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A. Description
Lung cancer is a type of cancer that begins in the lungs. The lungs are two
spongy organs in the chest that take in oxygen when we inhale and release
carbon dioxide when we exhale.
Lung cancer is the uncontrolled growth of abnormal cells that start off in one or
both lungs; usually in the cells that line the air passages. The abnormal cells do
not develop into healthy lung tissue, they divide rapidly and form tumors.
Types
Non-Small Cell Lung Cancer (NSCLC) is the most common type of lung cancer,
making up 80-85% of all cases. It typically grows and spreads more slowly than small
cell lung cancer (SCLC). NSCLC is staged based on the size of the primary tumor
and if and where the cancer has spread (stages I, II, III, IV). Some lung cancer
tumors are composed of cells from more than one type of NSCLC.
B. Incidence
Lung cancer (both small cell and non-small cell) is the second most common
cancer in both men and women (not counting skin cancer). In men, prostate cancer is
more common, while in women breast cancer is more common. About 14% of all new
cancers are lung cancers. The American Cancer Societys estimates for lung cancer in
the United States for 2017 are:
About 222,500 new cases of lung cancer (116,990 in men and 105,510 in
women)About 155,870 deaths from lung cancer (84,590 in men and 71,280 in
women)
Lung cancer is by far the leading cause of cancer death among both men and
women; about 1 out of 4 cancer deaths are from lung cancer. Each year, more
people die of lung cancer than of colon, breast, and prostate cancers combined.
Lung cancer mainly occurs in older people. About 2 out of 3 people diagnosed
with lung cancer are 65 or older, while less than 2% are younger than 45. The
average age at the time of diagnosis is about 70.
Overall, the chance that a man will develop lung cancer in his lifetime is about 1 in
14; for a woman, the risk is about 1 in 17. These numbers include both smokers
and non-smokers. For smokers the risk is much higher, while for non-smokers the
risk is lower.
Black men are about 20% more likely to develop lung cancer than white men.
Statistics on survival in people with lung cancer vary depending on the stage
(extent) of the cancer when it is diagnosed.
Globally, the most common cause of cancer death is lung cancer (1.59 million
deaths) followed by liver (745,000), stomach (723,000), colorectal (694,000), breast
(521,000) and esophageal (400,000).
In the Philippines, lung cancer is also the top cause of cancer-related deaths
among men, and the third cause of cancer deaths among women, outranked by breast
and cervical cancer. Health experts estimate that 10 Filipinos die of smoking-related
diseases every hour. Lung cancer deaths in the Philippines numbered 8,518 in the
country, according to the data published by the World Health Organization (WHO).
C. Risk Factors
1. Tobacco / Cigarette Smoking
Cigarette smoking is the number one risk factor for lung cancer. Tobacco smoke
is a toxic mix of more than 7,000 chemicals. Many are poisons. At least 70 are
known to cause cancer in people or animals. More than 85% of all lung cancer
occur among people who are either current or former tobacco smokers.
The relationship between smoking and lung cancer is caused by the carcinogens
present in tobacco smoke. The risk of developing lung cancer from smoking is
influenced by many factors including the age at which a person begins smoking.
The younger a person was at the time he or she started smoking, the greater the
risk of lung cancer. The effects of carcinogens accumulate overtime.
People who quit smoking have a lower risk of lung cancer than if they had
continued to smoke, but their risk is higher than the risk for people who never
smoked. Quitting smoking at any age can lower the risk of lung cancer
Second-hand Smoke: The lungs of anyone who breathes in air that contains
tobacco smoke are exposed to carcinogens. Therefore exposure to smoky air in
the home, workplace, or in public can increase a persons risk for lung cancer.
Secondhand smoke is thought to cause more than 7,000 deaths from lung cancer
each year.
2. Environmental Carcinogens
Environmental carcinogens are substances in the environment capable of producing
genetic damage that could contribute to the development of cancer.
A. Asbestos
Asbestos is a fibrous mineral that has been widely used in manufacturing,
construction, and industry. When asbestos is inhaled, the fibers can irritate
the lung and may eventually cause lung disease. People exposed to high
amounts of asbestos are at increased risk for lung cancer and malignant
mesothelioma, a rare form of cancer that involves the coverings of the
lungs.
Cigarette smoking drastically increases the chance of developing an
asbestos-related lung cancer in workers exposed to asbestos; asbestos
workers who do not smoke have a fivefold greater risk of developing lung
cancer than nonsmokers, but asbestos workers who smoke have a risk
that is fifty- to ninety-fold greater than nonsmokers.
B. Radon
Radon is naturally occurring, radioactive gas. It is odorless and tasteless.
It is formed from the radioactive decay of uranium that normally takes
place in the soil and disperses into the atmosphere.
If these particles are inhaled, they can deposit in the lungs and expose a
person to radiation. This can cause a variety of damage to cells and DNA
that can contribute to cancer. Exposure to high levels of radon is
associated with an increased risk of lung cancer. As with asbestos
exposure, concomitant smoking greatly increases the risk of lung cancer
with radon exposure.
