LUNG

CANCER
ARADHNA DEAN
M.SC NURSING
CTVS
 LUNGS
•
The lungs are paired elastic structures enclosed in the
thoracic cage, which is an airtight chamber with distensible
walls. The lungs extend from the diaphragm to just slightly
superior to the clavicles and lie against the ribs anteriorly
and posteriorly.
 SURFACES OF LUNGS
• Apex: the narrow superior surface of lung is the apex.
• Base: the broad inferior portion of lung is base.
• The coastal surface: surface of lungs lying against the ribs, the
coastal surface, matches the rounded curvature of the ribs.
• The medial surface: this surface is concave, contain a region,
the hilum, through which bronchi, pulmonary blood vessels,
lymphatic vessels and nerves enter and exit.
• 
LOBES OF LUNGS
FISSURES OF THE LUNGS
 COVERING OF LUNGS
• The lungs and wall of the thorax are lined
with a serous membrane called the pleura.
• The visceral pleura covers the lungs; the
parietal pleura lines the thorax.
• The small amount of pleural fluid between
these two membranes serves to lubricate the
thorax and lungs and permit smooth motion
of the lungs within the thoracic cavity with
each breath.
 BLOOD SUPPLY

The arterial supply is through branches of right and left

bronchial arteries and venous return is through bronchial
vein.
 FUNCTIONS:
The function of lungs is to receive air from
atmosphere through the nose and mouth and allows
the transfer of oxygen in the air passes into blood
stream.
• 
 MUSCLES ASSOCIATED IN
BREATHING
• The main muscles used in normal breathing are the intercostal
muscle and the diaphragm. During deep breathing , they are
assisted by muscle of neck, shoulder and abdomen.

• Intercostal muscles; there are 11 pairs of intercostals muscles.

They are arranged in two layers, the external and internal
intercostals muscles.
 RESPIRATORY CYCLE
• Pulmonary ventilation is a process by which gases are exchange
between the atmosphere and lung alveoli. The average respiratory
rate is 16-22 breath/min.
 
The ventilation occurs in three steps-
• Inspiration
• Expiration
• Pause
MECHANISM OF BREATHING
 LUNG CANCER
Lung cancer is the uncontrolled growth of abnormal cells
that starts off in one or both lungs. The abnormal cells do
not develop into healthy lung tissue and do not carry out the
functions of normal lung cells. Having less healthy lung
tissue makes the lungs work more, which makes it harder to
breathe.
 EPIDEMIOLOGY
According to the GLOBOCAN 2012 report, the estimated
incidence of lung cancer in India was 70,275 in all ages and both
sexes; the crude incidence rate per 100,000 was 5.6, the age-
standardized rate per 100,000(world), i.e. ASR(W) was 6.9, and
the cumulative risk was 0.85.
 CAUSES
•Most people who get lung cancer smoke or use tobacco
products.
•Exposure to second-hand smoke. People who do not smoke
can develop lung cancer from tobacco smoke in the air.
•Exposure to harmful substances such as asbestos or radon in
the environment places people at greater risk for lung cancer.
This exposure can be in the home or workplace.
SIGN AND SYMPTOMS

A cough that does not go Chest infections that do

away not go away
A change in the type of Tiredness
cough Unexpected weight loss
Chest pain with coughing No appetite
Coughing up blood
Unexplained pain in
Trouble breathing
A hoarse voice other parts of body
 
 TYPES
• Small cell lung cancer usually starts in the larger
breathing tubes, grows quickly and often spreads to other
parts of the body. It is less common.
• Non-small cell lung cancer is the most common. It
generally grows more slowly than small cell lung cancer.
THE 4 MAIN CELL TYPES OF NON-SMALL CELL
LUNG CANCER
• Squamous carcinoma – This type generally begins in the
lining of the airway in the larger breathing tubes. It tends to
spread less quickly than other forms of lung cancer.

• Adenocarcinoma – This type begins near

the outside surface of the lung. It can vary
in both size and how fast it grows.
• Bronchoalveolar – This is a type of adenocarcinoma. It
causes changes on an x-ray that are often mistaken for
an infection or pneumonia.

• Large cell carcinoma – This type may occur in any part

of the lung. However, it usually starts in the smaller
breathing tubes.
 OTHER CHEST CANCERS THAT
ARE LESS COMMON:
• Carcinoid tumors – This type of cancer is slow growing and usually starts in
the lung airways.
• Mesothelioma – This type of cancer starts in the mesothelial cells which are
on the surface of the lining of the lung, heart or abdomen (belly). This cancer
tends to be related to asbestos exposure.

• Thymoma – This type of tumor forms in the thymus gland. The gland sits
behind the breast bone in chest. Not all thymomas are cancer.
 
