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Management of LungManagement of Lung

Cancer & OccupationalCancer & OccupationalLung DiseaseLung Disease

Dr.Dr. ShamayShamayNgNg

(1 Nov 2012)(1 Nov 2012)

ObjectivesObjectives

Describe diagnostic methods, management & prognosis of CaDescribe diagnostic methods, management & prognosis of Calunglung

Understand the risk factors, signs / symptoms, and staging ofUnderstand the risk factors, signs / symptoms, and staging ofCa lungCa lung

Understand psychological suffering of patients with Ca lungUnderstand psychological suffering of patients with Ca lung

Understand the cause and prevention of occupational lungUnderstand the cause and prevention of occupational lungdiseasedisease

Understand the role of PTs in managing Ca lung andUnderstand the role of PTs in managing Ca lung andoccupational lung diseaseoccupational lung disease

Case 1:Case 1:

Lung CancerLung Cancer

Case 1: Class ActivityCase 1: Class Activity

Form small groups with 5 studentsForm small groups with 5 students

Read through the bedRead through the bed--note of Mr. Chiunote of Mr. Chiu

Answer the questions 1 to 5Answer the questions 1 to 5

15 Minutes Discussion!

1. Predisposing Factors for Mr. Chiu1. Predisposing Factors for Mr. Chius Disease:s Disease:

SmokingSmoking

22ndnd hand smoking : Increase the risk of familyhand smoking : Increase the risk of familymember having Ca lungmember having Ca lung

Smoking accounts for 90% of Ca lungSmoking accounts for 90% of Ca lung

Years of smoking x chance having Ca lungYears of smoking x chance having Ca lung

No. of cigarettes x chance having Ca lungNo. of cigarettes x chance having Ca lung

Other risk factors:Other risk factors:

zz Exposure to asbestos and radon, family history,Exposure to asbestos and radon, family history,excessive alcohol useexcessive alcohol use

2. Common Signs and Symptoms of Ca Lung2. Common Signs and Symptoms of Ca Lung

HaemoptysisHaemoptysis

Chest painChest pain

Persisted coughPersisted cough

SOBSOBHoarsenessHoarseness

WheezingWheezing

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2. Diagnosis of Ca Lung:2. Diagnosis of Ca Lung: Medical History:Medical History:

zz Risk factors,Risk factors, haemoptysishaemoptysis, weight loss, repeated pneumonia, weight loss, repeated pneumonia

Chest XChest X--Ray:Ray:

zz Both AP and lateral views to locate the massBoth AP and lateral views to locate the mass

Sputum Cytology:Sputum Cytology: Identify Types of CarcinomaIdentify Types of Carcinoma

zz Small cell lung cancer: Oat cell Ca/small cell undifferentiated CaSmall cell lung cancer: Oat cell Ca/small cell undifferentiated Ca

zz NonNon--small cell lung cancer:small cell lung cancer: SquamousSquamous cell carcinoma (45%),cell carcinoma (45%),adenocarcinomaadenocarcinoma (20%), large cell undifferentiated Ca (10%)(20%), large cell undifferentiated Ca (10%)

BronchoscopyBronchoscopy::

zz Identify centrally locatedIdentify centrally located tumourtumour, but not at distal bronchi, but not at distal bronchi

CT Scan:CT Scan:

zz Identify size, shape and location ofIdentify size, shape and location of tumourtumour

Needle Biopsy:Needle Biopsy:

zz Invasive technique to identify types of lung cancerInvasive technique to identify types of lung cancer

2. Diagnosis of Ca Lung:2. Diagnosis of Ca Lung:

Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)

Positron Emission Tomography (PET)Positron Emission Tomography (PET)

MediastinoscoMediastinosco

MediastinoscopyMediastinoscopy

Mediastinoscopy is a surgical procedure that enables

visualization of the contents of the mediastinum,usually forthe purpose of obtaining a biopsy.

