Lung Cancer MODULE G1 Chapter 26, pp. 354-367

Facts on Cancer Lung cancer is: 2008 estimate: 40 – 70 years of age 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 COMBINED! 2008 estimate: 215,000 new cases; males > females 161,840 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 Tumor Tumors can be Localized Invasive Benign Malignant

Terminology - oma means benign tumor Carcinoma means malignant 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 cells of the bronchial 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 Occupational exposure 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 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 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 Large irregular mass 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 Lobectomy Pneumonectomy 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 Immunotherapy and Interferon 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