Gastric Cancer: Сlinical Implementation of Artificial Intelligence, Synergeti...
Lung cancer
1.
2. Introduction
Bronchogenic cancer refers to a malignant tumor of
the lung arising within the wall or epithelial lining of
the bronchus
The lung is also a common site of metastasis by way
of venous circulation or lymphatic spread.
3. Epidemiology
Lung cancer is the number-one cancer killer among
men and women in the United States, accounting for
31% of cancer deaths in men and 25% in women
(American Cancer Society, 2002; Greenlee et al., 2001)
Lung cancer affects primarily those in the sixth or
seventh decade of life; less than 5% of patients are
under the age of 40.
In approximately 70% of lung cancer patients, the
disease has spread to regional lymphatics and other
sites by the time of diagnosis.
4. More than 85% of lung cancers are caused by the
inhalation of carcinogenic chemicals, most commonly
cigarette smoke (Schottenfeld, 2000).
5. Etiology
Cigarette smoking is the most important risk factor .
Smoking is responsible for approximately 80-90% of
all lung cancers.
Tobacco smoke contain 60 carcinogen in addition to
substances (carbonmonoxide, nicotine) that interfere
with normal cell development.
More than 80% of lung cancer cases are related to
smoking and the disease is 10 times more common in
smokers than in non smokers.
6. Contd…
The risk of lung cancer is gradually lowered when
smoking is discontinued and continue to decline with
time.
Ten years following cessation of smoking, lung cancer
mortality risk is reduced 30% to 50%.
7. Contd…
Occupational exposure to asbestos, arsenic,
chromium, nickel, iron, radioactive substances,
isopropyl oil, coal tar products, alone or in
combination with tobacco smoke
Gegetic predisposition : The first degree relatives of
people with lung cancer have a two to three fold excess
risk for lungs cancer
Age: it is increasing with age , occurring most
commonly in client age over 50.
9. Classification of lung cancer
Non-small cell carcinoma
Small cell carcinomas
Metastatic lung cancer
10. Non-small cell carcinoma
Non-small cell carcinoma represents 70% to 75% of
tumors
For non-small cell carcinoma, the cell types include
Adenocarcinoma (31% to 34%)
Squamous cell carcinoma (30%),
large cell carcinoma (10% to 16%)
bronchioalveolar carcinoma (3% to 4%).
11. Small cell carcinomas
Small cell cancers account for 20% to 25% of all
bronchogenic cancers (matthay, tanoue & carter, 2000).
Smallcell carcinoma also called “oat cell carcinoma’’
begins in the larger airways.
Most small cell carcinomas arise in the major bronchi
and spread by infiltration along the bronchial wall.
12. Contd…
The oat cell carcinoma contains dense neurosecretory
granules that often cause an endocrine/
paraneoplastic syndrome .
It is initially more sensitive to chemotherapy but
ultimately carries a worse prognosis and has often
metastasized.
This type of cancer is strongly associated with
smoking.
13. Metastatic lung cancer
It a another common form of lung cancer.
Tumors of the breast , colon, prostate, and
bladder commonly metastasize to the lungs.
14. Pathophysiology
Normal lung tissue is made up of cells that are
programmed by genes to create lung cells of a certain
size and shape that perform certain functions.
Lung cancer develops when these cells mutate and
reproduce excessively.
The cancerous lung tissue cannot exchange oxygen and
carbondioxyde and therefore perform no biological
function.
15. Contd..
Furthermore, tumor cells grow and invade surrounding lung
tissue.
This will limit expansion of the affected lobes of the lung
and interfere with gas exchange of oxygen and carbon
dioxide.
Airways are invaded , obstructing the flow of air.
Cancerous cells invade local lymph nodes and the
thoracic duct then distance metastasis occurs
17. Clinical Manifestations
lung cancer develops insidiously and is asymptomatic
until late in its course
The signs and symptoms depend on the location and size
of the tumor, the degree of obstruction, and the
existence of metastases to regional or distant sites.
The most frequent symptom of lung cancer is cough or
change in a chronic cough.
The cough starts as a dry, persistent cough, without sputum
production, when obstruction of airways occurs, the cough
may become productive due to infection.
