Lung Cancer

LUN G CANCER (BRONCH

OGENI C CARCIN OMA)

Lung cancer is the leading cause of cancer death in United States, accounting for 35% of male deaths and 21% of female deaths. About 80 to 90% of the mortality is directly related to smoking. However, of people who smoke, only 1 of 11 develops lung cancer, supporting the theory that genetic predisposition may be an important factor. It is known that women develop lung cancer at a younger age with a smaller pack-year history. There is a 35 to 53% increase in lung cancer for nonsmokers who live with smokers, and wives of smokers have a two to three times increased risk of developing lung cancer. Another risk factor is radon exposure, with 25% of cancer in nonsmoker and 5% in smokers attributed to this substance. Investigations into effects of diet have been done and are inconclusive, but it is possible that vitamin A, selenium, and vitamin E confer a productive effect. The most common cell types in smokers are squamous and adenocarcinoma, each accounting for about 35 to 40% of cases. Other cell types are small cell (about 25% of cases) and large cell. In nonsmokers, adenocarcinoma accounts for 55 to 70% of cases. Large-scale screening with CXRs and/or sputum cytologies has not been shown to have an impact on survival and is not cost-effective, but current recommendations by the National Cancer Institute recommend yearly CXRs for those at risk. Obviously, this is much more important for smokers. Tumor-associated genes for lung cancer as well as cancer suppression appear to be on chromosome 3, although 11 and 18 are also implicated. The effect of these markers continues to intrigue investigators. The staging of lung cancer is by an American joint committee TMN system and correlates well with survival. However, other prognostic factors in lung cancer include systematic signs such as fever, weight loss, and performance status. ETIOL OGY A. Ciga rette smokin g. 1. Overall risk of lung cancer in smokers is 10 times that of nonsmokers 2. Possible association of lung cancer with exposure to passive smoking 3. Cigarette smoke acts synergistically with environmental pollutants in carcinogens. B. Occupatio nal exposu re 1. Asbestos 2. Ionizing radiation 3. Arsenic 4. Nickel 5. Chromium 6. Chloromethyl ethers 7. Mustard gas

C. Atmosphe ric pollutio n due to industrial expansion D. Ge netic p redisp osition PATHOL OGY A. Histologica l classification of malignant epithelial lung tumors according to World Health Organization, 1981. 1. Squamous cell carcinoma- spindle cell (squamous) carcinoma. 2. Small cell carcinoma. a. Oat cell carcinoma b. Intermediate cell type c. Combined oat cell carcinoma 3. Adenocarcinoma a. Acinar adenocarcinoma b. Papillary adenocarcinoma c. Bronchiolo-alveolar adenocarcinoma d. Solid carcinoma with mucus formation 4. Large cell carcinoma a. Giant cell carcinoma b. Clear cell carcinoma 5. Adenosquamous carcinoma 6. Carcinoid tumor B. Locatio n of prim ary tum ors. 1. “Central” tumors- squamous and small cell carcinomas 2. “Peripheral” tumors- adenocarcinoma and large cell carcinomas. C. Methods of sp read. 1. Invades lymphatics and blood vessels, resulting in early metastasis 2. Oat cell carcinoma is most aggressive 3. 30-50% of patients with lung cancer have lymphatic or hematogenous spread at initial presentation 4. Metastases in order of preference- regional lymph nodes, liver, adrenals, brain, bone, and kidneys. 5. Contra lateral pulmonary metastases a post-mortem exam – 10-14% FOUR MAJOR TYPE S OF MALIGNANT EPITHE LIAL LUN G TUMOR S A. Ad enocarcin oma 1. 40% of malignant epithelial lung tumors. 2. Relative incidence appears to be increasing. 3. Often a “peripheral” tumor a. Arises mostly in the periphery of lung parenchyma. b. May be related to focal scars to regions of fibrosis. 4. Early metastasis because of early invasion of lymphatics and blood vessels. B. Sq uamous cell carcinom a 1. 30% of primary malignant epithelial lung tumors. 2. Occur in the segmental, lobar, or main stem bronchi.

