Lung Cancer



Lung Cancer


Jan Wemmer



I. Definition

A. Pathology

1. Lung cancer can arise from any tissue in the lungs.

2. It can spread by direct extension into surrounding structures or by metastasizing through the lymphatic or hematogenous systems.

B. Epidemiology

1. Most common form of cancer among men and women in the United States.

2. Leading cause of cancer death for both genders.

3. Overall survival for all lung cancers remains poor, with less than 15% of patients alive 5 years after diagnosis.

4. Prognosis is best with early-stage diagnosis, when treatment can lead to a 60% to 90% chance of cure. However, once the disease has spread beyond the early-stage tumor, curative treatment is unlikely.

C. Classification of lung cancer is based on cell histopathology.

1. Small-cell lung carcinomas (SCLC)

a. Account for about 20% to 25% of all lung cancers.

b. Tend to metastasize early in the course of the disease and commonly spread rapidly to bone, liver, central nervous system, lymph nodes, and pleura.

c. Further divided into the following subtypes:

(1) Oat cell

(2) Intermediate grade

(3) Mixed (small cell combined with another lung carcinoma cell type)

2. Non-small-cell lung carcinomas (NSCLC)

a. Account for 70% to 80% of lung cancers.

b. Usually spread by direct extension and compression of surrounding structures, but can metastasize to bone, liver, brain, adrenals, and pericardium.

c. Further differentiated into the following subtypes:

(1) Epidermoid or squamous cell carcinoma

(2) Adenocarcinoma (most commonly occurring lung cancer among nonsmokers and in women)

(3) Large-cell carcinoma (lowest incidence overall)

3. Pleural mesothelioma arise from the pleural lining of the lung.

a. About 75% of tumors are diffuse and usually malignant.

b. The remaining 25% are localized and usually benign.


II. Etiology


A. Tobacco smoke exposure is the main causative factor in both SCLC and NSCLC.

1. Tobacco smoke is a potent carcinogen, and it also promotes the carcinogenic effect of other substances.

2. Risk of lung cancer increases with the number of years of smoking, the number of cigarettes smoked, and the tar content of the cigarettes.

a. Cigarette smoking risk is quantified in pack-years, which is the number of packs smoked per day multiplied by the number of years of smoking.

b. At 10 pack-years, the number of deaths from lung cancer among smokers exceeds those among nonsmokers.

c. Risk of lung cancer starts to decrease 5 years after smoking cessation.

B. Asbestos exposure has been implicated in the development of lung cancers (especially mesothelioma) in miners, shipyard workers, and pipe fitters.

C. Radon exposure is considered a risk factor for lung cancers, particularly in uranium miners. It is uncertain at this time whether environmental exposure to radon constitutes significant risk for lung cancer.

D. Other substances may play a role in the development of lung cancer.

1. Arsenic

2. Coal

3. Chloromethyl methyl ether (CMME)

4. Chromium

5. Copper

6. Hydrocarbons

7. Ionizing radiation


III. Patient management:

is determined by cell type, stage of disease, and symptomatology.

A. Assessment: The following signs and symptoms of lung cancer may be due to local tumor effects, metastasis, or systemic effects caused by paraneoplastic syndromes (Gerber, Mazzone & Arroliga, 2002; Mazzone & Arroliga, 2003; Messori, Lanza, Serio & Salvolini, 2003; Wen & Schiff, 2003). (See Table 17-1 for paraneoplastic syndromes associated with lung cancer.)

1. Cough is the most common presenting symptom, occurring in up to 75% of patients.

a. Centrally located tumors (ie, mainstem bronchi) are most often seen in small cell and squamous cell cancers, and are likely to cause bronchial obstruction, or atelectasis, that stimulates the cough reflex.

b. Peripherally located tumors may also lead to coughing by creating pressure on the J receptors within the lung.

c. Cough is frequently intractable and exhausting.

d. Sputum production is usually indicative of a concomitant pulmonary infection due to airway obstruction and retained secretions.

2. Wheezes are present with airway obstruction or bronchospasm related to coughing.









TABLE 17-1 Paraneoplastic Syndromes Associated With Lung Cancer







































Syndrome

Primary Symptoms

SCLC

NSCLC


Cushing’s syndrome

Ectopic secretion of adrenocorticotropic hormone, edema, proximal myopathy, elevated plasma and urinary cortisol levels, hyperglycemia, hypokalemic alkalosis

X


Syndrome of inappropriate antidiuretic hormone (SIADH)

Hyponatremia, serum hypo-osmolality, urine hyperosmolality, elevated urine sodium, normal creatinine

X*

X


Hypercalcemia

Ectopic parathyroid hormone production and bone metastases are causes; serum calcium >11 mg/dL, anorexia, N/V, constipation, lethargy, irritability, confusion, coma, dehydration

