LUNG CANCER

(Bronchogenic Carcinoma)

Lung cancer is a disease of uncontrolled cell

growth in tissues of the lung. This growth may lead to
metastasis, which is the invasion of adjacent tissue
and infiltration beyond the lungs. The vast majority of
primary lung cancers are carcinomas of the lung,
which arises from transformed epithelial cells in
tracheobronchial airways. The World Health
Organization declared that it is the most common
cause of cancer-related death in men and women,
and is responsible for 1.3 million deaths worldwide
annually, as of 2004. The survival rate is low because of
spread to regional lymphatics (70% of patients) by the time of diagnosis. {REFERENCE:
http://www.scribd.com/doc/36236888/Lung-Cancer}

There are four major cells types of lung cancer. Epidermoid or squamous cell
carcinoma (30% of patients) is more centrally located, adenocarcinoma (31 to 34% of
patients) presents as peripheral masses and often metastasizes, large cell carcinoma
(10 to 16% of patients) is a fast-growing tumor that often arises peripherally, and small
cell carcinoma or oat cell carcinoma (20 to 25% of cases) usually arises in the major
bronchi. {REFERENCE: Brunner & Suddarth’s Handbook for Medical Surgical Nursing 11 th
Ed.}

The distinction of lung cancer is important because its treatments vary; non-small
cell lung carcinoma (NSCLC) is sometimes treated with surgery, while small cell lung
carcinoma (SCLC) usually responds better to chemotherapy and radiation. The
occurrence of lung cancer in nonsmokers, who account for as many as 15% of cases, is
often attributed to a combination of genetic factors, radon gas, asbestos, and air
pollution including second-hand smoke.
In the Philippines, the Philippine Cancer Society certified that in recent years,
approximately 17,238 new local cases were diagnosed annually. Median survival is 6
months, and the 5-year survival rate is only 5.28%. The greatest risk factor for
developing lung cancer is smoking, which can be attributed to nine out of 10 lung
cancer cases. It is estimated that at least 43 Filipinos die of lung cancer every day.
{REFERENCE: http://www.cnetwork.org.ph/media.asp?section=news&id=48}

Risk Factors:
 Tobacco smoking
 Second-hand smoke
 Exposure to environmental pollution (air pollution)
 Occupational exposure to chemicals and radon
 Dietary factors (vit.A and beta-carotene deficiency)
 Genetic predisposition
 Underlying respiratory disease (eg. COPD, Pulmonary TB)

Clinical Manifestations:
 Persistent and non-productive cough, which later becomes productive of thick,
purulent sputum
 Wheezing occurs when bronchus becomes partially obstructed; hemoptysis
 Recurring fever
 Chest or shoulder pain indicates chest wall or pleural involvement
 Chest pain tightness, hoarseness, dysphagia, head and neck edema, and
symptoms of pleural and pericardial infusion
 Metastasis on lymph nodes, bones, brain, contralateral lung, adrenal glands and
liver
 Weakness, anorexia, and weight loss
Assessment and Diagnostic Methods:
 Chest films, sputum examinations, endoscopy or bronchoscopy,
mediastinoscopy, fine-needle aspiration (FNA) and biopsy
 Various computed tomography (CT) scan and magnetic resonance imaging
(MRI)
 Pulmonary function test, arterial blood gas (ABG) analysis, ventilation-perfusion
scans, and exercise testing
 Staging of tumor
Staging of Lung Cancer

Lung cancer staging usually is described in terms of the TNM system—a classification
system developed and recently revised by the American Joint Committee on Cancer
(AJCC) and the Union Internationale Contre le Cancer (UICC; International Union
Against Cancer). According to this system:

 T = tumor size
 N = node involvement
 M = metastasis status

Lung cancer treatment ultimately depends upon the stage of the disease. In general, the
lower the stage, the more favorable is the patient's prognosis.

