BRONCHOGENIC CARCINOMA

Overview

Lung Cancer

• Cancer is caused by a variety of malignant neoplasm in which cells mutate and

invade surrounding tissue and can travel via lymphatic system or blood vessels to other
secondary sites.
• Primary cancer is the body system or site where the cancer was first observed
• Secondary when it spreads (metastasizes) from cancer in other areas of the
body.

Definition

• Bronchogenic carcinoma refers to the malignant tumor which grows in the

bronchus. Originating from mucus or gland of bronchus.

Classification of Lung Cancer Cells

1. Non Small Cell Lung Cancer (NSCLC)

• Adenocarcinoma

• Squamous Cell Carcinoma

• Large Cell Carcinoma

2. Small Cell Lung Cancer (SCLC)

• Oat Cell

• Intermediate

• Combined
Classifications

Non- small Cell lung Cancer

• Squamous cell carcinoma:

 is usually more centrally located and arises more commonly in the segmental
and subsegmental bronchi.
 Slow-growing, late metastasis

• Adenocarcinoma:
 is the most prevalent carcinoma of the lung in both men and women; it occurs
peripherally as peripheral masses or nodules and often metastasizes.
 Moderate growth rate, early metastasis
• Large-cell carcinoma
 Also called undifferentiated carcinoma
 Is a fast growing tumor that tends to arise peripherally
 Fast-growing, early metastasis

• Small cell carcinoma has three subtypes:

 oat-cell carcinoma
 intermediate cell type
 Combined oat- cell carcinoma.
  Tumors grows rapidly and are often located near a major bronchus
in the central part of the lungs
 Fast-growing, early metastasis

Etiology and Pathogenesis

• Occupational associations: asbestos, uranium( in miners), arsenical fumes,

nickel,radon gas ects.
• Other factors include air pollutions , ionizing radiation .
• Nowadays it is reported that tuberculosis is associated with the incidence of lung
cancer.
• Many factors influence the formation of lung cancer. The development of lung
cancer is multistep process. The transformation of normal bronchial epithelial
cells to malignant cells is unknown.

• Perhaps It is related to: damage to cellular DNA; alteration in cellular

oncogene expression; tumor-derived factors that stimulate cellular division.
• Chronic inflammation of the lung, such as from interstitial fibrosis and areas of
scarring is associated with the occurrence of adenocarcinoma.
• Genetic factors also involve the formation of lung cancer.
Anatomy and Physiology

Lung

The Lungs are paired elastic structures enclose in the thoracic cage, which os an
airtight chamber, with distensible walls. Ventilation requires movement of the walls of
the thoracic cage and of its floor, the diaphragm. The effect of its movement is
alternately to increase and decrease the capacity of the chest, when the capacity of the
chest is increased, air enters through the trachea (inspiration) because of the lowered
pressure within and inflates the lungs. When the chest wall and diaphragm return to
their previous positions (expiration), the lungs recoil and force the air out through the
bronchi and trachea. Inspiration occurs during the first third of the respiratory cycle,
expiration during the latter two thirds. The inspiratory phase of the respiration normally
requires energy, the expiratory phase is normally passive requiring very little energy. In
respiratory diseases such as chronic obstructive pulmonary disease (COPD), expiration
requires energy.

Pathophysiology

Precipitating Factors

Cigarette smoking

Second hand smoker

Pollution

Dietary deficits

Occupational exposures

Carcinogen

Rise from a singled transformed Epithelial cells

Carcinogen binds and damage DNA

 ↓

Cellular Changes, abnormal cell growth

Accumulation of genetic changes

Pulmonary epithelium undergoes malignant transformation

Lung Cancer

Assessment

Clinical Manifestations

• usually asymptomatic until late in its course

• cough or change in chronic cough

• dyspnea

• chest pain and tightness

• hoarseness

• dysphagia

• head and neck edema

• Persistent cough

• Blood tinged sputum or coughing up frank blood.

• Fatigue and weakness. Chest pain,

• Shortness of breath.

• Weight loss.

• Shoulder, arm, or bone pain.

• Sometimes the cancer is diagnosed on routine examination, and the patient has
no or minimal symptoms. Symptoms and signs are dependent upon the location and
spread of the tumor.

Diagnostic Test

• Chest X ray
WHY IS IT GIVEN?

Are done to detect size and position of the heart and structural abnormalities of the
lungs.

HOW DOES THE TEST WORK?