BronchoscopyBronchoscopy

FlexibleFlexible BroncoscopyBroncoscopy Chest XChest X--RayRay

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CT ScanCT Scan Fine Needle Aspiration & BiopsyFine Needle Aspiration & Biopsy

MediastinoscopyMediastinoscopywith Biopsywith Biopsy

Under GAUnder GA

Incision made in theIncision made in theneckneck

Mediastinosco eMediastinosco einsertedinserted

Lung tissues andLung tissues andlymph nodes biopsylymph nodes biopsycan be takencan be taken

Positron Emission TomographyPositron Emission Tomography(PET) Scan(PET) Scan

Injection of glucoseInjection of glucose--basedbasedradiopharmaceuticalradiopharmaceutical

Chemicals collected at targetChemicals collected at targettissues as biochemistry of cancertissues as biochemistry of cancercells aredifferentcells aredifferent

Patient lies on PET scannerPatient lies on PET scanner

Scanner detects the gamma raysScanner detects the gamma raysemitted from the patientemitted from the patient

Computer generates 3Computer generates 3--D picturesD pictures

Can locate the cancerous tissuesCan locate the cancerous tissues

Example of PET ScanExample of PET Scan Example of PET ScanExample of PET Scan

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4. Patients Concern:4. Patients Concern:

Disease Prognosis of Ca LungDisease Prognosis of Ca Lungzz 1 year survival rate: 40%1 year survival rate: 40%

zz 5 year survival rate: 14%5 year survival rate: 14%

zz If discovered early and having surgery:If discovered early and having surgery:

Alternative Treatment MethodsAlternative Treatment Methodszz ChemotherapyChemotherapy

zz RadiotherapyRadiotherapy

Personal or Family ImplicationsPersonal or Family Implicationszz Economic status in the familyEconomic status in the family

Staging of Lung CancerStaging of Lung Cancer

Stage of Cancer:Stage of Cancer: How bigHow big && How farHow far itit

spreadsspreadsNumber of Staging SystemNumber of Staging System

tagng ystemtagng ystem

The Number Staging SystemThe Number Staging System

Stage 1:Stage 1: Cancer is small, and only in 1Cancer is small, and only in 1area of lung (localized)area of lung (localized)

Stage 2 & 3:Stage 2 & 3: Cancer is larger, and haveCancer is larger, and have

nodes (locally advanced)nodes (locally advanced)

Stage 4:Stage 4: Cancer had spread to other bodyCancer had spread to other bodyparts (secondary /metastatic cancer)parts (secondary /metastatic cancer)

TNM Staging SystemTNM Staging System Size ofSize of TumorTumor(T)(T)

Whether cancer cells spread into lymphWhether cancer cells spread into lymphnodes (N)nodes (N)

Whether cancer cells spread/ metastasesWhether cancer cells spread/ metastases(M)(M)

T1 N0 M0: Small cancer which hasntT1 N0 M0: Small cancer which hasntspreadspread

T3 N1 M1: Larger cancer which spreads toT3 N1 M1: Larger cancer which spreads to

lymph nodes and other body partslymph nodes and other body parts

Stage of Lung CancerStage of Lung Cancer

Stage Operability 5-year Survival (%)

I Operable 50-60

II 30

IIIa 20

IIIb Inoperable 0

IV 0

4. Response to Patients:4. Response to Patients:

Showing EmpathyShowing Empathy

Accept patients being depressed or in aAccept patients being depressed or in abad moodbad mood

disease, prognosis, or alternativedisease, prognosis, or alternativetreatment method to patientstreatment method to patients

Direct the patients to doctors as necessaryDirect the patients to doctors as necessary

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5. Precautions for Chest Physiotherapy in5. Precautions for Chest Physiotherapy inCa Lung Patient (Unconfirmed Diagnosis):Ca Lung Patient (Unconfirmed Diagnosis):

HaemoptysisHaemoptysis::zz Contraindicated to percussion and vibrationContraindicated to percussion and vibration

Rib Metastasis:Rib Metastasis:zz Risk of #ribs during vigorous chestRisk of #ribs during vigorous chest physiophysio..

