Lung cancer.pptx

Lung cancer is the leading cause of cancer incidence and cancer death for both men and women.
Malignant chest tumor can be primary, arising within the lung, chest wall, or mediastinum, or it can be a metastasis from a primary tum or site elsewhere in the body.In approximately 70 percent of the patient with lung cancer disease has spread to regional lymphatic and other sites by the time of diagnosis

1. Lung cancer 7/11/2022 1

2. Outlines of seminar Introduction of benign lung tumour Introduction of carcinoma of lungs Etiology Clinical features Diagnostic investigations Staging Management Nursing management 7/11/2022 2

3. Benign Lung Tumors Benign growths are not necessarily harmless, even though this is implied by the name. Unlikely to spread, but they can become cancerous and they can also impair lung function. Benign tumours of the lung are uncommon and account for fewer than 15% of solitary lesions seen on chest radiographs. A peripheral tumour usually causes no symptoms until it is large; a central tumour may present with haemoptysis and signs of bronchial obstruction while small. A tumour is likely to be benign if it has not increased in size on chest radiographs for more than 2 years or it has some degree of calcification 7/11/2022 3

4. common types of benign lung tumors: Hamartomas   ( chondroadenomas )  most common type of benign lung tumor and the third most common cause of solitary pulmonary nodules. These firm marble like tumors are made up of tissue from the epithelial tissue as well as tissue such as fat and cartilage. They are usually located in the periphery of the lung . Usually appear in chest X-rays as a coin-like round growth. 7/11/2022 4

5. Bronchial adenomas   make up about half of all benign lung tumors. They are a diverse group of tumors that arise from mucous glands and ducts of the windpipe or large airways of the lung. A mucous gland adenoma is an example of a true benign bronchial adenoma. 7/11/2022 5

6. Bronchopulmonary carcinoid tumours These carcinoid tumours are derived from the neuroendocrine cells of bronchial glands. Most (80%) are found in the major bronchi and are characteristically slow growing and highly vascular. They are currently classified within a spectrum of neuroendocrine tumours . Most behave in a benign way; however, approximately 15% metastasize . Surgical excision is preferred.   7/11/2022 6

7. Rare neoplasms  may include chondromas , fibromas, lipoma, leiomyomas, hemangiomas. 7/11/2022 7

8. Causes of Benign Lung Tumors An infectious fungus ( histoplasmosis, cryptococcosis , or aspergillosis) Tuberculosis (TB) A lung abscess Smokers are at higher risk than non-smokers . 7/11/2022 8

9. Wegener granulomatosis ( multisystem autoimmune ) Sarcoidosis Birth defects such as a lung cyst or other lung malformation. 7/11/2022 9

10. S ymptoms of benign lung tumors Often there are no symptoms that a benign lung tumor is present. More than 90% are found by accident, when a patient receives a chest X-ray or CT scan for some other reason. If symptoms do appear, they may include: Persistent coughing or wheezing Shortness of breath or difficulty breathing Coughing up blood Rattling sounds in the lungs Higher likelihood of pneumonia Lung tissue collapse 7/11/2022 10

11. Diagnosis History and Physical exam Taking repeated X-rays, over a period of two years, shorter if the nodule is smaller than 6 millimeters and patient’s risk is low. If the nodule remains the same size for at least two years, it is considered benign (benign lung nodules grow slowly but cancerous nodules, on average double in size every four months). 7/11/2022 11

12. Positron emission tomography (PET) scan and CT Scan: Magnetic resonance imaging (MRI ) Biopsy Other tests: Blood tests, Tuberculin skin test to check for TB 7/11/2022 12

13. Treatment of Benign Lung Tumors B enign lung tumors require no treatment. It is wise, however, to monitor the tumor over at least a two-year period in order to note any changes that might indicate the presence of cancer. A biopsy or surgical removal of a tumor may be needed when: The patient is a smoker. The patient has difficulty breathing, or other troubling symptoms. Tests show that cancer could be present. The nodule continues to grow. 7/11/2022 13

14. Cancer of lungs Lung cancer is the leading cause of cancer incidence and cancer death for both men and women. Malignant chest tumor can be primary, arising within the lung, chest wall, or mediastinum, or it can be a metastasis from a primary tumor site elsewhere in the body . In approximately 70 percent of the patient with lung cancer disease has spread to regional lymphatic and other sites by the time of diagnosis. 7/11/2022 14

