Week 4 LO

Weekly Objectives

1. List the major air pollutants and the factors which influences deposition of pollutants within the respiratory
system (particles, ozone, oxides of nitrogen, sulfur oxides, environmental tobacco smoke, radon organic dusts,
metal fumes)

Pollutant Common Sources in Workplace Environments Related-Illness

Carbon Monoxide (CO) Any combustion source such as heaters, gas boilers, gas cookers,
generators. Particularly a risk in inadequately ventilated areas.
Nitrogen Dioxide (NO2) Any combustion source such as heaters, gas boilers, gas cookers,
generators.
Asbestos Building materials such as tiles for roofing, flooring and ceilings,
cement, and some heat resistant materials.
Formaldehyde Foams and coverings in and on fittings and furniture. Solvents,
paintings, coatings. Symptoms include irritation of the eyes, nose,
and throat.
Ozone External sources, particularly in the summer when outdoor ozone can
be elevated. Photocopiers can also generate high levels of ozone.
Radon A radioactive gas that occurs naturally in soil, rock and some building
materials. In the workplace its highest concentration is typically in
lower levels and basements. Warm air from heating can draw it up to
higher levels.
Fine Particulate Matter (PM) PM most usually comes from vehicle emissions in the external
environment. PM comprises solid and/or liquid particles suspended
in the air. Generally, the smaller the particles, the more dangerous
they are considered as they are more likely to penetrate deeper into
the lungs and bloodstream.
Sulphur Oxides Electric power companies that burn coal are a major source of sulfur
oxides.
Organic Dust Organic dusts includes flour, wood, cotton, tea dusts and pollen.
Tobacco Cigarettes
headache, dizziness, weakness, upset stomach,
vomiting, chest pain, and confusion. CO
symptoms are often described as “flu-like.” If you
breathe in a lot of CO it can make you pass out
or kill you.
Increased inflammation of the airways,
worsened cough and wheezing, reduced lung
function, increased asthma attacks, greater
likelihood of emergency department and
hospital admissions.
Asbestosis is a chronic lung disease caused by
inhaling asbestos fiber. Shortness of breath,
persistent dry cough, loss of appetite with
weight loss, fingertips and toes that appear
wider and rounder than normal (clubbing), chest
tightness or pain
Formaldehyde Poisoning is a disorder brought
about by breathing the fumes of formaldehyde.
Major symptoms may include eye, nose, and
throat irritation; headaches; and/or skin rashes.
a condition characterized by chest pain, itchy
eyes, and drowsiness, caused by exposure to
ozone, as experienced in the atmospheres of
smog and high-altitude airplanes.
That makes radon the second leading cause of
lung cancer after smoking. But even minor
symptoms like headaches, feeling unusually
tired, itching or burning eyes, irritated skin, nasal
congestion, a dry throat or nausea could be due
to your home's indoor air quality.
acute respiratory distress, asthma, chronic
obstructive pulmonary disease, and lung cancer.
At lower levels, chest pains, breathing problems,
eye irritation and a lowered resistance to heart
and lung diseases can be experienced. It has also
known to increase asthma attacks
Inhalation of organic dusts can induce allergic
reaction (e.g Hay fever) and also cause irritation
and inflammation of the airway. It can also
induce asthma and rhinitis.
Irritate airway epithelial cells and cillia. Causes
hypertrophy and hyperplasia of the mucus-
producing cells karena harus lebih aktif ngeluarin
mukus untuk buang particles asap rokok yang
masuk.

2. List the sources of exposure to pollutant in the work place

 Dust from such things as wood, coal, asbestos, silica and talc. Dust from cereal grains, coffee, pesticides, drugs or
enzyme powders, metals and fiberglass can also do damage to the lungs.

 Fumes from metal that are heated and cooled quickly. This process results in fine, solid particles to be released into
the air. Example of jobs that expose workers to these types of fumes includes, welding (pengelasan),
smelting(peleburan), furnace work, pottery making, plastic manufacture and rubber operations.

 Smoke from burning organic materials. Smoke contains a variety of particles, gases and vapors depending on what
substance is being burned. These particles, gases and vapors if inhaled, can damage the lungs. Firefighters are at an
increased risk.
  Gases such as Formaldehyde, Ammonia, Chlorine, Sulfur dioxide, Ozone and Nitrogen oxides. These gases are
associated with jobs involving chemical reactions and jobs that require high heat (e.g welding, smelting, oven drying
and furnace work).

 Vapors are gas forms of liquids that can revert back to liquid forms with particular temperature or pressure. Vapors
given off by solvents usually irritate the nose and throat first before affecting the lungs.

