LUNG CANCER

Nicole Pitzer
 • Treated at Vault 6
• 73 year old female
• Caucasian
• Has 3 daughters
THE PATIENT • Divorced
• Had a puppy but returned him after her
initial diagnosis in 2017 because she was
worried she wouldn’t be able to care for him
• Sells homes and gives out keys at the Jewish
Center
• Lives alone
 • Smoking history
• 75.00 pack year → 3 packs a day for 25 years
• Quit about 26 years ago
• Does not use smokeless tobacco
PAST SOCIAL & • Drinks alcohol
FAMILY HISTORY
• No drug use
• Exercises regularly
• Mother → colorectal CA & emphysema
• Father → pancreatic, leukemia, colon CA & heart disease
• Maternal Grandfather → colon CA
 PAST MEDICAL HISTORY

• Abnormal blood chemistry • Measles

• Acquired hypothyroidism • Tubular adenoma of colon
• Hashimoto disease • Most common type of polyp (cluster of cells
that forms in the lining of the colon)
• Anxiety
• Considered benign but can develop if not
• Celiac disease removed
• Chicken pox • Walking pneumonia
• COPD • 3 back surgeries and a plate put in her hip
• Lesion of pancreas • PTSD
• Previous lung cancer • Major depression
 ANATOMY 3

• Pleura sac encases the lungs

• Lungs sit superior to the diaphragm
• How many lobes does the right lung have? 3
• How many lobes does the left lung have? 2
• The top of the lungs are termed what? Apex
• The bottom of the lungs are termed what? Base
• Where is the hilum located? Where all the structures enter the lungs
 LYMPHATIC S 3

Superior Mediastinal Inferior Mediastinal Pulmonary

1. Superior Mediastinal 7. Subcarinal 9. Segmental

2. Paratracheal 8. Paraesophageal 10. Hilar
3. Pretracheal 9. Pulmonary ligament 11. Intrapulmonary
4. Lower Paratracheal 12. Peribronchial
What side can
cross over in
the drainage
flow of
lymphatics?
 ➢ The 2nd most common cancer diagnosis by
gender, behind prostate CA for men and breast
CA for women (**not including skin cancer)
➢ The most common cause of death from cancer
→ more people die of lung cancer than colon,
EPIDEMIOLOGY 1 ,9
breast, and prostate combined
➢ Most people diagnosed are 65 or over with the
average age being 70
➢ Overall chances of developing lung cancer in a
In 2019 so far: lifetime:
➢ Males: 1 in 15
➢ Females: 1 in 17
About 228,150 new cases of lung cancer: ➢ These #s are for smokers & nonsmokers
116,440 in men ➢ Black men are 15% more likely to develop than
111,710 in women white men
➢ White women are 14% more likely to develop
than black women
About 142,670 deaths from lung cancer: ➢ Higher in males than females although this gap is
closing
76,650 in men
➢ Black men are less likely to develop Small Cell
66,020 in women Lung Cancer than white men
➢ In general, 10-15% of all lung cancers are SCLC
Risk factors you can change:
➢ Tobacco smoke → very rare for someone who has never smoked to have SCLC
➢ Secondhand smoke
➢ Exposure to radon
➢ Exposure to asbestos
➢ Taking certain dietary substances → studies found that smokers who took beta carotene supplements had
an increased risk of lung cancer
➢ Arsenic in drinking water

Risk factors you cannot change:

➢ Previous radiation to the lungs *smoking or second hand smoke
➢ Air pollution links to 85-90% of the cases
➢ Personal or family history *radon exposure is the 2nd leading
cause
*Smoking marijuana
*E-cigarettes
*Talc and talcum powder

ETIOLOGY 3,7
 Cytological
specimen

HISTOPATHOLOGY 4
Small Small cells with a
high nucleo-
cell lung cytoplasmic ratio
that proliferate
Two main types of primary lung cancers: CA rapidly

1. Small cell lung cancer

2. Non-small cell lung cancer Histological
specimen
 Adenocarcinoma

Squamous cell
carcinoma
HISTOPATHOLOGY 4
Non-
small cell
Two main types of primary lung cancers: lung CA
Large cell
1. Small cell lung cancer carcinoma
2. Non-small cell lung cancer

NSCLC not
otherwise
specified (NOS)
 SIGNS & SYMPTOMS 3,8

• Cough that doesn’t go away

• Chest pain
• Dyspnea
• Wheezing
• Hoarseness
• Weight loss & loss of appetite
• Hemoptysis
• Fever with no known reason
• Feeling tired or weak
• Repeated problems with bronchitis or pneumonia
 DETECTION & DIAGNOSIS 5

• Chest x-ray • CT-guided needle biopsy

• CT scan • Sputum cytology → testing of lung
secretions/phlegm
• MRI
• Thoracentesis → if fluid has collected around
• PET scan the lungs (pleural effusion), can remove some of
• Bone scan this fluid to see if it was caused by cancer
spreading to the lining of the lungs
• Lab tests
• Skin is numbed and a hollow needle is inserted
between the ribs to drain the fluid → checked in a
lab for cancer cells
• Needle biopsy
• Fine needle aspiration
• Core biopsy
• Transthoracic needle biopsy
• Bronchoscopy with biopsy
CT GUIDED NEEDLE BIOPSY

