The document describes a case of a 26-year-old man presenting with facial swelling, lumps in his armpits, chest pain for 3 months, and weight loss over 6 months. Examination found nail clubbing and a chest X-ray showed abnormalities. Biopsy and scans confirmed stage IV lung cancer. Nail clubbing is associated with lung diseases and cancers and results from vascular changes and growth factors from the lungs. Different types of biopsies are used to diagnose cancers including needle, endoscopic, and surgical biopsies. The anatomy of the chest is also described including structures like the ribs, sternum, and thoracic skeleton that make up the rib cage.

1. MD-2204 (Respiratory System)
MD-2204 (Respiratory System)
PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB
BACHELOR MEDICINE AND SURGERY (MBBS)
UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN
MD-2204 (Respiratory System)
PROBLEM BASED LEARNING (PBL)
Dr Tin Htay Khine
Lung Cancer

2. Patient’s History
PROBLEM BASED LEARNING (PBL)
2015

3. • 26 year-old man
• Presented with :
– Facial swelling
– Lumps in axillae
– Chest pain on & off for 3 months
– Weight loss during past 6 months
• No medical,surgical or family history
• Not smoking cigarette but smoked cannabis (2
[14 years-old] 8 [18-24 years-old] joints daily)
• He was concious & afebrile
• No evidence of cyanosis
• He looked pale & cachexic

4. Nail Clubbing

5. Drumstick fingers & watch-glass nails
Deformity of the fingers &
fingernails
Associated with number of
diseases
Mostly heart & lungs
Idiopathic clubbing = rare

6. Sign & symptoms of nail clubbing
Fluctuation & softening
of the nail bed (↑
ballotability)
Loss of the normal
<160ᵒ angle (Lovibond
angle) bet the nailbed
& the fold (cuticula)
↑ convexity of the nail
fold
Thickening of the
whole distal end finger
(resembling drumstick)
Shiny aspect & striation
of the nail & skin

7. Schamroth’s Window Test
Popular test for
clubbing
Distal phalanges of
corresponding fingers
of opposite hands are
directly opposed
Small diamond-
shaped ‘window’
appear bet the
nailbeds
If this windows is
absent, the test is + &
the clubbing is present

8. Diseases Associations
Lung diseases
• Lung cancer
• Non small cell carcinoma
(54%)
• Small cell carcinoma (<5%)
• Interstitial lung CA
• Complicated TB
• Suppurative lung diseases
• Lung abscess
• Empyema
• Bronchiectasis
• Cyctic fibrosis
• Mesothelioma of the pleura
• Arteriovenous fistula
Heart diseases
• Sub-acute bacterial
endocarditis
• Benign tumor
• Tetralogy of Fallot
• Congenital cyanotic heart
diseases (most common)
• Any diseases featuring
chronic hypoxia
Gastrointestinal &
hepatobiliary
• Malabsorption
• Chron’s diseases & ulcerative
colitis
• Cirrhosis
• Hepatopulmonary syndrome
(complication of cirrhosis)
Others
• Grave’s diseases
(autoimmune
hyperthyroidism)
• Familial & racial clubbing &
pseudoclubbing
• Vascular anomalies of the
affected arm
• Axillary artery aneurysm
(unilateral clubbing)

9. Pathophysiology
of nail clubbing
Exact cause =
unknown
Vasodilation
Secretion of
growth factors
from lungs
Disorder in
prostaglandin
metabolism in 1ᵒ
osteoarthropathy
Led to
overproduction of
PGE2 by other
tissues

11. Discomfort or pain anywhere along
the front of your body between your
neck and upper abdomen.

12. • Pleuritic pain/worsened by breathing
PULMONARY EMBOLISM
• Inflammation of pleura/worsened by
inhalation and cough / sharp pain
PLEURISY
• Inflammation of bronchitis/related with
smoking
CHRONIC BRONCHITIS
• Inflammation of lung
PENUMONIA
• Inflammation costal cartilage
TIETZE’S SYNDROME
• Begin suddenly/PNEUMOTHORAX
LUNG COLLAPSE

