Lung Cancer

INTRODUCTION
Cancer is the term used for diseases in which abnormal cells divide (mitosis) without control. Cancer cells can invade nearby tissues and spread through the bloodstream and lymphatic system to other parts of the body (metastasis) . Cancer cells also avoid natural cell death (apoptosis). The word originated from the Latin word for crab, because the swollen veins around a surface tumor appeared like the legs of a crab.

ANATOMY OF HUMAN LUNG

ANATOMY OF LUNGS
Right lung=3 lobes Left lung=2 lobes Air enters lungs through trachea Trachea divides into bronchi Bronchi divide into bronchioles Alveoli are the air sacs at the end of the bronchioles Pleura = lining of the lungs

FUNCTIONS OF LUNGS
Every day one human being takes about 23,000 breaths, which bring almost 10,000 quarts of air into your lungs. The air that breath in contains several gases, including oxygen, that cells need to function. With each breath, lungs add fresh oxygen to blood, which then carries it to cells. The lungs are the essential respiration organ in humans. Their principal function is to transport oxygen from the atmosphere into the bloodstream, and to release carbon dioxide from the bloodstream into the atmosphere.

Seven cardinal signs of cancer

C Change in bowel or bladder habits could be a sign of colorectal cancer. sore that does not heal on A the skin or in the mouth could be a malignancy and should be checked by a doctor. U Unusual bleeding or discharge from the rectum, bladder or vagina could mean colorectal, prostate, bladder or cervical cancer.

CONTD
T Thickening of breast tissue or a new lump in the breast is a warning sign of breast cancer. A lump in the testes could mean testicular cancer. I Indigestion or trouble swallowing could be cancer of the mouth, throat, esophagus or stomach.

CONTD
O Obvious changes to moles or warts could mean skin cancer. N Nagging cough or hoarseness that persists for four to six weeks could be a sign of lung or throat cancer.

Lung Cancer: Defined

Uncontrolled growth of malignant cells in one or both lungs and tracheo-bronchial tree A result of repeated carcinogenic irritation causing increased rates of cell replication Proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ

Picture of the Cancerous Lungs

 Most frequently diagnosed cancer worldwide

About 1.35 million new cases diagnosed worldwide each year

Leading cause of cancer deaths in the United States

 Incidence and mortality rates begin to increase between the ages of 45 and 54 and rise progressively until age 75 Median age at diagnosis=70.07 Median age at death=71.07

 Males have a greater lifetime risk of lung cancer than females (7.81% vs. 5.8%)
Greater disparity in developing countries where cigarette use by females is low

 Higher incidence and mortality rates are reported among men from lower SES groups

 Cigarette smoking is the most important risk factor for lung cancer
Causes approximately 90% of male and 7580% of female lung cancer deaths

By the early 1950s, case control studies in the US and Great Britain clearly showed an association between smoking and lung cancer In 1964, the US Surgeon General released a report on the causal relationship

Smoking Facts
Tobacco use is the leading cause of lung cancer 87% of lung cancers are related to smoking Risk related to:
age of smoking onset amount smoked gender product smoked depth of inhalation

 More than 80 carcinogens in cigarette smoke according to the International Agency for Research on Cancer (IARC)
Polycyclic aromatic hydrocarbons (PAHs) are a well documented lung carcinogen

Secondhand smoke
Each year about 3,000 non-smoking adults die of lung cancer as a result of breathing secondhand smoke.

What about secondhand smoke?

Being in a nonsmoking section of a restaurant for 2 hours = Being in a smoky home for one day = Being in a smoky bar =
Mayo Clinic

 History of respiratory diseases such as asthma, bronchitis, emphysema, hay fever, or pneumonia may modify risk When combined with smoking, there is a complementary cycle of injury and repair that may increase risk Respiratory diseases may result in chronic immune stimulation that causes random pro-oncogenic mutations that increase risk Relationship is still speculative

 Animal models have indicated that dietary fat can promote chemically induced pulmonary tumors.
Relationship may be confounded by the association between smoking status and diet

Rates of lung cancer are highest in countries with greatest fat consumption after controlling for smoking.

