Lung Cancer Flashcards
1
Q
What are the main etiology and risk factors of lung cancer?
A
- smoking (87%+ of all lung cancer deaths)
- passive smoking (2nd hand smoke)
- Asbestos
- Radon
- occupational hazards & air pollution
- genetic susceptibility
- diet (not proven yet)
- advanced age
- race, being black
2
Q
What are the main methods of detection & screening lung cancer?
A
- CT scans > CXR
- sputum cytology (but needs 3 samples and only detects centrally located tumors with hemoptysis)
- Bronchoscopy - only for pre-invasive tumors
3
Q
What are the key components in assessing lung cancer patients?
A
- OPQRST & symptoms experienced - fully assess the location, severity, duration, quality, provocation/ alleviating factors, & ability to manage symptoms
- functional & fitness level decrease - lung ca & treatment has a negative effect d/t the fatigue & SOB it causes
- Cognitive deficits - esp verbal memory & frontal lobe executive functions
- emotional distress esp depression - profound in lung ca
- past medical history & any exposure to risk factors - eg. treatment for any previous respiratory factors
- physical H2T exam w/ emphasis on pulmonary & lympathic systems
4
Q
What are abnormal findings to look for in a physical assessment of a lung cancer patient?
A
- respiratory compromise - altered LoC & mental status, nasal flaring, cyanosis of mucous membranes & nailbeds, use of accessory muscles, asymmetrical use of chest wall muscle to breath, tripod position, asymmetry of trachea
- palpate, auscultate, percuss for complications of lung cancer eg. pleural effusion, pericardial effusion, pneumothorax, COPD, asthma, bronchitis, pneumonia
- palpate lymphatic nodes and abdomen for enlarged spleen or liver
- back pain, spine pain for metastatic disease
5
Q
What are the non-invasive diagnostic studies used in lung ca?
A
- Lab work - CBC, lytes, liver panel, chemistry profile
- CT chest - effective d/t the highly vascularized nature of lung cancers
- CXR - assess the primary tumor & any other pulmonary abnormalities, lymph node & bony involvement, liver or adrenal invasion
- MRI for mets
- bone imaging for bone mets
- PET scan - detects lung ca based on the difference in glucose usage in ca cells vs normal cells (higher in lung ca cells). Use PET in conjunction w/ CT chest esp to distinguish resectable stage IIIA vs non-resectable stage IV NSCLC
- ECG & PFT if needed, eg. for chest radiotherapy
6
Q
What are the invasive diagnostic studies used in lung cancer? (Primary tumor)
A
Tissue sampling is necessary to dx the type of ca (eg. SCLC vs NSCLC). Tissue sampling used:
- sputum cytology (only for centrally located tumors w/ hemoptysis)
- bronchoscopy to collect tissue
- transthoracic needle aspiration for large primary tumors (2cm+) and peripheral nodules that can’t be reached by bronchoscopy
- thoracoscopy/thoracotomy - 1st procedure for non-met, small inaccessible tumor or sus pumonary nodule found on CT/PET scan
7
Q
Why is it important to evaluate mediastinal lymph nodes in lung ca?
A
Evaluation of mediastinal lymph nodes greatly affects prognosis & whether or not it is operable (IIIA) or in-operable (IIIB)
8
Q
What are the diagnostic studies for mediastinal lymph nodes for lung cancer patients?
A
depending on lymph node size (CT, endoscopy ultrasound) or metabolism (PET) but not definitive dx. biopsy for 1cm+ lymph nodes on CT or (+) FDG-PET
- mediastinoscopy (gold standard for lymph node evaluation) done in general anesthesia, outpatient setting. Incision in suprasternal notch to sample most mediastinal lymph nodes
- endobrachial ultrasound - biopsy needle is passed through the working channel of an endoscope through the esophageal wall and guided w/ ultrasound towards nodes of interest
9
Q
What are the diagnostic studies for metastatic lung disease?
A
FDG-PET scan - when no sign of metastatic disease on CT chest
- adrenal gland/liver biopsy for suspective met disease in operable patients
10
Q
What are the 2 & 4 main types of lung ca?
A
- Small cell (SCLC) vs Non-Small Cell Lung ca (NSLC)
- SCLC and 1. squamous cell carcinoma 2. adenocarcinoma 3. large cell carcinoma (3 types of NSLC) = 4 major types
11
Q
What is SCLC and what distinguishes it from the other types of lung ca?
