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1 CASE STUDY: LUNG CANCER Case Study: Lung Cancer Abby Duthler Grand Valley State University 2 CASE STUDY: LUNG CANCER Presenting Signs and Symptoms This patient is a 53-year-old female. She has a history of a chronic cough. She smoked about a pack a day for 30 years. She quit smoking in December of 2014. It is not reported where she worked or lived for most of her life, or if her family had a history of lung cancer. She has never had previous radiation. She had a cough that would not go away for months and months. This is what caused her to see a doctor. Epidemiology Lung cancer is the leading cause of cancer death in the United States. Lung cancer is the second most common cancer in both men and women. The American Cancer Society estimates that there will be about 221,200 new cases of lung cancer and about 158,040 deaths from lung cancer in the United States in 2015. Lung cancer mainly occurs in older people with the average age at diagnosis at 70 years old. Men are slightly more likely to develop lung cancer. African Americans are more likely to develop lung cancer than Caucasians. People that live in bigger cities also are more likely to develop lung cancer than people that live in the country (American Cancer Society, 2015). Etiology Lung cancer has several risk factors. A risk factor is anything that could affect a person’s chance of developing a disease or in this case, lung cancer. Some of these risk factors for lung cancer include tobacco smoke, radon, asbestos, other carcinogens in the work place, air pollution, previous radiation therapy, and personal or family history of lung cancer. Smoking is the leading risk factor for lung cancer. Smoking causes at least 80% of lung cancer deaths. Cigar and pipe and light 3 CASE STUDY: LUNG CANCER cigarette smoking are as likely to cause lung cancer than regular cigarette smoking. If you breath in smoke from other people smoking can increase your chance of developing lung cancer by almost 30%. This is called secondhand smoking, which is thought to cause about 7,000 deaths from lung cancer a year. Radon is the second most common cause for lung cancer, and the first cause for lung cancer among nonsmokers. Radon is a naturally radioactive gas that is from the breakdown of soil and rocks. It cannot be seen, felt, or smelled. Radon is not dangerous outside, but indoors it is more concentrated. Radon levels in soil vary across the United States, but can be high anywhere. Workplace exposure to asbestos fibers is also a risk factor for developing lung cancer. Recently, the government regulations have reduced the use of asbestos in commercial and industrial products. It is still found in some buildings, but it is not typically dangerous unless it is released into air by renovation, demolition, or deterioration. Other workplace carcinogens that are a risk factor for developing lung cancer include radioactive ores like uranium, inhaled chemicals or minerals like arsenic, beryllium, cadmium, silica, etc., and diesel exhaust. Air pollution in cities can also increase your chances of developing lung cancer slightly. People who have had previous radiation therapy to their chest are at a higher risk for developing lung cancer. If you have already had lung cancer, you are at a higher risk for developing another lung cancer. If your family has a history of lung cancer, you are also at a higher risk for developing lung cancer (American Cancer Society, 2015). Compare to Typical 4 CASE STUDY: LUNG CANCER The most likely reason that this patient developed lung cancer was because of her smoking for a long time. Otherwise, she is a little younger than the average age at diagnosis, she is a female, and has had not previous history of radiation to the thorax area that could be an indication for cancer to develop. Patient Work Up Information Date Procedure 10/2014 Chief Complaint with chest x-ray CT of thorax 1/12/2015 1/16/2015 1/27/2015 2/2/2015 2/10/2015 2/16/2015 Results Significant Cough Showed a right middle lobe capacity Right middle lobe consolidation and collapse Bronchoscopy with Showed non-small cell carcinoma, biopsy poorly differentiated PET/CT Right middle lobe mass intensely hypermetabolic Referred to a Diagnosed as stage IIIA non-small