 STAGES OF SMALL CELL LUNG CANCER

There are two main stages of small cell lung cancer.

• Limited stage: Cancer cells are found only in one lung and
pleural space.
• Extensive stage: The cancer is in the other lung and/or other
parts of the body like the brain, bone, liver and adrenal glands.
STAGES OF NON-SMALL CELL LUNG
CANCER
It can be hard to know exactly the stage of the lung cancer.
Sometimes the stages overlap or blend together. Stages of cancer are
determined by a system called TNM:
• Tumour: the size and location of where the cancer started
• Node: lymph node (filters in the body into which cancer can
spread)
• Metastasis: where the cancer has spread (usually through the
bloodstream) Lung cancer
• Stage 0
If cancer cells are in the lung or bronchus but the cells have not formed an
actual tumor. This is also called carcinoma in situ.
• Stage 1A
Tumour is up to 3 cm. No lymph node involvement. No metastasis.  
• Stage 1B
Tumour is between 3 and 5 cm. No lymph node involvement. No metastasis.
• Stage 2A
Tumour is between 5 and 7 cm. No lymph node involvement. No metastasis.
Tumour is up to 5 cm. Local lymph nodes are involved. No metastasis.
Stage 2B
•Tumor is between 5 and 7 cm. Local lymph nodes
are involved. No metastasis.
•Tumour is more than 7 cm or spreads into nearby
structures (chest wall, diaphragm, lining around the
heart) or multiple tumors are seen in one lobe of the
lung. No lymph node involvement. No metastasis.
Stage 3A
• Any size tumor. Regional lymph nodes on the same side of the tumor are involved.
No metastasis.
• Any size tumor that spreads into some nearby structures (chest wall, diaphragm,
lining around the heart). Local and/or regional lymph nodes are involved. No
metastasis.
• Multiple tumors are seen in one lobe of the lung. Local and/or regional lymph nodes
are involved. No metastasis.
• Any size tumor that spreads into critical nearby structures (such as the heart, major
blood vessels, wind pipe). Local lymph nodes may be involved. No metastasis.
• Multipletumors in multiple lobes of the same lung. Local lymph nodes may be
involved. No metastasis.
Stage 3B
• Any size tumor. Regional lymph nodes on the side opposite of
the tumor or above the collar bone are involved. No metastasis.
• Any size tumor that spreads into critical nearby structures (heart,
major blood vessels, wind pipe, etc). Regional lymph nodes on
the same size of the tumor are involved. No metastasis.
• Multipletumors in multiple lobes of the same lung. Regional
lymph nodes on the same size of the tumor are involved. No
metastasis.
Stage 4
• Metastases (such as opposite lung, liver, bones, brain) are
found. Any size tumor. Lymph nodes may be involved.
• Tumors are found in the lining around the lungs or heart.
Fluid involved with cancer cells is found around the
lungs or heart. Any size tumor. Lymph nodes may be
involved .
 DIAGNOSTIC TESTS
• Chest x-ray
• CT or/ CAT scan
• MRI
• PET (positron emission tomography) – uses a low-dose
radioactive sugar that is injected into the body, and will help to
light up cancer cells. A PET scan, along with a CT or CAT scan,
can often inform the doctor if the cancer has spread.
• 
• BIOPSY
Needle biopsy – uses a needle to remove a small amount of fluid or
cells from the tumor or lymph nodes. These cells are examined under
a microscope for cancer. Sometimes, a needle biopsy is done by
guiding a needle under CT scan or Ultrasound scan to the area of
concern. The area where the needle is inserted is “numbed or frozen”
with a local anesthetic.
• Bronchoscopy – a doctor puts a thin tube with a small camera on the
end down airway and into lungs. This lets the doctor see and take
samples of tissues. The samples are sent to the lab to check for cancer.
• EBUS (endobronchial ultrasound) – uses sound waves to guide the doctor to take
samples of tissues from the lymph nodes found in the mediastinum area of chest. The
mediastinum is in the middle of chest behind the breast bone . The EBUS is done
with a Bronchoscopy or upper endoscopy. Client is given medication (sedative)
during this procedure.
• Mediastinoscopy – is when a small incision (cut) is made near the breast bone so the
doctor can examine the lymph nodes along the windpipe behind breast bone for
cancer or other disease.
• Thoracoscopy is a type of surgical procedure. The doctor makes a small incision
(cut) through the chest wall and uses a camera to check structures inside the chest for
cancer and take tissue samples. Client is put to sleep with a general anesthetic for this
procedure.
 MANAGEMENT
There are 3 major treatments:
•Surgery
•Systemic therapy – uses drugs that destroy or damage
cancer cells. It can include chemotherapy, targeted therapy or
immunotherapy.
•Radiation therapy
• 
 SURGERY
• Segmental or wedge resection –Indicated in
Bronchiectasis, Early Stage 1 cancer, Lung nodules,
Tuberculosis and Suppurative lesion.
• Lobectomy
• Pneumonectomy – the entire lung is removed. Indicated
in chronic lung infection, traumatic lung injury and
congenital lung disease.
• Video Assisted Thorascopic Surgery (VATS) – is a type of surgery done by placing
instruments and cameras through small holes in the chest wall, rather than having an
incision.
• The procedure is performed under general anesthesia with the patient in a lateral decubitus
position.
• A set of surgical instruments should be available on stand-by in case it is needed to convert
to thoracotomy. For minor procedures three 1 cm incisions are used for the corresponding
“ports”, thus allowing triangulation of the instruments: the camera is usually placed in the
central port and the other two are used for biopsy and retraction instruments. Various
stapling devices or the Nd: YAG lasers are invaluable adjuncts in more complex procedures.
• Contraindicated in patients with pleural effusion, obesity, increased thickness of chest wall,
narrow rib cage, a small chest or underlying conditions associated with increased bleeding,
the blood obscuring the lens, or absorbing light.
 SYSTEMIC THERAPY
Chemotherapy
• Chemotherapy uses drugs to attack and destroy cancer cells or to prevent
their growth. A single dose of chemotherapy only attacks some of the
cancer cells. Most chemotherapy is given over a period of time, on a
schedule in what is called cycles. Each type of chemotherapy has its own
schedule and may include one dose or several doses in a cycle.
• In special, very selective cases, chemotherapy is used to try to shrink the
cancer so that surgery is possible. This treatment is called neoadjuvant
therapy. This can only be done if the cancer is in just one area of the lung.
• 
How often patient will need chemotherapy depends on:
• the drugs being used
• how well person tolerate the drugs
• how the cancer responds to the drugs

