Classifications of Lung Cancer:

I. NON-SMALL CELL LUNG CARCINOMA (NSCLC) - arises in the major bronchi and spread by infiltration along
the bronchial wall

Five Types of NSCLC

1. Squamous cell carcinoma is usually more centrally located and arises more commonly in the segmental and
subsegmental bronchi.
2. Adenocarcinoma  is the most prevalent carcinoma of the lung in both men and women; it accounts for about
30%-40% of lung cancers. it occurs peripherally as peripheral masses or nodules and often metastasizes. Most
common lung cancer in people who have not smoked: more common in women.
3. Adenosquamous carcinoma comprises 0.4 % to 4% of diagnosed NSCLC. It is defined as having more than 10%
mixed glandular and squamous components. It has a poorer prognosis than either squamous and
adenocarcinomas. Molecular testing is recommended for these cancers.
4. Large cell carcinoma (undifferentiated carcinoma) is a fast-growing tumor that tends to arise peripherally.
5. Carcinoid tumors include two subtypes: typical and atypical. Typical carcinoid carries relatively better prognosis
and is only occasionally associated with carcinoid syndrome.
6. Bronchoalveolar cell cancer is found in the terminal bronchi and alveoli and is usually slower growing compared
with other bronchogenic carcinomas.

II. SMALL CELL LUNG CARCINOMA (SCLC) - is characterized by small cells with scant cytoplasm and no distinct
nucleoli.
- Most arise in the major bronchi and spread by infiltration along the bronchial wall.
- It is classified as limited or extensive.
-  is almost usually with smoking.
- The central nervous system, liver, and bone are the most common sites.
-  It has a higher doubling time and metastasizes early; therefore, it is always considered a systemic
disease at diagnosis.
 COMPARISON OF TYPES OF PRIMARY LUNG CANCER
CELL TYPE RISK FACTORS CHARACTERISTICS RESPONSE TO THERAPY
Non-Small Cell Lung Cancer (NSCLC)
Adenocarcinoma Has been associated with Most common type of lung Surgical resection may be
smoking and chronic cancer; accounts for about attempted depending on the
interstitial fibrosis 30%-40% of lung cancers; staging. Cancer does not
most common lung cancer in respond well to chemotherapy
people who have not smoked;
more common in women.
Often has no clinical
manifestations until
widespread metastasis is
present
Squamous Cell Almost always associated Second most common type of Surgical resection may be
Carcinoma with cigarette smoking; lung cancer; accounts for attempted.
Is associated with about 30% of lung cancers; is Depending on the staging, life
exposure to more common in men expectancy is better than the
environmental Arises from bronchial small cell lung cancer.
carcinogens (e.g., epithelium (surface cells) of
uranium, asbestos) lungs or bronchus
Slow-growing cancer that
usually begins in the bronchial
tubes; disease nodules tend to
be clumped together;
produces earlier symptoms
because of bronchial
obstructive characteristics.
Does not have a strong
tendency to metastasize

Large Cell High correlation with The least common form of Surgery is not usually
(undifferentiated cigarette smoking and NSCLS; accounts for 5%-15% attempted because of high
carcinoma) exposure to of lung cancers. rate of metastases.
environmental Composed of large-sized cells Tumor may be radiosensitive
carcinogens that are anaplastic and often but often recurs.
arise in the bronchi
Small Cell Lung Cancer (SCLC)
Small Cell Carcinoma Always associated with Accounts for about 20% of Chemotherapy mainstay of
smoking, exposure to lung cancers. treatment but overall patient
environmental Is most malignant form of lung has poor prognosis.
carcinogens cancer. Radiation is used as adjuvant
Tends to spread early via therapy as well as palliative
lymphatics and bloodstream. measure.
Is frequently associated with
endocrine disturbances
STAGES of the tumor – refers to size of tumor, whether lymph nodes are involved, and whether the cancer has spread
- Tissue biopsy, lymph node biopsy, or mediastinoscopy determines initial staging
- Staging helps determine whether the tumor should be removed.