cell different doctor lung cancer and suggested chemoradiation Referred to Spectrum Health Lung MST clinic Consult for radiation Anatomy The lungs are vital part of gas exchange in the body. They are the organs that are responsible for bringing in oxygen, putting it in the blood, taking carbon dioxide out of the blood, and getting carbon dioxide out of the body. The lungs sit in the thoracic cavity of the body on either side of the heart. The diaphragm sits below the thoracic cavity and is the muscle that helps the lungs inflate and deflate. When the diaphragm contracts, it pulls the bottom of the lungs down, forcing them to fill with air. When the diaphragm relaxes, it allows the lungs to relax back up, forcing air out 5 CASE STUDY: LUNG CANCER of the lungs. The air comes into the body through the mouth or nose, through the pharynx, larynx, and trachea. The trachea then splits into a left and right primary bronchus, which enter into the lungs. The primary bronchi split into secondary bronchi, which continue to split until they are bronchioles, which enter the alveoli (Figure 1). The alveoli are where the gas exchange occurs. The left lung is slightly smaller because the heart sits slightly towards the left with only two lobes: upper and lower. The right lung is slightly shorter because the liver pushes it up slightly with three lobes: upper, middle, and lower (Figure 2). On the medial side of both lungs there is an area called the hilum (Figure 3). The hilar area is where the arteries, veins, bronchi, and nerves enter the lungs (O'Loughlin, 2012). The blood vessels that go into and out of the lungs through the hilum are the pulmonary arteries and veins. These blood vessels come and go directly to the heart where they split until they are capillaries in the areolas where gas exchange occurs (Figure 4). The pulmonary arteries are the only arteries in the body that are deoxygenated, and pulmonary veins are the only veins in the body that are oxygenated (O'Loughlin, 2012). Lymphatic Drainage The lymph nodes in this region include the superior mediastinal nodes, inferior mediastinal nodes, aortic nodes, and N1 nodes. The superior mediastinal nodes follow the trachea down and include the highest mediastinal, upper paratracheal, pre-vascular and retrotracheal, and lower paratracheal. The inferior mediastinal nodes follow the esophagus down and include the subcarinal, paraesophageal, and pulmonary ligament. The aortic nodes are around the aortic 6 CASE STUDY: LUNG CANCER arch and pulmonary trunk and include the subaortic and para-aortic. The N1 nodes are the nodes that enter the lungs and include the hilar, interlobar, lobar, segmental, and subsegmental (Figure 5) (O'Loughlin, 2012). Anatomy Graphics Figure 1: http://www.buzzle.com/articles/structure-of-the-human-respiratory-system.html CASE STUDY: LUNG CANCER 7 Figure 2: http://printablecolouringpages.co.uk/?s=anatomy%20of%20the%20lung&page=1 Figure 3: CASE STUDY: LUNG CANCER http://www.britannica.com/EBchecked/topic/351473/lung Figure 4: http://www.hwcrc.org/Health/Disease/circulatory%20system.htm Figure 5: http://thoracicsurgery.stanford.edu/patient_care/lung_cancer.html 8 9 CASE STUDY: LUNG CANCER Pathology Lung cancer is split up into two main groups: small cell lung cancer and nonsmall cell lung cancer. Small cell lung cancers are named for their small cell size. These cancers typically start near the center of the chest near the bronchi. Small cell lung cancer is fast growing and spreads more quickly than non-small cell carcinoma. Small cell carcinoma is also very rare in people who don’t smoke. Types of small cell lung cancer include Fusiform, Polygonal, and Lymphocyte-like (Suh, 2013; Beadsmoore & Screaton, 2002). Non-small cell lung cancer is the name given to lung cancers that aren’t small cell lung cancer. This includes Adenocarcinoma, Large cell carcinoma, and epidermoid (squamous cell) carcinoma. All of these carcinomas can be put together under the term non-small cell lung cancer because they act similarly. They all have a larger cell size. They grow slower when compared to small cell lung cancer. These carcinomas can occur in both smokers and non-smokers alike (Suh, 2013; Beadsmoore & Screaton, 2002). Another type of lung cancer is called mesothelioma. Mesothelioma does not fit into the category of small cell lung cancer or non-small cell lung cancer because it acts differently clinically. The main cause of Mesothelioma is exposure to asbestos. Mesothelioma is much less common than both small cell lung cancer and non-small cell lung cancer, and patients have a worse outcome (Suh, 2013; Beadsmoore & Screaton, 2002). 