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LUNG CANCER

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.

Lung cancer is divided into two main categories:

Non-small cell lung cancer (NSCLC)


o NSCLC is further classified into squamous cell carcinoma,
adenocarcinoma, and large cell carcinoma. Because treatment varies
greatly depending on the type and stage of lung cancer, the diagnostic
workup is critical in terms of identifying the specific type of lung cancer, the
stage of the dis-ease, and the ability of the patient to tolerate treatment.
NSCLC represents 80% of all lung cancers, with adenocarcinoma
accounting for 40% of all cases of lung cancer. Squamous cell carcinoma
occurs most frequently in the central zone of the lung whereas
adenocarcinoma tumors are peripheral in origin, arising from the alveolar
surface epithelium or bronchial mucosal glands. Large cell carcinoma
composes only 15% of all lung cancers and appears to be decreasing in
incidence because of improved diagnostic techniques.
Small cell lung cancer (SCLC)
o The second major type of lung cancer is SCLC, in which there are also
several histologic groupings: pure small cell, mixed small cell, and large
cell carcinoma, as well as combined small cell. SCLC is usually more
aggressive than NSCLC and presents as a central lesion with hilar and
mediastinal invasion along with regional adenopathy. Distant metastasis
at presentation is common in patients with SCLC.
o The most common sites of metastasis of lung cancer are the bones, liver,
adrenal glands, pericardium, brain, and spinal cord. Staging for NSCLC is
done using the internationally accepted TNM (tumor, node, metastasis)
staging system. Prognosis and treatment of SCLC are determined using a
staging system developed by the Veterans Administration Lung Cancer
Study Group, although some hospitals and cancer centers are beginning
to apply the TNM system to SCLC. SCLC is divided into two stages:
limited-stage and extensive-stage disease. In patients with limited-stage
disease, the cancer is restricted to the ipsilateral hemithorax, which can be
treated with a single radiation port. However, patients with extensive-stage
disease have obvious metastasis. The overall 5-year survival rate for all
patients with lung cancer is approximately 15%; depending on the
histology and stage of disease, the 5-year survival rate ranges from
1%-60%.

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.

Lifetime chance of getting lung cancer:

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

A cough that does not go away or gets worse over time


o Presence of a mass irritates the cough receptors in the airway
Coughing up blood (Hemoptysis)
o It occurs in a significant number of people who have lung cancer. Any
amount of coughed-up blood is cause for concern.
o Blood vessels resulting from tumor-induced angiogenesis are leaky and
tortuous, predisposing them to easy rupture and causing hemoptysis
Chest pain
o A symptom in about one-fourth of people with lung cancer.
o The pain is dull, aching, and persistent.
o Lung tumor causes tightness in the chest or presses on nerves
Shortness of breath
o Usually results from a blockage to the flow of air in part of the lung,
collection of fluid around the lung (pleural effusion), or the spread of tumor
throughout the lungs.
Wheezing or hoarseness
o May signal blockage or inflammation in the lungs that may go along with
cancer.
o Chronic coughing or a tumor that interferes with the vocal cords can cause
people with lung cancer to have a raspy voice.
Weight loss
o May be because cancer cells use up much of the bodys energy supply, or
they may release substances that change the way the body makes energy
from food.
Repeated respiratory infections,
o Lung tumors can block the airway, causing frequent infections such as
bronchitis and pneumonia.

Signs of advanced stages of lung cancer:

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:

Bone pain because the cancer spreads to the adjacent bones


Headaches, dizziness or limbs that become weak or numb due to cancer
spreading to the nervous system
Jaundice if the cancer metastasizes to the liver
Lumps in the neck or collar bone region

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.

2. Spiral Computed Tomography (CT) Scan

A CT scan combines many x-rays to make detailed cross-sectional images of the


body. A CT (computerized tomography) scan uses x-ray beams to take
three-dimensional pictures of the inside of the body.
A patient may be asked not to eat or drink for a few hours before the CT scan. An
iodine contrast dye also may be injected into a vein in the arm to make the scan
pictures clearer. Before the scan, check for allergy to iodine, fish or dyes.
A CT scan usually takes less than 10 minutes. A CT scan is more likely to show
lung tumors than a routine chest x-ray. It can also show the size, shape, and
position of any lung tumors and can help find enlarged lymph nodes that might
contain cancer that has spread from the lung.