A
- rapid cell growth, tendency to spread - 60% met disease on dx - w/ poor prognosis (2-4 month survival if untreated); overall survivorship w/ chemotherapy is 5-10% - great sensitivity to chemotherapy
- arises from Kulchitsky’s cell (a type of neuroendocrine cells) in the basal cell lining in the bronchia mucosa that secretes peptide hormones
- 3 types - 1. SCLC 90% of SCLCs 2. mixed cell & large cell variant 3. combined small and non-small cell carcinoma
- arises in a central endobronchial location
12
Q
How does SCLC present itself?
A
Symptoms
- weight loss, anorexia, fatigue
- cough, dyspnea, wheezing & hemoptysis
Complications:
- post-obstructive pneumonia & atelectasis
- hilar adenophathy (ie. enlargement of lymph nodes in the pulmonary hila)
- Superior vena cava syndrome (RARE)
- compression of mediastinal structures eg. laryngeal nerve -> hoarseness, esophagus -> dysphagia
- paraneoplastic syndrome d/t secreted neuropeptide hormones 1. proximal muscle weakness (Eaton-Lambert Syndrome) 2. hyponatremia from SIADH 3. Cushing syndrome from ACTH 4. various neurologic syndromes
13
Q
What are the clinical manifestations of distant mets of SCLC?
A
- CNS - headache, seizures, visual disturbances
- liver - jaundice, asymptomatic elevations in liver enzymes
- bone marrow - decreased CBCs
14
Q
What is paraneoplastic syndrome?
A
- group of rare disorders that occur when the body (ie. nervous system) respond to a neoplasm
- It is what happens when the nervous system mistakenly attacks nervous cells instead of cancer cells w/ T-cells
- often happens in middle aged or older patients
15
Q
How is SCLC staged?
A
- 2 stage system - limited vs extensive disease
- limited disease (LD) = tumor confined to one hemithorax of origin, mediastinum, supraclavicular nodes (no universal definition tbh); any person with 2 year disease free survivorship
- extended disease (ED) - any disease not captured by the LD definition; any disease w/ distant mets
16
Q
What affects the prognosis of SCLC?
A
LD
- hgb level & total WBC
- performance status –> affects survival, duration & degree of response
- neuron-specific enolase biomarker (positive prognosis for survival)
ED
- lactate levels
- performance status
- weight loss,
- mets - #, liver or brain mets, nodal involvement –> affects survival, duration & degree of response
positive prognosis factors:
- female –> more likely to get CR
- complete response (CR) to treatment
- early stage of disease & good performance status
- normal ALP, LD levels
- thoracic irradiation
poor prognostic factors:
- 60 y/o+
- weight loss
17
Q
When is the role of surgery in SCLC?
A
- primarily used for stage I LD patients w/ isolated lesions & surgical resection
- generally not used in SCLC due to how it is usually extensively spread
- adjuvant combination chemo is advised for surgically resected patients
18
Q
What is the role of chemotherapy & radiation in LD SCLC?
A
- SCLC = very chemo & radio sensitive, therefore chemotherapy + RT = standard for LD SCLC
RADIATION (RT) IN LD SCLC
- prevents local recurrence of disease by eliminating depositions of tumor cells at primary site and to palliative symptoms from LD and ED
- must minimize the toxicities/SE of RT d/t the usually large area to be irradiated d/t SCLC usually manifesting w/ LN involvement + tumor mass + atelectasis eg. esophagitis, pneumonitis and radiation myelopathy (dmg to spinal cord from rad)
- prophylactic cranial RT d/t chemo not crossing BBB to prevent brain mets - strongly recommended for LD/ED patients in CR. Not recommended w/ multiple comorbidities, poor performance status or impaired mental status. cannot be given w/ systemic chemo d/t risk of increased toxicity
CHEMO IN LD SCLC
- Concurrent CHEMO + RT = increased survival than just chemo alone. Better for young people (>55) than 75+
- optimal dosing + sequencing = controversial
- Concurrent RT + Chemo > sequential treatment
- Etoposide + Cisplatin w/ concurrent chest RT
19
Q
What is the role of chemotherapy & radiation in ED SCLC?
A
- like LD, combination chemo = standard of care for ED SCLC.
- usually platinum based chemo, sometimes sub’d with etoposide for less toxicity & better tolerability
- RT is important for palliation of symptoms caused by the tumor or mets but not used in addition to chemo
20
Q
What is the role of chemo and radiation in recurrent SCLC?
