Lung Cancer

MODULE G1

Chapter 26, pp. 354-367

Facts on Cancer• Lung cancer is:

• The second most common cancer in men (Prostate)• The second most common cancer in women (Breast)• The leading cause of death from cancer in men (3x > Prostate;

almost 7x in MI)• The leading cause of death from cancer in women (almost 2x

breast; 4.5x in MI)• More people die from lung cancer than colon, breast, and

prostate COMBINEDCOMBINED!• 2008 estimate:

• 215,000215,000 new cases; males > females• 161,840161,840 deaths

• 40 – 70 years of age• Cancer is strongly associated with smoking (85% of

cases)• Second hand smoke• Environmental/industrial hazards – asbestos, radon

Cancer of the Lung

• Definition:• Progressive, uncontrolled multiplication of

abnormal cells causing new tissue growth.• Result of stimuli that damage the genetic material

(DNA) of cells. • Abnormal cells called a Neoplasm or TumorNeoplasm or Tumor

• Tumors can be• Localized• Invasive• Benign• Malignant

Terminology

• - oma means benign tumor• Fibroma (fibroid tumor)• Myoma• Lipoma• Neuroma

• Carcinoma means malignant tumor

• - sarcoma means highly malignant tumor• Fibrosarcoma• leiomyosarcoma

Benign Tumor

• Does not endanger life unless it interferes with organ function.

• It will push aside normal tissue but not invade it.

• Slow growth.

• Easily removed surgically.

Malignant Tumor

• Cells grow in a disorganized manner and very rapidly.

• Invade normal tissue.• Rob surrounding cells of nutrition.• Result in necrosis, ulceration and cavity

formation.• Metastatic

• Tumor cells travel to the bloodstream &/or lymphatic channels and invade or form secondary tumors in other organs.

Malignant Tumors In the Lungs

• Most commonly originate in the bronchial mucosa of the TB tree.• Bronchogenic carcinoma or lung cancer.

• As the tumor enlarges it invades the airways, alveoli and blood vessels.• Airway obstruction & increased secretions.• Atelectasis & consolidation.• Erosion of blood vessels cause hemoptysis.• Pleural effusions.• Cavity Formation.

Etiology

• Four major types of Bronchogenic Tumors:• Non-Small Cell Lung Cancer (NSCLC)

• Squamous (epidermoid) cell• Adenocarcinoma• Large-cell carcinoma

• Small-Cell Lung Cancer (SCLC)• Oat Cell

Squamous Cell

• 30-35% of cases.

• Originates from the basal cellsbasal cells of the bronchial epitheliumbronchial epithelium.

• Late metastatic tendency.

• Doubling time of 100 days.

• Located in large bronchi near the hilum.• 1/3 of cases originate in periphery of lung.

• Cavity formation is seen in 10-20%

• Linked to smoking.

Adenocarcinoma

• 25-35% of cancers. • Arises from mucus glands in the TB tree.• Growth rate is moderate; doubling time is 180

days.• Found in the lung periphery.• Cavity formation is common.• Bronchoalveolar cell carcinoma is a type of

adenocarcinoma (15% of adenocarcinomas) that affects the airspaces but does not extend beyond lung.

Large Cell Carcinoma

• 10-15% of cases.

• Found in both the periphery or central region of the lung.

• Rapid growth rate.

• Early metastatic tendency.

• Doubling time of 100 days.

• Cavity formation is common.

Small Cell – Oat Cell

• 13-15% of the lung cancers. • Arises from Kulchitsky’s (K-type) cells in the

bronchial epithelium.• Found near the hilum region.• Grows very rapidly; Doubling time is 30 days.

• 60% of patients have widespread metastatic disease at the time of diagnosis

• Can create its own hormones.• Metastasizes early (bone, liver, brain)• Oval shaped.

Etiology

• Cigarette Smoking• 87% of cancers is due to cigarette smoking.

• 90% in men, 80% in women.• Greatest incidence with Small Cell, Squamous, and

adenocarcinoma.

• Occupational exposure• Inhalation of asbestos and other agents.• Usually has a smoking co-factor.• 15% incidence in men, 5% in women.

