Transcript Egan`s_Lung_CA

Chapter 28
Lung Cancer
Objectives
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Describe the epidemiology of lung cancer in the
United States, particularly current trends.
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Describe risk factors for lung cancer.
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Describe the classification of lung cancer types and
the cellular features of the four common types of lung
cancer.
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Describe current understanding of the
pathophysiology of lung cancer.
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Objectives (cont.)
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Describe the clinical features of the common
types of lung cancer.
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Describe the diagnostic approach to lung
cancer.
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Describe the staging system for lung cancer.
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Objectives (cont.)
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Describe the treatment and outcomes for the
common types of lung cancer by stage.
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Describe the role of the respiratory therapist
in managing patients with lung cancer.
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Epidemiology
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In 2006, there were ~175,000 new cases of lung
cancer in the United States.
Second most common type of cancer in men and
women
WHO estimates ~2 million cases of lung cancer per
year.
It is the leading cause of cancer-related death.
85–90% of patients have a smoking history.
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Epidemiology (cont.)
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Lung Cancer Classification
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Classified as small cell or non–small cell carcinoma
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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
Small cell lung carcinoma (SCLC): ~20% of U.S.
cases
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Pathophysiology
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Poorly understood
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Genetic material in lung cells damaged secondary to
exposure to carcinogens, i.e., those in tobacco
smoke
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There may be a genetic predisposition.
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The more genetic activation of the following pathways
occurs; more likely, lung cancer’s growth is
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Stimulation of cell growth, differentiation, apoptosis,
angiogenesis, tumor progression, immune regulation
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Clinical Features
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Diagnosis
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~85% of patients will be symptomatic (see Box 28-2).
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Remainder detected by radiographic evaluation
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Chest radiograph and CT scan initial evaluation
Will show nodules (<3 cm) and masses (>3 cm)
Other findings: enlarged lymph nodes, effusions
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If radiograph, symptoms, history are very suggestive
of malignancy may move straight to surgery
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If unsure if malignant or benign, further testing
indicated
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Diagnosis (cont.)
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Adjunct imaging
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PET scan
• Malignant cells are very metabolically active, take up
radioactive glucose, scan reveals spots
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SPECT and contrast-enhanced CT used less often
Nonsurgical tissue biopsy obtained by:
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Flexible bronchoscopy (FB): large airway growths
• Saline washings, brushings, needle or forceps biopsy
 Transthoracic needle biopsy: peripheral masses
• Shielded needle guided by fluoroscopy or CT
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Staging
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The staging of NSCLC is based on the TNM staging
system (T: tumor, N: lymph node, M: metastases)
“T” component of staging (extent of primary tumor)
T1: 3 cm without invading local tissue
T2: >3 cm may invade pleura or extend into
bronchus, may cause segmental or lobar atelectasis
T3: any size extends into surrounding structures,
excluding main mediastinal structures.
T4: any size invading mediastinal structures or
presence of malignant pericardial or pleural
effusion
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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
“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.)
Staging of SCLC
 Divided into two groups
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Limited: cancer is confined to one hemithorax.
• Includes ipsilateral mediastinal and supraclavicular
nodes
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Extensive: cancer has spread beyond the original
hemithorax.
As staging guides therapy, it is important to
determine the correct stage.
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Staging (cont.)
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Determination of staging for all lung cancers:
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CT of chest and upper abdomen is ordered for all.
MRI only superior to CT scan for a 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 and mediastinal
dissection.
Patient performance status is important in determining
prognosis and ability to tolerate surgery.
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Screening for Lung Cancer
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Due to the high proportion of patients who present
with advanced lung cancer and its associated
mortality, screening is very attractive.
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Techniques
 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 and Outcomes
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Prognosis for NSCLC
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