LUNG CANCER - Bronchogenic Carcinoma Use chemo and radiation

Patient deteriorates very quickly...Don't delay Tx

Classification and Staging
LUNG CANCER CLASSIFICATION
• Small Cell Lung Cancer (SCLC)
TNM SYSTEM
• Non Small Cell Lung Cancer (NSCLC)
NON SMALL CELL LUNG CANCER NSCLC
Primary Primary Distal Small Cell Lung Cancer SCLC
Tumor (T) Lymph metastasis
node (N) (M) - 13% of tumors
• Almost all cases is caused by cigarette smoking
T1 <3 cm in N0 None M0 None • Most aggressive form of lung cancer, grows quickly,
diameter
starts in the airways in the center of the chest
main
bronchus Non Small Cell Lung Cancer NSCLC
- 84% of tumors
T3 >3 cm, s5 N1 epsilateral M1 Distant
cm L.N. metastasis • Squamous Cell
• Large Cell
entire *peribronch
ial 8 • Adenocarcionma
lung
*ipsilateral • Others
hilar
*intrapulmo
nary
Type of Squam Large Adenoc Others
T3 >5 cm, s7 N2 ipsilateral Cancer ous Cell arcino (Bronc
cm L.N. Cell (undiffe ma hoalve
*diaphrag *mediastina
rentiate ola
m l d r cells)
*chest wall *subcarinal carcino
*mediastin ma)
al pleura
*pericardiu
m Occurre 20% 5% 41%
nce
*main
bronchus
but NOT Charact *Central *Central *Periph *Termin
the carina. eristics ly ly eral al
*Periph bronchi
T4 7cm N3 Metastasis
in
Arise eral Most
*mediastinu contralater more in prevale Grows
m, heart, al L.N. segme Fast nt slowly
great ntal growing carcino
vessels, *mediastina
recurrent l and ma in
laryngeal n. *hilar subseg Arise both
(hoarsenes *scalene mental periphe sex
s), *supraclavi
vortebrae, cular
bronchi rally
osophagus, Manifes
or carina. t as
mass
or
SMALL CELL LUNG CANCER SCLC nodule
s
Small Cell lung cancer
Often
metast
Limited Disease Extensive Disease asis
The tumor is The tumor has metastasized
confined to the outside of the ipsilateral
ipsilateral hemithorax
hemithorax
You cannot do surgery to remove it
Risk Factors Assessment and Diagnostic Findings
• Smoking (pack years)
• Male > Female Diagnostic tools
• Electronic Nicotine Deliver System • Chest ray for pulmonary density, pulmonary nodule,
• Secondhand smoke atelectasis, infection
• Environmental and occupational exposure • CT Scan - for small nodules not examined by xray,
• Radon, arsenic, asbestos, mustard gas also to examine lymphadenopathy
• Genetics • Annual lung cancer screening for adults 55-80 years
• EGFR genes - produces epidermal growth factor with 30 pack year smoking or stopped smoking during
receptor the last 15 years
• K-RAS or ALK Oncogenes for NSCLC • Fiberoptic Bronchoscopy - most commonly used
• Dietary deficits to diagnose lung cancer
• Underlying Respiratory disease such as COPD and • Transthoracic Fine-Needle Aspiration under CT
TB Scan - for peripheral lesion
• Carcinoma arise at sites of previous scarring of lung
For metastasis
Clinical manifestations • Bone scan
• Manifestation develops insidiously and • Abdominal scans
asymptomatic until late • PET scan
• Depends on the location and size of tumor, Degree • Liver ultrasound
of obstruction, degree of metastases • CT scan and MRI
• Most frequent symptom is cough or change in a • Mediastinoscopy or mediastinotomy - to obtain
chronic cough biopsy sample in lymph node of mediastinum
• may start as a dry, persistent cough, without sputum
production. MEDICAL MANAGEMENT
• When obstruction of airways occurs, the cough may
become productive due to infection. NON SMALL CELL LUNG CANCER
• A cough that changes in character should arouse •Surgery, radiation, chemotherapy, immunotherapy,
suspicion of lung cancer. or combination
• Dyspnea is prominent in early stages due to tumor • Gene therapy - targets EGFR mutations and ALK
occlusion and ROSI
• Hemoptysis due to alveolar compression rearrangements
• Chest or shoulder pain - may indicate chest wall or
pleural involvement SMALL CELL LUNG CANCER
• Fever - early symptom due to persistent infection in •Surgery (if cancer is in 1 lung and no metastasis),
the area of pneumonitis distal to tumor oradiation,
• cancer of the lung should be suspected in people olaser to open airway endoscopic stent
with repeated unresolved upper respiratory tract
infections. SURGICAL MANAGEMENT