STAGING OF NON-SMALL CELL LUNG CANCER

STAGES CHARACTERISTICS
I - Tumor is small and localized to lung. No lymph nodes involvement
A - tumor < 3cm
B - tumor > 3cm and invading surrounding local areas
II
A - tumor < 3cm with invasion of lymph nodes in same side of chest
B - tumor > 3cm involving the bronchus and lymph nodes on same side of chest and tissue of other local
organs
III
A - tumor spread to the nearby structures (chest wall, pleura, pericardium) and regional lymph nodes
B - extensive tumor involving heart, trachea, esophagus, mediastinum, malignant pleural effusion,
contralateral lymph nodes, scalene or supraclavicular lymph nodes
V - distant metastasis
The Risk Factors Associated with Lung Cancer are as follows:
 Smoking – risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplies by
the number of years smoked)
 Second-hand smoke – passive smoking
 Environmental and occupational exposure
o Radon – a colorless, odorless gas found in soil and rocks.
o Motor vehicle emissions and pollutants – fine refineries and manufacturing plants
o Industrial carcinogens – chronic exposure such as arsenic, asbestos, mustard gas, chromates,
coke oven fumes, nickel, oil, and radiation
 Genetics – personal or family history of lung cancer
 Radiation therapy to the chest - cancer survivors who had radiation therapy to the chest are at higher risk of
lung cancer.
 Dietary factors – low intake of fruits and vegetables which are high in vitamin A (carotene)
Clinical Manifestations:
a. Cough – most common symptom – dry, persistent cough without sputum production
b. Dyspnea
c. Hemoptysis – important symptom in history taking of smoking
d. Wheezing
e. Hoarseness of voice
f. Dysphagia
g. Head and neck edema
h. Symptoms of pleural or pericardial effusion
i. Chest or shoulder pain – late manifestation, may indicate chest
wall or pleural involvement by a tumor, maybe related to metastasis
to the bone
j. Recurring fever – is an early symptom in response to a persistent infection in an area of pneumonitis distal to the
tumor.
*Cancer of the lung should be suspected in people with repeated unresolved upper respiratory tract
infections.

 Non-specific symptoms
a. Weakness
b. Anorexia
c. Weight loss

NURSING ALERT! A cough that changes in character should arouse suspicion of lung cancer.

The most common sites of metastases are lymph nodes, bone, brain, contralateral lung, adrenal glands and liver.
Assessment and Diagnostic findings:
 Radiologic staging
1. Chest x-ray – to search for pulmonary density, a solitary peripheral nodule (coin nodule), atelectasis and
infection
2. Low-dose CT scan (LDCT) – used to identify small nodules not visualized in chest x-ray and also to
serially examine areas for lymphadenopathy
The only recommended screening test for lung cancer is low-dose computed tomography (also
called a low-dose CT scan). Screening is recommended only for adults who have no symptoms
but are at high risk.

 Who should be screened?

 Have a history of heavy smoking, and
 Smoke now or have quit within the past 15 years, and
 Are between 55 and 80 years old.
3. Imaging with PET or PET-CT - directed at sites of potential metastasis when symptoms or focal findings are
present or when chest CT shows evidence of advanced disease
- is also helpful in excluding recurrent tumors after initial therapy. It also can identify recurrence versus
metabolic changes post radiation therapy.

 Invasive staging - is to obtain tissue or pathologic confirmation of malignancy, confirm staging, and histological
differentiation of cancer.
4. Bronchoscopic Endobronchial Ultrasound-Transbronchial Needle Aspiration (TBNA) – is more commonly used and
provides a detailed study of the tracheobronchial tree and allows for brushings, washings, and biopsies of
suspicious areas
5. Mediastinoscopy – is used to determine whether the tumor has spread to the hilar lymph nodes of the right lung.
- Maybe used to obtain biopsy samples from lymph nodes in the mediastinum
- It gives some access to the hilar lymphatics of the left lung
- has a sensitivity of 78% and specificity of 100% .
-  General anesthesia is required
6. Thoracoscopy - used for mediastinal lymph node sampling (lymph node biopsy)
- Video-assisted thoracoscopy surgery (VATS)
- RATS (robotic-assisted thoracoscopy) – newer version

Collaborative Management
 Surgery – surgical resection is the preferred method in treating with patients with localized non-small tumors,
no evidence of metastatic spread, and adequate pulmonary function.
- Cure rate depends on type and stage of cancer
- Primarily used in NSCLC
 Lung Resection
 Lobectomy – a single lobe of the lung is removed – most common surgical procedure for a small,
apparently curable tumor of the lung
 Bilobectomy – 2 lobes of the lung are removed
  Sleeve resection - cancerous lobe(s) is removed and a segment of the main bronchus is resected
 Pneumonectomy – removal of the entire lung
 Segmentectomy – a segment of the lung is removed
 Wedge resection – removal of a small, pie-shaped area of the segment
 Chest wall resection with removal of cancerous lung tissue – for cancers that have invaded the chest
wall

 Radiation therapy
 Used to control neoplasms that cannot be surgically resected but are responsive to radiation (small cell and
epidermoid tumors are usually radiation sensitive)
 Used to reduce the size of tumor for operation
 May help relieve cough, chest pain, dyspnea, hemoptysis, and bone and liver pain
 It is usually toxic to normal tissue within the radiation field

Complications are as follows: these complications may impair ventilatory and diffusion capacity and significantly
reduce pulmonary reserve
 Esophagitis
 Pneumonitis
 Radiation lung fibrosis

What to monitor throughout the treatment?