3. Genetic Factors
The transformation of normal cells into cancer cells is a complex, multi-step
process. Genes control how a persons body handles carcinogens, how
susceptible it is to genetic damage, and how capable it is of repairing damage that
occurs.
Genes also control how well the immune system detects and destroys cancer
cells. Therefore, an individuals unique genetic make-up contributes to his or her
susceptibility or resistance to lung carcinogens. For example, people whose
parents or siblings have had lung cancer maybe at increased risk of developing
lung cancer.
4. Age
Genetic damage tends to accumulate over time. it is believe that cells accumulate
multiple genetic defects before becoming cancerous. Therefore, as we age, the
probability of accumulating enough genetic damage to lead to cancer increases.
In addition, the immune system works less effectively as we age. This increases
the likelihood that cancer cells will slip through the natural cancer surveillance
system.
5. Arsenic
Arsenic is a natural element that can be found in rocks and soil, water, air, and in
plants and animals. It can also be released into the environment from some
agricultural and industrial sources. Specifically the inorganic compound. These
compounds are found in industry, in building products (such as some
pressure-treated woods), and in arsenic-contaminated water. This is the form of
arsenic that tends to be more toxic and has been linked to cancer.
Studies of people in parts of Southeast Asia and South America with high levels of
arsenic in their drinking water have found higher risks of cancers of
the bladder, kidney, lung, skin, and, less consistently, colon, prostate, and liver.
The studies that have been done have generally not found a strong link between
cancer and the lower levels of arsenic exposure.
D. Manifestations
Advanced stages of lung cancer are often characterized by the spread of the
cancer to distant sites in the body. This may affect the bones, liver or brain. As other parts
of the body are affected, new lung cancer symptoms may develop, including:
E. Diagnostic Procedures
Purpose
To look at suspicious areas that might be cancer
To learn if and how far cancer has spread
To help determine if treatment is working
To look for possible signs of cancer coming back after treatment
1. Chest X-ray
An x-ray of the chest is a scan that can show tumors one centimeter wide or larger.
Small, hidden tumors dont always show up on x-rays.
This is often the first test the doctor will do to look for any abnormal areas in the
lungs.
6. Bone Scan
A bone scan can help show if a cancer has spread to the bones. This test is done
mainly when there is reason to think the cancer may have spread to the bones (because
of symptoms such as bone pain) and other test results arent clear.
For this test, patient is injected with a slightly radioactive chemical that collects
mainly in abnormal areas of bone. A special camera is then used to create a picture of
areas of radioactivity in the body.
Sputum cytology
For this test, a sample of sputum (mucus you cough up from the lungs) is looked at
under a microscope to see if it has cancer cells. The best way to do this is to get early
morning samples from patient 3 days in a row. This test is more likely to help find cancers
that start in the major airways of the lung, such as most small cell lung cancers and
squamous cell lung cancers. It may not be as helpful for finding other types of lung
cancer.
Thoracentesis
If fluid has built up around a patient lungs (called a pleural effusion), doctors can use
thoracentesis to relieve symptoms and to see if it is caused by cancer spreading to the
lining of the lungs (pleura). The buildup might also be caused by other conditions, such
as heart failure or an infection.
For this procedure, the skin is numbed and a hollow needle is inserted between the
ribs to drain the fluid. (In a similar test called pericardiocentesis, fluid is removed from
within the sac around the heart.) A microscope is used to check the fluid for cancer cells.
Chemical tests of the fluid are also sometimes useful in telling a malignant (cancerous)
pleural effusion from one that is not.
If a malignant pleural effusion has been diagnosed, thoracentesis may be repeated
to remove more fluid. Fluid buildup can keep the lungs from filling with air, so
thoracentesis can help a person breathe better.
Needle biopsy
Doctors can often use a hollow needle to get a small sample from a suspicious area
(mass).
In a fine needle aspiration (FNA) biopsy, the doctor uses a syringe with a very thin,
hollow needle to withdraw (aspirate) cells and small fragments of tissue.
In a core biopsy, a larger needle is used to remove one or more small cores of tissue.
Samples from core biopsies are larger than FNA biopsies, so they are often preferred.
An advantage of needle biopsies is that they dont require a surgical incision, but in some
cases they might not provide enough of a sample to make a diagnosis.
Bronchoscopy
Can help the doctor find some tumors or blockages in the larger airways of the lungs.
It may be used to find a lung tumor or to take a sample of a tumor to see if it is cancer.
For this exam, a lighted, flexible fiber-optic tube (called a bronchoscope) is passed
through the mouth or nose and down into the windpipe and bronchi. The mouth and
throat are sprayed first with a numbing medicine..
Small instruments can be passed down the bronchoscope to take biopsy samples.
The doctor can also sample cells that line the airways by using a small brush (bronchial
brushing) or by rinsing the airways with sterile saltwater (bronchial washing). These
tissue and cell samples are then looked at under a microscope.
Endobronchial ultrasound.
A bronchoscope is fitted with an ultrasound transducer at its tip and is passed down
into the windpipe. This is done with numbing medicine (local anesthesia) and light
sedation.