3. Relatively slow-growing and late to metastasize 4. Spread pattern a. Direct invasion of peribronchial lymph nodes and replacement of adjacent pulmonary parenchyma. b. Peripheral tumors commonly invade chest wall. 5. Microscopically. a. Well-differentiated tumors produce keratin, epithelial pearls, and squamous pattern. b. Poorly-differentiated tumors with less obvious keratinization. C. Smal l cel l ca rcinoma (o at cell carcin oma) 1. 20% of malignant epithelia lung tumors. 2. Originate in the major bronchus at or near the hilum. 3. Noted for its rapid growth and early metastasis via lymphatic and hematogenous spread. 4. Staging (not based on TNM) a. Limited- disease limited to one hemi thorax b. Extensive- spread beyond one hemi thorax 5. Precise diagnosis required because treatment and prognosis of small cell carcinoma differs considerably from non small cell. D. Lar ge cell carcinom a 1. 10% of malignant epithelial lung tumors 2. “Peripheral” tumor 3. Heterogeneous group a. Not showing squamous or glandular differentiation b. Not being of small cell type c. Ultra structurally- most are poorly-differentiated adenocarcinomas 4. Rapid growth and early metastasis. MET AST ATIC TUM ORS IN THE CHEST A. Lun gs a re one of the most frequ ent sites fo r metas tases. B. Lun gs a re first org an to filter ma ny veno us-bor ne metastases . C. May present as dif fuse pulm onary involvem ent or solitary pulmonary nodule D. Common ma ligna ncies metas tatic to lu ng - breast, melanoma, renal cell, prostate, thyroid, pancreatic, small tissue sarcoma, and osteosarcoma. CLINICAL FE ATURES A. Local ma nifesta tio ns may be nonspecific, since most patients also suffer from chronic bronchitis and emphysema due to cigarette smoking. 1. Cough and sputum a. Evaluate for change of an established cough. b. Evaluate for change in quality or quantity of sputum. 2. Dyspnea- sudden onset may indicate obstruction of a main bronchus. 3. Hemoptysis. 4. Wheezing. 5. Chest or shoulder pain- may indicate chest wall or pleural involvement by a tumor

6. 7. 8. 9.

Hoarseness (involving the recurrent laryngeal nerve) Dysphagia Head and neck edema Symptoms of pleural or pericardial effusion  Non specific symptoms of weakness, weight-loss also may be diagnostic.

AS SES SMENT AND DIAGN OSTIC FINDINGS A. Chest X-ray -To search for pulmonary density, a solitary peripheral nodule (coin lesion), atelectasis and infection. B. CT Sca n -Used to identify small nodules not visualized on the chest x-ray and also to examine serially areas of the thoracic cage.\ C. Ple ural flui d cytology a. When effusion present on chest radiograph b. 40-75% sensitivity c. Highest yield for adenocarcinoma D. Br onchoscopy a. Higher yield in patient with central tumors; can evaluate for synchronous lesions. b. Complications rare with fiber optic bronchoscope c. Allows transbronchial biopsies, brush cytology, and bronchial washings for cytology E. Medi astinoscopy a. 50% of patients have involved mediastinal lymph nodes at initial presentation b. Mediastinoscopy may be used prior to thoracotomy to evaluate respectability c. Tumor yield approximately 30-40% of exams F. Pe rcutaneous ne edle bi opsy a. Negative result does not rule out carcinoma b. Indications 1. When surgery is most likely not in the treatment plan (small cell) 2. Patients who cannot tolerate a thoracotomy c. Contraindications 1. Bleeding diathesis 2. Bullous disease near the lesion d. 96% sensitivity with two attempts e. Complications 1. Pneumothorax – 24%; only 10% require chest tube placement 2. Minor hemoptysis – 6%

T-N -M CL ASSIFICA TION Primary Tumor (T) Metastasis (M) TO: no tumor TX: positive cytology TIS: carcinoma in situ T1: <3 cm, no bronchial Invasion T2: >3 cm, invades hilum Pleura or bronchus T3: invades parietal pleura, Chest wall, diaphragm Mediastinum T4: invades unresectable Structures – aorta, Atrium, vertebral body

Nodal Involvement (N) NO: no nodes NX: unable to assess N1: ipsilateral nodes (Peribronchial or hilar) N2: ipsilateral nodes (mediastinal) N3: contra lateral nodes (mediastinal)

Distant MO: no metastasis MX: unable to assess M1: metastasis

MEDICAL MANA GEMENT The objective of management is to provide a cure, if possible. Treatment depends on the cell type, the stage of the disease, and the physiologic status (particularly cardiac and pulmonary status) of the patient. In general, treatment may involve surgery, radiation therapy, or chemotherapy – or a combination of these. Newer and more specific therapies to modulate the immune system (gene therapy, therapy with defined tumor antigens) are under study and show promise in treating lung cancer. A. Su rgical Man ageme nt Surgical resection is the preferred method of treating patients with localized non-small cell tumors, no evidence of metastatic spread, and adequate cardiopulmonary function. TYP ES OF LUNG RE • • • • • •

SECTIONS

Lobectomy: a single lobe of lung is removed Bilobectomy: two lobes of the lung are removed Sleeve resection: cancerous lobe(s) is removed and a segment of the main bronchus is resected Pneumonectomy: removal of the entire lung Segmentectomy: a segment of the lung is removed* Wedge resection: removal of a small, pie-shaped area of the segment*

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Chest wall resection with removal of cancerous lung tissue: for cancers that have invaded the chest wall

