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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 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.
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.
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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.
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.
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.
Difficult to assess association between alcohol and lung cancer due to confounding by smoking status
Asbestos Arsenic Bischloromthyl ether Chromium Nickel Polycyclic aromatic compounds Vinyl chloride
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
Many studies have demonstrated that cancer cases have a significant decrease in DNA repair capacity compared to controls
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
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%
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.
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
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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.
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.
. Involvement of esophagus ,
causing dysphagia.
Contd..
causing early morning headache, facial congestion and edema involving the upper limb, distention of jugular vein and veins of the chest.
Cntd.
3- Others:
Digital clubbing , Hypertrophic pulmenary osteoarthropathy (sq.cell cancer) , Nephrotic syndrome, Hypercoagulopathy (adenocarcinoma), Thrombophelibitis migricans.
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.
.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
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.
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.
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.