Tumors

The primary tumor (T) is classified according to the following categories:

TX: Tumor cannot be evaluated or tumor is proven by the presence of cancer cells in
the sputum or bronchial washings, but it cannot be seen during imaging or
bronchoscopy ("occult" tumor)
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor 3 centimeters (< 3 cm) or less in greatest dimension, surrounded by lung or
pleura, and not located in the main stem bronchus
T2: Tumor more than 3 centimeters (> 3 cm) in greatest dimension, or tumor involving
the main stem bronchus, 2 cm or more from the carina, or tumor invading the
visceral pleura, or tumor with incomplete lung expansion or obstructive lung
infection that does not involve the entire lung
T3: Tumor of any size that directly invades the chest wall, diaphragm, pleura, or
pericardium, or tumor that involves the main stem bronchus less than 2 centimeters
(< 2 cm) from the carina (ridge between the right and left main stem bronchi), or
tumor that is associated with complete lung collapse or obstructive lung infection
involving the entire lung.
 T4: Tumor of any size that invades the heart, great vessels (aorta, superior or inferior
vena cava, pulmonary artery, or pulmonary vein), trachea, esophagus, vertebral
body, or carina, or separate tumor nodules in the same lung lobe, or tumor
associated with a malignant pleural effusion.

Nodes

The regional lymph nodes (N) are clinically divided into the following categories:

NX: Regional lymph nodes cannot be assessed

N0: Regional lymph nodes contain no metastases
N1: Metastasis to same-side peribronchial (around the bronchi) and/or hilar (pit in the
lungs where vessels enter and exit) lymph nodes and nodes within the lungs that
are involved by direct spread of the primary tumor
N2: Metastasis to same-side mediastinal and/or subcarinal (under the carina, or tracheal
ridge) lymph nodes.
N3: Metastasis to opposite-side mediastinal or hilar nodes or to same- or opposite-side
scalene (neck/upper rib) or supracalvicular (above collarbone) lymph nodes.

Metastasis

The state of metastasis (M) is defined as follows:

MX: Distant metastases cannot be assessed

M0: No distant metastases are found
Distant metastases are present (this also includes separate tumor nodules in a
M1:
different lobe of lung on either side).

Staging

The TNM system—which includes the overall features of the tumor, lymph nodes, and
metastatic status—places lung cancer growth at a particular stage. Apart from hidden,
yet to be identified tumors (occult: TxN0M0) and confined carcinomas in situ (stage 0;
tis), there are four basic stages within the tnm classification system:
 STAGING TNM System
Stage IA T1, N0, M0

IB T2, N0, M0
Stage IIA N1, M0

IIB T2, N1, M0 or T3, N0, M0

Stage IIIA T1-2, N2, M0 or T3, N1-2, M0

IIIB T(any), N3, M0 or T4, N(any), M0

Stage IV T(any), N(any), M1

The TNM staging system is not often used for patients with small cell lung
carcinoma (SCLC), because most have suspected or definite metastatic disease at the
time of diagnosis. Survival in these patients usually is unaffected by minor differences in
the extent of tumor involvement. Instead, most experts use a simple, two-stage system
created by the Veterans Administration Lung Cancer Study Group. This system defines
SCLC as being of "limited" or "extensive" stage.

Pathogenesis

Similar to many other cancers, lung cancer is initiated by activation of oncogenes

or inactivation of tumor suppressor genes. Oncogenes are genes that are believed to
make people more susceptible to cancer. Proto-oncogenes are believed to turn into
oncogenes when exposed to particular carcinogens. Mutations in the K-ras proto-
oncogene are responsible for 10–30% of lung adenocarcinomas The epidermal growth
factor receptor (EGFR) regulates cell proliferation, apoptosis, angiogenesis, and tumor
invasion.[66] Mutations and amplification of EGFR are common in non-small cell lung
cancer and provide the basis for treatment with EGFR-inhibitors. Chromosomal damage
can lead to loss of heterozygosity. This can cause inactivation of tumor suppressor
genes eventually leading to formation of tissue mass leading to manifestations of sign &
symptoms like; chest pain, dyspnea and productive cough.
 NOTES:
PATHOPHYSIOLOGY
of LUNG
 K-Ras-CANCERprotein gene
responsible for cell growth,
differentiation and survival
 Proto-oncogenes= normal
gene that becomes
Modifiable: Non-Modifiable: oncogene (mutated genes)

• Lifestyle (Smoking) •Age  Loss of heterozygosity

(LOH) in a cell represents
• Environmental • Gender the loss of normal function
• Occupation • Genetics of one allele of a gene in
which the other allele was
already inactivated.