 Mists or sprays from paints, lacquers (e.g varnish), hair spray, pesticides, cleaning products, acids, oils and solvents
(e.g turpentine)

3. Describe the macroscopic and microscopic pathology of the major types of lung and pleural cancers-squamous,
adenocarcinoma, large cell, small cell carcinoma and pleural mesothelioma.

4. Recognize the clinical therapeutic implications of small cell carcinoma and non-small cell carcinoma (SSC and
NSSC)

5. Describe the clinical procedures to get cells and tissues for the diagnosis of lung cancer

Bronchoscopy (Transbronchial Biopsy)

Your doctor puts a flexible tube that's about as wide as a pencil into your mouth or nose, and from there into your lungs. A
light and camera help guide tiny tools that take cells from your lung out through the tube. You'll be awake while this is going
on, but you may get medication through an IV to help you to relax, as well as oxygen through a mask or nose tube. To figure
out the right spot to do the biopsy, your doctor may take an X-ray. Then he'll spray numbing medication into your throat.

Lung Needle Biopsy (Transthoracic Biopsy)

You usually get this type of lung biopsy when cells can't be reached with a bronchoscopy. Your doctor places a needle
through your chest between two ribs to take a sample from the outer area of your lungs. You'll be awake and your skin will
be numbed, and you may get a sedative to relax. To find the best place to do the procedure, you'll get an ultrasound, CT
scan, or a special type of X-ray known as fluoroscopy.

Thoracoscopic Lung Biopsy (Thoracoscopy)

You may also hear your doctor call this a video-assisted thoracoscopic surgery (VATS). It checks for problems on the outside
of your lungs. You'll get general anesthesia for this procedure, which means you won't be awake for it. Your doctor puts a
breathing tube down your throat and into your lungs and keeps tabs on your breathing, blood pressure, oxygen levels, and
heart rate. The doctor makes up to three small cuts on your chest between your ribs, then puts a thin, lighted tube with a
camera on the end and uses tiny tools to pull out some cells.

Open Lung Biopsy (Limited Thoracotomy)

Your doctor will usually only suggest this type of biopsy when other methods can't get cell samples. As with a thoracoscopic
lung biopsy, you won't be awake for this procedure. Your surgeon makes a larger cut than in other methods, which may run
from your chest and under your arms to your back. That lets your doctor reach your lungs and remove the cells.

6. List some of pneumoconiosis which will develop lung cancer

7. Distinguish lung tumor and mediastinum tumor

8. Describe the principles of chest radiography, computed tomography, magnetic resonance imaging and positron
emission tomography.

9. Describe how important the cigarette smoke causing lung cancer

10. Describe the indication of oxygen therapy

Case Objectives

1. Explain signs and symptoms of lung cancer

The most common symptoms of lung cancer are:

 A cough that does not go away or gets worse

 Coughing up blood or rust-colored sputum (spit or phlegm)

 Chest pain that is often worse with deep breathing, coughing, or laughing

 Hoarseness

 Loss of appetite

 Unexplained weight loss

 Shortness of breath

 Feeling tired or weak

 Infections such as bronchitis and pneumonia that don’t go away or keep coming back

 New onset of wheezing

If lung cancer spreads to other parts of the body, it may cause:

 Bone pain (like pain in the back or hips)

 Nervous system changes (such as headache, weakness or numbness of an arm or leg, dizziness, balance problems,
or seizures), from cancer spread to the brain

 Yellowing of the skin and eyes (jaundice), from cancer spread to the liver

 Swelling of lymph nodes (collection of immune system cells) such as those in the neck or above the collarbone

2. Identify the risk factors for lung cancer pathogenesis (esp.smoking)

Risk factors you can change:

 Tobacco smoke

 Exposure to radon

Radon is a naturally occurring radioactive gas that results from the breakdown of uranium in soil and rocks. You can’t see,
taste, or smell it. According to the US Environmental Protection Agency (EPA), radon is the second leading cause of lung
cancer in this country, and is the leading cause among non-smokers.

 Exposure to asbestos

People who work with asbestos (such as in mines, mills, textile plants, places where insulation is used, and shipyards) are
several times more likely to die of lung cancer. Lung cancer risk is much greater in workers exposed to asbestos who also
smoke. It’s not clear how much low-level or short-term exposure to asbestos might raise lung cancer risk. People exposed
to large amounts of asbestos also have a greater risk of developing mesothelioma, a type of cancer that starts in the pleura
(the lining surrounding the lungs). For more on this type of cancer, see Malignant Mesothelioma.