• ? Radon

Staging of Non-small Cell Lung Cancer

• Staging System• T – Tumor

• Status of primary tumor (size & type).

• N – Node• Local and regional lymph node involvement.

• M – Metastases• Spread to other tissues.

• Prognostic Indicator• Survival rates

Stages of Cancer• See Handout

• Stage 0• Stage IA & IB• Stage IIA & IIB• Stage III A & IIIB• Stage IV

• Stage I and II: Surgery with or without adjuvant chemotherapy

• Stage IIIA: Surgery with or without adjuvant therapy or concurrent chemoradiation

• Stage IIIB: Radiation with or without chemotherapy

• Stage IV: Chemotherapy with or without palliative radiation)

Staging of Small Cell Carcinoma

• 2 stages• Limited• Extensive

• Tx is chemotherapy.

• Survival is 8-14 months after chemotherapy.

5-Year Survival Rates

LUNG BREAST

Stage I 60 to 80% 98%

Stage II 25 to 50% 76 to 88%

Stage IIIA 10 to 40% 56%

Stage IIIB Less than 5% 49%

Stage IV Less than 2% 16%

Pulmonary Functions

• Restrictive Disease or Mixed Obstructive & Restrictive.• Decreased Volumes• Decreased Flows

Symptoms

• 25% are asymptomatic• Cough• Increased sputum production• Hemoptysis• Wheezing (localized)• Weight Loss• SOB/dyspnea• Hoarseness• Chest Pain (if tumor invades chest wall/pleura)• Clubbing

Chest X-ray

• Small oval or coin lesion• Solitary Pulmonary Nodule

• Large irregular mass

• Consolidation

• Pleural effusions

• Involvement of the mediastinum or diaphragm.

• By the time lung cancer is seen on x-ray, it usually is in the invasive stage.

Non-respiratory Findings

• Tumor invasion of the mediastinum• Recurrent laryngeal nerve

• Hoarseness

• Esophagus• Difficulty swallowing

• Electrolyte disturbances• High Ca levels

• Horner’s Syndrome – Compression of sympathetic nerve of the face leading to constriction of the pupil.

Non-Respiratory Findings

• Superior Vena Cava Syndrome• Interrupts blood flow from head and upper

body.• Swelling of face and neck and arms.• Dilation of chest and arm veins (collaterals).

• Muscle weakness.

• Endocrine disorders.

Diagnostic Testing

• Chest x-ray

• Bronchoscopy & Laryngoscopy• Biopsy (Transbronchial needle aspiration)

• CT scan/MRI/Bone Scans

• Transthoracic needle aspiration (TTNA)

• Thoracentesis• Pleural fluid

• Sputum Culture• Cytology

Positron Emission Tomography Scanning

• PET• Uses fluorodeoxyglucose (FDG)• A cancerous tumor is a highly active

metabolic tissue with a great affinity for glucose which shows up as a signal during PET scanning

• Cancerous tumors have greater uptake of the glucose than benign tumors

Management

• Curative

• Palliative (relief of symptoms)

Management

• Radiation• 50% of cases.• High voltage x-ray beams deliver radiation

to the tumor.• Radioactive particles kill tumor cells.• Can Cause Pulmonary Fibrosis.

Surgical Management

• Lung resection• Removal of a lung section

• Lobectomy• Removal of a lobe

• Pneumonectomy• Removal of a lung

• Only 1/3 of patients are candidates for surgery• May not be able to remove tumor

Management

• Chemotherapy• Drugs are used to kill the cancer cells• Can cause pulmonary fibrosis

• Immunotherapy and Interferon• Experimental

Evaluation of Surgical Risk

• FEV1 > 2L or 70% of predicted indicates good lung reserve & low surgical risk.

• FEV1 < 35% of predicted is a contraindication to surgery.• Radiation & Chemotherapy

Respiratory Management

• Bronchial Hygiene Protocol

• Hyperinflation Protocol• CPAP or BIPAP

• Oxygen Therapy Protocol

Special Considerations

• Cancer patients often have altered immune systems. • Susceptible to contacting other infections.• In the past pt’s were in “protective isolation”.• Private room.

• Psychological • Stages of Terminal Illness.

• Denial, Anger, Bargaining, Depression, Acceptance