 Lowered risk associated with consumption of fresh vegetables and fruits

Risk in those with highest intake was about one-half of those with lowest intake

Beneficial micronutrients in fruits and vegetables

Carotenoids Isothiocyanates Folate Selenium

 Difficult to assess association between alcohol and lung cancer due to confounding by smoking status

 IARC categorized several occupational agents as known carcinogens

Radon
x Well established lung carcinogen, responsible for 6.5% of lung cancer deaths in the United Kingdom in 1998

Asbestos Arsenic Bischloromthyl ether Chromium Nickel Polycyclic aromatic compounds Vinyl chloride

 Only a fraction of long-term smokers will develop lung cancer

Likely impacted by genetic susceptibility

Familial aggregation
Studies have reported an excess of lung cancer mortality in relatives of lung cancer patients

 Polymorphisms in genes encoding for enzymes responsible for detoxification of carcinogens affect the internal dose of tobacco carcinogens that lung tissue is exposed to Many different polymorphisms
Cytochrome P-450

 Defective repair of genetic damage is an important determinant of susceptibility to lung cancer

Hypersensitivity to carcinogenic exposure

Many studies have demonstrated that cancer cases have a significant decrease in DNA repair capacity compared to controls

Where does it travel?

Lymph Nodes, Brain, Liver, Adrenal, Gland, Bones 40% of metastasis occurs in the Adrenal Gland

PATHOPHYSIOLOGY
More than 90% of lung cancer originate from the epithelium of bronchus. They slowly & it takes 8 to 10 years, for a tumor to reach 1cm in size.  Cancerous lung tissue cannot exchange oxygen & carbon dioxide  It impairs the functioning of the lung

 Tumor cells grow & invade surrounding lung tissue  Air way invaded & obstructing the flow of the air  Cancerous cells invade local lymph nodes & thoracic duct  Significant growth of the tumor

Evolution of Intraepithelial Neoplasia

Normal Hyperplasia/Metaplasia Dysplasia

Cancer

Mild/Moderate/Severe/CIS

Squamous

Adenomatous

Types:
There are 4 major types : Non- small cell carcinoma:1- epidermiod [squamous] -35% 2- adeno carinema -30% 3- large cell carcinoma -15% 4- small cell lung cancer -20%

Epidermiod carcinoma -35% :

Occurs most frequently in men and old people Usually starts on one breathing tubes. Tend to be localized in the chest longer than other types of lung cancer.

Does not tend to metastasize early. It is strongly associated with smoking.

Adenocarcinnoma-30%:
Most common cancer among women. Usually started near the outer edges of the lung. Invasion of pleura and mediastinal lymph node is common.
May spread to other parts of the body.

Can be seen in non smoker.

Large cell carcinoma 15% :

Less well differentiated. May occur at any part of the lung. Tumors are large by the time they are diagnosed. Has greater possibility of spreading to brain and mediastinum.

Small cell lung cancer:

Small cell lung cancer also called oatcell because SCLC cells have oat grain appearance. It arises from endocrine cells [kulchitisky cells] where many hormones are secreted

Spread to lymph nodes and other organs

more quickly than NSCLC .

Cntd.
Usually started in one larger breathing tube. .Tend to grow rapidly . Commonly has spread by the time and is considered a systemic disease. It is the only one of the bronchial carcinomas that respond to chemotherapy

NON SMALL CELL LUNG CANCER

It is staged according to the size of the tumor, the level of lymph node involvement and the extent to which the cancer has spread. The stages include: STAGE 0:Cancer is limited to the lining of the air passage and hasnt invaded lung tissue. STAGE1:Invaded to lung tissue Hasnt invaded to lymph nodes

CONTD
STAGE II: Spread to neighboring lymph nodes Invaded the chest wall STAGE IIIA: Spread from the lung to lymph nodes. STAGE III B: Spread locally to areas . STAGE IV :spread to other parts of the body.

T 1: tumor < 3 cm T2: tumor > 3 cm, >2 cm from carina, invading the pleura, partial lung collapse T3: <2 cm from carina, mediastinal pleura, pericardium, chest wall, diaphragm, complete lung collapse T4: Carinal invasion, trachea, esophagus, heart, great vessels, vertebra, pleural effusion, satellite tumor N1: Ipsilateral hilar nodes N2: Mediastinal nodes N3: Contralateral hilar & any supraclavicular nodes M0: No distant mets M1: Distant metastases

NSCLC Staging

SCLC
Limited Stage Defined as tumor involvement of one lung, the mediastinum and ipsilateral and/or contralateral supraclavicular lymph nodes or disease that can be encompassed in a single radiotherapy port. Extensive Stage Defined as tumor that has spread beyond one lung, mediastinum, and supraclavicular lymph nodes. Common distant sites of metastases are the adrenals, bone, liver, bone marrow, and brain.

Presentations:
Lung cancer may present in number of different ways : Most commonly symptoms reflect local involvement of the bronchus. May also arise from spread to the chest wall or mediastinum or from distant blood-borne spread.