- Lymph involvement PREOPERATIVE PHASE

• Chest pain and tightness Evaluate whether the tumor is resectable
• Hoarseness (laryngeal nerve) • Evaluate whether patient can tolerate surgery
• Dysphagia Provide preoperative diagnostic studies for a baseline
• Head and neck edema comparison during the postoperative period
• Pleural or pericardial effusion • Provide preoperative diagnostic studies for a
• Most common site of metastasis is lymph nodes, baseline comparison during the postoperative period
bone, brain, collateral lung, adrenal gland
HEALTH TEACHINGS
- Nonspecific symptom • Frequent turning - promote drainage of lung
• Weakness secretions
• Anorexia • Incentive spirometry - done before surgery to
• Weight loss (10% in one month) familiarize the device
• Diaphragmatic and pursed lip breathing for • one lobar bronchus, together with a part of the right
atelectasis or left bronchus, is excised.
• Coughing schedule - may be uncomfortable, teach • The distal bronchus is reanastomosed to the
how to splint incision with hands, pillow, folded towel proximal bronchus or trachea.
• Forced Expiratory Technique (FET) - expulsion of air
thru open glottis. It stimulates pulmonary expansion Lung Volume Reduction
and alveolar inflation • Lung volume reduction is a surgical procedure
• Therapeutic communication involving the removal of 20% to 30% of a patient's
lung through a midsternal incision or
TYPES OF SURGERY video thoracoscopy
● Pneumonectomy
● Lobectomy POSTOPERATIVE PHASE
● Segmentectomy/Segmental Resection ● Check Vital signs
● Wedge Resection ● Ensure airway patency
● Bronchoplastic Resection ● Monitor signs for respiratory distress
● Lung Volume Reduction ● Monitor for postoperative complications such
as pneumothorax, atelectasis, etc.
Pneumonectomy o removal of entire lung
• Tumor cannot be removed by less extensive Chest tube drainage
procedure
• The removal of the right lung is riskier than the
removal of the left, because the right lung has a larger
vascular bed and its removal imposes a greater
physiologic burden
• Position after - Affected side to re-expand non
affected lung

Lobectomy
o removal of a lobe of a lung
• More common than pneumonectomy
• Position postop - unaffected side to re-expand the
remaining affected lung

Segmentectomy

Wedge Resection
• For diagnostic lung biopsy and excision of small HEALTH TEACHINGS
peripheral nodules • Alternate walking and other activities with frequent
rest periods, expecting weakness and fatigue for the
Bronchoplastic Resection first 3 weeks
• Perform arm and shoulder exercises as prescribed. BREAST CANCER
• Perform breathing exercises several times daily for
the first few weeks at home. BREAST ASSESSMENT
• Avoid lifting >20 lb until complete healing has taken ● Performing breast palpation
place ● Use your three middle fingers to palpate the
• Avoid bronchial irritants (smoke, fumes, air pollution, patient's breasts systematically.
aerosol sprays). ● Rotate your fingers gently against the chest
• Avoid others with known colds or lung infections. wall. Make sure you include the tail of
Spence in your examination.
OTHERS ●
Airway clearance through Examining the areola and nipple
• DBE ● After palpating the breasts, palpate the
• CPT areola and nipple.
• Directed cough ● Gently squeeze the nipple between your
• Suctioning thumb and index finger to check for
• Bronchodilators discharge.
• Supplemental oxygen
- Reduce fatigue
- Provide psychological support

OTHERS
• Radiation Therapy
• Chemo Therapy
• Palliative Care

EVALUATE BREAST LUMPS

 • Tubular carcinoma
• Inflammatory carcinoma
• Paget Disease

INFILTRATING DUCTAL CARCINOMA

• Most common 70-80%
• Arise from duct system and invade
surrounding tissue
• Form a solid irregular mass

INFILTRATING DUCTAL CARCINOMA

Cancer begins within the duct and spreads to the
breast's parenchymal tissue.

