Chapter 28 Lung Cancer Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Chapter 28

Lung Cancer

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 2

Learning Objectives

Describe the epidemiology of lung cancer in the United States, particularly current trends.

Describe risk factors for lung cancer. Describe the classification of lung cancer

types and the cellular features of the four common types of lung cancer.

Describe current understanding of the pathophysiology of lung cancer.


Learning Objectives (cont.)

Describe the clinical features of the common types of lung cancer.

Describe the diagnostic approach to lung cancer.

Describe the staging system for lung cancer. Describe the treatment and outcomes for the

common types of lung cancer by stage. Describe the role of the respiratory therapist

in managing patients with lung cancer.

Epidemiology

In 2010, there were ~222,520 new cases of lung cancer (bronchogenic carcinoma) in United States

Second most common type of cancer in men & women

WHO estimates ~2 million cases of lung cancer/year

Leading cause of cancer-related death 85–90% of patients have smoking history


Epidemiology (cont.)



Risk factors of lung cancer include the following, except:

A. occupational and environmental exposure to asbestos, arsenic, etc.

B. genetic predisposition

C. Asthma

D. dietary factors

Epidemiology (cont.)



Lung Cancer Classification

Classified as small cell (oat cell) or non–small cell carcinoma

Non–small cell lung carcinoma (NSCLC) consists of: Adenocarcinoma: most common type, ~40% of all

lung cancers in United States Squamous cell carcinoma: 2nd most common type Large cell carcinoma: rarest form of lung cancer

Small cell lung carcinoma (SCLC): ~20% of U.S. cases

Lung Cancer Classification (cont.)



Pathophysiology Complex & poorly understood Genetic material in lung cells damaged

secondary to exposure to carcinogens, i.e., those in tobacco smoke

There may be genetic predisposition Genes influenced produce proteins involved

in cell growth, differentiation, apoptosis, angiogenesis, tumor progression, & immune regulation If enough of these pathways have been affected,

lung cancer will occur


Which of the following is the most common form of bronchogenic carcinoma?

A. squamous cell carcinoma

B. oat-cell carcinoma

C. adenocarcinoma

D. large-cell carcinoma

Clinical Features

Local growth Cough Dyspnea Hemoptysis Pain

Regional growth Dysphagia Dyspnea Harseness Horner syndrome Hypoxia Pancoast syndrome

Pericardial & pleural effusions Superior vena cava syndrome

Paraneoplastic Cutaneous or skeletal Acanthosis nigricans Clubbing Dermatomyositis Hypertrophic osteoarthropathy

Metastatic disease Headache Hepatomegaly Mental status change Pain Papilledema Seizures Skin or soft tissue mass Syncope Weakness

Endocrine Cusing syndrome Humoral hypercalcemia SIADH Tumor necroiss factor (cachexia)

Hematologic Anemia or polycythemia

Disseminated intravascular coagulation Eosinophilia

Granulocytosis Thrombophlebitis


Clinical Features (cont.)

Neurologic Cancer-associated retinopathy Encephalomyelitis

Lambert-Eaton syndrome Neuropathies Cerebellar degeneration

Renal Glomerulonephritis Nephrotic syndrome



Common lung cancer manifestations include the following, except:

A. dyspnea

B. hemoptysis

C. hypotension

D. pain


Diagnosis ~85% of patients will be symptomatic (see

Box 28-2) Remainder detected by radiographic

evaluation Chest radiograph & CT scan used as initial

evaluation Will show nodules (<3 cm) & masses (>3 cm) Other findings: enlarged lymph nodes or pleural

effusions


Diagnosis (cont.)

May proceed directly to surgery if radiograph, symptoms, & history are suggestive of malignancy

If unsure, further testing is indicated Adjunct imaging

Positron emission tomography (PET) • Malignant cells are metabolically very active & take up

radioactive glucose

• Scan reveals spots of attached radioactive tracer trapped in cells

• Sensitivity of 97% & specificity of 78% Single-photon emission computed tomography

(SPECT) & contrast-enhanced CT used less often

Diagnosis (cont.)

Nonsurgical tissue biopsy obtained by: Flexible bronchoscopy (FB):

• High diagnostic yield for lesions that are endoscopically visible within large airways

• Samples taken using saline washings, brush through camera, & needle or forceps

Transthoracic needle biopsy: • Aspirating needle guided by fluoroscopy or CT to obtain

samples of peripheral lesions



Staging

NSCLC staging is based on TNM staging system “T” component of staging (extent of primary tumor)

• T1: 3 cm confined to lung & cannot extend into main bronchus (T1a: <2 cm & T1b: 2-3 cm)

• T2: >3 cm may invade pleura or extend into bronchus, may cause segmental or lobar atelectasis (T2a: 3-5 cm & T2b: 5-7 cm)

• T3: ≥ 7 cm any size extending into surrounding structures, excluding main mediastinal structures

• T4: any size invading mediastinal structures or presence of malignant pericardial or pleural effusion


Based on the TNM staging, how would you classify a tumor found in the main bronchus that is 4 cm in diameter?