13. • Pressure from the cancer mass
LUNG CANCER
• Pus collection in naturally existing
cavity
PLEURAL
EMPYEMA
• Caused by normal flora in mouth and
GIT/worsened pain by taking a deep
breath
PULMONARY
ACTINOMYCOSIS
• Chronic inflammation by
Mycobacterium tuberculosisTUBERCULOSIS

16. DEFINITION
TYPES OF LUMP
LUMP EXAMINATION

17. What is Lump
• A lump is an abnormal protuberance and a
palpable mass that generally has no definite
size and shape
• Common occurrence that can grow in any
part of the body which may or may not be
harmful
• The medical significance of lump depends on
the character or nature of the lump including
the areas where it has developed

18. Type of Lump
• DERMATOFIBROMA
• LIPOMA
• CYST
• WARTS
• ANGIOMA
• MALIGNANT TUMORS

19. • Dermatofibromas
Dermatofibromas are very common and is
characterized by dimpling of the overlying skin. This
type of lump can occur in any areas of the body but it
is more commonly found under the skin of the legs.

20. • Lipoma
Lipomas are fatty lumps that are benign in nature and
occur where the fat can get bigger. Lipomas can cause
symptoms when the lump has increased in size and put
pressure on the surrounding tissues.

21. • Cysts
SKIN: Cysts are round lumps that develop under the skin and have
a yellowish color. It is movable and feels like a pebble under the
skin. The cyst is generally harmless with a size that typically stays
the same although may also increase in size.
WRIST: Ganglion cysts develop as rubbery or soft swellings, usually
in response to a minor injury that triggers excess joint fluid to
collect in a saclike structure next to the joint. Ganglion cysts also
can occur on the fingers or feet.
OTHER LOCATION: KNEE, KIDNEY, BREAST, CERVIX & OVARY

22. • Warts
Warts are skin colored lumps that usually occur in
clusters. It is generally harmless but is contagious and
can spread into other areas of the body or can be
transmitted to others.
Warts are benign (not cancerous) skin growths that
appear when a virus infects the top layer of the skin.
Viruses that cause warts are called human papillomavirus
(HPV)

23. • Angiomas
Angiomas are harmless lumps composed of a collection
of blood vessels that make the lumps appear bright red
or slightly purplish.

24. • Malignant tumors
Malignant tumors are the type of lump that grows
rapidly and the consistency of the lump is rather hard
and immovable.
Eg: Liposarcoma, Fibrosarcoma, Angiosarcoma
Abdominal giant liposarcoma
Primary cutaneous angiosarcoma

25. LUMP EXAMINATION
1) Proper exposure of the lump site
2) Inspection
- Site : Anatomical site of lump by using
body land mark
- Overlying skin : texture (colour, rough,
dry, etc.)
- Shape
- Margins
- Size

26. 3) Palpation
Feel:
Tenderness and temperature
Surface (smooth, irregular, nodular)
Edge (sharp or blunt, smooth or rough or nodular, well defined
or diffuse, etc)
Consistency (stony hard, firm, rubbery, spongy, soft)
Press:
Pulsatility (expansile pulsation, transmitted pulsation)
Compressibility (disappear on pressure and reappear on release)
Reducibility (reappear only on application of another force:
cough)
Fluctuation (the 2 fingers moved apart when middle area
pressed)
Fluid thrill: indicates presence of fluid

27. 4) Percussion
-Dull/resonant
-Resonant if fluctuant swelling due to presence of air
5)Auscultation
-Listen for bruits, venous hums, etc
-Vascular swellings will have systolic bruits (such as
aneurysms),
-arterio-venous malformations will have a continuous
bruit heard throughout diastole and systole
-hernias which contain gut loops might let you hear
bowel sounds

28. 6) Examine surrounding tissue
-Lymph node:
In cases of acutely tender and inflamed swellings,
local lymph nodes might be swollen (pointing
towards an infection).
-Any swelling at other part : same/difference
-State of local tissue: arteries (ischemia), nerves
(muscle wasting and change in sensation), lymphatic
(edema), bones and joints (erosion), inflammation.
7) General physical examination on the
patient : Health overview