INFILTRATING LOBULAR CARCINOMA

• 10-15 %
SELF BREAST EXAMINATION • From lobular epithelium
• Done every month after menstruation • Area of ill-defined thickening in the
• Done the same day of the month for breast
postmenopausal women • Often multicentric and can be bilateral

TYPES OF BREAST CANCER MEDULLARY CARCINOMA

• Ductal Carcinoma in Situ (DCIS) • <1%
• Invasive Cancer • Tumor grow in a capsule inside a duct. Often
- DUCTAL CARCINOMA IN SITU DCIS o proliferation becomes large
of malignant cells inside the milk ducts without • Prognosis is often favorable
invasion into the surrounding tissue
• DCIS is frequently manifested on a mammogram MUCINOUS CARCINOMA
with the appearance of calcifications and is • 2%
considered breast cancer stage 0. •Persist in women who are postmenopausal and >75
years
DUCTAL CARCINOMA IN SITU DCIS • Slow growing, favorable prognosis

TUBULAR CARCINOMA
•1-5%
•Excellent prognosis

INFLAMMATORY CARCINOMA
• 1-5%
Ductal carcinoma in situ is breast cancer in the • Aggressive, with unique symptoms
earliest stage develop ing in the ducts • Diffuse edema and erythema of skin (Peau d
orange)
MEDICAL MANAGEMENT
• Surgery, chemotherapy, radiation therapy INFLAMMATORY CARCINOMA
• Grade 1 (slow grade) - grow slowly • Caused by malignant cell blocking the lymph
• Grade 2 (moderate grade) - cells look different from channels
normal breast cells • Can be confused with infection
• Grade 3 (high grade) - grows quickly • Can spread to other parts rapidly

INVASIVE CANCER PAGET DISEASE

• Infiltrating ductal carcinoma • 1-4%
• Infiltrating lobular carcinoma • More common in men than women
• Medullary carcinoma • Scaly, erythematous, pruritic lesion of nipple
• Mucinous carcinoma
RISK FACTORS Fibrocystic changes
• 80% are sporadic (no known family history) Fibrocystic changes (benign cysts) are round, elastic,
• 20% are familial mobile masses that are commonly tender on
• BRCA 1 and BRCA 2 mutations in chromosome 17 palpation, especially around menstruation. Multiple
• These are tumor suppressor genes cysts may be present. Typically, there's no evidence
• BRCA mutations is associated with 70% risk of of skin retraction.
Breast CAncer
• Alcohol Fibroadenoma
• Obesity A fibroadenoma is a benign, round, lobular, and well-
• Smoking demarcated mobile mass that feels slippery and firm
• Sedentary lifestyle to soft on palpation. It's usually nontender and causes
• Night shift work no visible skin retraction.

Hormonal Factors Nipple retraction

● Early menarche - Before 12 yrs of age After Nipple retraction, the inward displacement of the
● Late menopause - 55 yrs of age nipple below the level of surrounding breast tissue,
● Nulliparity - No full-term pregnancies may indicate an inflammatory breast lesion or cancer.
● Late age at first full-term pregnancy - After It results from scar tis sue formation within a lesion or
30 yrs of age large mammary duct. As the scar tissue shortens, it
● Hormone therapy (formerly referred to as pulls adjacent tissue inward, causing nipple deviation,
hormone replacement therapy) - Current or flattening, and finally retraction.
recent use of combined postmenopausal
hormone therapy (estrogen and Paget's disease
progesterone); Long-term use (several years Paget's disease is a rare form of breast cancer that
or more) usually starts as a red, granular or crusted, scaly
lesion on the nipple or areola. The lesion may
CLINICAL MANIFESTATION ulcerate and cause erosion of the nipple.
- Common in upper outer quadrant in where most
breast tissue is located ASSESSMENT AND DIAGNOSTIC FINDNGS
- Nontender lesion, fixed rather than mobile, hard with
irregular borders STAGING
- Complaint of diffuse breast pain and tenderness with
menstruation is usually associated with benign breast
disease
- Common route of spread is through axillary
Lymph node
- Common metastasis are in bone, lung, liver, brain

Dimpling
Breast dimpling— the puckering or retraction of skin
on the breast— results from abnormal attachment of
the skin to underlying tissue. It suggests an
inflammatory or malignant mass beneath the skin
surface and usually represents a late sign of breast
cancer.