Directs x-ray through the chest and onto film positioned behind the patient’s back. As x-
ray are directed to the patient, some are absorbed by the body and others pass through
the x-ray film. Areas of the body that absorb x-rays appear light on the x-ray film. Dark
areas on the film represent x-ray that passed through the body.

WHAT TO DO?

• Explain the test to the patient and that the patient will be asked to hold his or her
breath while the x-ray is taken.
• Before the test, remove all jewelry, zippers, hooks, and any metal on the part of
the body being x-rayed.
Bronchoscopy

WHY IS IT DONE?
Bronchoscopy is used to view the bronchial tree and to remove foreign obstructions,
obtain tissues for biopsy, or for suctioning fluid.

HOW DOES IT WORK?

The patient is anesthetized and a bronchoscope is inserted into the patient’s mouth and
down the trachea and bronchial tree. The bronchoscope contains a tiny video camera
and probes that the physician manipulates to perform the procedure.

WHAT TO DO?
Before the procedure

• The patient must sign an informed consent for an invasive procedure.

• The patient is NPO for 8 hours except in an emergency, to reduce chances of
vomiting when the bronchoscope is passed down the throat.
During the procedure

• Monitor vital signs, respiratory effort, and skin color, cardiac monitor.
After the procedure

• The patient remains nothing by mouth, (NPO) until the gag reflex returns to
avoid aspiration.
• Verify the cough and gag reflex returns.
• Monitor respirations for rate, effort, use of accessory muscles, and breath
sounds.
• Monitor heart rate and respiratory status for change.
• Monitor sputum for blood due to irritation within bronchi.

Pulmonary Angiography

WHY IS IT DONE??

• Provides a view of the pulmonary circulatory system so that the physician can
determine the condition of blood flow to the lungs.

HOW DOES THE TEST WORK?

•Radiopaque dye is inserted into the patient’s veins after a catheter has been
passed through the heart into the pulmonary artery fluoroscopically. The image is
watched on a screen as the dye flows through he pulmonary circulatory system.
WHAT TO DO?

Before the procedure:

• Verify the patient is not allergic to contrast dye, iodine, or shellfish. If the patient
is then either another diagnostic study will be done, or the patient will be
premedicated for this test if no other test is deemed appropriate.
Diphenhydramine and prednisone may be given prior to the test to lessen or
prevent an allergic reaction while closely monitoring the patient.
• The patient must sign an informed consent based on institutional policy.
• Instruct the patient that a flushed feeling is common hen the dye is injected
intravenously.
During the procedure:

• Monitor patient for tolerance of procedure and possible reaction to dye.

After the procedure:
 • Monitor the insertion site for bleeding.

Sputum Culture and Sensitivity

WHY IT IS DONE?

• Sputum from the patient is cultured to determine which, if any, bacteria is

contained in the sputum and determine which antibiotic kills the bacteria.

HOW DOES THE TEST WORK?

• Sputum is collected from the patient in a sterile container and sent to the lab
where the sample is smeared in Petri dishes and incubated to grow the bacteria.
Samples of the bacteria are stained and examined under a microscope to identify
the bacteria. The samples are checked periodically, but are usually given 72
hours to complete the testing process. Once identified, bacteria are exposed to
known antibiotics to determine which antibiotic kills the bacteria.

WHAT TO DO?

Before the test:

• Use a sterile specimen container to determine that the bacteria that grow in the
lab have come from the patient and not from contamination.
• Collect sputum only and not saliva- there are bacteria naturally found in the
mouth, so saliva samples will grow bacteria in the lab even though it is not
causing any infection.
After the test:

• Sample needs to go to lab

Teach the patient:

• How to properly obtain sputum sample.

Thoracentesis

WHY IT IS DONE?

• Removal of fluid from the pleural sac to drain fluid or identify the contents of the
fluid.

HOW DOES THE TEST WORK?

 • The patient either sits at the edge of the bed or lies on the unaffected side. The
affected site is anesthetized. A needle work is inserted into the plural sac and
fluid is drained using a syringe.

WHAT TO DO?

Before the test:

• The patient must sign an informed consent for an invasive procedure.

• Position the patient at the edge of the bed or lying on the unaffected side with the
head of the bed elevated 30 degrees.
During the test:

• Monitor the patient for tolerance of the procedure.