10 CASE STUDY: LUNG CANCER Staging Lung cancer uses a staging system called TNM. The “T” stands for tumor size and can range from small (T1) to large (T4). The “N” stands for lymph nodes involved and can range from none (N0) to many (N3). The “M” stands for if it has metastasized and can range from it has not metastasized (M0) to it has metastasized (M1). For lung cancer, each category is specific. The T categories are Tis through T4. Tis is for a carcinoma that is in situ. T1 is for a tumor that is 3cm or less in greatest dimension. T2 is for a tumor that is larger than 3cm but less than 7cm or a tumor with the following features: involves main bronchus 2cm or less away from carina, involves visceral pleura, extends to hilar region but does not involve entire lung. T3 is for a tumor that is 7cm or greater or one that directly invades parietal pleura, chest wall, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium. T3 can also be for a tumor in the main bronchus. T4 is for a tumor that has invaded any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodules in a different ipsilateral lobe. The N categories range from N0 to N3. N0 is for a tumor that has not spread to the nearby lymph nodes. N1 is for tumors that have spread to ipsilateral peribronchial and/or hilar lymph nodes and intrapulmonary nodes. N2 is for a tumor that has spread to ipsilateral mediastinal and/or subcarinal lymph nodes. N3 is for a tumor that has spread to contralateral mediastinal, contralateral hilar, scalene, or supraclavicular lymph nodes. The M categories range from M0 to M1. M0 is for a tumor that has not spread to distant 11 CASE STUDY: LUNG CANCER organs. M1 is for a tumor that has spread to distant organs (Greene & American Joint Committee on Cancer, 2002). The stages range from 0 to IV. The relation of stage and the TNM system can be seen in the following chart (Greene & American Joint Committee on Cancer, 2002): Stage 0 Tis T1 Stage I T2 T1 T2 Stage II T2 T3 T1 T1 T2 T2 Stage III T3 T3 T3 T4 Any T Stage IV Any T N0 N0 N0 N1 N0 N1 N0 N2 N3 N2 N3 N1 N2 N3 Any N Any N Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 M1 Grading Lung cancer uses a four-grade system. This system ranges from GX to G4. GX is for tumors that the grade cannot be assessed. G1 is for tumors that are well differentiated. Well differentiated means that the cancer cells look more like normal tissue. G2 is tumors that are moderately differentiated. G3 is for tumors that are poorly differentiated. G4 is for tumors that are undifferentiated. Undifferentiated means that the cancer cells look nothing like normal tissue. Undifferentiated tumors 12 CASE STUDY: LUNG CANCER tend to grow more rapidly than well-differentiated tumors (Greene & American Joint Committee on Cancer, 2002). Patient Pathology, Stage, and Grade This patient was diagnosed with stage III, grade 3 non-small cell lung cancer. She was diagnosed with stage III because her tumor involved the hilar region, paratracheal nodes, but it had not metastasized distantly. She was diagnosed grade 3 because her tumor was poorly differentiated. She was diagnosed with non-small cell lung cancer. This means that she had a tumor that had relatively large cells, grows slowly for a lung cancer, and was not specific to her as a smoker. Her outcomes look better than if diagnosed with small cell carcinoma or mesothelioma. Treatment Plan and Prescription This patient has the following prescription: Plan Locatio n Total Dose (cGy) 800 Modality Fx Lung Treatme nt Volume GTV 3D CRT IMRT Px Dose/ fx (cGy) 1/day 200 6X 4 Lung PTV 5200 6X 26 1/day 200 Isodose (%) Port # 97 1-2 100 covers 95% of target 3 Treatment Information and Set-up A 4DCT simulation was done for this patient. Physician wanted to use contrast, but contrast was not used because of complications. Patient was set up supine in an upper alpha cradle with her arms above her head. A blue knee sponge was used