Pulmonary cancer

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• PULMONARY CANCER
• MODERATOR SPEAKER
• Mr. ankit singh Preeti tiwari
• Nursing tutor Bsc (N)
• 
  3rd year

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• LAYOUT
• Review of anatomy and physiology
• Introduction
• Historical aspect
• Incidence
• Definition
• Types of lung cancer SCLC
• NSCLC
• Stages of cancer
• Etiology
• Patho - physiology
• Signs and symptoms
• Diagnosis ,staging and grading
• Management Medical management
• Surgical management
• palliative care
• Nursing management
• Conclusion
• References

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Review of anatomy and physiology of lungs
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Anatomy

• The lungs are paired, elastic structures enclosed
  in the thoracic cage , which is an right chamber
  with distensible walls .
• Weight of right lung 375 - 500gm
• Weight of left lung 325 -450 gm
• Each lung is divided into lobes .the right lung
  has upper ,middle and lower lobes ,whereas the
  left lung consists of upper and lower lobes.
• Each lobe is further sub divided into 2-5
  segments separated by fissures, which are
  extension of pleura.

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Pleura

• The lungs and thoracic cavity is lined with a
  serous membrane called the pleura.
• Pleura
• Visceral Parietal
• pleura pleura
• Pleural fluid(filled between
• these membranes)
• Mediastium
• Its in middle of thorax contain the 2 lungs.
• Alveoli
• Air filled sac like structure
• Approximately 300 million alveoli

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Types of epithelial cells
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Physiology of lungs

• Inhalation and exhalation are pulmonary
  ventilation-thats breathing
• External respiration exchanges gases between the
  lungs and the bloodstream
• Internal respiration exchanges gases between the
  bloodstream and body tissues
• Air vibrating the vocal cords creates sound

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Introduction

• Lung cancer cells have accumulated a number of
  molecular genetic and epigenetic lesions, which
  appear necessary to transform normal bronchial
  epithelium to an overt lung cancer .
• Of the three major classes of human cancer
  genes, the proto oncogenes and tumor suppressor
  genes (TSGs) are involved in lung carcinogenesis
  .
• Tumors of the lung may be benign or malignant .
  A malignant chest tumor can be primary ,arising
  within the lungs ,chest wall or mediastinum or it
  can be a metastasis from primary tumor site
  elsewhere in the body .
• Many of the proto oncogene and TSG changes are
  present in both major lung cancer subtypes small
  cell lung cancer (SCLC) and nonsmall cell lung
  cancer (NSCLC) .

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Historical aspects

• Lung cancer is the second highest cancer
  incidence in both sexes after prostatemales
  and breast females cancers .
• It wasnt even recognized as a distinct disease
  until 1761 .
• In Germany in 1929 ,physician Fritz Lickint
  recognized the between smoking and lung cancer
  ,which to an aggressive antismoking campaign .
• First successful pneumonectomy was performed in
  1933.
• Palliative radiotherapy used since 1940s .
• Radical radiotherapy initially used in 1950s

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Incidence

• Lung cancer mainly occurs in older people. About
  2 out of 3 people diagnosed wit lung cancer are
  65or older .
• About 14 of all new cases of cancers are lung
  cancer .
• About 2,24,390 new cases of lung cancers1,17,920
  in men and 1,06,470 in women .
• Second highest cancer incidence in both sexes.
• Lung cancer has poor prognosis .

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Definition

• Lung carcinoma ,is a malignant lung tumor
  characterized by uncontrolled cell growth in
  tissues of the lung .
• If left untreated ,this growth can spread
  beyond the lung by the process of metastasis into
  nearby tissues or other parts of the body.