• Monitor respiratory status for rate, effort, skin color, use of accessory muscle,
and breath sounds.
After the test:

• Lay the patient on the affected side for 1 hour following the procedure. This
applies direct pressure to the puncture site, reducing the chance of bleeding.
• Monitor the injection site for leakage; reinforce dressing noted.
• Monitor respiratory status for changes.

Pulmonary Function Test (PFT)

WHY IS IT DONE?

• This test assesses the lungs’ ability to move air. Monitor change from normal
function; differentiate obstructive from restrictive disease.

HOW DOES THE TEST WORK?

The patient takes a deep breath. The spirometer is inserted into the patient’s mouth and
the patient breathes outward quickly at full force until all air is expelled. A deep breath is
then taken in through the mouthpiece and this process is repeated three times. A
computer then calculates the lungs’ volume and vital capacity by measuring the amount
of air moving in and out. The force of the air flow is measured. The duration of time of
exhalation is measured.

What to do?

Before the test:

 • The patient should not smoke prior to the test. Smoking may have an effect on
the outcome of the test.

During the test:

• Instruct the patient to take a deep breath and then exhale completely into the
spirometer followed by deep inhalation.

After the test:

• Administer bronchodilators after the initial testing is gone and repeat the test if
indicated. This will show the effect of bronchodilators on pulmonary function.
Albuterol or levalbuterol are typically used.

Lung Biopsy

Why is it done?

Removal of a tissue to be examined by the histology lab for abnormalities

How does the test work?

A tissue sample can be extracted by inserting a needle through the chest and
into the lung or by using a bronchoscope. A biopsy can also be performed as an
open procedure through the chest wall, opening the lung to remove tissue
samples.

What to do?

Before the test:

• The patient must sign an informed consent. This is required for an invasive
procedure which will remove something from the body.
• NPO for 8 hours to decrease the chance of aspiration if done as an open
procedure.

During the test:

• Monitor vital signs, skin color, and respiratory effort; cardiac monitor;

After the test:

• Examine the incision site for bleeding.

• Monitor respiration for changes, potential for pneumothorax development after a
piece of the lung has been removed.
Arterial Blood Gas (ABG)

Why is it done?

This determines the patient’s ventilation, tissue oxygenation, and acid-base

status.

How does the test work?

Three top five milliliters of blood is sampled from an artery in a heparinized

syringe. If the sample cannot be analyzed right away, it should be placed on ice.

• The normal results are;

o pH 7.35-7.45
o Pa02 80-100 mmhg
o PaCO2 35-45 mmHg
o HCO3 22-26 mEq/L

What to do?

Before the test:

• Provide the lab with information on whether or not patient is receiving

supplemental oxygen or mechanical ventilation as well as the amount of oxygen
received or the setting of the ventilator. Oxygen supplementation at the time of
testing will be reported with the results.
• Note the patient’s temperature. Alteration in temperature may alter the results of
the test.

After the test:

• Apply mechanical pressure to puncture site for 5 minutes.

• Apply pressure to puncture site for 30 minutes once the bleeding stopped.
• Monitor the puncture site for bleeding.

Medical Management

Surgical management

Types of Lung Resection

 • Lobectomy: a single lobe of lung is removed.
• Bilobectomy: Two 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 entire lung
• Segmentectomy: A segment of lung is removed
• Wedge resection: Removal of 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 to decrease tumor size.
• Chemotherapy use to alter tumor growth patterns to treat distant metastases or
small cell cancer of the lungsand as an adjunct to surgeryor radiation therapy,
often with a combination of drugs: cyclophosphamide, doxorubicin, vincristine,
etoposide, cisplatin, may see relapse after treatment.
• Oxygen therapy to supplement the needs of the body.
• High- protein, high calorie, diet to meet the needs of the body.
• Administer antiemetics to combat side effects of chemotherapy: ondansetron,
prochlorperazine.
• Administer analgesics for pain control: morphine, fentanyl

Nursing Management

1. Monitor respiratory status, looking at rate, effort, use of accessory muscles, and
skin color; auscultate breath sounds.
2. Monitor pain and administer analgesics appropriately.
3. Monitor vital signs for changes, elevated pulse, elevated respiration, change in
BP, and elevated temperature, which may signal infection.
4. Monitor pulse oximetery for decrease in oxygenation levels.
5. Assist patient with turning, coughing, and deep-breathing exercise.
6. Place patient in semi-Fowler’s position to ease respiratory effort.
7. Explain to the patient:
8. The importance of taking rest periods