• Most chemotherapy for lung cancer is given through a

vein. This is called intravenous (IV) chemotherapy,
although some types of chemotherapy are given in pills.
Drugs
CYTOTOXIC DRUGS
• Alkylating agent-cyclophosphamide, ifosfamide
• Platinum coordination complexes-cisplatin,carboplatin
• Antimetabolites-methotrexate
• Microtubule damaging agents-vincristine,vinblastine
• Topoisomerase-2 inhibitors-etoposide
• Topoisomerase-1 inhibitors-topotecan
• Antibiotics-actinomycind,bleomycins
• Miscellaneous-arsenic trioxide
HORMONAL DRUGS
• Glucocorticoids- prednisolone
• Estrogens- fosfestrol
• Selective estrogen receptor modulators- tamoxifen
• Selective estrogen receptor down- fulvestrant
• Aromatase inhibitors- anastrozole
• Anti androgen flutamide
• 5-alpha reductase inhibitor- dutasteride
• Gnrh analoguues- triptorelin
• Progestine- hydroxyprogesterone acetate
• Blood tests. While on chemotherapy, patient will need
regular blood tests to make sure it is safe to continue.
This could be as often as once a week. It is possible that
chemotherapy may be delayed due to the results of
patient blood tests.
• Chemotherapy drugs, not only damage the cancer cell but
they also can damage normal cells which can cause side-
effects such as hair loss, nausea, and risk of infection.
 TARGETED THERAPIES
Targeted therapies are drugs (pills) that have improved
the treatment of non-small cell lung cancer. These drugs
are different than chemotherapy in that they can target or
block the growth or spread of cancer cells without
damaging normal cells. Special testing is done on the
cancer cells before starting targeted therapies. A new
biopsy is sometimes needed for this testing.
There are many types of targeted therapies used for patients
with non-small cell lung cancer:
• Epidermal Growth Factor Receptor (EGFR) Inhibitors such as:
afatinib, erlotinib, gefitinib and osimertinib
• Anaplastic Lymphoma Kinase (ALK) Translocation Inhibitors:
alectinib, crizotinib, ceritinib
• ROS1 translocation inhibitors such as: crizotinib
• BRAF mutation inhibitors such as: dabrafenib and trametinib
 IMMUNOTHERAPY
• Immunotherapy is the use of medicines to trigger a person’s
own immune system to recognize and destroy cancer cells
more effectively. Cancer cells sometimes use “check-points”
to avoid being attacked by the immune system. Newer drugs
(check-point inhibitors) hold a lot of promise as cancer
treatments. Immunotherapy can be used to treat some forms
of non-small cell lung cancer.
 RADIATION THERAPY
• There are different types of radiation therapy that can be used in the
treatment of lung cancer. Radiation treatment depends on the stage of
patient cancer, as well as the size and location of the lung tumor.
Radiation targets a specific body area. Radiation is a local treatment and
only works where it is aimed.
• Radiation takes careful planning. Before treatment
starts, patient may go
to CT simulation where the doctors can plan the treatment before it is
given.
EXTERNAL BEAM RADIATION
THERAPY
External beam radiation therapy is directed from outside
of the body. This is the most commonly used type of
radiation. It is typically given in small daily doses called
fractions. A single dose or fraction lasts about 10 to 15
minutes. The number of fractions can vary and can be
given over 3 to 6 weeks.
 RESPIRATORY MOTION
When we breathe our lungs increase and decrease in size.
A tumor in the lung will move along with that breathing motion.
During the planning of radiation, doctor will commonly use a special CT scan called a
4-Dimensional CT (4DCT) to judge the amount of movement that is taking place when
person breathe.
Sometimes, the movement is so great that doctor will decide to use other techniques to
manage breathing.
These techniques include devices to compress stomach in order to limit breathing
