related to cell 85% of lung cancer is related to cell mutation from carcinogenic chemical mutation from carcinogenic chemical inhalation, especially from inhalation, especially from smokingsmokingPrimary inhalation (x 10 incidence than in Primary inhalation (x 10 incidence than in non-smokers)non-smokers)Secondary passive smoking in a smoke-Secondary passive smoking in a smoke-filled roomfilled roomRisk is associated with number of packs Risk is associated with number of packs smoked daily, years smoking, filtration, tar smoked daily, years smoking, filtration, tar

Lung Cancer:Lung Cancer:Aetiology/ Risk FactorsAetiology/ Risk Factors

SmokingSmokingEnvironmental / occupational hazards:Environmental / occupational hazards:Urban areas (↑ pollutants)Urban areas (↑ pollutants)Industrial carcinogens (asbestos, coal Industrial carcinogens (asbestos, coal smoke, radiation)smoke, radiation)Genetic pre-disposition: ↑ risk x 3 whether Genetic pre-disposition: ↑ risk x 3 whether smoker or notsmoker or notDietary factors: diet low in fruit and Dietary factors: diet low in fruit and vegetable, especially vitamin A and C vegetable, especially vitamin A and C

Lung Cancer: ClassificationLung Cancer: Classification

Non-smallNon-small CellCell CarcinomaCarcinoma (75%): (75%):

Squamous cell (bronchial epithelium)Squamous cell (bronchial epithelium)

Adenocarcinoma (peripheral tumours → Adenocarcinoma (peripheral tumours → metastases)metastases)

Large cell (peripheral, rapid growing)Large cell (peripheral, rapid growing)

Bronchio-alveolar cell (terminal bronchi)Bronchio-alveolar cell (terminal bronchi)

SmallSmall CellCell CarcinomaCarcinoma (25%): rapid (25%): rapid infiltration and metastasesinfiltration and metastases

Lung Cancer: Lung Cancer: PathophysiologyPathophysiology

A single epithelial or gland cell of the A single epithelial or gland cell of the tracheo-bronchial airways is damaged tracheo-bronchial airways is damaged through binding of carcinogenic chemicals through binding of carcinogenic chemicals to the cell DNA →to the cell DNA →Cellular changes (mutation) occur and Cellular changes (mutation) occur and abnormal cell growth → malignant cellabnormal cell growth → malignant cellDamaged DNA is unstable and passes on Damaged DNA is unstable and passes on changes to daughter cellschanges to daughter cellsThis is the start of invasive carcinomaThis is the start of invasive carcinoma

Lung Cancer: ProgressionLung Cancer: Progression

Insidious progression:Insidious progression:

The condition is usually well-developed The condition is usually well-developed before symptoms appearbefore symptoms appear

Lung Cancer: Lung Cancer: Clinical ManifestationsClinical Manifestations

Chronic cough (dry persistent or purulent): Chronic cough (dry persistent or purulent): *a cough which changes in character *a cough which changes in character should be investigated*should be investigated*Wheezing, chest tightness, hoarseness, Wheezing, chest tightness, hoarseness, dysphagiadysphagiaHaemoptysisHaemoptysisPain: pleuritic, shoulder, rib (metastases)Pain: pleuritic, shoulder, rib (metastases)Weakness, fatigue, weight loss, anorexiaWeakness, fatigue, weight loss, anorexiaFever (if pneumonia develops)Fever (if pneumonia develops)

Lung Cancer:Lung Cancer:DiagnosisDiagnosis

History and physical assessmentHistory and physical assessment

Chest XrayChest Xray

CT scanCT scan

Sputum cytologySputum cytology

Bronchoscopy: examination, brushings, Bronchoscopy: examination, brushings, washings, biopsywashings, biopsy

Trans-thoracic fine needle aspiration Trans-thoracic fine needle aspiration (fluoroscopic guidance) occasionally(fluoroscopic guidance) occasionally

Lung Cancer: Lung Cancer: Other Assessment in DiagnosisOther Assessment in Diagnosis

Presence of metastases:Presence of metastases:Bone scanBone scanAbdominal scanAbdominal scanLiver scanLiver scanBrain scanBrain scan(MRI)(MRI)AssessmentAssessment of lung impairment and of lung impairment and function:function:PFT, ABG, VQ ratio, treadmill, ECGPFT, ABG, VQ ratio, treadmill, ECG

Lung Cancer:Lung Cancer:Staging Staging

In addition to histology of bronchial In addition to histology of bronchial carcinoma, carcinoma, stagingstaging assists the treatment assists the treatment plan:plan:

Carcinoma in situCarcinoma in situ

Localised infiltrationLocalised infiltration

Metastases to other organsMetastases to other organs

Lung Cancer: Lung Cancer: ManagementManagement

SeparatelySeparately or or inin combinationcombination::SurgerySurgeryRadiationRadiationChemotherapy Chemotherapy

Determined by:Determined by:Type of tumour and stagingType of tumour and stagingGeneral condition of the patientGeneral condition of the patient

