lung cancer f
TRANSCRIPT
-
8/6/2019 Lung Cancer f.
1/91
LungCancer
-
8/6/2019 Lung Cancer f.
2/91
INTRODUCTION
Cancer is the term used for diseases in whichabnormal cells divide (mitosis) without control.Cancer cells can invade nearby tissues andspread through the bloodstream and lymphaticsystem to other parts of the body (metastasis) .Cancer cells also avoid natural cell death(apoptosis).
The word originated from the Latin word forcrab, because the swollen veins around a surfacetumor appeared like the legs of a crab.
-
8/6/2019 Lung Cancer f.
3/91
-
8/6/2019 Lung Cancer f.
4/91
-
8/6/2019 Lung Cancer f.
5/91
Right lung=3 lobes
Left lung=2 lobes
Air enters lungsthrough trachea
Trachea divides intobronchi
Bronchi divide intobronchioles
Alveoli are the air sacsat the end of thebronchioles
Pleura = lining of the
lungs
ANATOMY OF LUNGS
-
8/6/2019 Lung Cancer f.
6/91
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, includingoxygen, 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 theatmosphere into the bloodstream, and to release carbondioxide from the bloodstream into the atmosphere.
-
8/6/2019 Lung Cancer f.
7/91
Seven cardinal signs of cancer
C Change in bowel or bladderhabits could be a sign ofcolorectal cancer.
A sore that does not heal onthe skin or in the mouth could bea malignancy and should bechecked by a doctor.
U Unusual bleeding or dischargefrom the rectum, bladder orvagina could mean colorectal,
prostate, bladder or cervicalcancer.
-
8/6/2019 Lung Cancer f.
8/91
-
8/6/2019 Lung Cancer f.
9/91
CONTDO Obvious changes to molesor warts could mean skincancer.
N Nagging cough orhoarseness that persists forfour to six weeks could be a
sign of lung or throat cancer.
-
8/6/2019 Lung Cancer f.
10/91
Lung Cancer: Defined
Uncontrolled growth of malignant cells inone or both lungs and tracheo-bronchialtree
A result of repeated carcinogenicirritation causing increased rates of cellreplication
Proliferation of abnormal cells leads tohyperplasia, dysplasia or carcinoma in
situ
-
8/6/2019 Lung Cancer f.
11/91
Picture of the CancerousLungs
-
8/6/2019 Lung Cancer f.
12/91
-
8/6/2019 Lung Cancer f.
13/91
Most frequently diagnosed cancer
worldwide About 1.35 million new cases diagnosed
worldwide each year
Leading cause of cancer deaths inthe United States
-
8/6/2019 Lung Cancer f.
14/91
Incidence andmortality ratesbegin to increasebetween the agesof 45 and 54 andrise progressivelyuntil age 75
Median age atdiagnosis=70.07
Median age atdeath=71.07
-
8/6/2019 Lung Cancer f.
15/91
Males have a greater lifetime risk oflung cancer than females (7.81% vs.
5.8%)
Greater disparity in developing countrieswhere cigarette use by females is low
-
8/6/2019 Lung Cancer f.
16/91
Higher incidence and mortality ratesare reported among men from lower
SES groups
-
8/6/2019 Lung Cancer f.
17/91
Cigarette smoking is the most importantrisk factor for lung cancer
Causes approximately 90% of male and 75-80% of female lung cancer deaths
By the early 1950s, case control studiesin the US and Great Britain clearlyshowed an association between smokingand lung cancer
In 1964, the US Surgeon Generalreleased a report on the causal
relationship
-
8/6/2019 Lung Cancer f.
18/91
Smoking Facts
Tobacco use is theleading cause of lungcancer
87% of lung cancersare related to smoking
Risk related to:
age of smoking onset
amount smoked gender
product smoked
depth of inhalation
-
8/6/2019 Lung Cancer f.
19/91
More than 80carcinogens in cigarettesmoke according to theInternational Agencyfor Research on Cancer(IARC)
Polycyclic aromatic
hydrocarbons (PA
Hs) area well documented lungcarcinogen
-
8/6/2019 Lung Cancer f.
20/91
Secondhand smoke
Each year about 3,000 non-smoking
adults die of lung cancer as a result ofbreathing secondhand smoke.
-
8/6/2019 Lung Cancer f.
21/91
Whatabout
secondhand smoke?
Being in a nonsmoking section of arestaurant for 2 hours =
Being in a smoky home for one day =
Being in a smoky bar =
Mayo Clinic
-
8/6/2019 Lung Cancer f.