Local effects of tumor within the bronchus :

1- cough ( in 80% of cases ) : - It is the most common early symptoms. - sputum is purulant if there is secondary infection. - A change in the character of the (regular cough) associated with other new respiratory symptoms increase the possibilityof B.C.

2-Haemoptysis (in 70% of cases): - Repeated episodes of scanty cough hemoptysis or blood streaking of sputum in smokers are highly suggestive of B.C and should be always investigated .

Cntd.
3- Dyspnea ( 60% of cases ): - reflect occulusion of a large bronchus resulting in collapse of a lobe of the lung or development of plearal effusion. 4- Pleural pain : - reflect malignant invasion of the pleura or reflect infection distal to a tumuor (wich is recurrent and fail to resolve).

Direct spread:
Involvement of pleura and ribs . -Pancoasts tumour: involvement of lower part of the brachial plexus ( C8 , T1,T2) causing severe pain of the shoulder and down inner surface of the arm. -Horner syndrom: due to involvement of the sympathetic ganglion.

Contd.

-Recurrent laryngeal nerve palsy :

causing unilateral vocal cord paresis with hoarsness of voice and a bovine cough.

.Invation of phrenic nerve ,

causing paralysis of the diaghragm.

. Involvement of esophagus ,
causing dysphagia.

. Cardiovascular: atrial fibrillation,

temponade ,pericarditis, pericardial effusion .

Contd..

. Superior vena cava obstruction

causing early morning headache, facial congestion and edema involving the upper limb, distention of jugular vein and veins of the chest.

Nonmetastatic extra pulmonary manifistation: 1- Endocrine manifestation:

12% of tumors ,in particular small cell tumors present with SIADH, ACTH secretion(SCLC), hypercalcemia (sq.cell carcinoma),bone metastasis gynaecomastia(LCLC) .

Contd. 2- Neurological manifetation: e.g: sensory polyneuropathy ,myelopathy, cerebellar degeneration.

Cntd.
3- Others:
Digital clubbing , Hypertrophic pulmenary osteoarthropathy (sq.cell cancer) , Nephrotic syndrome, Hypercoagulopathy (adenocarcinoma), Thrombophelibitis migricans.

Blood borne metastasis:

.Bony metastasis giving severe bony pain

and pathalogical fractures. .liver metastasis (Jundice)

.Brain metastasis (change in personality,

epilpsy,focal neurological symptoms).

DIAGNOSTIC STUDIES

Physical signs:
Examination is usually normal unless there is significant bronchial obstruction or tumor has spread to pleura or mediastinum.

Cntd.
1- physical signs of collapse (in large obstructing tumor) which may rise to pneumonia. 2- monophonic or unilateral wheeze (fixed bronchial obstruction). 3- stridor (obstruction at or above the level of main carina.

Contd..
4- hoarsness of voice associated with bovine cough (recurrent laryngeal nerve palsy). 5- dullness percussion and absent breath sounds at the lung base (unilateral diaphragmatic palsy due to involvement of phrenic nerve)

Contd.
6- physical signs of pleursy or pleural effusion (involvement of pleura). 7- bilateral engorgement of the jangular vein and later edema affecting face, neck, arms. 8- tenderness and pain of long bone and joints .

Investigation:
Sputum cytology: high yield for endobronchial tumors such as squamous cell and small cell carcinoma.

chest x-ray:
common radiological presentation of bronchial carcinoma. 1- unilateral hilar-enlagement. 2- peripheral pulmonary opacity. 3- lung, lobe or segmental collapse.

. Bronchoscopy : gives high yield in

excess of 90% (allows biopsy and bronchial brush samples) if fail precautious fine needle aspiration under CT.

.CT thorax and upper abdomen. .Head CT scan. .Radio nuclide bone scanning. .liver US. .bone marrow biopsy.

MANAGEMENT

MANAGEMENT
Medical management : 1. Radiation therapy 2. Chemotherapy 3. Bronchoscopic laser therapy 4. Photodynamic therapy 5. Airway stenting Surgical management : 1. Surgical resection

 Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells . Xrays, gamma rays, and charged particles are types of radiation used for cancer treatment. The radiation may be delivered by a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy, also called brachytherapy). About half of all cancer patients receive some type of radiation therapy sometime during the course of their treatment.

RADIATION THERAPY

How does radiation therapy kill cancer cells?