29. TERATOMA

30. TERATOMA
• A teratoma is a type of germ cell tumor
which contains several different types of
cells, caused when germ cells actively
dividing and start replicating at site
where they should not.
• This type of tumor actually present at
birth but only noticed until later in life
• They can contain skin,hair,bone,cell like
those found in organ and glands

31. Benign & malignant
• Cystic form teratoma
• Remove by surgery
benign
• Solid form teratoma
• Chemotheraphy and radiation
malignant

32. • Other cancers often associated is :
Small cell
carcinoma
Acute
myelogenous
leukemia (AML)
Myelodysplasia
(MDS)
Embryonal
rhabdomyosarcoma
Malignant
histiocytosis

33. • Malignant teratoma occurs most often in
young men in their 20s - 30s
• It is often located in the chest area.
• The symptoms include :
Chest pain Cough fatigue Shortness of
breath
Limited ability
to tolerate
exercise

35. CANNABIS

36. • commonly known as
marijuana
• the word used to describe
the dried flowers, seeds and
leaves of the Indian hemp
plant
• Street names, such as: astro
turf, bhang, dagga, dope,
ganja, grass, hemp, home
grown, J, Mary Jane, pot,
reefer, roach, Texas tea and
weed.

37. -Material from the Cannabis plants
• Cannabis sativa and Cannabis indica
-Cannabis smoking is the inhalation of smoke or
vapors released by heating the flowers, leaves, or
extracts of cannabis
- Contain psychoactive chemical :
• Tetrahydrocannabinol (THC)
• Cannabidiol (CBD),
• Cannabinol (CBN)
• Cannabigerol (CBG)

38. SMOKING METHODS

39. How cannabis makes you feel
• The effects of cannabis vary from person to person:
– some people may feel chilled out, relaxed and happy
– others get the giggles or become more talkative
– hunger pangs are common – this is sometimes known as
"getting the munchies"
– you may become more aware of your senses
– it’s common to feel as though time is slowing down
• Cannabis can have other effects too:
– it makes some people feel faint and/or sick – this is sometimes
known as a "whitey"
– it can make you feel sleepy and lethargic
– some people find it affects their memory, making it harder to
remember things
– it makes some people feel confused, anxious or paranoid, and
some experience panic attacks and hallucinations.

40. RISK
ASSOCIATED
WITH CANNABIS
LUNG
-Like tobacco, it contains
cancer-causing
chemicals (carcinogens)
that increase your risk of
lung cancer
FERTILITY
-disrupt sperm
production in males
and ovulation in
females.
MENTAL HEALTH
- increased risk of
developing a psychotic
illness, such as
schizophrenia.
- Depressive disorder
ABILITY TO
DRIVE
UNBORN BABY
-affect your baby's brain
development
-smoking cannabis with tobacco
is associated with an increased
risk of your baby being born
small or premature.

42. Does cannabis have medicinal
benefits?
• Herbal cannabis contains many different compounds, called
cannabinoids, which have different effects. One of these
cannabinoids – tetrahydrocannabinol, or THC for short – is
the active ingredient of a prescribed drug called Sativex.
Currently this is only licensed in the UK as a treatment to
relieve the pain of muscle spasms in multiple sclerosis.
• Further research is under way to test the effectiveness of
cannabis-based drugs for a range of other conditions
including the eye disease glaucoma, appetite loss in people
with HIV or AIDS, epilepsy in children and pain associated
with cancer. We won’t know whether or not these
treatments are effective until trials have concluded.

43. CHEST X-RAY

45. ABNORMAL X-RAY & CT SCAN

47. PBL SESSION 2
MD2204
Respiratory
System

48. Types of biopsy
 What is BIOPSY?
A biopsy is a procedure to remove
a piece of tissue or a sample of cells
from your body so that it can be
analyzed in a laboratory
While imaging tests, such as X-rays,
are helpful in detecting masses or
areas of abnormality, they alone
can't differentiate cancerous cells
from noncancerous cells. For the
majority of cancers, the only way to
make a definitive diagnosis is to
perform a biopsy to collect cells for
closer examination.