3. CT Guided Needle Biopsy


If a suspected area of cancer is deep within the patients body, a CT scan can be
used to guide a biopsy needle precisely into the suspected area.
4. Magnetic Resonance Imaging (MRI) Scan
MRI scans use radio waves and strong magnets instead of x-rays. A contrast
material called gadolinium is often injected into a vein before the scan to better see
details. MRI scans are most often used to look for possible spread of lung cancer
to the brain or spinal cord

5. Positron Emission tTomography (PET) scan


For a PET scan, patients are injected with a slightly radioactive form of sugar,
which collects mainly in cancer cells. A special camera is then used to create a
picture of areas of radioactivity in the body.
A PET scan can be a very important test if patient appear to have early stage (or
limited) small cell lung cancer SCLC. The doctor can use this test to see if the
cancer has spread to lymph nodes or other organs, which can help determine
patients treatment options. PET/CT scan:

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.

Transthoracic needle biopsy


If the suspected tumor is in the outer part of the lungs, the biopsy needle can be
inserted through the skin on the chest wall. The area where the needle is to be inserted
may be numbed with local anesthesia first. The doctor then guides the needle into the
area while looking at the lungs with either fluoroscopy (which is like an x-ray, but the
image is shown on a screen rather than on film) or CT scans. Unlike fluoroscopy, CT
doesnt give a constant picture, so the needle is inserted toward the mass, a CT image is
taken, and the direction of the needle is guided based on the image. This is repeated a
few times until the needle is within the mass.
A possible complication of this procedure is that air may leak out of the lung at the
biopsy site and into the space between the lung and the chest wall. This is called a
pneumothorax. It can cause part of the lung to collapse and could cause trouble
breathing. If the air leak is small, it often gets better without any treatment. Larger air
leaks are treated by putting a small tube into the chest space and sucking out the air over
a day or two, after which it usually heals on its own.
Other approaches to needle biopsies: An FNA biopsy may also be done to check for
cancer in the lymph nodes between the lungs:

Transtracheal FNA or transbronchial FNA


is done by passing the needle through the wall of the trachea (windpipe) or bronchi
(the large airways leading into the lungs) during bronchoscopy or endobronchial
ultrasound.
Some patients have an FNA biopsy done during endoscopic esophageal ultrasound
(described below) by passing the needle through the wall of the esophagus.

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.

Tests to find lung cancer spread


If lung cancer has been found, its often important to know if it has spread to the
lymph nodes in the space between the lungs (mediastinum) or other nearby areas. This
can affect a persons treatment options.

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.

Endoscopic esophageal ultrasound

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 and mediastinotomy


These procedures may be done to look more directly at and get samples from the
structures in the mediastinum (the area between the lungs). They are done in an
operating room by a surgeon while the patient is under general anesthesia (in a deep
sleep). The main difference between the two is in the location and size of the incision.

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.

Lung function tests


Lung (or pulmonary) function tests (PFTs) may be done after lung cancer is
diagnosed to see how well the lungs are working. They are generally only needed if
surgery might be an option in treating the cancer, which is rare in small cell lung cancer.
Surgery to remove lung cancer requires removing part or all of a lung, so its important to
know how well the lungs are working beforehand.
There are different types of PFTs, but they all basically have you breathe in and out
through a tube that is connected to a machine that measures airflow.
A complete blood count (CBC) determines whether the blood has normal numbers
of different types of blood cells. These cancer markers can be detected from the late
stages of the patient.

Isocitrate dehydrogenase (IDH1)


Present at high levels in lung cancers and can be detected in the blood, making it a
noninvasive diagnostic marker for lung cancers, according to a study published in Clinical
Cancer Research, a journal of the American Association for Cancer Research. He and
colleagues found that IDH1 could be detected in the blood of lung cancer patients with 76
percent sensitivity and 77 percent specificity.

CEA: Carcinoembryonic antigen (CEA)


It is a protein found in many types of cells but associated with tumors and the
developing fetus. CEA is tested in blood. The normal range is <2.5 ng/ml in an adult
non-smoker and <5.0 ng/ml in a smoker.
The CEA is often positive in malignancies other than colonic. In cancer of the breast,
lung, pancreas, stomach, and ovary the CEA may be elevated and can be used to
monitor the progress of disease or response to treatment.

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.

In general, treatment may involve surgery, radiation therapy, or chemotherapy or a


combination of these.