 Exposure to other cancer-causing agents in the workplace

Other carcinogens (cancer-causing agents) found in some workplaces that can increase lung cancer risk include: Radioactive
ores such as uranium; Inhaled chemicals such as arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds,
chromium compounds, coal products, mustard gas, and chloromethyl ethers; Diesel exhaust

 Taking certain dietary supplement

Studies looking at the possible role of vitamin supplements in reducing lung cancer risk have had disappointing results. In
fact, 2 large studies found that smokers who took beta carotene supplements actually had an increased risk of lung cancer.

 Arsenic in drinking water

Risk Factors you can not change:

  Previous radiation therapy to the lungs

 Air pollution

 Personal or family history of lung cancer

Factors with uncertain or unproven effects on lung cancer risk:

 Smoking marijuana

 E-cigarettes

E-cigarettes are a type of electronic nicotine delivery system. They do not contain any tobacco but the Food and Drug
Administration (FDA) classifies them as “tobacco” products.

 Talc and talcum powder

Talc is a mineral that in its natural form may contain asbestos. Some studies have suggested that talc miners and people
who operate talc mills might have a higher risk of lung cancer and other respiratory diseases because of their exposure to
industrial grade talc. But other studies have not found an increase in lung cancer rate.

3. Mention classification of lung cancer based on pathology

a. Small cell lung cancer (SCLC)

About 10% to 15% of all lung cancers are SCLC and it is sometimes called oat cell cancer. This type of lung cancer tends to
grow and spread faster than NSCLC. About 70% of people with SCLC will have cancer that has already spread at the time
they are diagnosed. Since this cancer grows quickly, it tends to respond well to chemotherapy and radiation therapy.
Unfortunately, for most people, the cancer will return at some point.

b. Non-Small cell lung cancer (NSLC)

i. Adenocarcinoma

Adenocarcinomas start in the cells that would normally secrete substances such as mucus. This type of lung cancer occurs
mainly in current or former smokers, but it is also the most common type of lung cancer seen in non-smokers. It is more
common in women than in men, and it is more likely to occur in younger people than other types of lung cancer.
Adenocarcinoma is usually found in the outer parts of the lung and is more likely to be found before it has spread. People
with a type of adenocarcinoma called adenocarcinoma in situ (previously called bronchioloalveolar carcinoma) tend to have
a better outlook than those with other types of lung cancer.

ii. Squamous cell cancer

Squamous cell carcinomas start in squamous cells, which are flat cells that line the inside of the airways in the lungs. They
are often linked to a history of smoking and tend to be found in the central part of the lungs, near a main airway
(bronchus).

iii. Large cell carcinoma

Large cell carcinoma can appear in any part of the lung. It tends to grow and spread quickly, which can make it harder to
treat. A subtype of large cell carcinoma, known as large cell neuroendocrine carcinoma, is a fast-growing cancer that is very
similar to small cell lung cancer.

iv. Undifferentiated non-small cell lung cancer

A few other subtypes of NSCLC, such as adenosquamous carcinoma and sarcomatoid carcinoma, are much less common.

4. Describe lung cancer staging and diagnosis

STAGES OF NON-SMALL CELL LUNG CANCER

 Stage I: The cancer is located only in the lungs and has not spread to any lymph nodes.
  Stage II: The cancer is in the lung and nearby lymph nodes.

 Stage III: Cancer is found in the lung and in the lymph nodes in the middle of the chest, also described as locally
advanced disease. Stage III has two subtypes:

o If the cancer has spread only to lymph nodes on the same side of the chest where the cancer started, it
is called stage IIIA.

o If the cancer has spread to the lymph nodes on the opposite side of the chest, or above the collar bone,
it is called stage IIIB.

 Stage IV: This is the most advanced stage of lung cancer, and is also described as advanced disease. This is when
the cancer has spread to both lungs, to fluid in the area around the lungs, or to another part of the body, such as
the liver or other organs.

Clinicians use a staging system for lung cancer called TNM, where:

 T describes the size of the tumour (cancerous tissue)

 N describes the spread of the cancer into lymph nodes

 M describes whether the cancer has spread to another area of the body such as the liver (metastasis)

There are 4 main stages for T:

T1 lung cancer means that the cancer is still inside the lung.