49. Continue...
 TYPES OF BIOPSY
A) Endoscopic biopsy
B) Needle biopsy
C) Skin biopsy
D) Surgical biopsy
E) Stereotactic Core biopsy
F) Ultrasound Guided Core biopsy

50. Continue...
 During endoscopy, the doctor uses a thin, flexible
tube (endoscope) with a light on the end to see
structures inside your body. Special tools are
passed through the tube to take a small sample
of tissue to be analyzed.

51. Continue...

52. Continue...
 During a needle biopsy, the doctor uses a special
needle to extract cells from a suspicious area.
 A needle biopsy is often used on tumors that
doctor can feel through the skin, such as
suspicious breast lumps and enlarged lymph
nodes. When combined with an imaging
procedure, such as X-ray, needle biopsy can be
used to collect cells from a suspicious area that
can't be felt through the skin.

53. Continue...

54. Continue...
 A skin (cutaneous) biopsy removes cells from the
surface of your body. A skin biopsy is used most
often to diagnose skin conditions, including
cancers, such as melanoma. What type of skin
biopsy you undergo will depend on the type of
cancer suspected and the extent of the
suspicious cells

55. Continue...

56. Continue...
 If the cells in question can't be accessed with other biopsy
procedures or if other biopsy results have been inconclusive,
the doctor may recommend a surgical biopsy.
 During a surgical biopsy, a surgeon makes an incision in the
skin to access the suspicious area of cells. Examples of surgical
biopsy procedures include surgery to remove a breast lump for
a possible breast cancer diagnosis and surgery to remove a
lymph node for a possible lymphoma diagnosis.
 Surgical biopsy procedures can be used to remove part of an
abnormal area of cells (incisional biopsy). Or surgical biopsy
may be used to remove an entire area of abnormal cells
(excisional biopsy).
 The may receive local anesthetics to numb the area of the
biopsy. Some surgical biopsy procedures require general
anesthetics to make y unconscious during the procedure.
Patient may also be required to stay in the hospital for
observation after the procedure.

57. Continue...
 Stereotactic core biopsy is the biopsy procedure
which require guide using the mammogram.

58. Continue...
 Ultrasound guided core biopsy is the biopsy
procedure which require guide of ultrasound
device.

59. Continue...
 Ultrasound guided core biopsy is the biopsy
procedure which require guide of ultrasound
device.

60. Differential Diagnosis
• Lung Carcinoma (chest pain, weight loss)
• Tuberculosis (weight loss, cachexic)
• Lymphoma (right axillary lymphadenopathy)
Confirmed Diagnosis
Stage IV Lung Cancer

61. ANATOMY OF CHEST

62. • b/t neck and diaphragm in front of body
• Helps protect some of the major internal
organs.
• Supported and protected by the ribcage and
shoulder.
ANATOMY OF CHEST

63. ANATOMY OF CHEST

64. • All the breadth of the shoulders is due to the
shoulder girdle, and contains the axillae and the
heads of the humerus.
• Thoracic skeleton
• It consists of the ribs and sternum.
• The ribs of the thorax are numbered in ascending
order from 1-12.
• Ribs 1-7 are true ribs.
• Ribs 8-10 are termed false ribs.
• Ribs 11 & 12 are known as floating.
ANATOMY OF CHEST

65. ANATOMY OF CHEST

66. ANATOMY OF CHEST
•PECTORALIS MAJOR:
Large fan-shaped muscle.
Majority of the chest muscle
mass. It originates at clavicle,
ribs, and sternum, and
inserts into the upper
portion of your humerus.
The pectoralis major helps
moves your arm toward.
•PECTORALIS MINOR:
Thin, triangular muscle that is found
underneath the pectoralis major. It
attaches at the 3rd, 4th and 5th rib,
and it reaches to the scapula
(shoulder blade). Its job is to help pull
the shoulder down.
•SERRATUS ANTERIOR:
Originates on the surface of the 1st to 8th ribs at
the side of the chest and inserts along the entire
anterior length of the medial border of the
scapula. It is functions are to move the scapula
forward and upward.