22/91
History of respiratory diseases such asasthma, bronchitis, emphysema, hayfever, or pneumonia may modify risk
When combined with smoking, there is acomplementary cycle of injury and repairthat may increase risk
Respiratory diseases may result in
chronic immune stimulation that causesrandom pro-oncogenic mutations thatincrease risk
Relationship is still speculative
-
8/6/2019 Lung Cancer f.
23/91
Animal models have indicated that dietaryfat can promote chemically induced
pulmonary tumors. Relationship may be confounded by the
association between smoking status and diet
Rates of lung cancer are highest incountries with greatest fat consumptionafter controlling for smoking.
-
8/6/2019 Lung Cancer f.
24/91
Lowered risk associated with consumptionof fresh vegetables and fruits Risk in those with highest intake was about
one-half of those with lowest intake
Beneficial micronutrients in fruits andvegetables Carotenoids Isothiocyanates Folate Selenium
-
8/6/2019 Lung Cancer f.
25/91
Difficult to assess association betweenalcohol and lung cancer due to
confounding by smoking status
-
8/6/2019 Lung Cancer f.
26/91
IARC categorized several occupational
agents as known carcinogens Radon
x Well established lung carcinogen, responsible for 6.5%of lung cancer deaths in the United Kingdom in 1998
Asbestos
Arsenic
Bischloromthyl ether
Chromium Nickel
Polycyclic aromatic compounds
Vinyl chloride
-
8/6/2019 Lung Cancer f.
27/91
Only a fraction of long-term smokers willdevelop lung cancer
Likely impacted by genetic susceptibility Familial aggregation
Studies have reported an excess of lung cancermortality in relatives of lung cancer patients
-
8/6/2019 Lung Cancer f.
28/91
Polymorphisms in genes encoding forenzymes responsible for detoxification of
carcinogens affect the internal dose oftobacco carcinogens that lung tissue isexposed to
Many different polymorphisms
Cytochrome P-450
-
8/6/2019 Lung Cancer f.
29/91
Defective repair of genetic damage is animportant determinant of susceptibility to
lung cancer Hypersensitivity to carcinogenic exposure
Many studies have demonstrated that cancercases have a significant decrease in DNA
repair capacity compared to controls
-
8/6/2019 Lung Cancer f.
30/91
Where does it travel?
Lymph Nodes, Brain, Liver, Adrenal,Gland, Bones
40% of metastasis occurs in the
Adrenal Gland
-
8/6/2019 Lung Cancer f.
31/91
PATHOPHYSIOLOGYMore than 90% of lung cancer originate
from the epithelium of bronchus. Theyslowly & it takes 8 to 10 years, for atumor to reach 1cm in size.
Cancerous lung tissue cannot exchangeoxygen & carbon dioxide
It impairs the functioning of the lung
-
8/6/2019 Lung Cancer f.
32/91
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
-
8/6/2019 Lung Cancer f.
33/91
Evolution of Intraepithelial Neoplasia
Mild/Moderate/Severe/CIS
Squamous
Adenomatous
Normal Hyperplasia/Metaplasia Dysplasia Cancer
-
8/6/2019 Lung Cancer f.
34/91
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%
-
8/6/2019 Lung Cancer f.
35/91
Epidermiod carcinoma -35% :
Occurs most frequently in men and oldpeople
Usually starts on one breathing tubes. Tend to be localized in the chest longer
than other types of lung cancer.
Does not tend to metastasize early.
It is strongly associated with smoking.
-
8/6/2019 Lung Cancer f.
36/91
Adenocarcinnoma-30%:
Most common cancer amongwomen.
Usually started near the outer
edges of the lung. Invasion of pleura and
mediastinal lymph node is
common. May spread to other parts of thebody.
Can be seen in non smoker.
-
8/6/2019 Lung Cancer f.
37/91
Large cell carcinoma 15% :
Less well differentiated. May occur at any part of the
lung.
Tumors are large by the timethey are diagnosed.
Has greater possibility ofspreading to brain andmediastinum.
-
8/6/2019 Lung Cancer f.
38/91
Small cell lung cancer:
Small cell lung cancer also called oatcellbecause SCLC cells have oat grainappearance.
It arises from endocrine cells[kulchitisky cells] where many hormonesare secreted
Spread to lymph nodes and other organsmore quickly than NSCLC .
-
8/6/2019 Lung Cancer f.
39/91
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 bronchialcarcinomas that respond to chemotherapy
-
8/6/2019 Lung Cancer f.