 Patients nutritional status
 Psychological outlook,
 fatigue lever
 signs of anemia
 infection

 Chemotherapy
 used to alter tumor growth patterns,
  to treat patients with distant metastases or small cell cancer of the lung, and to supplement surgery or
radiation therapy
 it may provide relief especially of pain, but it does not usually cure the disease or prolong life to any great
degree.
 It is valuable in reducing pressure symptoms of the lung cancer and in treating brain, spinal cord, and
pericardial metastasis.
 The choice of agent depends on the growth of tumor cell and the specific phase of cell cycle that the
medication affects, maybe administered before surgery (neoadjuvant therapy) or after surgery (adjuvant
therapy)
 Combination of 2 or more medications may be more beneficial than single-dose regimens
 Chemotherapeutic agents used – the choice of the agent depends on the growth of the tumor cell and specific
phase of the cell cycle that the medication affects
 Ifosfamide –alkylating agent
 Platinum analogues – Cisplatin and Carboplatin
 Taxanes – Paclitaxel, Docetaxel
 Mitomycin C
 Vinca alkaloids – Vinblastine and Vindesine
 Doxorubicin
 Gemcitabine
 Navelbine
 Irinotecan – (CPT-11)
 Etoposide – VP-16
 Pemetrexed – (Alimta)
Oral form chemo drug:
 Gefitinib (Iressa)
 Erlotinib (Tarceva)
 Palliative therapy includes
a. radiation therapy to shrink the tumor to provide pain relief,
b. a variety of bronchoscopic interventions to open a narrowed bronchus or airway
c. pain management and other comfort measures
d. evaluation and referral to hospice care are important in planning for comfortable and dignified end-of-
life care for the patient and family

Treatment – related Complications

 Surgery
 Respiratory failure if cardiopulmonary system is compromised before surgery
 Surgical complications and prolonged ventilation are potential outcomes
 Radiation therapy
 Diminished cardiopulmonary function
 Pulmonary fibrosis
 Pericarditis
 Myelitis
 Cor pulmonale
 Chemotherapy
 Pneumonitis
 Pulmonary toxicity – potential side effect

Nursing Management:
 1. Manage symptoms
- the nurse instructs the patient and family about the potential side effects of the specific
treatment and strategies to manage symptoms such as dyspnea, fatigue, n/v and anorexia
2. Relieve breathing problems
- airway clearance technique to maintain airway patency through the removal of secretions
- Techniques such as deep breathing exercises, chest physiotherapy, directed cough, suctioning,
and bronchoscopy in some patients
- Bronchodilator medications maybe prescribed
- Supplemental oxygen
- To decrease dyspnea, encourage patient to assume position (high Fowler’s position) that
promote lung expansion and perform breathing exercises for lung expansion and relaxation
- Educate patient about energy conservation and airway clearance technique
- Refer patient to pulmonary rehabilitation program – is applied to patients with lung cancer
depends on the severity of disease and patient’s wishes
3. Pain control
- Asses the intensity, location and duration of pain
- Monitor v/s noting elevated temperature
- Administer opioid analgesics as prescribed for severe pain
- Turning and reposition frequently
- Provide psychological support
- Provide diversional therapy
4. Reducing fatigue
- nurse should asses level of fatigue, identify potential treatable causes, and validating with the
patient that fatigue is indeed an important symptom
- Educate patient about conservation of energy conservation techniques or referral to physical
therapy, occupational therapy, or pulmonary rehabilitation programs
- Guided exercise
5. Providing psychological support : the nurse must help the patient and family deal with the following:
- The poor prognosis and relatively rapid progression of the disease
- Informed decision making regarding the possible treatment options
- Methods to maintain the patient’s quality of life during the course the disease
- End-of-life treatment options
Lung cancer is not curable and all clinicians should urge patients
to quit smoking; screening may be useful in selective patients.