67. ANATOMY OF CHEST
•INTERCOSTAL MUSCLE :
several groups of muscles
that run between the ribs,
and help form and move
the chest wall. The
intercostal muscles are
mainly involved in the
mechanical aspect of
breathing.

68. Complication and pathophysiology
of lung cancer

69. Define lung cancer
• Lung cancer (malignancy of the lungs) is
defined as an uncontrolled growth of
abnormal cells in one or both of the lungs

70. Types of Lung Cancer
• Two main Types of Lung Cancer:
– Non Small Cell Lung Cancer (most common ~80%)
• SQUAMOUS CELL CARCINOMA
• ADENOCARCINOMA
• LARGE CELL CARCINOMA
– Small Cell Lung Cancer (20-25% of all lung cancers)
• Combined patterns
– Mixed sq.cell carcinoma + adenocarcinoma
– Mixerd sq.cell carcinoma + SCC

71. Squamous Cell Carcinoma
• Malignant bronchial epithelial tumour showing
keratinization and/or intercellular bridges.
• Strongly associated with smoking
• Majority arise centrally in major bronchi –
(obstruction and infection)
• Cavitations in 10%

72. Click to add title

73. Adenocarcinoma
• Malignant tumour with glandular
differentiation or mucin production.
• Gross : Adenocarcinoma of the lung. Usually
found as white-tan nodule at the periphery of
the lung.
• Many variants : Acinar, papillary,
bronchioloalveolar, solid, mixed subtypes
• Strongly associated with asbestose

75. Small Cell Carcinoma
• Oat cell carcinoma”
• It arises from endocrine cells (Kulchitsky
cells).
• Closely associated with smoking

76. Pathophysiology
disease limited to air passage lining: has not
invaded lung tissue; can usually be treated and
eliminated
disease limited to lung tissue; has not
invaded lymph nodes or other organs;
spread to lymph nodes and chest wall
(chest pain)

77. continue
• disease has invaded lymph nodes outside of
the lung area; (need surgery)
• disease has invaded organs and structures
surrounding the lungs such as the heart,
trachea and esophagus
• disease has invaded structures and organs
throughout the body, such as liver, bones and
brain; less than 2% chance of survival at 5
years if treated at this stage

78. Complication
• Shortness of breath. Due to cancer has block the major
airways. Lung cancer can also cause accumulation fluid around
the lungs, thus SOB
• Coughing up blood. Due to rupture of cappilary,
bronchiolalviolar lead to blood cough (hemoptysis).
• Pain. Advanced lung cancer that spreads to the lining of a lung
or to another area of the body, such as a bone, can cause pain.
• Fluid in the chest (pleural effusion). Lung cancer can cause
fluid to accumulate in the space that surrounds the affected
lung in the chest cavity (pleural space).
• Cancer that spreads to other parts of the body
(metastasis). Lung cancer often spreads (metastasizes) to other
parts of the body, such as the brain and the bones.

79. MANAGEMENT OF CANCER

80. SURGERY
RADIATION THERAPY
CHEMOTHERAPY
TARGETED THERAPIES
IMMUNO THERAPY
HORMONAL THERAPY
ANGIOGENESIS INHIBITOR

81. SURGERY
• The goal of the surgery can be either the removal of
only the tumor, or the entire organ.
• In theory, non-hematological cancers can be cured if
entirely removed by surgery.
• When the cancer has metastasized to other sites in
the body prior to surgery, complete surgical excision
is usually impossible.
• Examples of surgical procedures for cancer
include mastectomy for breast
cancer, prostatectomy for prostate cancer, and lung
cancer surgery for non-small cell lung cancer

83. RADIATION THERAPY
• use of ionizing radiation to kill cancer cells and
shrink tumors.
• administered externally via external beam
radiotherapy (EBRT) or internally via brachytherapy.
• effects of radiation therapy are localised .
• used to treat almost every type of solid tumor.
• destroys cells in the area being by damaging their
genetic material, making it impossible for these cells
to continue to grow and divide.