40/91
NON SMALL CELL LUNG
CANCERIt is staged according to the sizeof the tumor, the level of lymphnode involvement and the extent
to which the cancer has spread.The stages include:STAGE 0:Cancer is limited to
the lining of the air passage andhasnt invaded lung tissue.STAGE1:Invaded to lung tissue
Hasnt invaded to lymph nodes
-
8/6/2019 Lung Cancer f.
41/91
CONTD
STAGEII: Spread to neighboringlymph nodes Invaded the chest wall
STAGEIIIA: Spread from the lung tolymph nodes.
STAGEIII B: Spread locally to areas .
STAGEIV :spread to other parts ofthe body.
NSCLC S i
-
8/6/2019 Lung Cancer f.
42/91
NSCLC StagingT 1: tumor < 3 cm
T2: tumor > 3 cm, >2 cm from carina, invading the
pleura, partial lung collapseT3:
-
8/6/2019 Lung Cancer f.
43/91
SCLC Limited StageDefined as tumor involvement of one lung,the mediastinum and ipsilateral and/orcontralateral supraclavicular lymph nodes
or disease that can be encompassed in asingle radiotherapy port.
Extensive Stage
Defined as tumor that has spread beyondone lung, mediastinum, and supraclavicularlymph nodes. Common distant sites ofmetastases are the adrenals, bone, liver,bone marrow, and brain.
-
8/6/2019 Lung Cancer f.
44/91
Presentations:
Lung cancer may present innumber of different ways :
Most commonly symptomsreflect local involvement of thebronchus.
May also arise from spread to
the chest wall or mediastinum orfrom distant blood-bornespread.
-
8/6/2019 Lung Cancer f.
45/91
Local effects of tumor withinthe bronchus :
1- cough ( in 80% of cases ) :
- It is the most common early symptoms.
- sputum is purulant if there is secondaryinfection.
- A change in the character of the (regular
cough) associated with other newrespiratory symptoms increase thepossibilityof B.C.
-
8/6/2019 Lung Cancer f.
46/91
2-Haemoptysis (in 70% of cases):
- Repeated episodes of scanty
cough hemoptysis or blood streaking of sputum in smokersare highly suggestive of B.C and
should be always investigated .
-
8/6/2019 Lung Cancer f.
47/91
Cntd.
3- Dyspnea ( 60% of cases ):- reflect occulusion of a largebronchus resulting in collapse of a
lobe of the lung or development ofplearal effusion.4- Pleural pain :- reflect malignant invasion of thepleura or reflect infection distalto a tumuor (wich is recurrentand fail to resolve).
-
8/6/2019 Lung Cancer f.
48/91
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 anddown inner surface of the arm.
-Horner syndrom: due to involvement of the
sympathetic ganglion.
-
8/6/2019 Lung Cancer f.
49/91
Contd.
-Recurrent laryngeal nerve palsy :causing unilateral vocal cord paresiswith hoarsness of voice and a bovine
cough..Invation of phrenic nerve ,
causing paralysis of thediaghragm.
-
8/6/2019 Lung Cancer f.
50/91
.Involvement of esophagus ,causing dysphagia.
.Cardiovascular: atrial fibrillation,temponade ,pericarditis,pericardial effusion .
-
8/6/2019 Lung Cancer f.
51/91
Contd..
. Superior vena cava obstructioncausing early morning headache,facial congestion and edema
involving the upper limb,distention of jugular vein andveins of the chest.
-
8/6/2019 Lung Cancer f.
52/91
Nonmetastatic extrapulmonary manifistation:1- Endocrine manifestation:12% of tumors ,in particular small
cell tumors present withSIADH, ACTH secretion(SCLC),hypercalcemia (sq.cellcarcinoma),bone metastasis
gynaecomastia(LCLC) .
-
8/6/2019 Lung Cancer f.
53/91
Contd.
2- Neurological manifetation:e.g: sensory polyneuropathy
,myelopathy, cerebellardegeneration.
-
8/6/2019 Lung Cancer f.
54/91
Cntd.
3- Others: Digital clubbing ,
Hypertrophic pulmenary osteo-
arthropathy (sq.cell cancer) , Nephrotic syndrome,
Hypercoagulopathy (adenocarcinoma),
Thrombophelibitis migricans.
-
8/6/2019 Lung Cancer f.
55/91
Blood borne metastasis:
.Bony metastasis giving severe bony painand pathalogical fractures.
.liver metastasis (Jundice)
.Brain metastasis (change in personality,epilpsy,focal neurological symptoms).
-
8/6/2019 Lung Cancer f.
56/91
DIAGNOSTIC STUDIES
-
8/6/2019 Lung Cancer f.
