1. Lung Cancer
MODULE G1
Chapter 26, pp

2. 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

6. 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

7. 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

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

15. 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.

18. 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.

21. 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.

24. 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

25. 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

26. 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)

27. Staging of Small Cell Carcinoma
2 stages
Limited
Extensive
Tx is chemotherapy.
Survival is 8-14 months after chemotherapy.

28. 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%

29. Pulmonary Functions
Restrictive Disease or Mixed Obstructive & Restrictive.
Decreased Volumes
Decreased Flows

30. 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

31. 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.

33. 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.

34. 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.

35. 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

36. 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

37. Management
Curative
Palliative (relief of symptoms)

38. Management Radiation 50% of cases.
High voltage x-ray beams deliver radiation to the tumor.
Radioactive particles kill tumor cells.
Can Cause Pulmonary Fibrosis.

39. 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

40. Management Chemotherapy Immunotherapy and Interferon
Drugs are used to kill the cancer cells
Can cause pulmonary fibrosis
Immunotherapy and Interferon
Experimental

41. 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

42. Respiratory Management
Bronchial Hygiene Protocol
Hyperinflation Protocol
CPAP or BIPAP
Oxygen Therapy Protocol

43. 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