15. Primary lung cancer Lung cancer is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Most cancers that start in the lung, known as primary lung cancers, are carcinomas i.e. malignancies that arise from epithelial cells. 7/11/2022 15

16. Types Based on the size and appearance of the cancer cells, lung cancer is classifies as: Small Cell Lung cancer (SCLC ) Non Small Cell Lung cancer (NSCLC) Secondary or Metastatic lung cancers 7/11/2022 16

17. Small Cell Lung cancer (SCLC ) Also called oat-cell carcinoma because of the packed nature of small dense cells, begins in the larger airways and becomes sizeable. The oat cells contain dense neurosecretory granules vesicles containing neuroendocrine hormones . These cancers grow quickly and spread early in the course of the disease. Sixty to seventy percent have metastatic disease at presentation. 7/11/2022 17

18. Most small cell cancers arise in the major bronchi and spread by infiltration along the bronchial wall This type of lung cancer is strongly associated with smoking. These represent about 20% of all lung cancer. The tumours are very responsive to chemotherapy but carries a worse prognosis as they tend to metastasize early to lymph nodes and by blood-borne spread. 7/11/2022 18

19. Non Small Cell Lung Cancer (NSCLC ) Non–small cell lung carcinoma (NSCLC) represents approximately 80% of tumors The three main subtypes of NSCLC are:   Adenocarcinoma : Nearly 40% of lung cancers are adenocarcinoma, which begin in the alveolus S quamous cell carcinoma : Accounts for about 20 - 30% of lung cancers which typically occur close to bronchi. Large-cell carcinoma : About 15% of lung cancers are large-cell carcinoma. These are so named because the cancer cells are large, with excess cytoplasm, large nuclei and noticeable nucleoli. 7/11/2022 19

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21. Secondary or Metastatic lung cancers Secondary lung cancers (or lung metastases ) are tumors which have spread to the lung from another cancer somewhere else in the body. The lung is a common site for metastasis from other cancers. This is because all blood flows through the lungs and may contain tumour cells from any other part of the body. Tumors of the breast, prostate, colon and bladder commonly metastasize to the lung. 7/11/2022 21

22. Etiology Cigarette Smoking- People who smoke is 10 times more likely to develop lung cancer than non smoker . Smoking accounts for about 85% of lung cancer cases. Passive smoking- Research has shown that non-smokers who reside with a smoker have a 20- 30 % increase in risk for developing lung cancer when compared with other non-smokers. Marijuana smoke contains many of the carcinogens as those in tobacco smoke. 7/11/2022 22

23. Occupational Exposure to asbestos, radon gas , radiation. Air pollution: chemicals released from the burning of fossil fuels, motor vehicle emissions. I ndoor air pollution related to the burning of wood, dung or crop residue for cooking and heating. Women who are exposed to indoor coal smoke have about twice the risk and a number of the by-products of burning biomass 7/11/2022 23

24. Preexisting Lung Damage Genetic predisposition: Some familial predisposition to lung cancer seems apparent, because the incidence of lung cancer in close relatives of patients with lung cancer appears to be two to three times that in the general population regardless of smoking status. 7/11/2022 24

25. Pathogenesis Lung cancer is initiated by activation of oncogenes or inactivation of tumor suppressor genes. Carcinogens cause mutations in these genes which induce the development of cancer Mutations in the K- ras proto-oncogene are responsible for 10–30% of lung adenocarcinomas The epidermal growth factor receptor (EGFR) regulates cell proliferation, apoptosis, angiogenesis, and tumor invasion. . Mutations and amplification of EGFR are common in non-small-cell lung carcinoma. 7/11/2022 25

26. Lung cancers arise from a single transformed epithelial cell , in which the carcinogen binds to and damages the cell’s DNA. This damage results in cellular changes , abnormal cell growth, and eventually a malignant cell . As the damaged DNA is passed on to daughter cells, the DNA undergoes further changes and becomes unstable. With the accumulation of genetic changes, the pulmonary epithelium undergoes malignant transformation from normal epithelium eventually to invasive carcinoma. Carcinoma tends to arise at sites of previous scarring (TB, fibrosis) in the lung 7/11/2022 26

27. Clinical features Often, lung cancer develops insidiously and is asymptomatic until late in its course . Clinical features of lung carcinoma depend on : the site of the lesion ; the invasion of neighbouring structures; the extent of metastases. The most frequent symptom of lung cancer is chronic cough . The cough may start as a dry, persistent cough, without sputum production. Haemoptysis occurs in fewer than 50% of patients presenting for the first time. 7/11/2022 27