X

X*


Lambert-Eaton myasthenic syndrome (LEMS)

Impairment of acetylcholine release from cholinergic terminals, muscle weakness, and hyperreflexia (especially lower extremities), autonomic dysfunction; symptoms may appear 2 to 4 years before tumor is diagnosed

X*

X


Encephalomyelitis

Dementia, cerebellar degeneration, brainstem encephalitis, myelitis; may occur months to years before tumor is diagnosed; may be associated with autoimmune mechanism

X*

X


Trousseau’s syndrome

Hypercoagulable state; migratory venous thrombophlebitis and thromboembolism; unresponsive to oral anticoagulants

X

X


An asterisk in a column indicates higher prevalence of that complication.


3. Loud wheezes or stridor is most likely caused by obstruction of the large airways.

4. Hemoptysis can occur when tumors erode into the blood vessels in the lung.

5. Dyspnea may have multiple tumor-related etiologies, including compression of airways, atelectasis, pleural effusion, and pulmonary embolism.

6. Hoarseness is due to vocal cord paralysis resulting from tumor impingement on the laryngeal nerve.

7. Pain

a. Chest wall pain caused by lung tumors may be described as an intermittent ache on one side, may be pleuritic in nature, or may be subscapular.

b. Large tumors in the apex of the lung (Pancoast tumor) may cause pressure on the brachial plexus and result in shoulder pain (one of the symptoms of Horner’s syndrome).


c. Pain located elsewhere may be due to bone metastasis.

8. Horner’s syndrome, associated with apical tumors, causes nerve compression with shoulder or arm pain, ptosis, and weight loss.

9. Weight loss is most commonly a symptom of late-stage disease, but may occur at any time.

a. Well-established negative prognostic factors for patients with lung cancer include weight loss, poor performance status, presence of systemic symptoms, and a later stage at diagnosis.

b. Weight loss bears such prognostic significance with this disease that many treatment protocols have significant weight loss as an exclusion criteria.

10. Altered mental status is a common occurrence and may be due to various etiologies.

a. Hypoxia can affect mental status and judgment.

b. Most often an indicator of brain metastasis.

c. Hypercalcemia should be considered in susceptible patients.

B. Diagnostic Parameters: Studies are performed to determine cell type and stage of disease (Tables 17-2, 17-3, and 17-4) and their prognostic implications (Table 17-5).

1. Staging

a. SCLC may be staged using two categories:

(1) Limited stage (tumor confined to one hemithorax and regional lymph nodes and can fit into one radiation portal)

(2) Extensive stage (outside of limited stage) metastatic

b. NSCLC is most commonly classified using TNM (tumor, node, metastasis) classifications (see Table 17-3) and stage I-IV grouping (see Table 17-4).

2. Diagnostic tests (see Table 17-2 for nursing interventions related to these pulmonary tests)

a. Cytologic specimens may be obtained by several different techniques:

(1) Sputum cytology

(2) Fiberoptic bronchoscopy with brush washings

(a) Ensure platelets >50,000 to 100,000/mm3 before procedure (exact count may vary with planned procedure or physician preference).

(b) Establish a normal international normalized ratio (INR).

(3) Mediastinoscopy with biopsy is especially useful if lymph nodes are visualized on positron emission tomography (PET) or computed tomography (CT).

(4) Percutaneous needle biopsy may be used alone or in combination to determine cell type.

b. Radiography (CXR), CT, magnetic resonance imaging (MRI), and PET are used to ascertain the location and size of the primary tumor and to determine sites of metastasis within and outside the thorax.

(1) CXR may show a space-occupying, enhancing mass, although this test has proven too insensitive for early detection to be used as a screening tool, even in high-risk people.

(2) CT scan (especially spiral/helical CT) is helpful in identifying suspicious masses and their exact location.












TABLE 17-2 Diagnostic Tests Used for Assessment/Management of Lung Cancer










































































































































Procedure/Description

Potential Complication

Nursing Management


Bronchoscopy: To Localize or Perform a Biopsy on a Lesion


Local anesthetic (duration 2-8 hours)

Loss of gag reflex


  • Give patient nothing by mouth before the procedure and until the gag reflex has returned.



  • Light sedation is also often used to reduce anxiety and distress during the procedure.



  • Maintain flat or semi-Fowler’s position.



  • Administer bronchodilator.


Hyperextended neck

Tension on neck muscles and vertebrae


  • Apply ice collar first 24 hours, then heat.



  • Provide lozenges and gargles when gag reflex returns.



  • Administer analgesics if pain is severe.


Insertion of bronchoscope

Laryngeal edema
Possible laryngospasms or bronchospasms


  • Observe for and report respiratory distress.