motion, inserting gold markers inside the tumor in order to follow it during treatment,
or using respiratory gating, which controls the radiation beam to only ‘turn on’ when
the tumor is in the right spot.
 STEREOTACTIC RADIATION THERAPY
Stereotactic radiation therapy uses specialized techniques to help
focus radiation therapy to treat small isolated tumors using a
machine outside the body.
The radiation is given in larger daily doses, which are typically 4
to 8 treatments, and each treatment lasts about 30 to 60 minutes.
The decision to use stereotactic radiation therapy is based on
the size of the tumor and its location.
 BRACHYTHERAPY
Brachytherapy is a type of radiation therapy where a small tube
(a catheter) is placed down patients airway during a
bronchoscopy.
Then, a radiation source is placed inside the body near the tumor.
The radiation is produced by a tiny radioactive 'seed' placed in
body through that catheter.
• Pleurodesis – Is when the fluid is drained and then medication
such as doxycycline are placed inside the chest area to help the
lung stick to the chest wall and prevent the fluid from coming
back, The tube is removed after the lungs re-expand.
This procedure generally requires a stay at the hospital for several
days.
• Laser treatment Laser treatment uses an intense narrow beam of
laser light to kill cancer cells.
It is only used for very small tumors or to shrink a tumor that is
blocking the trachea or main bronchus.
 RADIO FREQUENCY ABLATION
(RFA)
Physician may refer for radiofrequency ablation (RFA) if patient
have a localized small sized lung cancer that is not suitable for
surgery or unwanted surgery or radiation.
RFA uses radiofrequency waves sent through a specialized needle
which is inserted with the use of image guidance by
interventional radiologists into the tumour. RFA creates heat to
destroy the cancer cells from within the tumour. RFA is a single
session treatment done under sedation and local anesthetic.
 NURSING DIAGNOSIS
• Impaired Gas Exchange related to removal of lung tissue, altered
oxygen supply (hypoventilation), decreased oxygen-carrying
capacity of blood (blood loss) as evidenced by dyspnea,
restlessness/changes in mentation, hypoxemia and hypercapnia,
cyanosis.
• Ineffective Airway Clearance related to increased amount/viscosity
of secretions, restricted chest movement/pain, fatigue/weakness as
evidenced by changes in rate/depth of respiration, abnormal breath
sounds, ineffective cough, dyspnea.
• Acute Pain related to Surgical incision, tissue trauma, and disruption
of intercostal nerves, presence of chest tube , cancer invasion of
pleura, chest wall as evidenced by verbal reports of discomfort.

• Fear/Anxiety related to situational crises, threat to/change in health

status as evidenced by expressions of denial, shock, guilt, insomnia.

• Knowledge Deficient related to lack of exposure, unfamiliarity with

information/resources as evidenced by inappropriate or exaggerated
behaviors e.g. hysterical, hostile, agitated, apathetic.
 CONCLUSION
The abnormal cells do not develop into healthy lung tissue
and do not carry out the functions of normal lung cells.
Having less healthy lung tissue makes the lungs work more,
which makes it harder to breathe.
 BIBLIOGRAPHY
•Gerard J, Tortora, Bryan H. Derrickson; Principles Of Anatomy And Physiology; 12 th
Edithion. Asia; John Wiley And Sons; 2009.
•Anne Waugh, Allison Grant, Anatomy And Physiology. 10th Edition. United Kingdom:
Elsevier,2006.
•Ross And Wilson; The Text Book Of Anatomy And Physiology In Health And Illness,
10th Edition, Published By Elsevier; Page No. 238-256
•Chintamani: Lewis’s Medical Surgical Nursing; 2nd Edition; Published By Elsevier;
Page No. 504-513
•Suzannec. Smeltzer, Brunner And Suddarth’s Textbook Of Medical- Surgical Nursing
Vol-2; 12th Edition; Page No. 497-504