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Types of lung cancer
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Small cell lung carcinoma SCLC

• In this classification, SCLC was divided into
  three subtypes that consist of oat cell,
  intermediate cell type, and combined oat cell
  (SCLC combined with squamous or adenocarcinoma).
• Accounts for 15 of cases
• Generally starts in of the larger breathing
  tubes or arises in the central airways and
  initially infiltrates the submucosa, gradually
  obstructing the lumen by extrinsic or
  endobronchial spread.
• Spreads more quickly and aggressively
• Found mostly in heavy smokers

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Non small cell lung cancer NSCLC

• Most common type
• About 80-85 are NSCLC
• Grows more slowly

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Classification of NSCLC a) large cell
carcinoma

• 10-20 cases are of lung cancer
• It can occur in any part of the lung
• Tends to grow and spread faster
• Cavitation common
• Although the WHO classification subdivides this
  group into giant cell and clear cell varieties.
• Histological view

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b) Adenocarcinoma

• Increasing in frequency .
• 40-50 of all lung cancers
• Clearly defined peripheral lesions
• Glandular appearance under a microscope
• Easily seen on a CXR
• Can occur in non smokes
• Slow metastatic in nature pts present with or
  develop brain ,adrenal or bone metastasis
• Histological view
  

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c) Squamous cell or epidermoid carcinoma

• Moderate to poor differentiation
• 30 -40 of lung cancer
• Arise from bronchial epithelium (occur centrally
  in the large bronchi)
• Uncommon metastasis,slow growth
  
• Associated with smoking
• slow growth
• Not easily visualized on x-ray
• Histological view

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Stages of cancer
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Etiology

• Tobacco smoke ( Of the three major classes of
  carcinogens in tobacco smoke (polycyclic aromatic
  hydrocarbons, such as benzoapyrene
  nitrosamines and aromatic amines),
• Second hand smoke
• Genetic predisposition
• Chromosomal
  abnormality( In SCLCs, losses from chromosomes
  3p, 5q, 13q, and 17p predominates In NSCLCs,
  deletions of 3p, 9p, and 17p, together with 7,
  i(5)(p10), and i(8)(q10) are often seen.)
• Protooncogenes and growth
  stimulation (Protooncogene products include
  several growth factor receptors, such as
  epidermal growth factor receptor (EGFR), ERBB2,
  KIT, and MET.)
• Tumor suppressor genes
  and growth suppression (p53 or TP53 , p16INK4A,
  Cyclin D1 and Cyclin-Dependent Kinase-4 ,
  Retinoblastoma Protein )

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• Occupational exposure
  asbestos, 28,29,30,31,32,33,34,35,36,37,38 and
  39 radon 40,41,42,43 and 44bis(chloromethyl)ethe
  r, polycyclic aromatic hydrocarbons, chromium,
  nickel, and inorganic arsenic compounds.
  Silicosis ,coal workers pneumoconiosis and
  environmental exposure .
• Certain dietary supplements
• ß-carotene supplements ,are at
  high risk
• Over 50 years of age

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Pathophysiology
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Sign and symptoms

• There are two types of sign and symptoms of lung
  cancer
• Localized (involves lung)
• Generalized (involves other areas throughout the
  body)

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Localized Sign and symptoms

• Persistent cough and fatigue
• Breathing difficulty ,stridor
• Blood in phlegm
• Frank hemoptysis
• Hoarseness ,hiccups
• Weight loss
• Chest pain and tightness
• Pleural effusion
• Rust coloured purulent sputum

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Generalized sign and symptoms

• Bone pain
• Headaches , mental status changes or neurological
  findings
• Abdominal pain
• Elevated LFT ,enlarged liver
• GI disturbances (anorexia ,dysphagia , cachexia
  ), jaundice
• Weight loss
• Hand and neck edema

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Staging and grading ( TNM Classification)
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TNM Classification system
T N M Extent of primary tumor Absence or presence of extent of regional lymph node metastasis Absence or presence of distant metastasis
Primary tumor(T) Tx To Tis T1,T2,T3,T4 Cant be expressed No evidence of primary tumor Carcinoma in situ Increasing size of primary tumor
Regional lymph nodes(N) Nx No N1,N2,N3 Cant be expressed No metastasis of lymph node Increasing involvement of regional of regional lymph nodes
Distant metastasis(M) Mx Mo M1 Cant be assessed No distant metastasis Distant metastasis
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Diagnostic evaluation