SurgerySurgery

SurgerySurgery

SurgicalSurgical resectionresection is the preferred is the preferred treatment if:treatment if:There is no evidence of metastasesThere is no evidence of metastasesPatient’s general condition would toleratePatient’s general condition would tolerateSurgery is used for non-small cell Surgery is used for non-small cell carcinoma with no infiltration (small cell carcinoma with no infiltration (small cell infiltrates through the lymphatics early)infiltrates through the lymphatics early)Often a patient presents with metastases Often a patient presents with metastases already and surgery would not be usefulalready and surgery would not be useful

SurgerySurgery

Procedures include:Procedures include:

LobectomyLobectomy

PneumonectomyPneumonectomy

(Both involve Thoracotomy)(Both involve Thoracotomy)

Surgery: Pre-operative Surgery: Pre-operative Management and Nursing CareManagement and Nursing Care

Pre-operative assessment:Pre-operative assessment:PFT, ABG, VQ ratio, treadmill, ECGPFT, ABG, VQ ratio, treadmill, ECGLFT, KFT, RBS, CBC, Group X-matchLFT, KFT, RBS, CBC, Group X-matchChestChest physiotherapyphysiotherapy: use of nebulised : use of nebulised bronchodilators and postural drainage to bronchodilators and postural drainage to encourage expectoration; leg exercisesencourage expectoration; leg exercisesPatientPatient teachingteaching: breathing/ coughing : breathing/ coughing technique, site and extent of wound, chest technique, site and extent of wound, chest drains, possible ventilation, relieve anxietydrains, possible ventilation, relieve anxiety

Surgery: Surgery: Post-operative ManagementPost-operative Management

ICU: ventilator if required ICU: ventilator if required Humidified O2; nebulised bronchodilatorsHumidified O2; nebulised bronchodilatorsIVI; IV antibiotics/ medicationsIVI; IV antibiotics/ medicationsChest drainsChest drainsABG; serum electrolytesABG; serum electrolytesChest physioChest physioProphylactic Heparin; anti-embolism Prophylactic Heparin; anti-embolism stockingsstockings

Surgery: Surgery: Post-operative Nursing CarePost-operative Nursing Care

ICU: ventilator if required ICU: ventilator if required

Position patient semi-sitting once able, Position patient semi-sitting once able, pillows to support (thoracotomy wound) pillows to support (thoracotomy wound)

Monitor vital signs, especially respirationsMonitor vital signs, especially respirations

Care of O2, IVI, wound dressing, chest Care of O2, IVI, wound dressing, chest drains, mouth, pressure areas, urination drains, mouth, pressure areas, urination

Adequate pain relief; emotional supportAdequate pain relief; emotional support

Breathing, leg, arm, shoulder exercisesBreathing, leg, arm, shoulder exercises

RadiotherapyRadiotherapy

Radiotherapy: IndicationsRadiotherapy: Indications

RadiationRadiation therapytherapy is useful for neoplasms is useful for neoplasms which are:which are:

Difficult to resectDifficult to resect

Small-cell infiltratingSmall-cell infiltrating

Also used pre- or post-surgery →Also used pre- or post-surgery →

Lung Cancer: Lung Cancer: Radiotherapy and SurgeryRadiotherapy and Surgery

Radiation pre- or post-surgery:Radiation pre- or post-surgery:

Radiation inhibits cell growth, reducing the Radiation inhibits cell growth, reducing the size of a tumour → size of a tumour →

More accessible for surgeryMore accessible for surgery

Reduces symptoms of pressure therefore:Reduces symptoms of pressure therefore:

Relieves dyspnoea, cough, chest pain, Relieves dyspnoea, cough, chest pain, haemoptysis, bone pain haemoptysis, bone pain

Improves quality of life Improves quality of life

Lung Cancer: Lung Cancer: Radiotherapy ProtocolRadiotherapy Protocol

Usually almost daily sessions for 4 weeksUsually almost daily sessions for 4 weeks

Area to be treated is marked and kept dry Area to be treated is marked and kept dry and cooland cool

Careful monitoring of blood count and Careful monitoring of blood count and general well-being throughout the general well-being throughout the treatment period treatment period

Radiotherapy: Side EffectsRadiotherapy: Side Effects

Radiotherapy is Radiotherapy is toxictoxic to good cells to good cellsMay lead to oesophagitis, pneumonitis, May lead to oesophagitis, pneumonitis, fibrosis and impaired VQ ratiofibrosis and impaired VQ ratio

Other side effects are related to bone Other side effects are related to bone marrow depression: marrow depression: Anaemia, Anaemia, fatiguefatigue, bruising, ↓ immune , bruising, ↓ immune response and infection (including response and infection (including opportunistic infection as candida)opportunistic infection as candida)

ChemotherapyChemotherapy

Lung Cancer: Lung Cancer: ChemotherapyChemotherapy

Chemotherapy may be used in combination Chemotherapy may be used in combination with the other 2 more major treatmentswith the other 2 more major treatmentsAffects cell growth and multiplication Affects cell growth and multiplication therefore reduces tumour size and relieves therefore reduces tumour size and relieves symptoms as radiotherapysymptoms as radiotherapySide effects as radiotherapy Side effects as radiotherapy (Chemotherapy and nursing care previously (Chemotherapy and nursing care previously discussed: see Leukaemia 1 lecture, discussed: see Leukaemia 1 lecture, Haematology Module) Haematology Module)