85. CHEMOTHERAPY
• treatment of cancer with drugs.
• usually refers to cytotoxic drugs which affect rapidly
dividing cells in general.
• Most forms of chemotherapy target all rapidly
dividing cells and are not specific to cancer cells.
• Hence, chemotherapy has the potential to harm
healthy tissue, especially those tissues that have a
high replacement rate .

87. TARGATED THERAPIES
• the use of agents specific for the deregulated
proteins of cancer cells.
• can also involve small peptides as "homing devices"
which can bind to cell surface receptors or
affected extracellular matrix surrounding the tumor.

89. IMMUNOTHERAPY
• diverse set of therapeutic strategies designed to
induce the patient's own immune system to fight the
tumor.
• use of interferons, vaccines and other cytokines to
induce an immune response.
• Allogeneic hematopoietic stem cell
transplantation ("bone marrow transplantation"
from a genetically non-identical donor) can be
considered a form of immunotherapy, since the
donor's immune cells will often attack the tumor.

91. HORMONAL THERAPY
• The growth of some cancers can be inhibited by
providing or blocking certain hormones.
• Common examples of hormone-sensitive tumors
include certain types of breast and prostate cancers.

93. ANGIOGENESIS INHIBITOR
• Angiogenesis inhibitors prevent the extensive growth
of blood vessels that tumors require to survive.
• One of the main problems with anti-angiogenesis
drugs is that many factors stimulate blood vessel
growth.
• Anti-angiogenesis drugs only target one factor, so
the other factors continue to stimulate blood vessel
growth

95. cycle of chemotherapy

96. CHEMOTHERAPY
treatment with
chemicals
kills cells that
divide or grow
rapidly
Shrink,prevent
spreading,slow
growth
skin, lining of the
digestive tract,
hair follicles
Cause side
effect

97. • treatment with anti-cancer drugs
•
oral,topically,intraperitoneally,intramuscula
r, intravenous
• drugs - bloodstream -throughout the body-
useful for cancer anywhere in the body.
Chemo is usually the main treatment for
small cell lung cancer (SCLC).
CHEMOTHERAPY

98. CHEMOTHERAPY
• the type of cancer you have
• where the cancer is in your body
• where in your body it has spread to (if it has
spread)
• general health.
• You will be offered the best standard treatment
available that current research shows will be
most helpful in your situation. This is why you
may meet other people with the same cancer as
you who are having different chemotherapy
treatments.

99. SIDE EFFECTS OF CHEMO
• Hair loss
• Mouth sores
• Loss of appetite
• Nausea ,vomiting
• Diarrhea or constipation
• Easy bruising or bleeding (few blood
platelets)
• Fatigue ,infection(few red blood cells)

100. CYCLES OF CHEMO
• given according to a treatment plan
(protocol)
• consists of several cycles of
chemotherapy
• with a rest period between each cycle.
• rest periods longer than treatment
periods
• allow body to recover from any unwanted
effects of the drug.

102. First line
• best in clinical trials for- same type,stage
• Drugs-combination,alone,
• Cisplatin,etoposide,irinotecan,paclitaxel
Second
line
• first line didn’t work@cause severe side
effect
• Drugs-combination,alone
• Decreased in chance getting good result
• CAVE regimen
FIRST AND SECOND LINE TREATMENT

