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LUNG CANCER

Tayler-Jo Mullins
Statistics
• ranks 2nd in cancer incidence in males and females, after prostate for males and breast
for females
• ranks 1st leading cause of cancer deaths in males and females
• each year, more people die from lung cancer than colon, breast and prostate cancers
combined
• over 50% of new lung cancer cases are diagnosed at very late stages (III or IV)
Statistics
• occurs more often in patients 65 and older, with a mean age of 70
• women have a lower rate of developing lung cancer (1 in 17) than men (1 in 15), but
this gap is closing
• black men are 20% more likely to develop lung cancer than white men

• The American Cancer Society’s estimates for lung cancer in the United States for 2018
are:
• About 234,030 new cases of lung cancer (121,680 in men and 112,350 in women)
• About 154,050 deaths from lung cancer (83,550 in men and 70,500 in women)
• which is 66% death rate and 32% survival rate
Patient X
• 55-years-old • alcohol abuse (2 to 3 24oz. cans of
beer per day)
• male
• African American • smoked since he was 18-years-old (1 to
2 packs a day)
• single
• marijuana use 30 years ago
• no children
• hypercalcemia
• worked at recycling plant
• until he quit about a year ago because
of progressive fatigue
Risk Factors
• tobacco use
• smoking is linked to 85-90% of lung cancer cases
• cigars and pipes
• secondhand smoke is thought to cause 7,000 deaths from lung cancer per year
• exposure to carcinogens in the workplace
• “Waste and recyclable materials generate a lot of dust that can have serious health consequences.
This dust can contain micro-particles of plastics, glass, biohazards, toxic substances such as asbestos or
silica, and other respiratory irritants. Even animal feces, rotting food, and other organic waste can
become airborne in the form of “bio aerosols”. (Bergmill, 2017)”
• U.S. Department of Labor: 2016 Census of Fatal Occupational Injuries ranked refuse and recycling
material collectors as the 5th most dangerous job in America.
• exposure to asbestos
• air pollution
• exposure to radon
• arsenic in drinking water (Southeast Asia and South America)
• previous radiation therapy to the lungs
• personal or family history of lung cancer
• marijuana has uncertain/unproven effects on lung cancer
Signs/Symptoms
• coughing up blood or rust-colored sputum (spit or phlegm)
• 2 episodes of hemoptysis and coughing up yellow sputum
• chest pain that is often worse with deep breathing, coughing, or laughing
• weight loss and loss of appetite
• lost around 30 lbs. in previous 3 to 4 months before consult
• shortness of breath/dyspnea
• feeling tired or weak
• cough that does not go away or gets worse
• hoarseness
• infections such as bronchitis and pneumonia that don’t go away or keep coming back
• new onset of wheezing
Diagnostic
• CT of chest:
• RUL mass
• hilar/mediastinal lymphadenopathy (disease of lymph nodes, in which they are abnormal in size, number or
consistency)
• nodules in right middle/lower lobes
• complete occlusion of SVC (superior vena cava syndrome: obstruction of blood flow)
• obstruction of RUL bronchus

• CT of abdomen:
• no suspicious metastatic disease
• hepatomegaly (abnormal enlargement of liver)
• Brain MRI:
• no significant abnormality
• PET:
• RUL mass
• RLL-extensive intrathoracic adenopathy; including invasion of right hilar lymph nodes and metastatic lymph in
subcarinal, paratracheal, AP window (subaortic), bilateral supraclavicular and right axilla
RT axilla and bilateral
supraclavicular nodes
Diagnosis
• Biopsy: Non-Small (Squamous) Cell Carcinoma of the right lung
• AJCC Staging: IIIB
Classifications
• Small Cell accounts for 15% of lung cancers
• Non-Small Cell accounts for 85% of lung cancers
• adenocarcinoma (50%)
• squamous cell carcinoma (35%)
• large cell carcinoma (15%)
• adenosquamous
Staging for Non-Small Cell
• Stage I: invasion of underlying lung tissue, but has not spread to lymph nodes
• Stage II: spread to neighboring lymph nodes or invaded the chest wall
• Stage IIIA: spread from the lungs to lymph nodes in the center of chest
• Stage IIIB: has spread to local area within the chest (i.e. heart, blood vessels, trachea,
esophagus) or nodes in collarbone area or to tissue that surrounds the lung (pleura)
• Stage IV: spread to other parts of the body
• Common Metastatic Sites: liver, bone, adrenal glands and brain
• majority of patients develop metastasis either prior to diagnosis or later
Staging for Small Cell
• Limited: cancer is confined to one lung and to neighboring lymph nodes
• Extensive: cancer has spread beyond the single lung and nearby nodes; may involve
opposite lung, more remote lymph nodes or even other organs
Patient’s Treatment
• Surgery
• not performed
• is not typical for later stages stage, only I and II
• only 20% of lung cancer patients are surgical candidates