The transducer can be pointed in different directions to look at lymph nodes and
other structures in the mediastinum (the area between the lungs). If suspicious areas
such as enlarged lymph nodes are seen on the ultrasound, a hollow needle can be
passed through the bronchoscope to get biopsy samples of them. The samples are then
sent to a lab to be looked at with a microscope.
This test is like endobronchial ultrasound, except the doctor passes an endoscope (a
lighted, flexible scope) down the throat and into the esophagus (the tube connecting the
throat to the stomach). This is done with numbing medicine (local anesthesia) and light
sedation.
The esophagus is just behind the windpipe and is close to some lymph nodes inside
the chest to which lung cancer may spread. As with endobronchial ultrasound, the
transducer can be pointed in different directions to look at lymph nodes and other
structures inside the chest that might contain lung cancer. If enlarged lymph nodes are
seen on the ultrasound, a hollow needle can be passed through the endoscope to get
biopsy samples of them. The samples are then sent to a lab to be looked at under a
microscope.
Mediastinoscopy
A small cut is made in the front of the neck and a thin, hollow, lighted tube is inserted
behind the sternum (breast bone) and in front of the windpipe to look at the area.
Instruments can be passed through this tube to take tissue samples from the lymph
nodes along the windpipe and the major bronchial tube areas. Looking at the samples
under a microscope can show if they contain cancer cells.
Mediastinotomy
The surgeon makes a slightly larger incision (usually about 2 inches long) between
the second and third ribs next to the breast bone. This lets the surgeon reach some
lymph nodes that cannot be reached by mediastinoscopy.
Thoracoscopy
This procedure can be done to find out if cancer has spread to the spaces between
the lungs and the chest wall, or to the linings of these spaces (called pleura). It can also
be used to sample tumors on the outer parts of the lungs as well as nearby lymph nodes
and fluid, and to assess whether a tumor is growing into nearby tissues or organs. This
procedure is not often done just to diagnose lung cancer, unless other tests such as
needle biopsies are unable to get enough samples for the diagnosis.
F. Management
The objective of management is to provide a cure, if possible. Treatment depends on:
Cell type
The Stage of the disease
The physiologic status (particularly cardiac and pulmonary status) of the patient.
2. Bilobectomy
Two lobes of the lungs are removed
4. Pneumonectomy
It is the removal of an entire lung and is performed chiefly for cancer when the
lesion cannot be removed by a less extensive procedure.
It may also be performed for lung abscesses, bronchiectasis, or extensive
unilateral tuberculosis.
So, a posterolateral or anterolateral thoracotomy incision is made, sometimes
with resection of a rib. The pulmonary artery and the pulmonary veins are ligated
and severed. The main bronchus is divided and the lung removed. The bronchial
stump is stabled and usually no drains are used because the accumulation of fluid
in the empty hemithorax prevents mediastinal shift.
The removal of the right lung is more dangerous than the removal of the left
because the right lung has a larger vascular bed and its removal imposes a
greater physiologic burden.
5. Wedge Resection
A wedge resection of a small, well-circumscribed lesion may be performed without
regard for the location of the intersegmental planes.
The pleural cavity usually is drained because of the possibility of an air blood leak.
This procedure is performed for diagnostic lung biopsy and for the excision of
small peripheral nodules.
F.3. Chemotherapy
Antineoplastic agents are used in an attempt to kill and destroy the cancer cells.
It is used to:
o Alter tumor growth patterns
o Treat patients with distant metastases or small cell cancer of the lug
o An adjunct to surgery or radiation therapy
Combination of two or more medications may be more beneficial than single-dose
regimens.
A large number of medications are active against lung cancer. A variety of
chemotherapeutic agents are used including:
o Alkylating Agents
It interferes with the cell's DNA and inhibits cancer cell growth.
E.g. Ifosfamadie
o Platinum analogues
It covalently bind to the DNA and work nonspecifically regarding
the cell cycle. They enhance the tumor activity of etoposide and
are widely used as radiosensitizers.
E.g Cisplatin and Carboplatin
o Taxane
Drugs that inhibit microtubule formation resulting in cell cycle arrest
and apoptosis, used in cancer chemotherapy. Microtubules are
essential to cell division, and taxanes therefore stop this action by
freezing the mitosis process.
Paclitaxel and Decotaxel
o Vinca Alkaloids
It disrupts mitosis by binding to tubulin, thus preventing
microtubules from forming. These are also known as anti-mitotic,
antimicrotubule agents, or mitosis inhibitors.
Vinblastine and Vindesine
o Doxorubicin, gemcitabine, vinorelbine, irinotecan
CPT-11
CPT-11 is classified as a "plant alkaloid" and
"topoisomerase I inhibitor."
o Etoposide
Topoisomerase inhibitors (such as etoposide) are drugs that
interfere with the action of topoisomerase enzymes
(topoisomerase I and II). Topoisomerase enzymes control the
manipulation of the structure of DNA necessary for replication.
VP-16
The choice of agent depends on the growth of the tumor cell and the specific
phase of the cell cycle that the medication affects.