A
- most people respond to first line treatment though majority will relapse
- post relapse prognosis is poor (2-3 months)
- less than 3 month is considered to be refractory/chemoresistant and is considered for palliative care or clinical trials
- 2nd line treatment is considered for early relapsers depending on performance status, comorbidities
21
Q
how does squamous cell carcinoma develop (NSCLC)?
A
1, usually originate as central tumors in the proximal bronchi
- they progress from non-invasive metaplasia & dysplasia to carcinoma in situ
- once a carcinoma, it penetrates the basement membrane and becomes invasive - ie. metastatic
22
Q
What are the main characteristics of squamous cell carcinoma?
A
- 30% of all lung cancers
- appears as sheets of well to poorly differentiated epithelial cells
- hypercalcemia
- slow growing (goes from in situ to clinically apparent tumor in 3-4 years)
Diagnosis:
- keratin formation
- keratin pearl formation
- intercellular bridges
23
Q
What are the main characteristics of adenocarcinoma?
A
- most common type of lung cancer; most common in non-smokers`
- arises from alveolar surface of the epitheleum or bronchial mucosal glands where it produces mucin; usually in the periphery of the lung
- usually less respiratory symptoms compared to other centrally located tumors
- grow slower than SCLC but invade lymphatic & blood vessels early
24
Q
What is bronchioalveolar carcinoma (BAC) and why is it significant?
A
- uncommon type of lung adenocarcinoma that affects mostly young patients and women who are non-smokers
lesser tendencey for mets and typically better survival rate compared to adenocarcinoma
25
What are the main characteristics of large cell carcinoma (NSCLC)?
- 15% of all lung cancers
- less differentiated than other types of NSCLC
- do not exhibit glandular/squamous characteristics on light microscopy
- found in periphery of lung, invading subsegmental bronchi or larger airways
- central necrosis common
26
What is the clinical presentation of NSCLC cancers?
- starts as central or peripheral and grows within lung parenchyma or bronchia wall. When spread, airway occlusion or compression of pulmonary areas of the vasculature, nerves and alveolar structures
- mets usually to bone, liver, adrenal glands, pericardium and brain
- manifestation depends on manifestations of local tumor, regional spread and distant mets
- usually symptomatic at time of dx (usually some kind of oncologic emergency)
27
What are the prognostic factors (of survival) in patients with NSCLC?
- performance status
- early stage of disease
- no significant wt less
- female gender
- survivability from least to best: large cell > adenocarcinoma > squamous cell > BAC
- biologic markers: no p53, K-ras oncogenes, yes H-ras p231 expression
- low hgb (<100 g/l)
- tumor size >5cm
- concurrent COPD w/ worsening pulmonary function
28
How is treatment determined for NSCLC?
- stage of disease
- pt performance status
- comorbidities
- symptoms
a combination or single type of treatment (surgery, RT or chemo) depending on the status of the disease
29
What is the role of surgery in treating NSCLC?
- primary treatment for stage I & II NSCLC - cure
- some stage IIIA, usually no IIIB
- type of surgery depends on tumor location, patient comorbidites and cardiopulmonary reserve of patient
- often combined with chemo d/t high chance of systemic recurrence
30
What are the main types of surgeries in NSCLC?
- Lobectomy for removal of lobe & lymph nodes
- pneumonectomy of entire lung for centrally located tumors
- wedge resection - removal of triangle shaped piece targeting area of tumor
31
What are the nursing considerations towards post-op surgical patients with NSCLC?
- focus on pulmonary, cardiac, and pain & symptom management
- dyspnea - most common post op symptom - will be more controlled w/ increased mobility, pain control
- at risk for atrial arythmias d/t irritation of vagus nerve
- smoking cessation program pre-op
- emotional support
32
What is the role of adjuvant chemotherapy in stage I-IIIA NSCLC?
- given as adjuvant chemotherapy post-op to prevent recurrence
- cisplatin & platinum based chemo in stage I-II postop resection
33
What is the role of neo-adjuvant chemotherapy in stage I-IIIA NSCLC?
- given to downstage the disease prior to surgery and decrease perioperative tumor seeding
- needs further research for this in early stage NSCLC
34
What is the role of chemotherapy in advanced stage NSCLC?
- stage IIIB & IV not cure-able, therefore focus is on optimization of QoL since response rates & survival time is low
- must be managed w/ supportive care
- is started ASAP to prevent deterioration in performance status or weight loss
- platinum based therapy as first line, docetaxel is second line