A. T1

B. T2

C. T3

D. T4


Staging (cont.)

“N” component of staging (regional lymph node involvement)

• N0: no demonstrable involvement of nodes

• N1: ipsilateral nodal involvement

• N2: ipsilateral mediastinal lymph nodes

• N3: contralateral mediastinal or hilar nodal involvement, either sides involvement of scalene or supraclavicular lymph nodes

“M” component of staging (metastases)• M0: no metastases• M1: metastases present

Staging (cont.)

Staging of NSCLC



Staging (cont.)

Staging of SCLC Divided into two groups

• Limited: cancer is confined to one hemithorax. Includes ipsilateral mediastinal & supraclavicular nodes

• Extensive: cancer has spread beyond original hemithorax

Since staging guides therapy, it is important to determine correct stage


Staging (cont.)

Determination of staging for all lung cancers: CT of chest & upper abdomen is ordered for all MRI only superior to CT scan for Pancoast tumor FDG-PET best to determine staging of mediastinal

nodes FB with transbronchial needle aspiration help for

mediastinal staging Gold standard remains surgical resection &

mediastinal dissection Patient performance status is important in

determining prognosis & ability to tolerate surgery


Screening for Lung Cancer

Due to high proportion of patients who present with advanced lung cancer & its associated mortality, screening is very attractive

Techniques Chest radiograph and/or sputum exam

• Studies did not support beneficial outcome

Low-dose CT imaging • No proof it is of any benefit

• May be useful in high-risk individuals

Treatment & Outcomes


NON–SMALL CELL STAGES IA, IB, IIA, IIB

• Surgical resection is the standard of care if patient deemed able to tolerate

• Limited resection if patient is unable to tolerate larger resection.

• Radiotherapy, particularly stereotactic body radiotherapy in N0 disease, if patient is unable to tolerate or chooses not to undergo resection.

• Adjuvant radiotherapy is possibly of use if incomplete resection has occurred.

• Adjuvant chemotherapy in those with stage II disease who can tolerate it. Consider in stage IB. STAGE IIIA

• Concurrent chemoradiotherapy using a platinum-based regimen if performance status is reasonable.

• Induction chemoradiotherapy followed by resection and adjuvant chemotherapy in selected patients, ideally as part of a study protocol.

STAGE IIIB

• Concurrent chemoradiotherapy using a platinum-based regimen if performance status is reasonable.

• Induction chemoradiotherapy followed by resection in highly selected patients, only as part of a study protocol. STAGE IV

• Platinum-based chemotherapy regimen in patients with adequate performance status.

• Targeted therapies (EGFR and VEGF inhibitors) in appropriate subgroups. SMALL CELL

LIMITED STAGE

• Combination chemotherapy with concurrent hyperfractionated radiotherapy if performance status is adequate.

• Prophylactic cranial radiation for those with a complete response to chemoradiotherapy. EXTENSIVE STAGE

• Combination chemotherapy if performance status is adequate.

Courtesy The Cleveland Clinic, Cleveland, OH)


A 54 year old male factory worker has been currently diagnosed with non-small cell stage IV bronchogenic carcinoma. Which of the following treatments would he undergo?

A. surgical resection

B. induction chemoradiotherapy

C. platinum-based chemotherapy

D. Prophylactic cranial radiation

Prognosis for NSCLC


The Future

Attainable vision for 2031: Primary prevention campaigns having successfully

minimized number of smoking individuals Legislation has passed laws to prevent tobacco

smoking in public places Progression of occupational exposure avoidance Successful measures enacted to clean air

Improved diagnostic procedures


Role of Respiratory Therapists

Prevention /education Smoking cessation

Evaluation & management Assist MD in brochoscopy used in diagnosis Mobilization of bronchial secretions from

excessive mucus production & accumulation associated with lung cancer

Supplemental oxygen to treat associated hypoxemia unless caused by capillary shunting

Psychological support


Chapter 28 Lung Cancer Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Documents

lung cancer copyright

imprint of elsevier

epidemiology of lung

pathophysiology of lung

common types of lung

risk factors of lung

cases copyright

common type of cancer