  • Obtain topical corticosteroid spray for the airway or racemic epinephrine as ordered by the physician.



  • Administer oxygen.


Brush or needle biopsy

Possible bleeding

•

Observe and report:


–

Hemoptysis.

Possible infection


–

Symptoms of upper respiratory infection—fever, cough, haziness on chest x-ray.



–

Dyspnea, decreased breath sounds, cyanosis.

Possible pneumothorax


–

Pneumothorax is often a slow-developing occurrence after procedure due to a slow air leak, so it may present as dyspnea, chest discomfort, unequal chest excursion, diminished breath sounds on the lung where biopsy was performed, tympany of chest on side where biopsy was performed.


•

Administer oxygen.


Mediastinoscopy: To evaluate lymph node involvement


General anesthetic

Aspiration


  • Give client nothing by mouth before the procedure and until the gag reflex has returned.


Insertion of scope into the intercostal space

Manipulation of the trachea
Possible air leaks into the skin


  • Administer analgesics as needed.



  • Assess for subcutaneous emphysema

Possible pneumothorax

•

Observe and report:

Possible bleeding


–

Hemoptysis.

Possible mediastinitis


–

Symptoms of upper respiratory infection—fever, cough, haziness on chest x-ray.



–

Dyspnea, decreased breath sounds, cyanosis.



–

Pneumothorax is often a slow-developing occurrence after procedure due to a slow air leak, so it may present as dyspnea, chest discomfort, unequal chest excursion, diminished breath sounds on the lung where biopsy was performed, tympany of chest on side where biopsy was performed.


•

Administer oxygen.


Postoperative recovery period

Two to three small incisions with sutures


  • Administer mild analgesics as needed.



  • Clean and dress the exit wounds to prevent infection.



  • Assess for the presence of subcutaneous emphysema at the surgical sites and report to physician if present.

Possible chest tube remaining postoperatively


  • Observe drainage, exit site, respiraremaining tory fluctuations in the tubing, and presence or absence of an air leak.



  • Patients with an air leak should not be transported without suction unless specifically ordered by the physician.



  • Provide education, home care consultation, and follow-up visit plans for patients who go home with tubes in place.


Radiologic/nuclear imaging studies: To localize lesion or detect node involvement


Chest x-ray

Radiologic exposure


  • Instruct the patient of the need to take a deep breath and hold it for several seconds.



  • Advise the patient when results may be available.


Computed tomography (CT) scan—Serial x-ray examination of sectional planes of the thorax and computer analysis to provide three-dimensional studies of the tissue

Noninvasive and a very short procedure if a spiral CT scanner is used, but patient must remain still and the machine surrounds the body and makes noises.


  • Instruct the patient of the need to take a deep breath and hold it for several seconds.



  • Advise the patient when results may be available.


CT scan with contrast media containing iodides or radioactive materials

Intravenous administration
Possible hypersensitivity to contrast media (rare)
Renal challenge of contrast media with subsequent renal insufficiency


  • Warn patient of immediate sensations of warmth, flushing, bitter or salty taste, nausea/vomiting, and itching, and pain at the insertion site.



  • Perform emergency procedures as needed.



  • Assess baseline renal status with blood urea nitrogen (BUN), creatinine, and possibly creatinine clearance.



  • Provide hydration before and after procedure as ordered.


Positron emission tomography (PET) scanning

Intravenous administration
Possible hypersensitivity to contrast

See above for implications.


Percutaneous CT- or Ultrasound-Guided Needle Biopsy: To Obtain Histopathologic Specimen


CT scan or ultrasound with skin marking to note the location of a mass, nodule, or enlarged lymph node.

Pain at injection site and the discomfort of maintaining a specified position for a period of time. If particularly difficult, the scan or ultrasound may be simultaneous to the biopsy.


  • Teach patient importance of histo logic diagnosis.



  • Provide specific education about diagnostic test.


Sputum Cytology: To Collect and Assess Shedding Endobronchial Tissue for Histologic Diagnosis


Three containers with fixative given to the patient for collection of sputum and saliva for cytology

None


  • Instruct patient to collect daily specimens upon arising and before oral intake or brushing of teeth.



  • Inform patient about time required to analyze tissue and complete report.


Adapted from Lind, J. (1998). Nursing care of the client with lung cancer. In J. Itano & K. Taoka (Eds.), ONS core curriculum for oncology nursing (3rd ed., pp. 448-458). Philadelphia: W. B. Saunders.

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Biological Therapies
  2. Breast Cancer
  3. Delirium
  4. Pain

Stay updated, free articles. Join our Telegram channel
Tags:
Sep 16, 2016 | Posted by in NURSING | Comments Off on Lung Cancer

Full access? Get Clinical Tree
Get Clinical Tree app for offline access