Carcinogenics agent will enter the respiratory tract

It will attack the epithelial cells/ lining of the lungs

Mutations in the K-RAS proto oncogenes will contribute to develop non-small cancer cells

Proto-oncogenes will turn into oncogenes

Chromosomal damage can lead to heterozygosity

Can cause inactivation of tumor suppressor genes

NSCC will proliferate due to inhibition of tumor supressor genes

Formation of tissue mass leading to manifestations of sign & symptoms like; chest pain, dyspnea and productive cough.
MANAGEMENT for LUNG CANCER

Preventive Management:

In the vast majority of cases, lung cancer is relatively easy to prevent. People
who do not smoke or who stop smoking are at very low risk for contracting the
disease. Some authorities suspect that second-hand smoke may also pose a threat for
lung cancer. Second-hand smoke is smoke that a person breathes in from another
person's cigarette, cigar, or pipe.

Other ways to prevent lung cancer are to avoid contact with chemicals that
can cause the disease (such as asbestos) and to have one's home checked for
radon gas. Home test kits for radon are available. They are easy to use and can tell in
a matter of minutes whether radon is present in a building. {REFERENCE:
http://www.faqs.org/health/Sick-V3/Lung-Cancer-Prevention.html#ixzz0zqlhgDaJ}

Medical Management:

 Lung resection

- is a procedure wherein the

surgeon makes an incision in the
chest. If necessary, a rib is
removed from the chest to gain
better access to the diseased part
of the lung. The lung is examined
and the area of concern, such as
a tumor, is identified. The tumor or
diseased area is then removed. If
cancerous tumors are removed, the lymph nodes near the lung and
draining the lung are also removed. After removal of the diseased area,
the muscles are sutured and reconstructed where necessary. A chest tube
 is left in place to remove fluid, blood, and air from the lung and chest wall.
The incision is closed with sutures, clips, or staples.

 Radiation Therapy - also called radiation oncology, is the medical use of ionizing
radiation as part of cancer treatment to control malignant cells.

 Chemotherapy

 Immunotherapy

 Therapies such as gene and tumor antigens are still under study

Assessment and Diagnostic Methods:

 Chest X-ray, sputum examinations, endoscopy or bronchoscopy,
mediastinoscopy
 Fine-needle aspiration (FNA) and biopsy
 CT scan and magnetic resonance imaging (MRI)
 Pulmonary function test, arterial blood gas (ABG) analysis
 Ventilation-perfusion scans and exercise testing
 Staging of tumor

Surgical Management:
 Lobectomy - surgical excision of a lobe
 Pneumonectomy - is a surgical procedure to remove a lung
 Thoracotomy - is an incision into the pleural space of the chest to gain access to
the thoracic organs
 Electrosurgery - is the application of a high-frequency electric current to
biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue
 Cryosurgery - is the application of extreme cold to destroy abnormal or diseased
tissue.
 Chemosurgery - the destruction of tissue by chemical agents for therapeutic
purposes; originally applied to chemical fixation of malignant, gangrenous or
 infected tissue, with use of frozen sections to facilitate systematic microscopic
control of its excision.
 Laser surgery - is surgery using a laser to cut tissue instead of a scalpel

Nursing Management:
 Relieving breathing problems
- Maintain airway patency; remove secretions
- Encourage DBE, aerosol therapy, oxygen therapy, mechanical ventilation
- Encourage position that promotes lung expansion
- Advise use of relaxation and energy-conservation techniques
- Refer for pulmonary rehabilitation
 Reducing fatigue
- Assess level of fatigue and identify cause
- Educate patient about energy-conservation techniques and exercises
appropriate
- Refer to PT or RT as indicated
 Psychological support
- Help the patient and family deal with poor prognosis and progression of
the disease
- Assess psychological aspects and assist patient in coping
- Assist patient and family with informed decision making regarding
treatment options
- Support patient and family in the end-of-life decisions and treatment
options

Nursing Diagnosis:
 Impaired tissue integrity related to the effects of treatment
 Imbalanced nutrition less than body requirements related to anorexia,
malabsorption and cachexia (wasting syndrome: eg. weight loss)
 Pain or chronic pain related to disease
 Fatigue related to physical and psychological stressors
 Disturbed body image related to changes in the appearance and role
functions
 Anticipatory grieving related to expected loss and altered role function