Definition

Lung cancer or bronchogenic cancer is a malignant tumor of the lung arising within the bronchial wall or epithelium. The lung is also a common site of metastasis from cancer elsewhere in the body through venous circulation or lymphatic spread.

TWO WAYS THAT CANCERS CAN ARISE IN LUNGS: 1. PRIMARY TUMORS

Primary tumors of the lung can arise from the different tissues present such as epithelium, lymphatics, mesothelium and soft tissue, and diagnosis is based on the histological findings of biopsy seen by light microscopy.

By far the most common, and exhibiting the greatest diversity are epithelial tumors. Mixed tumors exist and these are often classified according to the most predominant cell type found, it is likely that all lung cancers exhibit this to some extent. However this requires examination with electron microscopy, and yields little of clinical benefit.

2. SECONDARY TUMORS
Secondary tumours of the lung are very common, usually affecting the parenchyma, and often arise from primary tumours in; kidney, prostate, breast, bone, gastrointestinal tract, cervix or ovary. These usually present as round shadows of about 1.5-3 cm diameter on chest X-rays, in patients previously diagnosed with the primary. Sometimes, they can present in undiagnosed asymptomatic patients, and the primary found later on CT scans or other investigations.

Classifications of lung cancer according to cell type:

1. Squamous cell carcinoma (epidermoid carcinoma) accounts for about30 or 40% of primary lung tumors. They grow most commonly in the central areas in or around major bronchi. They grow in a stratified or pseudoductal arrangement, the cells have an epithelial pearl formation with individual cell keratinization. These tumours deposit keratin, and as they grow develop a necrotic, keratinous mass which appears cheesy on dissection. Widespread Metastases occur

2. Adenocarcinomas
arise peripherally from mucous glands and the cells retain some of the tubular, acinar or papillary differentiation and mucus production. They commonly invade pleura and mediastinal lymph nodes and often metastasise to the brain and bones. Adenocarcinoma commonly arises around scar tissue and is also associated with asbestos exposure. One form of adenocarcinoma is often distinguished from others, bronchiolo-alveolar carcinoma, these characteristically have well differentiated bland cells which grow along alveolar ducts. Adenocarcinomas are proportionally less common in non-smokers.

3. Large cell carcinoma accounts for about 20% of all lung cancers. It has slow growth rate and more often peripheral mass, either single or multiple masses. It is located centrally, midlung or peripherally.

4. Small (Oat) cell carcinoma accounts for about 20-30% of all lung cancers, these cells secrete a large amount of polypeptide hormones. This produces extra-pulmonary manifestations such as SIADH and ectopic adrenocorticotrophin syndrome. This form of lung cancer is responsive to chemotherapy. Under the microscope they form sheets of darkly staining cells with prominent nuclei and little cytoplasm,their secretory activity can be seen as the presence of neurosecretory granules in the cytoplasm seen by electron microscopy. This form is very strongly linked to smoking as a causative factor.

RISK FACTORS
Cigarette smoking

Second-hand smoke
Genetic predisposition

Age- younger than 45 y/o

Tuberculosis Low levels of radiation, radon, arsenic, chromium, nickel, iron, coal tar products and asbestos exposure

Clinical Manifestations
Dyspnea (shortness of breath)

Hemoptysis (coughing up blood)

chronic coughing or change in regular coughing pattern decreased breath sounds, wheezing and possible pleural friction rub on examination

cachexia (weight loss), anorexia, fatigue, and loss of appetite Malaise Fever dysphonia (hoarse voice) clubbing of the fingernails (uncommon)

chest pain (aching poorly localized)

dysphagia (difficulty swallowing).

Diagnostic Evaluation
1. Chest X-ray may be suspicious for mass

Chest radiograph showing a cancerous tumor in the left lung.

2. CT-scan or PET scan For better visualization of tumor.

CT scan showing a cancerous tumor in the left lung.

3. Sputum and pleural fluid samples for cytologic examination may show malignant cells 4.Fiberoptic bronchoscopy determines the location and extent of the tumor and may be used to obtain a biopsy specimen
5. Lymph node biopsy and mediastinoscopy may be ordered to establish lymphatic spread and help plan treatment

*Mediastinoscopy and thoracotomy are considered the gold standard for staging lung cancer
6. Pulmonary function tests, which may be combined with a splitfunction perfusion scan, determines if the patient will have adequate pulmonary reserve to withstand surgical procedure.

Therapeutic Interventions
1. Oxygen through nasal cannula based on the level of dyspnea. 2. Enteral or total parenteral nutrition for malnourished patients who are unable or unwilling to eat
3. Removal of pleural fluid (by thoracentesis or tube thoracostomy) and instillation of sclerosing agent to obliterate pleural space and prevent fluid recurrence. 4. Radiation therapy in combination with other methods

Pharmacologic Intervention
1. Expectorants and antimicrobial agents to relieve dyspnea and infection 2. Analgesics given regularly to maintain pain at tolerable level. 3. Chemotherapy using cisplatin in combination with a variety of other agents and immunotherapy treatments may be indicated.

Surgical Intervention
1. Laser Surgery- used as a palliative measure for relief of endobronchial obstructions that are not surgically resectable. 2. Pulmonary Resectioncomplete resection of tumor remains the best chance of cure. 3. Wedge resection- a small localized area of tumor near the surface of the lung is removed using special stapling devices. 4. Segmental Resection- removal of one or more lung segments. Pneumonectomy specimen containing asquamous cell carcinoma, seen as a white area near the bronchi 5. Lobectomy- removal of an entire lobe of the lung. 6. Pneumonectomy- removal of an entire lung.

Monitoring
1. Monitor blood work for hypercalcemia from bone metastasis, neutropenia from chemotherapy , and hyponatremia is that may result from SIADH. 2. Monitor for upperbody edema because if superior vena cava obstruction as complication. 3. Monitor nutritional status through serial weights dietary log and prealbumin measurements.

Supportive Care
1.Elevate the HOB to ease the work of breathing and to prevent fluid collection in upper body 2. Teach breathing retaining exercises to increase diaphragmatic excursion and reduce work of breathing 3. Augment the patients ability to cough effectively: a. Splint the patients chest manually with hands b. Instruct the patient to inspire fully and cough 2 to 3 times in one breath c. Provide humidifier or vaporizer to provide moisture to loosen secretions

4. Teach relaxation techniques to reduce anxiety associated with dyspnea.

5. Encourage the patient to conserve energy by decreasing activities

6. Ensure adequate protein intake--- milk, eggs, oral nutritional supplements; and chicken, fowl and fish if other meats are not tolerated--- to promote healing and prevent edema
a. Advise patient to eat in small amounts of high-calorie and high-protein foods frequently rather than three daily meals. b. Change diet consistency to soft or liquid if patient has esophagitis from radiation. 7. Consider alternative pain control methods, such as biofeedback and relaxation methods.