under her knees with her feet banded together. Three tattoos were put on 13 CASE STUDY: LUNG CANCER her on her chest: one right lateral, one left lateral, and one anterior. A box was placed on her chest to track her breathing. A 4DCT was performed with parameters of above eyes to below lungs and consisted of 2184 image slices. With this 4DCT the Physician and Dosimetrist could then create the radiation treatment plan. Treatment Type and Delivery Plan 3D CRT IMR T Mach ine Linac Gantry Angle 0° Collimator Angle 90° Couch Angle 0° Wedge Bolus SSD MU 15 in none 88.9 Ener gy 159 6X Linac 181° CW 179° 30° 0° none none 91.1 493 6X Complications and Side Effects After the first week of radiation therapy, the patient started experiencing some side effects. These included fatigue, heartburn/dyspepsia. She was told to take Prilosec for the heartburn. After the second week of radiation therapy, she complained of fatigue, dysphagia, and esophagitis. A dietician saw her and explained the importance of nutrition and eating. She claimed that she did not need anything for the pain. Adjuvant Therapies For lung cancer, a few adjuvant therapies may be used. These include surgery, Radiofrequency ablation, chemotherapy, targeted therapy, and immunotherapy. Surgery can be difficult to do due to poor health of many of lung cancer patients. If the patient is cleared, surgery is best used for non-small cell lung cancer. No matter who the patient is, surgery for lung cancer has high risks and may not be done due to the amount of lung removed. The different possible surgeries CASE STUDY: LUNG CANCER 14 that may be done include a pneumonectomy, lobectomy, or segmentectomy. A pneumonectomy removes the entire lung. A lobectomy removes a lobe. A segmentectomy removes part of a lobe. Possible side effects from surgery may include difficult breathing, infection or bleeding. Infection can be treated with antibiotics, and bleeding can be treated with pressure and non-adherent pads with tape (American Cancer Society, 2015). Radiofrequency ablation is another adjuvant therapy that can be used. Radiofrequency ablation uses an electric current to kill cancer cells. This therapy works best for non-small cell lung cancer that is near the edge of a lung. A small incision is made and a probe is inserted into this incision and hits the tumor. Once in place, an electric current runs through the probe and heats up and destroys the cancer cells. This can be done as an outpatient procedure. Major complaints are rare, but they include partial lung collapse or bleeding into the lung. Both of these side effects can resolve on their own (American Cancer Society, 2015). Chemotherapy is the chemical treatment of a disease. This can either be through IVs or prescribed pills. Chemotherapy drugs that are common for nonsmall cell lung cancer include Cisplatin, Carboplatin, Paclitaxel, albumin-bound paclitaxel, Docetaxel, Gemcitabine, Vinorelbine, Irinotecan, Etoposide, Vinblastin, and Pemetrexed. Some side effects of chemotherapy could include loss of appetite, fatigue, hair loss, increased chance of getting sick, nausea and vomiting. Loss of appetite may be treated by setting routine meal times, drinking more water, and eating high calorie foods. Fatigue may be treated by eating enough, letting others help, and getting enough rest. Hair loss cannot be treated, but a wig or scarf can help CASE STUDY: LUNG CANCER 15 cover it up. Increased chance of sickness can be treated by washing hands well, staying away from germs, and trying not to get cuts. Nausea and vomiting can be treated with anti-nausea medicine (Chemotherapy Side Effects Sheet, 2012). Targeted therapy is a therapy that uses drugs to specifically target cancers. To grow, tumors need vessels to grow around them to supply them with nutrients. This process is called angiogenesis. There are targeted therapy drugs that block this process that are called angiogenesis inhibitors. Epidermal growth factor receptor is found on cells to help them grow and divide. Some targeted therapy drugs target this protein. These have side effects such as diarrhea, skin problems, mouth sores, or loss of appetite (American Cancer Society, 2015). Immunotherapy is another type of adjuvant therapy used for non-small cell lung cancer. Immunotherapy stimulates the body’s immune system to fight the disease off itself. Side effects of this type of therapy include fatigue, cough, nausea, itching, skin rash, decreased appetite, constipation, joint pain, and diarrhea. All of these side effects can be managed with other medicine, but they will be alleviated when treatment is over. Patient’s Adjuvant Therapies The patient had already had a biopsy done. She was going through chemotherapy along with radiation therapy as well. No side effects were reported by these additional treatments. 