F.1. Surgical Management


Surgical resection is the preferred method of treating patients with localized
non-small cell tumors, no evidence of metastatic spread, and adequate
cardiopulmonary function.
If the patients cardiovascular status, pulmonary function and functional status are
satisfactory, surgery is generally well tolerated.
Contraindicated to:
Coronary artery disease
Pulmonary insufficiency
Other comorbidities
Surgery is primarily used for non-small cell carcinomas because small cell cancer
of the lung grows rapidly and metastasized early and extensively. Unfortunately,
in many patients with bronchogenic cancer, the lesion is inoperable at the time of
diagnosis.

Several different types of lung resections may be performed:


1. Lobectomy
It is the most common surgical procedure for a small, apparently curable tumor of
the lung in which a lobe of the lung is remove.
When the pathology is limited to one area of a lung, a lobectomy is performed. It is
more common than pneumonectomy.
The surgeon makes a thoracotomy incision:
o Its exact location depends on the lobe to be resected.
o When the pleural space is entered, the involve lung collapses and the
lobar vessels and the bronchus are ligated and divided.
o After the lobe is removed, the remaining loves of the lung are reexpanded.
o Usually, two chest catheters are inserted for drainage.
The upper tube is for air removal
The lower one is for fluid draining.
The chest tube is connected to a chest drainage apparatus
for several days.

2. Bilobectomy
Two lobes of the lungs are removed

3. Segmentectomy (Segmental Resection)


Some lesions are located in only one segment of the lung. Bronchopulmonary
segments are subdivisions of the lung that function as individual units. These are
held together by delicate connective tissue.
If disease process is limited to a single segment, care is used to preserve as
much healthy and functional lung tissue as possible.
Single segments can be removed from any lobe
o There is some form of segmental symmetry between the right and left
lungs, even though the left lung is smaller and only contains two lobes. In
general, each lung has 10 segments.

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.

6. Brochoplastic or Sleeve Resection


It is a procedure in which only one lobar bronchus, together with a part of the right
or left bronchus, is excised. The distal bronchus is re-anastomosed to the
proximal bronchus or trachea.

F.2. Radiation Therapy


Radiation therapy uses high-powered energy beams from sources such as X-rays
and protons to kill cancer cells.
o External Beam Radiation - Radiation therapy directed at the lung cancer
from outside the body.
o Brachytherapy Putting inside needles, seeds or catheters and placed
inside the body near the cancer (brachytherapy).
Radiation therapy may cure a small percentage of patients. It is useful in
controlling neoplasms that cannot be surgically resected but are responsive to
radiation.
Radiation also may be used to reduce the size of a tumor, to make an inoperable
tumor operable, or to relieve the pressure of the tumor on vital structures.
It can control symptoms of spinal cord metastasis and superior vena caval
compression.
Radiation may help relieve:
o Cough
o Chest pain
o Dyspnea
o Hemoptysis
o Bone and liver pain
Relief of symptoms may last from a few weeks to many months
and is important in improving the quality of the remaining period of
life
It is usually toxic to normal tissue within the radiation field and this may lead to
complications such as esophagitis, pneumonitis and radiation lung fibrosis.
o This may impair ventilation and diffusion capacity and significantly reduce
pulmonary reserve.

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.

F.4. Palliative Therapy


When chemotherapy is part of the treatment for lung cancer, palliative care can
manage side effects such as nausea, vomiting, pain, fatigue, constipation and
diarrhea, depression and insomnia.
It may include radiation therapy to shrink the tumor to provide pain relief, a variety
of bronchoscopic interventions to open a narrowed bronchus or airway, and pain
management and other comfort measures.
Evaluation and referral for hospice care are important in planning for comfortable
and dignified end-of-life care for the patient and family.
G. Nursing Care Plan
1. Impaired gas exchange
2. Acute pain
3. Ineffective airway clearance

I. Impaired gas exchange related to alveolar-capillary membrane compression


secondary to tumor growth as manifested by dyspnea, hypercapnia, hypoxemia,
and use of accessory muscles.
II. Acute pain related to compression of pain receptors secondary to local tumor
growth as manifested by grimacing, tachycardia, tachypnea, and guarding
behavior
III. Ineffective airway clearance related to restricted chest movements secondary to
pain as manifested by retained secretions, abnormal breath sounds, hypopnea,
and feelings of discomfort

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