Radiation therapy kills cancer cells by damaging their DNA (the molecules inside cells that carry genetic information and pass it from one generation to the next) . Radiation therapy can either damage DNA directly or create charged particles (free radicals) within the cells that can in turn damage the DNA. Cancer cells whose DNA is damaged beyond repair stop dividing or die. When the damaged cells die, they are broken down and eliminated by the bodys natural processes.

Linear Accelerator Used for External-beam Radiation Therapy

SIDE EFFECTS OF RADIATION THERAPY

Acute side effects of radiation therapy are:Cough Pharyngitis Esophagitis Anorexia Weight loss Fatigue Skin reactions

CONTD.
Late side effects of radiation therapy may or may not occur. Depending on the area of the body treated, late side effects can include :
Fibrosis (the replacement of normal tissue with scar tissue, leading to restricted movement of the affected area). Damage to the bowels, causing diarrhea and bleeding. Memory loss. Infertility (inability to have a child). DRUG AMINOFOSTINE IS GIVEN TO LESSEN THE SIDE EFFECTS OF RADIATION THERAPY.

CHEMOTHERAPY
Chemotherapy (also called chemo) is a type of cancer treatment that uses drugs to destroy cancer cells. Chemotherapy works by stopping or slowing the growth of cancer cells, which grow and divide quickly. But it can also harm healthy cells that divide quickly, such as those that line your mouth and intestines or cause your hair to grow. Damage to healthy cells may cause side effects. Often, side effects get better or go away after chemotherapy is over.

DRUGS USED FOR CHEMOTHERAPY

Cisplantin Vincristine Palcitaxel Cyclophosphamide Doxorubicin

SIDE EFFECTS OF CHEMOTHERAPY

 Nephrotoxicity Nausea Vomiting Myelosupression Pulmonary toxicity

PHOTODYNAMIC THERAPY
Photodynamic therapy (PDT) is a treatment that uses a drug, called a photosensitizer or photosensitizing agent, and a particular type of light. When photosensitizers are exposed to a specific wavelength of light, they produce a form of oxygen that kills nearby cells.

How is PDT used to treat cancer?

In the first step of PDT for cancer treatment, a photosensitizing agent is injected into the bloodstream. The agent is absorbed by cells all over the body but stays in cancer cells longer than it does in normal cells. Approximately 24 to 72 hours after injection, when most of the agent has left normal cells but remains in cancer cells, the tumor is exposed to light. The photosensitizer in the tumor absorbs the light and produces an active form of oxygen that destroys nearby cancer cells.

AIRWAY STUNT

Surgery

NURSING MANAGEMENT

NSG ASSESSMENT
Determine the understanding of patient & the family concerning the diagnostic tests. Assess the level of anxiety. Determine onset & duration of coughing, sputum production, & degree of dyspnea.

CONTD
Auscultate for breath sounds. Observe symmetry of chest during respiration. Ask about pain, its location, intensity & factors influencing pain.

NSG DIAGNOSES
Ineffective breathing pattern related to obstructive respiratory processes associated with lung cancer Imbalanced nutrition: less than body requirements related to hyper metabolic state, taste aversion, anorexia

CONTD
Acute or chronic pain related to tumor effects, invasion of adjacent structures, toxicities associated with radiotherapy/ chemotherapy Anxiety related to uncertain outcomes & fear recurrence

NSG INTERVENTIONS
Improving breathing patterns Elevate head of bed to promote gravity drainage. Teach breathing retraining exercises. Give prescribed treatment such as antimicrobial agents. Augment the patients ability to cough.

CONTD
Adminster oxygen if prescribed. Allow patient to sleep in reclining chair or with head of bed elevated if severely dyspneic. Improving nutritional status : Encourage small amounts of high calroie & high protein foods. Ensure adequate protein intake : milk, eggs, chicken, fish, cheese etc.

CONTD
Adminster or encourage prescribed vitamin supplement . Change consistency of diet to soft or liquid. Give enteral or total parenteral nutrition for malnourished patients who is unable to eat. Controlling pain : Assess condition of the patient. Give analgesics to the patient.

CONTD
Evaluate problems of insomnia, depression, anxiety etc. Initiate bowel training program. Minimizing anxiety : Try to have the patient exress concerns ; share these concerns. Expect some feelings of anxiety. Encourage the patient to communicate feelings.

HEALTH EDUCATION
QUIT SMOKING, IF PATIENT QUIT SMOKING THEN

HEALTH EDUCATION
Help the patient Teach the patient to to realize that every pain & ache is caused by lung cancer. Take NSAIDS or other prescribed medication. Tell the patient about treatment. Advise the patient to report new or persistent pain.