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CASE STUDY: LUNG CANCER
Case Study: Lung Cancer
Abby Duthler
Grand Valley State University
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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
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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
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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
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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
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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
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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
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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).
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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
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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
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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
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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
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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
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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.
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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).
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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.
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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.
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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
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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.