Download Egan Ch 28 Lung Cancer

Chapter 28
Lung Cancer
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
Learning Objectives
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Describe the epidemiology of lung cancer in
the United States, particularly current trends.
Describe risk factors for lung cancer.
Describe the classification of lung cancer
types and the cellular features of the four
common types of lung cancer.
Describe current understanding of the
pathophysiology of lung cancer.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Learning Objectives (cont.)
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Describe the clinical features of the common
types of lung cancer.
Describe the diagnostic approach to lung
cancer.
Describe the staging system for lung cancer.
Describe the treatment and outcomes for the
common types of lung cancer by stage.
Describe the role of the respiratory therapist
in managing patients with lung cancer.
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Epidemiology
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In 2010, there were ~222,520 new cases of
lung cancer (bronchogenic carcinoma) in
United States
Second most common type of cancer in men
& women
WHO estimates ~2 million cases of lung
cancer/year
Leading cause of cancer-related death
85–90% of patients have smoking history
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Epidemiology (cont.)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Risk factors of lung cancer include the following,
except:
A. occupational and environmental exposure to
asbestos, arsenic, etc.
B. genetic predisposition
C. Asthma
D. dietary factors
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Epidemiology (cont.)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Lung Cancer Classification
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Classified as small cell (oat cell) or non–small
cell carcinoma
Non–small cell lung carcinoma (NSCLC)
consists of:
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Adenocarcinoma: most common type, ~40% of all
lung cancers in United States
 Squamous cell carcinoma: 2nd most common type
 Large cell carcinoma: rarest form of lung cancer
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Small cell lung carcinoma (SCLC): ~20% of
U.S. cases
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Lung Cancer Classification (cont.)
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Pathophysiology
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Complex & poorly understood
Genetic material in lung cells damaged
secondary to exposure to carcinogens, i.e.,
those in tobacco smoke
There may be genetic predisposition
Genes influenced produce proteins involved
in cell growth, differentiation, apoptosis,
angiogenesis, tumor progression, & immune
regulation
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If enough of these pathways have been affected,
lung cancer will occur
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Which of the following is the most common form of
bronchogenic carcinoma?
A.
B.
C.
D.
squamous cell carcinoma
oat-cell carcinoma
adenocarcinoma
large-cell carcinoma
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Clinical Features
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Local growth
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Cough
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Dyspnea
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Hemoptysis
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Pain
Regional growth
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Dysphagia
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Dyspnea
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Harseness
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Horner syndrome
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Hypoxia
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Pancoast syndrome
Pericardial & pleural effusions
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Superior vena cava syndrome
Paraneoplastic
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Cutaneous or skeletal
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Acanthosis nigricans
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Clubbing
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Dermatomyositis
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Hypertrophic osteoarthropathy
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Metastatic disease
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Headache
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Hepatomegaly
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Mental status change
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Pain
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Papilledema
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Seizures
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Skin or soft tissue mass
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Syncope
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Weakness
Endocrine
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Cusing syndrome
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Humoral hypercalcemia
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SIADH
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Tumor necroiss factor (cachexia)
Hematologic
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Anemia or polycythemia
Disseminated intravascular coagulation
Eosinophilia
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Granulocytosis
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Thrombophlebitis
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Clinical Features (cont.)
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Neurologic
Cancer-associated retinopathy
Encephalomyelitis
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Lambert-Eaton syndrome
Neuropathies
Cerebellar degeneration
Renal
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Glomerulonephritis
Nephrotic syndrome
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Common lung cancer manifestations include the
following, except:
A.
B.
C.
D.
dyspnea
hemoptysis
hypotension
pain
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Diagnosis
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~85% of patients will be symptomatic (see
Box 28-2)
Remainder detected by radiographic
evaluation
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Chest radiograph & CT scan used as initial
evaluation
Will show nodules (<3 cm) & masses (>3 cm)
Other findings: enlarged lymph nodes or pleural
effusions
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Diagnosis (cont.)
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May proceed directly to surgery if radiograph,
symptoms, & history are suggestive of malignancy
If unsure, further testing is indicated
Adjunct imaging
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Positron emission tomography (PET)
• Malignant cells are metabolically very active & take up
radioactive glucose
• Scan reveals spots of attached radioactive tracer trapped in
cells
• Sensitivity of 97% & specificity of 78%
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Single-photon emission computed tomography
(SPECT) & contrast-enhanced CT used less often
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Diagnosis (cont.)
