Pulmonary Cancer

8/4/2019 Pulmonary Cancer

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Lung cancer or bronchogenic cancer is

a malignant tumor of the lung arisingwithin the bronchial wall or epithelium.

The lung is also a common site of

metastasis from cancer elsewhere inthe body through venous circulation or

lymphatic spread.

Definition


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By far the most common, and exhibiting

the greatest diversity are epithelial

tumors. Mixed tumors exist and these areoften classified according to the most

predominant cell type found, it is likelythat all lung cancers exhibit this to someextent. However this requires

examination with electron microscopy,and yields little of clinical benefit.


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Secondary tumours of the lung are very common,usually affecting the parenchyma, and often arisefrom primary tumours in; kidney, prostate, breast,

bone, gastrointestinal tract, cervix or ovary. Theseusually present as round shadows of about 1.5-3 cmdiameter on chest X-rays, in patients previouslydiagnosed with the primary. Sometimes, they can

present in undiagnosed asymptomatic patients,and the primary found later on CT scans or otherinvestigations.

2. SECONDARY TUMORS


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1. Squamous cell carcinoma (epidermoid

carcinoma)

accounts for about30 or 40% of primarylung tumors. They grow most commonly in

the central areas in or around majorbronchi. They grow in a stratified orpseudoductal arrangement, the cells havean epithelial pearl formation withindividual cell keratinization. These

tumours deposit keratin, and as they growdevelop a necrotic, keratinous mass whichappears cheesy on dissection. WidespreadMetastases occur

Classifications of lung canceraccording to cell type:


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2. Adenocarcinomas

arise peripherally from mucous glands and

the cells retain some of the tubular, acinar orpapillary differentiation and mucus

production. They commonly invade pleura

and mediastinal lymph nodes and often

metastasise to the brain and

bones.

Adenocarcinoma commonly arisesaround scar tissue and is also associated with

asbestos exposure. One form of

adenocarcinoma is often distinguished from

others, bronchiolo-alveolar carcinoma, these

characteristically have well differentiated

bland cells which grow along alveolar ducts.

Adenocarcinomas are proportionally less

common in non-smokers.


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3. Large cell carcinoma

accounts for about 20%of all lung cancers. It hasslow growth rate and

more often peripheralmass, either single ormultiple masses. It islocated centrally,midlung or peripherally.


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4. Small (Oat) cell carcinoma

accounts for about 20-30% of all lungcancers, these cells secrete a largeamount of polypeptide hormones.This produces extra-pulmonarymanifestations such as SIADH andectopic adrenocorticotrophin

syndrome. This form of lung cancer isresponsive to chemotherapy. Underthe microscope they form sheets ofdarkly staining cells with prominentnuclei and little cytoplasm,their

secretory activity can be seen as thepresence of neurosecretory granulesin the cytoplasm seen by electronmicroscopy. This form is very stronglylinked to smoking as a causativefactor.


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Cigarette smoking

Second-hand smoke

Genetic predisposition

Age- younger than 45 y/o

Tuberculosis

Low levels of radiation, radon, arsenic,chromium, nickel, iron, coal tar products andasbestos exposure

RISK FACTORS


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cachexia (weight loss),anorexia, fatigue, and lossof appetite

Malaise

Fever

dysphonia (hoarse voice)

clubbing of the fingernails

(uncommon) dysphagia (difficulty

swallowing).

Dyspnea (shortness of breath)

Hemoptysis (coughing upblood)

chronic coughing or change inregular coughing pattern

decreased breath sounds,wheezing and possible pleuralfriction rub on examination

chest pain (aching poorlylocalized)

Clinical Manifestations


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1. Chest X-ray

may be suspicious formass

Diagnostic Evaluation

Chest radiograph showing acancerous tumor in the left

lung.


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2. CT-scan or PET scan

For better visualization oftumor.

CT scan showing a canceroustumor in the left lung.


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*Mediastinoscopy andthoracotomy are

considered the goldstandard for staging lungcancer

6. Pulmonary function

tests, which may becombined with a split-function perfusion scan,determines if the patientwill have adequatepulmonary reserve towithstand surgical

procedure.

3. Sputum and pleural fluidsamples for cytologicexamination may show

malignant cells

4.Fiberoptic bronchoscopydetermines the locationand extent of the tumor

and may be used to obtaina biopsy specimen

5. Lymph node biopsy andmediastinoscopy may be

ordered to establishlymphatic spread and helpplan treatment


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3. Removal of pleural fluid (bythoracentesis or tubethoracostomy) and instillationof sclerosing agent to

obliterate pleural space andprevent fluid recurrence.

4. Radiation therapy incombination with othermethods

1. Oxygen through nasalcannula based on the levelof dyspnea.

2. Enteral or totalparenteral nutrition formalnourished patientswho are unable orunwilling to eat

Therapeutic Interventions


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1. Expectorants and antimicrobial agents torelieve dyspnea and infection

2. Analgesics given regularly to maintain pain at

tolerable level.

3. Chemotherapy using cisplatin in combinationwith a variety of other agents and

immunotherapy treatments may be indicated.

Pharmacologic Intervention


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5. Lobectomy- removal of an entire lobeof the lung.

6. Pneumonectomy- removal of anentire lung.

1. Laser Surgery- used as apalliative measure for relief ofendobronchial obstructions thatare not surgically resectable.

2. Pulmonary Resection-

complete resection of tumorremains the best chance of cure.

3. Wedge resection- a smalllocalized area of tumor near thesurface of the lung is removed

using special stapling devices.

4. Segmental Resection- removalof one or more lung segments.

Surgical Intervention

Pneumonectomy specimen containingasquamous cell carcinoma, seen as a whitearea near the bronchi


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1. Monitor blood work for hypercalcemia from bonemetastasis, neutropenia from chemotherapy , andhyponatremia is that may result from SIADH.

2. Monitor for upperbody edema because if superiorvena cava obstruction as complication.

3. Monitor nutritional status through serial weights

dietary log and prealbumin measurements.

Monitoring


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1.Elevate the HOB to ease the work of breathing andto prevent fluid collection in upper body

2. Teach breathing retaining exercises to increase

diaphragmatic excursion and reduce work of breathing3. Augment the patients ability to cough effectively:

a. Splint the patients chest manually with hands

b. Instruct the patient to inspire fully and cough 2 to 3times in one breath

c. Provide humidifier or vaporizer to provide moistureto loosen secretions

Supportive Care


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4. Teach relaxation techniques to reduce anxiety associated withdyspnea.

5. Encourage the patient to conserve energy by decreasingactivities

6. Ensure adequate protein intake--- milk, eggs, oral nutritionalsupplements; and chicken, fowl and fish if other meats are nottolerated--- to promote healing and prevent edema

a. Advise patient to eat in small amounts of high-calorie andhigh-protein foods frequently rather than three daily meals.

b. Change diet consistency to soft or liquid if patient hasesophagitis from radiation.

7. Consider alternative pain control methods, such asbiofeedback and relaxation methods.


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Pulmonary Cancer

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