28. Dyspnea due to occlusion of the airway or lung parenchyma by tumour , pleural effusion, pneumonia, or complications of treatment wheezing  or shortness of breath Chest or shoulder pain may indicate chest wall or pleural involvement by a tumor. Pain also is a late manifestation Systemic symptoms: weight loss, anorexia, fever, clubbing of the fingernails or fatigue 7/11/2022 28

29. R epeated unresolved upper respiratory tract infections . Pleural fluid is an ominous feature and the presence of blood in a pleural effusion suggests that the pleura has been directly invaded. Invasion of the mediastinum may result in hoarseness (because of recurrent laryngeal nerve involvement), dysphagia (because of the involvement of, or extrinsic pressure on, the oesophagus ) and superior venecaval obstruction . 7/11/2022 29

30. TNM staging Primary tumour (T ) TX : Tumour proven by the presence of malignant cells and bronchial secretions, but not visualised by radiography or bronchoscopy T0 : No evidence of primary tumour TIS : Carcinoma in situ T1 : A tumour that is 3 cm or less in greatest dimension, surrounded by lung or visceral pleura and without evidence of invasion proximal to a lobar bronchus 7/11/2022 30

31. T2 : any of a tumour of more than 3 cm but less than or equal to 7 cm across or a tumour of any size that either invades the visceral pleura or has associated atelectasis or obstructive pneumonitis, which extends to the hilar region, but does not involve an entire lung ; at bronchoscopy, the proximal extent of demonstrable tumour must be within bronchus or at least 2 cm distal to the carina 7/11/2022 31

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33. T3 :Any of: Tumor size more than 7 cm across or Direct extension into the chest wall, diaphragm, mediastinal pleura or pericardium, without involving the heart, great vessels, trachea, oesophagus or vertebral body, or a tumour in the main bronchus within 2 cm of the carina without involving the carina or Separate tumor nodule in the same lobe 7/11/2022 33

34. T4 : A tumour of any size, with invasion of the mediastinum or involving the heart, great vessels, trachea, oesophagus , vertebral body or carina, or Separate tumor nodule in a different lobe of the same lung 7/11/2022 34

35. Nodal involvement (N) N0 : No demonstrable metastasis or regional lymph node N1 : Metastasis to lymph nodes in the peribronchial or the ipsilateral hilar region, or both, including direct extension N2 : Metastasis to the ipsilateral, mediastinal and subcarinal lymph nodes N3 : Metastasis to the contralateral mediastinal lymph nodes, contralateral hilar lymph nodes or ipsilateral or contralateral supraclavicular lymph nodes 7/11/2022 35

36. Distant metastasis (M) M0 : No known distant metastasis M1 : Distant metastasis present 7/11/2022 36

37. Stages of lung cancer Stage IA ( T1N0M0) Cancer is limited to the lung and hasn't spread to the lymph nodes. The tumor is generally 3 centimeters or less in diameter with no metastasis. Stage IB : T2N0M0. A tumour of more than 3 cm but less than or equal to 7  cm or a tumour of any size that either invades the visceral pleura or has associated atelectasis or obstructive pneumonitis, which extends to the hilar region ,; however there is no metastasis to lymph nodes or distant sites. 7/11/2022 37

38. Stage IIA: T1N1M0 A tumour that is 3 cm or less in greatest dimension with metastasis to the nearby lymph nodes without distant metastasis. Stage IIB : T2N1M0 A tumour of more than 3 cm but less than or equal to 7 cm or a tumour of any size that either invades the visceral pleura or has associated atelectasis or obstructive pneumonitis, which extends to the hilar region with metastasis to the nearby lymph nodes without distant metastasis. 7/11/2022 38

39. Stage IIIA: T3N0M0 , T3N1M0, T1-3N2M0 The tumor at this stage may have grown very large and invaded other organs near the lungs or this stage may indicate a smaller tumor accompanied by cancer cells in lymph nodes farther away from the lungs . Stage IIIB: Any T N3 M0 T4 Any N M0 7/11/2022 39

40. 7/11/2022 40 Stage IV:   Any T Any N M1. Cancer has spread beyond the affected lung to the other lung or to distant areas of the body.