103. First-line chemotherapy for extensive-stage disease
Stage IV disease:
• maximum 4-6 cycles:
• Cisplatin 60-80 mg/m2 IV on day
1 plus etoposide 80-120 mg/m2 IV on days 1-3
every 21-28dor
• Carboplatin AUC 5-6 IV on day 1 plus etoposide
80-100 mg/m2 IV on days 1-3 every 28dor
• Cisplatin 60 mg/m2 IV on day 1 plus irinotecan 60
mg/m2 IV on days 1, 8, and 15 every 28d or
• Cisplatin 30 mg/m2 IV on days 1 and 8 or 80
mg/m2 IV on day 1 plus irinotecan 65 mg/m2 IV
on days 1 and 8 every 21d

104. Second-line chemotherapy for relapsed or refractory
disease
Stage IV disease
• at least 4-6 cycles but can be given until disease
progression in some cases
• Patients who have relapsed disease >6month after
completing first-line chemotherapy can be treated with
that original first-line regimen (typically a platinum-
based doublet) again, with and expected response rate
of 62-100%
• Etoposide 50 mg/m2 PO daily for 3wk every 4wkor
• Topotecan 2.3 mg/m2 PO on days 1-5 every 21dor
• Topotecan 1.5 mg/m2 IV on days 1-5 every 21dor
• Carboplatin AUC 5 IV on day 1 plus irinotecan 50
mg/m2 IV on days 1, 8, and 15 every 28do

105. Third-line chemotherapy for relapsed or refractory
disease
Stage IV disease
• Etoposide 50 mg/m2 PO daily for 3wk every 4wkor
• Topotecan 2.3 mg/m2 PO on days 1-5 every 21dor
• Topotecan 1.5 mg/m2 IV on days 1-5 every 21dor
• Carboplatin AUC 5 IV on day 1 plus irinotecan 50
mg/m2 IV on days 1, 8, and 15 every 28dor
• Carboplatin AUC 4-5 IV on day 1 plus irinotecan 150-
200 mg/m2 IV on day 1 every 21d] or
• Cisplatin 30 mg/m2 IV on days 1, 8, and 15 plus
irinotecan 60 mg/m2 IV on days 1, 8, and 15 every 28d

106. CISPLATIN
• Class: Platinum based atypical alkylator
• Mechanism of action: binding to DNA -
disrupting its function- preventing DNA,
RNA ,protein synthesis
• anti-tumor activity in a wide variety of
cancers
• Cisplatin is rarely used as an individual
agent

107. ETOPOSIDE
• Drug profile
• Class: Topoisomerase II inhibitor
• Mechanism of action: inhibits specific
enzyme in the cell -unravels DNA strands
break -leading to cell death.
• anti-tumor activity in a wide variety of
cancers
• One of component in drugs regimen to
patient prior bone marrow tranplantion

108. CAVE Regimen

109. What CAVE is
• CAVE is the name of a combination of
chemotherapy drugs used to treat small cell
lung cancer.
• It is made up of the drugs
– C = Cyclophosphamide
– A = Doxorubicin (also called Adriamycin)
– V = Vincristine
– E = Etoposide

110. • CAVE chemotherapy as cycles of
treatment. Its may have up to 6 cycles
• Each cycle lasts 3 weeks.

111. Mechanism of Action
• Etoposide (Toposar, VePesid)
– is an effective antitumor medication. It slows or
stops the growth of cancer cells in the body by
causing breakage in the DNA (genetic material)
strand. It may be given as an IV injection or as a
pill.
• Cyclophosphamide (Cytoxan, Neosar)
– interferes with the growth of normal cells and
cancer cells. It slows the growth of cancer cells
and their spread in the body. It may be given as an
IV injection or as a pill.

112. • Doxorubicin (Adriamycin, Rubex)
– causes destruction of DNA, which slows or stops
the growth and spread of cancer cells in the body.
It is an IV medication.
• Vincristine (Oncovin)
– is a plant-based compound. It causes cell death by
interfering with the way genetic material (DNA)
multiplies in the cell. It is only available as an IV
medication

113. Side Effects
• Tiredness and breathlessness
• An increased risk of getting an infection
• Dark marks may occur in the creases of your
skin
• Urine may become a pink or red colour
• Women may stop having periods but this may
be temporary
• Loss of fertility