16 CASE STUDY: LUNG CANCER Critical Structures and Tolerances Organ Breast Cartilage & Bone Arteries and veins Lymph Nodes Muscle Thyroid TD 5/5 (cGy) 6000 6000 >8000 5000 6000 4500 Skin 5500 Esophagus Heart 6000 4500 Liver 2500 Spinal Cord 4500 (Washington & Leaver, 2010). Injury Contracture Necrosis, Fracture sclerosis Atrophy, sclerosis Fibrosis Reduced hormone production Acute and Chronic Dermatitis Ulceration, stricture Pericarditis and pancarditis Acute and chronic hepatitis Infarction, Necrosis Routes of Spread Lung cancer typically will spread by direct extension, then to lymph nodes, and then to distant sites. The most common distant sites that lung cancer travels to are the brain, bones, adrenal glands, contralateral lung, liver, pericardium, kidneys, and subcutaneous tissues. However, any organ can be a distant metastatic site for lung cancer (Greene & American Joint Committee on Cancer, 2002). Prognosis and Survival There are a few factors that can affect the prognosis of non-small cell lung cancer. These include the stage, grade, age of patient, and if it’s a recurrent tumor after complete resection. A worse higher stage or grade can lead to a worse prognosis. A patient that is older will have a worse prognosis than a young patient. If the tumor is a recurrent tumor after a complete resection of the original tumor then the patient will have a poorer prognosis than an original tumor (Midthun, 2015). 17 CASE STUDY: LUNG CANCER Survival rates are typically given in 5 years. These rates show how likely it is for a patient to survive 5 years after being diagnosed. The American Cancer Society splits these survival rates up according to stage: Stage 5-year survival rate I 46% II 30% III 10% IV 1% (2015). Patient’s Prognosis and Survival This patient would have a pretty good prognosis compared to others diagnosed with stage III non-small cell lung cancer. This is because she is younger than the average age at diagnosis. However, because of her stage and grade, her prognosis is not very good. I would give her a 5-year survival rate of about 12%. The average 5-year survival rate for stage III non-small cell lung cancer is about 10%, and because of her age, I gave her a slightly higher 5-year survival rate. 18 CASE STUDY: LUNG CANCER Sources American Cancer Society. (2015, March 4). In American Cancer Society. Retrieved March 22, 2015, from http://www.cancer.org/cancer/lungcancer-nonsmallcell/detailedguide/non-small-cell-lung-cancer-risk-factors Beadsmoore, C. J., & Screaton, N. J. (2002, October 30). Classification, Staging, and Prognosis of Lung Cancer. European Journal of Radiology, 45(1), 8-17. Retrieved from http://ac.elscdn.com.ezproxy.gvsu.edu/S0720048X02002875/1-s2.0S0720048X02002875-main.pdf?_tid=0649dee4-dbd5-11e4-bdaa- 00000aab0f02&acdnat=1428267050_608e92ebc9d32d3d637de0921e3a26b 2 Chemotherapy Side Effects Sheets. (2012, December 10). Retrieved March 22, 2015, from http://www.cancer.gov/cancertopics/coping/physicaleffects/chemoside-effects Greene, F. L., & American Joint Committee on Cancer. (2002). AJCC cancer staging manual. New York: Springer. Midthun, D. E. (2015, March 30). Overview of the Initial Evaluation, Treatment, and Prognosis of Lung Cancer. UpToDate. O'Loughlin, M. (2012). Human Anatomy (International ed., Vol. Third, pp. 118-139, 440-512). New York City: McGraw-Hill. Suh, J. H. (2013, June 22). Current Readings: Pathology, Prognosis, and Lung Cancer. Seminars in Thoracic and Cardiovascular Surgery, 25(1), 14-21. CASE STUDY: LUNG CANCER 19 Retrieved from http://www.sciencedirect.com.ezproxy.gvsu.edu/science/article/pii/S1043 06791300004X# Washington, CM & Leaver, D. (2010). Principles and practices of radiation therapy. (3rd ed.). St. Louis, MO: Mosby Publishers.