18. Contd…
Hemoptysis or blood tinged sputum
Dyspnea, wheezing (suggests partial bronchial
obstruction).
Chest pain (poorly localized and aching)
Excessive sputum production, repeated upper
respiratory infections
Malaise, fever, weight loss, fatigue, anorexia
Paraneoplastic syndrome metabolic or neurologic
disturbances related to the secretion of substances by
the neoplasm
19. Contd….
Symptoms of metastasis :
bone pain; abdominal discomfort, nausea and
vomiting from liver involvement; pancytopenia from
bone marrow involvement; headache from CNS
metastasis
Usual sites of metastasis lymph nodes, bones, liver
20. The TNM staging system
The American Joint Committee on Cancer (AJCC) and
the International Union for Cancer Control (UICC)
maintain the TNM classification system as a tool to
stage different types of cancer based on certain
standards.
It’s reviewed every 6 to 8 years to include advances in
understanding of cancer.
21. TNM classification:
In the TNM system, each cancer is assigned a letter or
number to describe the tumor, node, and metastases.
T stands for tumor. It’s based on the size of the original
(primary) tumor and whether it has grown into nearby
tissues
N stands for node. It tells whether the cancer has
spread to the nearby lymph nodes
M stands for metastasis. It tells whether the cancer has
spread to distant parts of the body
22. TNM classification of Lung Cancer
Primary tumor (T)
TX Primary tumor cannot be assessed, or the tumor is proven by the
presence of malignant cells in sputum or bronchial washing but is
not visualized by imaging or bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor ≤ 3 cm in greatest dimension, surrounded by lung or visceral pleura,
no bronchoscopic evidence of invasion more proximal than the lobar
bronchus (not in the main bronchus); superficial spreading of tumor in the
central airways (confined to the bronchial wall )
T1a Tumor ≤ 2 cm in the greatest dimension
T1b Tumor > 2 cm but ≤ 3 cm in the greatest dimension
23. Contd…
T2 •Tumor > 3 cm but ≤ 7 cm or tumor with any
of the following:
•Invades visceral pleura
•Involves the main bronchus ≥ 2 cm distal to
the carina
•Associated with atelectasis/obstructive
pneumonitis extending to hilar region but
not involving the entire lung
T2a Tumor > 3 cm but ≤ 5 cm in the greatest
dimension
T2b Tumor > 5 cm but ≤ 7 cm in the greatest
dimension
24. Contd…
T3 •Tumor > 7 cm or one that directly invades any of
the following:
Chest wall (including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal pleura, or
parietal pericardium;
Or tumor in the main bronchus < 2 cm distal to the
carina but without involvement of the carina
Or associated atelectasis/obstructive pneumonitis
of the entire lung or separate tumor nodule(s) in
the same lobe
T4 Tumor of any size that invades any of the following:
mediastinum, heart, great vessels, trachea, recurrent
laryngeal nerve, esophagus, vertebral body, or carina; or
separate tumor nodule(s) in a different ipsilateral lobe
25. Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional node metastasis
N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph
nodes and intrapulmonary nodes, including involvement by direct
extension
N2 Metastasis in the ipsilateral mediastinal and/or subcarinal lymph node(s)
N3 Metastasis in the contralateral mediastinal, contralateral hilar, ipsilateral
or contralateral scalene, or supraclavicular lymph nodes
26. Distant metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
M1a Separate tumor nodule(s) in a contralateral
lobe; tumor with pleural nodules or
malignant pleural (or pericardial) effusion
M1b Distant metastasis
33. Diagnostic Evaluation
Chest X-ray
Computed tomography (CT) scan
positron-emission tomography (PET) scan
Cytologic examination of sputum/chest fluids for malignant
cells
Bronchoscopy for observation of location and extent of
tumor; for biopsy.
Lymph node biopsy; mediastinoscopy to establish lymphatic
spread; to plan treatment.
Pulmonary function tests (PFTs).
34.