Peau d'orange
Usually a late sign of breast cancer, peau d'orange
(orange peel skin) is the edematous thickening and
pitting of breast skin. This sign can also occur with
breast or axillary lymph node infection or Graves'
disease. Its striking orange peel appearance stems STAGING
from lymphatic edema around deepened hair follicles. • TNM system
o CXR, CTscan MRI, PET scan, blood work, tumor o the surgeon uses a handheld probe to locate the
markers sentinel lymph node, excises it, and sends it for
o Important factors are size and has spread to pathologic analysis, which is often performed
axillary lymph nodes immediately during the surgery using frozen-section
analysis
MAMMOGRAM
• Explain that it involves X-ray of the breast o The NURSING MANAGAEMENT
breast will be supported on a flat, firm surface - Frozen section is highly accurate but may cause
• The procedure will use 2 x-ray plates false-negative result
• Do not use deodorant, powder, lotion in axilla (false - Reassure that radioisotope and blue dye is safe
positive result) • May notice a blue-green discoloration in urine or
• There will be mild discomfort stool for first 24 hours as the dye is excreted
- Therapeutic Communication
SURGICAL MANAGEMENT
• Modified Radical Mastectomy POSTOPERATIVE CONSIDERATIONS
• Total Mastectomy Relieving pain and discomfort
• Radical Mastectomy • Patients sometimes complain of a slight increase in
• Breast Conservation Treatment pain after the first few days of surgery;
• Sentinel Lymph Node Biopsy o this may occur as patients regain sensation around
the surgical site and become more active.
MODIFIED RADICAL MASTECTOMY MRM
•For invasive breast cancer Postoperative sensations
•Removes breast tissue, including nipple areola • Common sensations include tenderness, soreness,
complex, axillary LN numbness, tightness, pulling, and twinges
•Pectoralis major and minor are intact • After mastectomy, some patients experience
phantom sensations and report a feeling that the
TOTAL MASTECTOMY breast or nipple is still present
• Removes breast and nipple areola complex, but • Patients should be reassured that this is a normal
without axillary lymph node part of healing and that these sensations are not
• For non invasive cancer (DCIS) indicative of a problem
• Can be performed prophylactically for high risk
(BRCA mutation) POSTOPERATIVE COMPLICATIONS
Lymphedema
RADICAL MASTECTOMY o chronic swelling of an extremity due to interrupted
• Removes breast, nipple areola complex, axilla LN, lymphatic circulation
and chest muscle o affects both the breast and ipsilateral limb. o painful
swelling of the arm as well as weakness, shoulder
BREAST CONSERVATION TREATMENT pain, and tingling sensations in the arm and shoulder
o a procedure that removes breast cancer while • After axillary lymph nodes are removed, collateral
preserving as much of the breast as possible circulation must assume this function.
• Lumpectomy, wide excision, partial or segmental • Transient edema in the postoperative period occurs
mastectomy, quadrantectomy until collateral circulation has completely taken over
• Remove lymph node if cancer is invasive this function which generally occurs within a month
• Use radiation after to completely irradicate cancer
cells NURSING CONSIDERATIONS
• After surgery is Semi-fowler with arm abducted and
SENTINEL LYMPH NODE BIOPSY elevated on pillow to promote lung expansion
o status of the lymph nodes is the most important • Normal Drain within first 24 hours is serosanguinous
prognostic factor in breast cancer • Check behind the patient for bleeding
o less invasive to Axillary Lymph Node Dissection • Observe for Arm Precautions
ALND
o The sentinel lymph node, which is the first node (or Hand and Arm Care After Axillary Lymph Node
nodes) in the lymphatic basin that receives drainage Dissection
from the primary tumor in the breast The nurse instructs the patient to:
 ● Avoid blood pressures, injections, and blood • expressing affection using alternative measures
draws in affected extremity. (e.g., hugging, kissing, manual stimulation).
● Use sunscreen (higher than 15 SPF) for
extended exposure to sun. SELF CARE WITH SURGICAL DRAIN
● Apply insect repellent to avoid insect bites. • Initially, it appears bloody but gradually changes to
● Wear gloves for gardening. serosanguineous, then serous fluid over several days
● Use cooking mitt for removing objects from • Drain is removed when output is less than 30 ml in 2
oven. consecutive 24-hour period (about 7-10 days)
● Avoid cutting cuticles; push them back
during manicures. ACTIVITY/RANGE OF MOTION EXERCISE
● Use electric razor for shaving armpit. • Goal is to increase circulation and muscle strength,
● Avoid lifting objects heavier than 5 to 10 lb. prevent joint stiffness and contractures, and restore
● If a trauma or break in the skin occurs, wash full range of motion
the area with soap and water, and apply an • three times a day for 20 minutes at a time until full
over-the-counter antibacterial ointment. range of motion is restored (generally 4 to 6 weeks).
Observe the area and extremity for 24 hours; • If the patient is having any discomfort, taking an
if redness, swelling, or a fever occurs, call analgesic agent 30 minutes before beginning the
the surgeon or nurse. exercises can be helpful.
• Taking a warm shower before exercising can also
POST MASTECTOMY ARM EXERCISES loosen stiff muscles and provide comfort.
"Walt climbing" • Heavy lifting (more than 5 to 10 lb) is avoided for
Rod/Broomstick lifting about 4 to 6 weeks
Rope Turning •normal household and work-related activities are
Pulley Tugging promoted to maintain muscle tone.