Lung and Lobar Collapse:Lung and Lobar Collapse:zz NOT indicated if collapse is caused by blockage fromNOT indicated if collapse is caused by blockage from

tumortumor

Brain Metastasis:Brain Metastasis:zz Mental state and neurological sign of patientsMental state and neurological sign of patients

6. Role of Physiotherapy:6. Role of Physiotherapy:

Maintain good ventilation and patency of airways in theMaintain good ventilation and patency of airways in thehealthy parts of lunghealthy parts of lung

Provide preProvide pre-- and postand post--bronchoscopicbronchoscopic physiotherapyphysiotherapy

Provide preProvide pre-- and postand post--operative physiotherapyoperative physiotherapy

Provide psychological support to patientsProvide psychological support to patients

Home O2 therapyHome O2 therapy

Hospice careHospice care

Case 2:Case 2:

SilicosisSilicosis (())

Case 2: Class ActivityCase 2: Class Activity

Divide into small groups with 5 studentsDivide into small groups with 5 students

Read through the notes of occupationalRead through the notes of occupationallung diseaselung disease

nswer t e questons tonswer t e questons to

10 Minutes Discussion!

Silicosis with Old Pulmonary TBSilicosis with Old Pulmonary TB SilicosisSilicosis

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PathophysiologyPathophysiology of Silicosisof Silicosis

Inhale silica for a period of timeInhale silica for a period of time

Silica deposit in the lung tissueSilica deposit in the lung tissue AveolarAveolar macrophages engulf silicamacrophages engulf silica

Macrophage causeMacrophage cause cytotoxincytotoxin enzymes toenzymes tobe releasedbe released

Fibrosis of lung parenchyma occursFibrosis of lung parenchyma occurs

Formation of discreteFormation of discrete silicoticsilicotic nodules overnodules overlung tissuelung tissue

1. Causative Factors for Mr. Leung Having1. Causative Factors for Mr. Leung HavingSilicosis:Silicosis:

Working as a Stone CutterWorking as a Stone Cutter

Exposure to Silicone Particles x 30 Years:Exposure to Silicone Particles x 30 Years:zz Long period of exposureLong period of exposure

Heavy Manual Work:Heavy Manual Work:

zz Increase minute volumeIncrease minute volume

zz Increase load of deposited particles inIncrease load of deposited particles inalveolialveoli

Smoker:Smoker:

zz Impeded cilia movementImpeded cilia movement

zz Decrease efficiency of removing particlesDecrease efficiency of removing particlesdeposited at large airwaysdeposited at large airways

1. Causative Factors for Mr. Leung Having1. Causative Factors for Mr. Leung HavingPulmonary TB:Pulmonary TB:

Presence of Quartz Dust:Presence of Quartz Dust:

zz Impede macrophages activitiesImpede macrophages activities

zz Damage pulmonary lymphatic systemDamage pulmonary lymphatic system

Insufficient Rest:Insufficient Rest:

zz Weaken body defense systemWeaken body defense system

Poor Hygiene Condition in Workplace:Poor Hygiene Condition in Workplace:

zz Limited water supply for washing hands and cleaningLimited water supply for washing hands and cleaningpurposepurpose

2. Silicosis is:2. Silicosis is:

Restrictive Lung DiseaseRestrictive Lung Disease

Throughout the lungs, fine fibrotic nodulesThroughout the lungs, fine fibrotic nodulesdevelops around the silica particles, anddevelops around the silica particles, andthese progress tothese progress to large areas of fibrosislarge areas of fibrosis

1. Volume1. Volume--time Curve of Obstructivetime Curve of Obstructiveand Restrictive Lung Diseaseand Restrictive Lung Disease

2. Flow2. Flow--volume Loop in Obstructivevolume Loop in Obstructiveand Restrictive Lung Diseaseand Restrictive Lung Disease

Examples of obstructivelung disease:COPD, asthma

Source:The Merck Manual

disease:silicosis

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