35. Management
In general, treatment may involve surgery, radiation
therapy, or chemotherapy—or a combination of these
Newer and more specific therapies to modulate the
immune system (gene therapy, therapy with defined tumor
antigens)
36. SURGICAL MANAGEMENT
Surgical resection is the preferred method of treating
patients with localized non-small cell tumors, no
evidence of metastatic spread, and adequate
cardiopulmonary function
The cure rate of surgical resection depends on the type
and stage of the cancer.
Surgery is primarily used for non-small cell
carcinomas because small cell cancer of the lung grows
rapidly and metastasizes early and extensively.
37. Contd…
The most common surgical procedure for a small,
apparently curable tumor of the lung is lobectomy (removal
of a lobe of the lung)
Types of Lung Resections
Lobectomy: a single lobe of lung is removed
Bilobectomy: two lobes of the lung are removed
Sleeve resection: cancerous lobe(s) is removed and a
segment of the main bronchus is resected
•Pneumonectomy: removal of entire lung
•Segmentectomy: a segment of the lung is removed*
• Wedge resection: removal of a small, pie-shaped area of
the segment*
Chest wall resection with removal of cancerous lung tissue:
for cancers that have invaded the chest wall
38. RADIATION THERAPY
Radiation therapy may cure a small percentage of
patients
It is useful in controlling neoplasm that cannot be
surgically resected but are responsive to radiation
Radiation also may be used to reduce the size of a
tumor, to make an inoperable tumor operable, or to
relieve the pressure of the tumor on vital structures
39. Contd…
It can control symptoms of spinal cord metastasis and
superior vena caval compression.
Also, prophylactic brain irradiation is used in certain
patients to treat microscopic metastases to the brain.
Radiation may help relieve cough, chest pain, dyspnea,
hemoptysis, and bone and liver pain.
40. Contd…
Radiation is administered over a period of 5-6 weeks,
either consecutively or in split courses. CT scannining
is performed before treatment to delineate precisely
the area to be irradiated
41. CHEMOTHERAPY
Chemotherapy is used
To alter tumor growth patterns
To treat patients with distant metastases or small cell
cancer of the lung,
As an adjunct to surgery or radiation therapy.
Combinations of two or more medications may be
more beneficial than single-dose regimens
The choice of agent depends on the growth of the
tumor cell and the specific phase of the cell cycle that
the medication affects
42. Chemotherapeutic Agents
A variety of are used, including
Alkylating agents (ifosfamide),
Platinum analogues (cisplatin and carboplatin),
Taxanes (paclitaxel, docetaxel),
Vinca alkaloids (vinblastine and vindesine),
Doxorubicin,
Gemcitabine,
Vinorelbine,
Irinotecan (CPT-11), and etoposide (VP-16)
43. Complications
Superior vena cava syndrome oncologic complication
caused by obstruction of major blood vessels draining
the head, neck, and upper torso.
Hypercalcemia commonly from bone metastasis.
Syndrome of inappropriate antidiuretic hormone with
hyponatremia and abnormal water retention
46. Nursing Assessment
Determine onset and duration of coughing, sputum
production, and the degree of dyspnea. Auscultate for
breath sounds. Observe symmetry of chest during
respirations.
Take anthropometric measurements: weigh patient,
review laboratory biochemical tests, and conduct
appraisal of 24-hour food intake.
Ask about pain, including location, intensity, and
factors influencing pain.
48. Nursing Diagnoses
Ineffective Breathing Pattern related to obstructive
and restrictive respiratory processes associated with
lung cancer
Imbalanced Nutrition: Less Than Body Requirements
related to hypermetabolic state, taste aversion,
anorexia secondary to radiotherapy/chemotherapy
Acute or Chronic Pain related to tumor effects,
invasion of adjacent structures, toxicities associated
with radiotherapy/chemotherapy
Anxiety related to uncertain outcome and fear of
recurrence
49. Improving Breathing Patterns
Prepare patient physically, emotionally, and
intellectually for prescribed therapeutic program.
Elevate head of bed to promote gravity drainage and
prevent fluid collection in upper body (from superior
vena cava syndrome).
Teach breathing retraining exercises to increase
diaphragmatic excursion with resultant reduction in
work of breathing
50. Contd…
Give prescribed treatment for productive cough
(expectorant, antimicrobial agent) to prevent
thickened or retained secretions and subsequent
dyspnea.