• Chemotherapy
• adjuvant with radiation therapy
• Carboplatin AUC 2/Paclitaxel (Taxol) 50mg/m
• Etoposide and Cisplatin
• these are NOT a cure, but help improve 5-year survival
Other Treatment Options
• Radiofrequency Ablation
• small tumors near the outer edge of lung, especially if they can not tolerate surgery
• outpatient procedure and local anesthesia
• a thin, needle-like probe is put through the skin, with CT guidance, until the tip is in the tumor. An
electric current is passed through the probe, which heats the tumor and destroys the cancer
cells
• Targeted Therapy
• Immunotherapy
Radiation Therapy Tx
• Setup • 6000cGy in 30 fractions (200cGy/fx)
• supine position • 3D/Conformal Plan with dual energies
• Dosemax Board with an reference # • 1. G10 LAO (10X)
• wing board with headrest and arms • 2. G335 RAO (6X)
above head holding hand bars
• 3. G290 RAO (6X)
• upper vac-loc bag
• 4. G245 RPO (6X)
• indexed knee sponge
• 4a. G245 RPO-RF (6X)
• 5. G210 RPO (10X)
• 5a. G210 RPO-RF (10X)
Critical Structures
• spinal cord: 4700cGy
• esophagus: 5500cGy
• heart: 4000cGy
• lungs: 1750cGy
• mean dose: 2035.5cGy
• PTV mean dose: 6297.9cGy
Radiation Therapy Tx
• radiation therapy is more of a palliative treatment than curative
• currently treating smaller margins with a big interest in conformal therapy
• allow chemotherapy to treat the lymph nodes
• margins should be placed 1.5-2cm around the tumor, while the tumor is moving
• tumors in parenchyma (alveoli, alveolar ducts, bronchioles) are more difficult to treat due to
movement during respiration
• lower lobe tumors require larger fields because of movement, while upper lobe tumors are easier
to include in the field
• could perform 4D CT-sim to account for tumor motion
• measures breathing and tumor movement during respiration
• breath hold, respiratory gating or free breathing are all possible options
Side Effects
• Acute (can occur 6 weeks after tx)
• skin reaction
• inflammation of esophagus causing pain on swallowing
• slight discomfort when swallowing
• loss of appetite, nausea, weight loss, weakness
• 5lb weight loss in a week
• sore throat
• inflammation of lung causing dry cough
• radiation pneumonitis (reaction of lung that may cause pneumonia)
• could also be a late effect
• coughing up blood from tumor destruction
• possible decrease in blood counts
• possible inflammation of heart sac causing chest pain, palpations, or heart failure
Side Effects
• Late
• esophageal strictures
• spinal cord damage causing weakness or paralysis
• pulmonary fibrosis that may worsen breathing and lung function
• scar tissue or changes in heart
• vascular complications

• Side Effects of Combined Regimen


• fatigue
• hair loss
• numbness in hands and feet
• low WBC count
• anemia: delayed chemotherapy
Medications
• Albuterol – for wheezing or shortness of breath
• Tiotropium – inhalation capsule
• Benzonatate – for cough
• Acetaminophen and Oxycodone – for pain management
• Docusate – stool softener
• Nutritional Supplements: Ensure and Magic cups
• Mucinex – sinus drainage
Prognosis and Survival
• 5-year Survival Rates for Non-Small Cell Lung Cancer
• IA: 92-68%
• II: 60-53%
• IIIA: 36%
• IIIB: 26%
• IV: 10-1%
• 5-year Survival Rates for Small Cell Lung Cancer
• I: 31%
• II: 19%
• III: 8%
• IV: 2%

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