57/91
Physical signs:
Examination is usually normalunless there is significantbronchial obstruction or tumor
has spread to pleura ormediastinum.
-
8/6/2019 Lung Cancer f.
58/91
Cntd.
1- physical signs of collapse (in largeobstructing tumor) which may rise topneumonia.
2- monophonic or unilateral wheeze (fixedbronchial obstruction).
3- stridor (obstruction at or above thelevel of main carina.
-
8/6/2019 Lung Cancer f.
59/91
Contd..
4- hoarsness of voice associated withbovine cough (recurrent laryngeal nervepalsy).
5- dullness percussion and absent breathsounds at the lung base (unilateraldiaphragmatic palsy due to involvement
of phrenic nerve)
-
8/6/2019 Lung Cancer f.
60/91
Contd.
6- physical signs of pleursy or pleuraleffusion (involvement of pleura).
7- bilateral engorgement of the jangularvein and later edema affecting face,neck, arms.
8- tenderness and pain of long bone andjoints .
-
8/6/2019 Lung Cancer f.
61/91
Investigation:
Sputum cytology: high yield for
endobronchial tumors such assquamous cell and small cellcarcinoma.
-
8/6/2019 Lung Cancer f.
62/91
chest x-ray:common radiologicalpresentation of bronchialcarcinoma.
1- unilateral hilar-enlagement.
2- peripheral pulmonary opacity.3- lung, lobe or segmental
collapse.
-
8/6/2019 Lung Cancer f.
63/91
. Bronchoscopy : gives high yield inexcess of 90% (allows biopsy andbronchial brush samples) if fail
precautious fine needle aspiration underCT.
-
8/6/2019 Lung Cancer f.
64/91
.CT thorax and upper abdomen.
.Head CT scan.
.Radio nuclide bone scanning.
.liver US.
.bone marrow biopsy.
-
8/6/2019 Lung Cancer f.
65/91
MANAGEMENT
-
8/6/2019 Lung Cancer f.
66/91
MANAGEMENT
Medical management :1. Radiation therapy
2. Chemotherapy
3. Bronchoscopic laser therapy
4. Photodynamic therapy
5. Airway stentingSurgical management :
1. Surgical resection
RADIATION THERAPY
-
8/6/2019 Lung Cancer f.
67/91
RADIATION THERAPY Radiation therapy uses high-energy radiation
to shrink tumors and kill cancer cells . X-rays, gamma rays, and charged particles aretypes of radiation used for cancertreatment.
The radiation may be delivered by a machineoutside the body (external-beam radiationtherapy), or it may come from radioactivematerial placed in the body near cancer cells
(internal radiation therapy, also calledbrachytherapy).
About half of all cancer patients receivesome type of radiation therapy sometime
during the course of their treatment.
H d d h
-
8/6/2019 Lung Cancer f.
68/91
How does radiation therapykill cancer cells?
Radiation therapy kills cancer cells bydamaging their DNA (the molecules inside cellsthat carry genetic information and pass itfrom one generation to the next) .
Radiation therapy can either damage DNAdirectly or create charged particles (freeradicals) within the cells that can in turndamage the DNA.
Cancer cells whose DNA is damaged beyondrepair stop dividing or die. When the damagedcells die, they are broken down and eliminatedby the bodys natural processes.
Linear Accelerator Used for
-
8/6/2019 Lung Cancer f.
69/91
Linear Accelerator Used forExternal-beam Radiation
Therapy
SIDE EFFECTS OF
-
8/6/2019 Lung Cancer f.
70/91
SIDEEFFECTS OFRADIATION THERAPY
Acute side effects of radiation therapyare:-
Cough
Pharyngitis
Esophagitis
Anorexia
Weight loss
Fatigue
Skin reactions
CONTD
-
8/6/2019 Lung Cancer f.
71/91
CONTD. Late side effects of radiation therapy
may or may not occur. Depending on thearea of the body treated, late sideeffects can include :
Fibrosis (the replacement of normal tissue
with scar tissue, leading to restrictedmovement of the affected area).
Damage to the bowels, causing diarrhea andbleeding.
Memory loss. Infertility (inability to have a child).
DRUG AMINOFOSTINE IS GIVEN TOLESSEN THE SIDEEFFECTS OF
RADIATION THERAPY.
CHEMOTHERAPY
-
8/6/2019 Lung Cancer f.
72/91
CHEMOTHERAPY Chemotherapy (also called chemo) is a
type of cancer treatment that uses drugsto destroy cancer cells.
Chemotherapy works by stopping orslowing 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 yourmouth 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.
DRUGS USED FOR
-
8/6/2019 Lung Cancer f.