41. Diagnostic Findings Medical History and Physical Examination for Lung Cancer   Chest radiography - An X-ray image of lungs may reveal an abnormal   pulmonary nodule (coin lesion), atelectasis, and infection . CT scan 7/11/2022 41

42. Positron emission tomography Sputum cytology Bronchoscopy :  to diagnose and determine the extent of lung cancer. Biopsy Percutaneous needle aspiration  of peripheral tumors may be done under the guidance of fluoroscopy or CT Scan.   7/11/2022 42

43. Mediastinotomy and Mediastinoscopy - for direct visualisation and to obtain biopsy samples from lymph nodes in the mediastinum. If surgery is a potential treatment, Pulmonary function tests, arterial blood gas analysis, V/Q scans , and exercise testing may all be used as part of the preoperative assessment. 7/11/2022 43

44. The more commonly used tumor markers in lung cancer are CEA , and sometimes CA-125. There is no any real role for tumor markers in lung cancer. 7/11/2022 44

45. Treatment of Lung Cancer Medical management Treatment depends on the cell type, the stage of the disease, and the patient’s physiologic status (particularly cardiac and pulmonary status). In general, treatment may involve surgery, radiation therapy, or chemotherapy—or a combination of these. 7/11/2022 45

46. Chemotherapy Chemotherapy is used to alter tumor growth patterns, to treat distant metastases or small cell cancer of the lung, and as an adjunct to surgery or radiation therapy. Chemotherapy may provide relief, especially of pain, but it does not usually cure the disease. Chemotherapy may be administered before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy ). Combinations of two or more medications may be more beneficial than single-dose regimens. 7/11/2022 46

47. Small-cell lung carcinoma (SCLC), even relatively early stage disease, is treated primarily with chemotherapy and radiation . In SCLC, cisplatin and etoposide are most commonly used . Combinations with carboplatin, gemcitabine, paclitaxel, vinorelbine , topotecan , and irinotecan are also used 7/11/2022 47

48. In advanced non-small cell lung carcinoma (NSCLC), chemotherapy improves survival and is used as first-line treatment, provided the person is well enough for the treatment. Typically, two drugs are used, of which one is often platinum-based (either cisplatin or carboplatin). Other commonly used drugs are gemcitabine, paclitaxel, docetaxel, etoposide or vinorelbine Chemotherapy before surgery in NSCLC that can be removed surgically also appears to improve outcome. 7/11/2022 48

49. Radiotherapy Radiotherapy is often given together with chemotherapy, and may be used with curative intent in people with NSCLC who are not eligible for surgery . Irradiation 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 . For potentially curable SCLC cases, chest radiotherapy is often recommended in addition to chemotherapy. 7/11/2022 49

50. For both NSCLC and SCLC patients, smaller doses of radiation to the chest may be used for symptom control (palliative radiotherapy) Prophylactic cranial irradiation (PCI) is a type of radiotherapy to the brain, used to reduce the risk of metastasis. PCI is most useful in SCLC. 7/11/2022 50

51. 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. If the patient’s cardiovascular status, pulmonary function , and functional status are satisfactory, surgery is generally well tolerated. Surgery is primarily used for NSCLCs, because small cell cancer of the lung grows rapidly and metastasizes early and extensively . 7/11/2022 51

52. The most common surgical procedure for a small, apparently curable tumor of the lung is: lobectomy (removal of a lobe of the lung). In some cases, an entire lung may be removed (pneumonectomy) Wedge resection to remove a small section of lung that contains the tumor along with a margin of healthy tissue. Segmental resection to remove a larger portion of lung, but not an entire lobe (bronchioles and its alveoli). 7/11/2022 52

53. Thoracoscopic lung resection Laser surgery is used. This involves the delivery of laser light inside the airway via a bronchoscope to remove the obstructing tumor Chest tube insertion Lung Transplantation 7/11/2022 53

54. Targeted therapy Several drugs especially for the treatment of advanced disease in lung cancer are used. Erlotinib , gefitinib and afatinib inhibit tyrosine kinase at the epidermal growth factor receptor. 7/11/2022 54

55. Complications of Lung Cancer Pleural effusion Superior vena cava syndrome Atelectasis and pneumonia Metastasis Surgical complications and prolonged mechanical ventilation Pulmonary toxicity Complication of treatment 7/11/2022 55