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Nonsurgical tissue biopsy obtained by:
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Flexible bronchoscopy (FB):
• High diagnostic yield for lesions that are endoscopically
visible within large airways
• Samples taken using saline washings, brush through
camera, & needle or forceps
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Transthoracic needle biopsy:
• Aspirating needle guided by fluoroscopy or CT to obtain
samples of peripheral lesions
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Staging
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NSCLC staging is based on TNM staging
system
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“T” component of staging (extent of primary tumor)
• T1: 3 cm confined to lung & cannot extend into main
bronchus (T1a: <2 cm & T1b: 2-3 cm)
• T2: >3 cm may invade pleura or extend into bronchus,
may cause segmental or lobar atelectasis (T2a: 3-5 cm &
T2b: 5-7 cm)
• T3: ≥ 7 cm any size extending into surrounding
structures, excluding main mediastinal structures
• T4: any size invading mediastinal structures or presence
of malignant pericardial or pleural effusion
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Based on the TNM staging, how would you classify
a tumor found in the main bronchus that is 4 cm in
diameter?
A.
B.
C.
D.
T1
T2
T3
T4
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Staging (cont.)
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“N” component of staging (regional lymph node
involvement)
• N0: no demonstrable involvement of nodes
• N1: ipsilateral nodal involvement
• N2: ipsilateral mediastinal lymph nodes
• N3: contralateral mediastinal or hilar nodal involvement,
either sides involvement of scalene or supraclavicular lymph
nodes
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“M” component of staging (metastases)
• M0: no metastases
• M1: metastases present
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Staging (cont.)
Staging of NSCLC
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Staging (cont.)
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Staging of SCLC
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Divided into two groups
• Limited: cancer is confined to one hemithorax.
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Includes ipsilateral mediastinal & supraclavicular nodes
• Extensive: cancer has spread beyond original
hemithorax
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Since staging guides therapy, it is important to
determine correct stage
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Staging (cont.)
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Determination of staging for all lung cancers:
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CT of chest & upper abdomen is ordered for all
MRI only superior to CT scan for Pancoast tumor
FDG-PET best to determine staging of mediastinal
nodes
FB with transbronchial needle aspiration help for
mediastinal staging
Gold standard remains surgical resection &
mediastinal dissection
Patient performance status is important in
determining prognosis & ability to tolerate surgery
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Screening for Lung Cancer
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Due to high proportion of patients who
present with advanced lung cancer & its
associated mortality, screening is very
attractive
Techniques
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Chest radiograph and/or sputum exam
• Studies did not support beneficial outcome
Low-dose CT imaging
• No proof it is of any benefit
• May be useful in high-risk individuals
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Treatment & Outcomes
NON–SMALL CELL
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STAGES IA, IB, IIA, IIB
• Surgical resection is the standard of care if patient deemed able to tolerate
• Limited resection if patient is unable to tolerate larger resection.
• Radiotherapy, particularly stereotactic body radiotherapy in N0 disease, if patient is unable to tolerate or chooses
not to undergo resection.
• Adjuvant radiotherapy is possibly of use if incomplete resection has occurred.
• Adjuvant chemotherapy in those with stage II disease who can tolerate it. Consider in stage IB.
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STAGE IIIA
• Concurrent chemoradiotherapy using a platinum-based regimen if performance status is reasonable.
• Induction chemoradiotherapy followed by resection and adjuvant chemotherapy in selected patients, ideally as
part of a study protocol.
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STAGE IIIB
• Concurrent chemoradiotherapy using a platinum-based regimen if performance status is reasonable.
• Induction chemoradiotherapy followed by resection in highly selected patients, only as part of a study protocol.
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STAGE IV
• Platinum-based chemotherapy regimen in patients with adequate performance status.
• Targeted therapies (EGFR and VEGF inhibitors) in appropriate subgroups.
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SMALL CELL
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LIMITED STAGE
• Combination chemotherapy with concurrent hyperfractionated radiotherapy if performance status is adequate.
• Prophylactic cranial radiation for those with a complete response to chemoradiotherapy.
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EXTENSIVE STAGE
• Combination chemotherapy if performance status is adequate.
Courtesy The Cleveland Clinic, Cleveland, OH)
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Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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A 54 year old male factory worker has been
currently diagnosed with non-small cell stage IV
bronchogenic carcinoma. Which of the following
treatments would he undergo?
A.
B.
C.
D.
surgical resection
induction chemoradiotherapy
platinum-based chemotherapy
Prophylactic cranial radiation
Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.
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Prognosis for NSCLC
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The Future
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Attainable vision for 2031:
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Primary prevention campaigns having successfully
minimized number of smoking individuals
Legislation has passed laws to prevent tobacco
smoking in public places
Progression of occupational exposure avoidance
Successful measures enacted to clean air
Improved diagnostic procedures
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Role of Respiratory Therapists
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Prevention /education
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Evaluation & management
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Smoking cessation
Assist MD in brochoscopy used in diagnosis
Mobilization of bronchial secretions from
excessive mucus production & accumulation
associated with lung cancer
Supplemental oxygen to treat associated
hypoxemia unless caused by capillary shunting
Psychological support
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