• History collection
• Physical examination
• CTX
• Sputum cytology
• Endoscopic ultrasound (EUS)

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• Bronchoscopy
• It can identify early
• mucosal changes suggestive
• of lung cancer.
• Thoracoscopy
• Video-assisted thoracoscopy has been used
  in the diagnosis and staging of lung cancer.
  Peripheral nodules can be identified and excised
  using video-assisted

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• Needle biopsy
• Fine needle aspiration biopsy(FNA)
• Core biopsy
• CT guided biopsy

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Medical management

• The use of radiation, chemotherapy,
  immunotherapy, percutaneous albation and
  palliative care either are given alone or in
  combination.
• 1. Radiation therapy
• Also called as radiotherapy, penetrating
  waves or particles such as X-rays ,? rays.
• Purpose kill or damage cancer cells
• Types of radiation
• a)External beam radiation
• b)Internal beam radiation
• c)Sealed source radiation
• d)Unsealed source of radiation

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2. Percutaneous albation

• Percutaneous image guided ablation is a minimally
  invasive treatment that can be offered to
  patients with early stage NSCLC or palliative
  treatment for patients with meatstatic disease
  includes radiofrequency ablation, cryoablation
  and microwave ablation.
• 3. Chemotherapy
• Treatment of cancer with anti-cancer drugs.
• Types
• a) Adjuvant chemotherapy
• b)Neoadjuvant chemotherapy

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Drugs
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Surgical management

• Lobectomy
• The entire lobe containing the
• tumor is removed.
• Pneumonectomy
• Removal of entire lung.

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• Wedge resection
• Removal of small, wedge-shaped
• piece of lung tissue to remove a small
• tumor or to diagnose.
• Segmental resection
• Also known as segmentectomy ,removal
• of a part of the lungs larger than a wedge
• section, but smaller than a complete lobe.
• Both surgeries may also be referred to as a
• sub-lobar resection.

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• Thoracotomy
• Its a surgical incision into
• the thorax.
• Thoracoplasty
• Its a repair of the thoracic cavity.

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• Pulmonary resection
• Complete resection of tumor remains
• the best chance of cure.
• Decortication
• Removal of the surface layer,
• membrane or fibrous cover of an organ.
• Bronchoscopic laser therapy
• Remove the obstructing lesions.

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Palliative therapy

• Palliative care, concurrent with standard
  0ncologic care for lung cancer, should be
  considered early in the course of illness for any
  patient with metastatic cancer.
• The place of palliative care within course of
  illness
• Diagnosis of serious illness
  Death

Life-prolonging therapy Palliative care
Medicare hospice benefit
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Complications

• Respiratory failure
• Diminished cardiopulmonary function
• Pulmonary fibrosis
• Pericarditis
• Myelitis
• Pneumomitis

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Nursing diagnosis

• Ineffective airway clearance related to increased
  tracheo-bronchial secretions and presence of
  tumor as evidenced by persistent cough, dyspnea.
• Altered breathing pattern related decreased lung
  capacity as evidenced by increased respiratory
  rate, unexplained dyspnea.
• Acute pain related to metastasis of tumor tissue
  as evidenced by facial expression and from pain
  score scale.
• Imbalanced nutritional status less than body
  requirement related to anorexia as evidenced by
  decreased by decreased bodily weight.
• Anxiety related to lack of knowledge about
  pulmonary cancer as evidenced by verbal
  communication with the client.

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Nursing management

• Airway control
• Assess the patency of air.
• Assess the respiratory status and provide high
  fowlers position.
• Smoking cessation
• Provide awareness information for smoking
  cessation classes.
• Management symptoms
• The nurse educates the patient and family about
  the potential side-effects of specific
  treatments.
• Reducing fatigue
• Fatigue is devasting symptom that affects quality
  of life in patient with cancer.

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Conclusion
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References
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Thank you .