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CNA Oncology Certification > Lung Cancer > Flashcards

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
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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
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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
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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
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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
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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
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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)

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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

  1. mediastinoscopy (gold standard for lymph node evaluation) done in general anesthesia, outpatient setting. Incision in suprasternal notch to sample most mediastinal lymph nodes
  2. 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
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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

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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

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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
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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
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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
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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
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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
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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

  1. they progress from non-invasive metaplasia & dysplasia to carcinoma in situ
  2. 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
Q

What are the main characteristics of large cell carcinoma (NSCLC)?

A
  • 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
Q

What is the clinical presentation of NSCLC cancers?

A
  • 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
Q

What are the prognostic factors (of survival) in patients with NSCLC?

A
  • 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
Q

How is treatment determined for NSCLC?

A
  • 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
Q

What is the role of surgery in treating NSCLC?

A
  • 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
Q

What are the main types of surgeries in NSCLC?

A
  • 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
Q

What are the nursing considerations towards post-op surgical patients with NSCLC?

A
  • 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
Q

What is the role of adjuvant chemotherapy in stage I-IIIA NSCLC?

A
  • given as adjuvant chemotherapy post-op to prevent recurrence
  • cisplatin & platinum based chemo in stage I-II postop resection
33
Q

What is the role of neo-adjuvant chemotherapy in stage I-IIIA NSCLC?

A
  • given to downstage the disease prior to surgery and decrease perioperative tumor seeding
  • needs further research for this in early stage NSCLC
34
Q

What is the role of chemotherapy in advanced stage NSCLC?

A
  • 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

CNA Oncology Certification (5 decks)

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