56. Nursing Management Assessment Assess and document respiratory rate and depth, skin and mucous membrane color, lung sounds, cough and sputum amount and character. Ask the patient to rate the degree of pain and dyspnea on appropriate scales. Ask about appetite and weight loss, as well as symptoms of other complications. Note activity tolerance and fatigue. In addition, the patient may be grieving about his or her illness and impending death. Assessment of the patient’s coping strategies and support systems 7/11/2022 56

57. Nursing Diagnosis Impaired gas exchange related to advanced disease condition. Ineffective airway clearance related to pain, fatigue and shortness of breath. Pain related to cancer mass compressing on adjacent structures Imbalanced nutrition less than body requirements related to low appetite Altered bowel habit(constipation) related to opioid use, side effects of chemotherapy. Anxiety/grief related to disease condition. Activity intolerance related to surgery, shortness of breaths. 7/11/2022 57

58. Relieving Breathing Problems Oxygen therapy may be necessary to relieve dyspnea. Positioning, relaxation and breathing exercises can help reduce dyspnea and feelings of panic . Anti anxiety drugs or morphine may also be helpful to reduce pain and discomfort. Resting between activities reduces the demand for oxygen. Encourage the patient to avoid smoking and exposure to secondary smoke . Bronchodilator medications may be prescribed to promote bronchial dilation. 7/11/2022 58

59. Maintaining effective airway A clear airway can be promoted with a room humidifier and oral fluids to reduce viscosity of secretions Nonproductive cough can be treated with an antitussive as ordered by the physician. Instruct the patient to notify the physician if hemoptysis is persistent. Exposure to powders, tobacco smoke, and aerosols increases airway irritation and should be eliminated. Help to perform deep-breathing exercises, chest physiotherapy, directed cough Suctioning may be necessary if the patient becomes too weak to cough effectively. 7/11/2022 59

60. Maintaining nutritional balance Nutrition can be maintained by eating frequent small meals. Nutritional supplements that are high in calories but easy to eat or drink may be used. A dietician consultation is helpful. Antiemetics before meals may help control nausea. Mints may help reduce the metallic taste left in the mouth by some chemotherapeutic medications. Good mouth care is essential and should be encouraged to patient. Total parenteral nutrition may be necessary late in the disease. 7/11/2022 60

61. R elieving pain and constipation Pain is controlled by opioids and supportive noninvasive therapies . Prevent constipation with the use of high fiber foods and extra fluids if tolerated. If these conservative measures are ineffective, request an order for a bulk forming agent, stool softener or laxative. 7/11/2022 61

62. Promoting activities tolerance Fatigue is prevented with frequent rest periods and assistance with activities of daily living. Encourage the patient to identify and engage in those activities that are most important to him or her and to avoid unnecessary or undesirable activities . Assume comfortable position. 7/11/2022 62

63. P roviding Psychological Support The patient who is grieving should be allowed the opportunity to talk about his or her life and impending death and to express anger or sadness. Do not force verbalization unless the patient wishes to talk. Encourage the family to stay with the patient as much as the patient wishes. Contact a spiritual counselor if the patient desires a referral. Hospice care is available for the patient who has a terminal condition. This allows the family to have the support needed to care for the patient in his or her home or a homelike environment. 7/11/2022 63

64. Pre operative care Reduce the clients anxiety level. Assess clients and family understanding about the disease condition and surgery, prognosis and provide further information. Explain that chest tubes, drain, oxygen therapy, intubation and ventilation may be required. Teach post operative exercises including use of spirometry, deep breathing and coughing exercises, leg exercise. General care as in other surgery. 7/11/2022 64

65. Post operative Care Maintain closed chest drainage Assess chest drainage. Measure and document the amount of drainage coming from pleural space in the collection chamber. 500 -1000 ml of drainage may occur in the first 24 hours .100- 300 ml may accumulate during first 2 hours, after this the drainage lessens. Monitor vital signs. Check fluid patency in collection chamber . 7/11/2022 65

66. References Black, J M. (2010). Medical Surgical Nursing .8 th ED. Philadelphia: Saunders An imprint of Elsevier Smeltzer , SC. Bare, B. (2010) . Textbook of medical surgical nursing. 12th edition. Philadelphia: Lippincott Williams and Wilkins. Mosby . comprehensive review of nursing . 60 th edition. India: An imprint of Elsevier Davidson’s (2014). clinical practice of medicine. 21 st edition. India: Elsevier http://my.clevelandclinic.org/health/articles/benign-lung-tumors 7/11/2022 66