73/91
DRUGS USED FORCHEMOTHERAPY
Cisplantin
Vincristine
Palcitaxel
Cyclophosphamide
Doxorubicin
SIDE EFFECTS OF CHEMOTHERAPY
-
8/6/2019 Lung Cancer f.
74/91
SIDEEFFECTS OFCHEMOTHERAPY
NephrotoxicityNausea
Vomiting
MyelosupressionPulmonary toxicity
-
8/6/2019 Lung Cancer f.
75/91
PHOTODYNAMIC THERAPY
Photodynamic therapy (PDT) is atreatment that uses a drug, called aphotosensitizer or photosensitizingagent, and a particular type of light.
When photosensitizers are exposed to aspecific wavelength of light, they
produce a form of oxygen that killsnearby cells.
How is PDT used to treat
-
8/6/2019 Lung Cancer f.
76/91
How is PDT used to treatcancer?
In the first step of PDT for cancer treatment,a photosensitizing agent is injected into thebloodstream.
The agent is absorbed by cells all over the body
but stays in cancer cells longer than it does innormal cells.
Approximately 24 to 72 hours after injection,when most of the agent has left normal cells
but remains in cancer cells, the tumor isexposed to light.
The photosensitizer in the tumor absorbs thelight and produces an active form of oxygenthat destroys nearby cancer cells.
-
8/6/2019 Lung Cancer f.
77/91
AIRWAY STUNT
-
8/6/2019 Lung Cancer f.
78/91
Surgery
-
8/6/2019 Lung Cancer f.
79/91
NURSING MANAGEMENT
-
8/6/2019 Lung Cancer f.
80/91
NSG ASSESSMENT
Determine the understanding ofpatient & the family concerning thediagnostic tests.
Assess the level of anxiety. Determine onset & duration of
coughing, sputum production, °ree of dyspnea.
-
8/6/2019 Lung Cancer f.
81/91
CONTD Auscultate for breath
sounds.
Observe symmetry of chestduring respiration.
Ask about pain, its location,
intensity & factorsinfluencing pain.
-
8/6/2019 Lung Cancer f.
82/91
NSG DIAGNOSES Ineffective breathing pattern
related to obstructiverespiratory processes
associated with lung cancer
Imbalanced nutrition: less than
body requirements related tohyper metabolic state, tasteaversion, anorexia
-
8/6/2019 Lung Cancer f.
83/91
CONTD Acute or chronic pain related to
tumor effects, invasion ofadjacent structures, toxicities
associated with radiotherapy/chemotherapy
Anxiety related to uncertain
outcomes & fear recurrence
NSG INTERVENTIONS
-
8/6/2019 Lung Cancer f.
84/91
NSG INTERVENTIONS
Improving breathingpatterns Elevate head of bed to promote
gravity drainage.
Teach breathing retrainingexercises.
Give prescribed treatment such as
antimicrobial agents. Augment the patients ability to
cough.
-
8/6/2019 Lung Cancer f.
85/91
CONTD Adminster oxygen if prescribed. Allow patient to sleep in reclining
chair or with head of bed elevated
if severely dyspneic.Improvingnutritionalstatus :
Encourage small amounts of highcalroie & high protein foods.
Ensure adequate protein intake :milk, eggs, chicken, fish, cheese etc.
CONTD
-
8/6/2019 Lung Cancer f.
86/91
CONTD Adminster or encourage prescribed
vitamin supplement . Change consistency of diet to soft or
liquid.
Give enteral or total parenteralnutrition for malnourished patientswho is unable to eat.
Controlling pain :
Assess condition of the patient.
Give analgesics to the patient.
-
8/6/2019 Lung Cancer f.
87/91
CONTD Evaluate problems of insomnia,
depression, anxiety etc.
Initiate bowel training program.
Minimizinganxiety : Try to have the patient exress
concerns ; share these concerns.
Expect some feelings of anxiety.
Encourage the patient to
communicate feelings.
HEALTH EDUCATION
-
8/6/2019 Lung Cancer f.
88/91
HEALTH EDUCATION
QUIT SMOKING,
IF PATIENTQUIT SMOKINGTHEN
-
8/6/2019 Lung Cancer f.
89/91
HEALTH EDUCATION
-
8/6/2019 Lung Cancer f.
90/91
HEALTH EDUCATION Help the patient Teach the
patient to to realize that everypain & ache is caused by lungcancer.
Take NSAIDS or otherprescribed medication.
Tell the patient abouttreatment.
Advise the patient to report
new or persistent pain.
-
8/6/2019 Lung Cancer f.
91/91