B. Non surg ical 1. Radiation a. Palliation – often helpful in relieving symptoms of superior vena cava obstruction and mediastinal invasion, as well as cough, hemoptysis, and pain (especially bone pain). b. Pre-operative irradiation (1) No improvement in survival, but increased post-operative complications (2) Expectation in superior sulcus tunor (Pancoast); improved survival (45% vs. 30%) with pre-operative irradiation and en bloc resection c. Post-operative irradiation- controversial, under study 2. Chemotherapy- used to treat patients with advanced disease; response rates to singleagent and combined-drug chemotherapy are low 3. Immunotherapy- may be useful to relieve endobronchial obstruction in unresectable tumors. TREA TM ENT OF SM ALL CELL CARCINOMA A. Su rgical interve ntion rarely indicated B. Multipl e drug re gimens are more effective than a single agent 1. Many combinations have been shown to extend survival 2. Side-effects are worse with multiple agents C. Tumor response seen in 75-95% of patients 1. 50% of patients with limited disease (disease limited for only one hemi thorax) see complete response 2. 20% of patients with widespread disease see complete response PRO GNO SIS A. Over all 5-yea r su rvival for patients with non0small cell carcinoma of the lung 1. Stage I, resected-80% 2. Stage II, resected-50% 3. Stage III-<10% B. 5-yea r su rvival by cell type 1. Squamous-68% 2. Adenocarcinoma-25% 3. Small cell- 0% (few patients survive 2 years from diagnosis) WOR K-UP OF SO LIT AR Y PU LMONAR Y NODUL E (SPN) A. Definitio n- peripheral pulmonary nodule less than 6 cm in diameter B. Incidence of SPN representing metastatic disease from an asymptomatic primary malignancy is exceedingly low. Extensive metastatic work-up is necessary

C. Consid er SPN metastatic if occurs in patient with current or previous extra pulmonary primary malignant tumor D. Incidence of disease that may present as SPN 1. Malignant nodules-40% a. Bronchogenic carcinoma- 30% b. Solitary metastatic lesions- 8% c. Bronchial adenoma (mainly carcinoid)- 2% 2. Benign nodules- 60% a. Infectious granulomas- 50% b. Non-infectious granulomas- 3% c. Benign tumors- 3% d. Miscellaneous- 4% E. Radi ogra phic ch aracteristics of ben ign nod ules a. Small, smooth, with sharply circumscribed margins b. Calcification- only 0.5% malignant c. No increase in size in 2 years- doubling time is 20 to 400 days for malignant tumors F. Mana gement of SPN 1. Further radiographic evaluation of the nodule, and evaluation for the other pulmonary nodules (chest CT, tomography) 2. Radiographic evidence of benignity- follow with yearly chest radiograph 3. Suspected malignancy a. Attempt needle biopsy for diagnosis b. Bronchoscopy c. Evaluate for thoracoscopy or thoracotomy with nodule resection. NUR SING AS PECTS The Dema nds of Nursin g The presence of cancer in a family produces not only physical but also mental and social problems, which are impossible for the family to cope with alone. There is a demand on the part of the nurse for sympathetic understanding and support in building and maintaining morale of the patient and his/her family. Guidance is necessary and the public health nurse must work closely with other members of the team as doctors, social workers, mental hygienist to ensure that a comprehensive cancer care is accorded to the cancer patient. Nursin g Responsibi lities and Functions The nurse providing nursing management to cancer patient must always remember that care is focused towards the relief of physical, mental and spiritual distress although medications can control pain, nausea and vomiting. Situation relief is of value. •

Refer immediately any case of suspected disease to physician

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Share with patient and family knowledge on available resources for accurate diagnosis and adequate treatment Assist and guide families in availing of existing health resources and facilities Record history of symptoms, which will help physician arrive at accurate diagnosis Assist physician in the performance of examinations and diagnosis test as aids to diagnosis and treatment Conduct nursing demonstrations to patients/ or families on proper nursing care, particularly on post-operative care of discharged hospital cases and terminal cancer patients who have to be taken cared of at home. Assist the patient and family in making necessary adjustment and developing proper attitudes towards prescribed treatment Provide guidance, counseling and supervision in the management of case at home Participate in the planning and implementation of rehabilitation program for post-operative and other cases in need of this service Help the patient and the family understand the most important facts about cancer Conduct and participate in health education programs on cancer for allied health workers and the general public

Poi nters for Nu rses to Consid er in the Care of Patients •

The important responsibility of the nurse is to assist the patient maintain his/her dignity and integrity. Aspects of care include continuing or sustained contact, communication, comfort, sensitivity, realism, confidence and above all, a sense of hope.

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Allow patient to ventilate his/her feelings which could be expressed in tears, anger, withdrawal or meaningless chatter, bitter despair or careless indifference. These must be accepted. Support comes through close warm relationship.

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Make arrangements for spiritual consolation.

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Nurse has a role in helping cancer patient return to society. Rehabilitation program must start, even before surgery until he/she adjust again to community life.

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Cancer care is multidisciplinary. Collaborate with other health workers. Nurse should serve as link or liaison or as patient advocate.