114. • Vincristine can temporarily stop the normal
muscle contractions of the bowel, causing
sickness, a swollen abdomen and cramps
• Sensitivity to sunlight
• Loss of appetide
• Metallic taste in mouth or loss of taste
• Sore mouth and throat, and possibly mouth
ulcers

115. • A side effect may get worse through your course of
treatment
• This depends on
– How many times you've had a drug before
– Your general health
– How much of the drug you have (the dose)
– Other drugs you are having

116. Contraindication
• Pregnant women
• Breastfeeding women

117. Prognosis of Lung Cancer

118. • The prognosis of lung cancer is dependent upon :
– where the cancer is located
– size of the cancer
– presence of symptoms
– type of lung cancer
– overall health status of the patient
• The overall prognosis for lung cancer is poor compared with
some other cancers.
• Survival rates for lung cancer are generally lower than those
for most cancers, with an overall 5-year survival rate for lung
cancer of about 17% compared to :
– 67% colon cancer
– 90% breast cancer
– 81% bladder cancer
– 99% prostate cancer

119. Outcomes in lung cancer according to clinical stage
Clinical stage
Five-year survival (%)
Non-small-cell lung
carcinoma
Small-cell lung
carcinoma
IA (up to 3cm) 50 38
IB (3-5 cm & nearby tissue) 47 21
IIA (5-7 cm & not in LN or <5 cm but in LN ) 36 38
IIB (5-7 cm in LN or >7 cm but not in LN)) 26 18
IIIA (> 7 cm & in LN) 19 13
IIIB (any size in nearby tissue or in LN of another
lung)
7 9
IV (in both lung or in other parts of body) 2 1

120. Small Cell Lung Carcinoma
• Most aggressive growth of all lung cancers,
• Most responsive to radiation therapy and
chemotherapy.
Because SCLC spreads rapidly and is usually
disseminated at the time of diagnosis, methods such as
surgical removal or localized radiation therapy are
less effective in treating this type of lung cancer.
When chemotherapy is used alone or in combination
with other methods, survival time can be prolonged
four- to fivefold
• Of all patients with SCLC, only 5% to 10% are still alive
5 years after diagnosis

121. Non Small Cell Lung Carcinoma
• For people with inoperable disease, outcomes
are worse in those with poor performance
status and weight loss of more than 10%
• The best prognosis is achieved with complete
surgical resection of stage IA disease, with up
to 70% five-year survival.

122. Epidemiology of Lung Cancer in
Malaysia

123. General view of cancers.
• Incidence of cancer in Malaysia increased
from 32,000 new cases in 2008 to 37,400 in
2012.
• It is expected to rise to 56,932 by 2025 if no
action is taken.
• World Cancer Day is done yearly on Feb 4 as a
reminder.

125. Lung Cancer (LA)
• 2,048 cases of lung cancer registered with
NCR, comprising 1,445 of males and 603 of
females.
• Second most common among males.
• Third most common cancer among
populations in Peninsular Malaysia.
• Chinese were found to have higher incidence
rate compared to Malay and Indians.

130. Health Education for Lung Cancer

131. Risk Factor
• People who smoke
• People exposed to second-hand smoke
• People exposed to indoor and outdoor air
pollution
• People exposed to certain toxic substances, such
as arsenic, radon or asbestos
• People whose jobs expose them to radiation
• People with personal or family histories of lung
cancer

132. So the advice here is..
• Smoking is the most important risk factor for
lung cancer.
• Don’t smoke. If you smoke, quit.
• Stay away from second-hand smoke
• Make your home and community smoke-free.
• Eat lots of fruits and vegetables.
• Some research says being physically active
may reduce your risk

133. • Stay away from air pollution, wear mask if
working in a polluted area.
• Check your home for radon.(considered as the
second leading cause of lung cancer and
leading environmental cause of cancer
mortality)
• Follow the guidelines of handling radioactive
material eg. Experiment or work
• Early detection by low-dose helical CT scans
reduced the rate of death from lung cancer.

134. OK! TQ FOR UR ATTENTION