Augment the patient's ability to cough effectively.
Splint chest manually with hands.
Instruct patient to inspire fully and cough two to three
times in one breath.
Provide humidifier/vaporizer to provide moisture to
loosen secretions.
Support patient undergoing removal of pleural fluid
(by thoracentesis or tube thoracostomy) and
instillation of sclerosing agent to obliterate pleural
space and prevent fluid recurrence.
51. Contd…
Administer oxygen by way of nasal cannula as
prescribed.
Encourage energy conservation through decreasing
activities.
Allow patient to sleep in a reclining chair or with head
of bed elevated if severely dyspneic.
Recognize the anxiety associated with dyspnea; teach
relaxation techniques.
52. Improving Nutritional Status
Emphasize that nutrition is an important part of the
treatment of lung cancer.
Encourage small amounts of high-calorie and high-
protein foods frequently, rather than three daily meals.
Suggest eating major meal in the morning if rapidly
becoming satiated and feeling full are problems.
Ensure adequate protein intake milk, eggs, chicken, fish,
cheese, and oral nutritional supplements if patient
cannot tolerate meats or other protein sources.
53. Contd..
Administer or encourage prescribed vitamin
supplement to avoid deficiency states, glossitis, and
cheilosis.
Change consistency of diet to soft or liquid if patient
has esophagitis from radiation therapy.
Give enteral or total parenteral nutrition for
malnourished patient who is unable or unwilling to
eat.
54. Controlling Pain
Take a history of pain complaint; assess presence/absence
of support system.
Administer prescribed drug, usually starting with
nonsteroidal anti-inflammatory drugs (NSAIDs) and
progressing to adjuvant analgesic and opioid agents.
Administer regularly to maintain pain at tolerable level.
Titrate to achieve pain control.
Consider alternative methods, such as cognitive and
behavioral training, biofeedback, relaxation, to increase
patient's sense of control.
55. Contd…
Evaluate problems of insomnia, depression, anxiety,
and so forth that may be contributing to patient's pain.
Initiate bowel training program, because constipation
is a adverse effect of some analgesic/opioid agents.
Facilitate referral to pain clinic/specialist if pain
becomes refractory (unyielding) to usual methods of
control.
56. Minimizing Anxiety
Realize that shock, disbelief, denial, anger, and
depression are all normal reactions to the diagnosis of
lung cancer.
Try to have the patient express concerns; share these
concerns with health professionals.
Encourage the patient to communicate feelings to
significant people in his life.
57. Contd..
Expect some feelings of anxiety and depression to
recur during illness.
Encourage the patient to keep active and remain in the
mainstream. Continue with usual activities (work,
recreation, sexual) as much as possible.
58. Patient Education and Health
Maintenance
Teach patient to use NSAID or other prescribed
medication as necessary for pain without being overly
concerned about addiction.
Help the patient realize that not every ache and pain is
caused by lung cancer; some patients do not
experience pain.
Tell the patient that radiation therapy may be used for
pain control if tumor has spread to bone.
59. Contd…
Advise the patient to report new or persistent pain; it
may be due to some other cause such as arthritis.
Suggest talking to a social worker about financial
assistance, or other services that may be needed
60. Evaluation: Expected Outcomes
Performs self-care without dyspnea
Eats small meals four to five times per day; weight
stable
Reports pain decreased from level 6 to level 2 with
medication
Verbalizes anger; practices relaxation techniques
61. References
Chintamani, Lewis, Heitkemper, Dirksen, O’Brien and
Bucher. (2011). Lewis’s Medical Surgical Nursing:
Assessment and Management of Clinical Problems. (7th
Ed.). Mosby. P 578
Black, J.M., Hawks, J.H., & Annabelle, M.K. (2005).
Medical-Surgical Nursing-clinical management for
positive outcomes.(6th ed.). 1611
Suzanne C. S., Brenda G. B., Janice L. H. , and Kerry H.
C. Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing.(11th ed). 554
Lippincott Manual of Nursing Practice. (2010).William
And Wilkins.Nineth edition.304