Hematoma TREATMENT MODALITIES

• Collection of blood inside cavity within the first 12 • RADIATION THERAPY
hours after surgery • CHEMOTHERAPY
• swelling, tightness, pain, and bruising of the skin. • HORMONAL THERAPY
• a compression wrap may be applied to the incision • TARGETED THERAPY
for approximately 12 hours
-The patient may take warm showers (if permitted by HORMONAL THERAPY
the surgeon) or apply warm compresses to help - for hormone receptor-positive tumors
increase the absorption. - slows or stops the growth of hormone-sensitive
• hematoma usually resolves in 4 to 5 weeks tumors by blocking the body's ability to produce
hormones or by interfering with effects of hormones
Seroma on breast cancer cells
• Collection of serous fluid - About two thirds of breast cancers depend on
• swelling, heaviness, discomfort, and a sloshing of estrogen for growth and express a nuclear receptor
fluid that binds to the estrogen; thus, they are estrogen
receptor positive (ER+).
Infection - Similarly, tumors that express the progesterone
• higher in patients with conditions such as diabetes, receptor are progesterone receptor positive (PR+)
immune disorders, and advanced age, as well as in - Tamoxifen
those with poor hygiene. - Selective estrogen receptor modulators (SERMs)
• Treatment consists of oral or IV antibiotics - has estrogen antagonistic (estrogen-blocking)
- Aromatase inhibitors
Sexual function - Anastrozole, letrozole, exemestane
• Once discharged from the hospital and feeling well, - Aromatase inhibitors work by blocking the enzyme
most patients are physically allowed to engage in aromatase from performing the conversion, thereby
sexual activity, if interested decreasing the level of circulating estrogen in
• varying the time of day for sexual activity peripheral tissues.
• assuming positions that are more comfortable,
 • Most commonly used
• Gluteal flap
• Latissimus dorsi flap (back muscle)

HEALTH TEACHINGS
- Deep breathing and leg exercises are essential due
to limited activity
- Elevate HOB 45 degree and flex the knees to
reduce abdominal tension
- Once able to ambulate, protect the surgical incision
by splinting
- Avoid high impact activities
- Avoid heavy lifting (more than 5-10lbs for 6-8 weeks)

NIPPLE-AREOLA RECONSTRUCTION
TARGETED THERAPY - Via skin graft using upper inner thigh (this skin has
- a type of cancer treatment that uses drugs or other darker pigmentation than the reconstructed breast)
substances to precisely identify and attack certain • Micropigmentation (tattooing) is done to achieve a
types of cancer cells. more natural color
- Trastuzumab
- if used in patient previously treated with
anthracycline, they have more risk of cardiac toxicity

BREAST RECONSTRUCTION
- provide a significant psychological benefit for women
- done by plastic surgeon
- Reconstruction will not affect the risk of cancer
recurrence

TISSUE EXPANDER FOLLOWED BY A

PERMANENT IMPLANT
- Places a tissue expander (balloon like device)
underneath the pectoralis muscle
- Injects small amount of saline via metal port to
inflate the expander for 6-8 weeks until expander is
fully inflated
- Places a tissue expander (balloon like device)
underneath the pectoralis muscle
- The patient must be cautioned not to have an MRI
while the tissue expander is in place because the port
contains metal.
- This is not an issue once the permanent implant is in
place because it does not contain any metal.

TISSUE TRANSFER PROCEDURES

- Autologous reconstruction is the use of the patient's
own tissue to create a breast mound
- A flap of skin, fat, and muscle with its attached blood
supply is rotated to the mastectomy site to create a
mound that simulates the breast.

DONOR SITES
• Transverse Rectus Abdominal myocutaneous
(TRAM) flap -Abdominal muscle