Fine needle aspiration

Core biopsy
Transthoracic needle biopsy
BRONCHOSCOPY
 TIMELINE

•Scan for diverticulitis 6/6/17 •Surveillance chest CT 7/26/19 •PET noted 8/16/19 •Brain MRI
•Revealed lung mass •New irregular nodule hypermetabolic •- For CNS
•RLL robotic lung in medial right middle •Chest CT noted enlarged subcarinal •Cytology and cell
•CT guided core lobectomy metastasis
lobe approx. 6 mm in mildly increased lymph node block
biopsy +adeno
•2.6 cm tumor size subcarinal lymph •Level 7 LN +adeno
node

5/19/17 4/12/19 8/8/19 9/5/19

 Stage Characteristics
STAGING 12
Stage 1 Invasion of the underlying lung
tissue but hasn’t spread to the
lymph nodes
Stage 2 Spread to neighboring lymph System that is used most often
nodes or invaded the chest wall for NSCLC is American Joint
Stage 3A Spread from the lung to lymph Committee on Cancer (AJCC)
nodes in the center of the chest TNM system
Stage 3B Spread locally to areas (heart, • T → size and extent of the
blood vessels, trachea and main tumor
esophagus) all within the chest –
• N → the spread to nearby
or to lymph nodes in the area of
the collarbone or to the tissue lymph nodes
that surrounds the lungs within • M → the spread to distant
the rib cage (pleura) sites
Stage 4 Spread to other parts of the
body, such as the liver, bones, or
brain
 STAGING 12

System that is used most often

for NSCLC is American Joint
Committee on Cancer (AJCC)
TNM system
• T → size and extent of the
main tumor
• N → the spread to nearby
lymph nodes
• M → the spread to distant
sites
 GRADING OF NSCLC 6

• Grade 1 → cells look very like normal cells; they tend to be slow growing and are less likely to spread than
higher grade cancer cells (low grade)
• Grade 2 → cells look more abnormal and are more likely to spread (moderately well differentiated or
moderate grade)
• Grade 3-4 → cells look very abnormal and not like normal cells; they tend to grow quickly and are more
likely to spread (poorly differentiated or high grade)
 POSSIBLE METHODS OF TREATMENT 3

Stage 1 Surgery (lobectomy and

mediastinal lymph
dissection)

Stage 2 Surgery, chemotherapy, radiation

Stage 3A Combine chemo-radiation,

sometimes surgery

Stage 3B Chemotherapy and sometimes • Had surgery with her primary

radiation • RLL lobectomy and mediastinal
lymphadenectomy
Stage 4 Chemotherapy, targeted drug • Chemoradiation
therapy, clinical trials • Carboplatin/Paclitaxel weekly
• Maintenance Durvalumab for up
to 1 year
CT/PET IMAGES
 Esophagus 5500 cGy Main bronchus
PTV
Heart 4000 cGy Trachea
GTV
Spinal cord 4700 cGy Carina
 POTENTIAL SIDE EFFECTS 2,3

CONSENT REMEDIES
• Acute
• Skin reaction: dryness, redness, itchiness ➢ Lotions
• Fatigue ➢ Light exercise, rest, adequate nutrition
• Sore throat
➢ Pain medication, magic mouthwash
• Inflammation of the esophagus causing pain on swallowing
(esophagitis)
• Loss of appetite, nausea, weight loss, weakness ➢ Small frequent meals, supplements, fluids, antiemetics
• Inflammation of lung causing dry cough
• Shortness of breath
• Radiation pneumonitis
• Late
• Esophageal strictures Follow up 11/12/19:
• Spinal cord damage
• Pulmonary fibrosis
esophagitis, shortness of
• Vascular complications breath & cough
• Brachial plexopathy
• Lhermitte’s Syndrome
PROGNOSIS & SURVIVAL 1 0

*based on people diagnosed with NSCLC between

From the American Cancer Society which
relies on information from the SEER database
2008 and 2014
that is maintained by the National Cancer
Institute (NCI). • Localized = no sign that the cancer has spread
SEER database does not group cancers by
outside of the lung
AJCC TNM stages, instead it groups cancers • Regional = cancer has spread outside the lung to
into how far it has spread. nearby structures or lymph nodes
• Distant = cancer has spread to distant parts of the
body
 POSSIBLE METASTATIC SITES 11

• The other lung

• Adrenal gland
• Bones
• Brain
• Liver
 DIFFICULTIES

• Had lots of questions

• Was very nervous
• Was squirmy some days
• Worried a lot
• Had to follow a routine or she thought something was wrong
• Aka if the gantry rotated the opposite direction for a cone beam
 PATIENT’S PERSPECTIVE

• Very frustrated with the recurrence

• She blames herself for her diagnosis claiming it is from her lack of “positivity”
• She was worried about “poisoning her body with chemotherapy” and losing
her hair
• Despite that, she was pretty much always happy to see our “cheerful, beautiful,
smiling faces”
• Appreciated how honest we were with her about the process and reminding
her that the side effects she was feeling were normal and not to worry about
extra things
• Was happy that her daughter was flying in from California for the last week of
her treatments
• Went to see her on her last day of treatment
 RESOURCES
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