T1 is broken down into 3 sub-stages:

 T1a – the tumour is no wider than 1cm

 T1b – the tumour is between 1cm and 2cm wide

 T1c – the tumour between 2cm and 3cm wide

T2 is used to describe 3 possibilities:

 the tumour is between 3cm and 5cm wide, or

 the tumour has spread into the main airway or the inner lining of the chest wall, or

 the lung has collapsed or is blocked due to inflammation

T3 is used to describe 3 possibilities:

 the tumour is between 5cm and 7cm wide, or

 there is more than 1 tumour in the lung, or

 the tumour has spread into the chest wall, the phrenic nerve (a nerve close to the lungs), or the outer layer of the
heart (pericardium)

T4 is used to describe a range of possibilities including:

 the tumour is wider than 7cm, or

 the tumour has spread into both sections of the lung (each lung is made up of 2 sections, known as lobes), or

 the tumour has spread into an area of the body near to the lung, such as the heart, the windpipe, the food pipe
(oesophagus) or a major blood vessel

There are 3 main stages for N:

N1 is used to describe cancerous cells in the lymph nodes located inside the lung or in the area where the lungs connect to
the airway (the hilum).
N2 is used to describe 2 possibilities:

 there are cancerous cells in the lymph nodes located in the centre of the chest on the same side as the affected
lung, or

 there are cancerous cells in the lymph nodes underneath the windpipe

N3 is used to describe 3 possibilities:

 there are cancerous cells in the lymph nodes located on the chest wall on the other side of the affected lung, or

 there are cancerous cells in the lymph nodes above the collar bone, or

 there are cancerous cells in the lymph nodes at the top of the lung

There are 2 main stages for M:

 M0 – the cancer has not spread outside the lung to another part of the body

 M1 – the cancer has spread outside the lung to another part of the body

Diagnosis for lung cancer:

5. Explain lung cancer treatment guidelines

SCLC

 Chemotherapy

Chemotherapy improves the survival of patients with limited-stage disease (LD) or extensive-stage disease (ED), but it is
curative in only a minority of patients. Because patients with SCLC tend to develop distant metastases, localized forms of
treatment, such as surgical resection or radiation therapy, rarely produce long-term survival.

 Radiation Therapy

SCLC is highly radiosensitive and thoracic radiation therapy improves survival of patients with LD and ED tumors.

NSCLC

 Surgery

o Pneumonectomy: This surgery removes an entire lung. This might be needed if the tumor is close to the center of the
chest.

o Lobectomy: The lungs are made up of 5 lobes (3 on the right and 2 on the left). In this surgery, the entire lobe
containing the tumor(s) is removed. If it can be done, this is often the preferred type of operation for NSCLC.

o Segmentectomy or wedge resection: In these surgeries, only part of a lobe is removed. This approach might be used if
a person doesn’t have enough normal lung function to withstand removing the whole lobe.

o Sleeve resection: This operation may be used to treat some cancers in large airways in the lungs. If you think of the
large airway with a tumor as similar to the sleeve of a shirt with a stain a few inches above the wrist, the sleeve
resection would be like cutting across the sleeve (airway) above and below the stain (tumor) and then sewing the cuff
back onto the shortened sleeve.

 Radiofrequency

Radiofrequency ablation (RFA) might be considered for some people with small lung tumors that are near the outer edge of
the lungs, especially if they can’t tolerate surgery. RFA uses high-energy radio waves to heat the tumor. A thin, needle-like
probe is put through the skin and moved in until the tip is in the tumor. Placement of the probe is guided by CT scans. Once
the tip is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells.
  Radiation

External beam radiation therapy (EBRT) focuses radiation from outside the body onto the cancer. This is the type of
radiation therapy most often used to treat NSCLC or its spread to other organs.

In people with NSCLC, brachytherapy is sometimes used to shrink tumors in the airway to relieve symptoms. The doctor
places a small source of radioactive material (often in the form of small pellets) directly into the cancer or into the airway
next to the cancer.

 Chemotherapy

Cisplatin, Carboplatin, Paclitaxel (Taxol), Albumin-bound paclitaxel (nab-paclitaxel, Abraxane), Docetaxel (Taxotere),
Gemcitabine (Gemzar), Vinorelbine (Navelbine), Etoposide (VP-16), Pemetrexed (Alimta).

 Targeted therapy

o Drugs that target tumor blood vessel growth (angiogenesis)

o Drugs that target cells with EGFR gene changes

o EGFR inhibitors that target cells with the T790M mutation

o EGFR inhibitors used for squamous cell NSCLC

o Drugs that target cells with ALK gene changes

o Drugs that target cells with ROS1 gene changes

o Drugs that target cells with BRAF gene changes

o Drugs that target cells with NTRK gene changes

 Immunotherapy

Nivolumab (Opdivo) and pembrolizumab (Keytruda) target PD-1, a protein on certain immune cells (called T cells) that
normally helps keep these cells from attacking other cells in the body. By blocking PD-1, these drugs boost the immune
response against cancer cells. This can shrink some tumors or slow their growth.

Atezolizumab (Tecentriq) targets PD-L1, a protein related to PD-1 that is found on some tumor cells and immune cells.
Blocking this protein can also help boost the immune response against cancer cells.

 Palliative therapy

o Treating fluid buildup in the area around the lung

o Treating fluid buildup around the heart

o Treating an airway blocked by a tumor