________________________________________________ #30721 Lung Cancer: Diagnosis and Management COURSE #30721 — 10 CONTACT HOURS Release Date: 09/01/15 expiRation Date: 08/31/18 Lung Cancer: Diagnosis and Management Division Planner Disclosure HOW TO RECEIVE CREDIT The division planner has disclosed no relevant financial relationship with any product manufacturer or service • Read the enclosed course. provider mentioned. • Complete the questions at the end of the course. • Return your completed Evaluation to NetCE by Audience mail or fax, or complete online at www.NetCE. This course is designed for all nurses, especially those com. (If you are a Florida nurse, please return involved in the care of patients with lung cancer. the included Answer Sheet/Evaluation.) Your Accreditations & Approvals postmark or facsimile date will be used as your In support of improving patient care, completion date. NetCE is jointly accredited by the • Receive your Certificate(s) of Completion by mail, Accreditation Council for Continu- fax, or email. ing Medical Education (ACCME), the Accreditation Council for Phar- macy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing Faculty education for the healthcare team. Marilyn Fuller Delong, MA, BSN, RN, received her basic nursing education at St. Luke’s School of Nursing Designations of Credit in Cedar Rapids, Iowa, her BSN from Coe College and NetCE designates this continuing education activity her MA from California State University, Long Beach. for 10 ANCC contact hours. She has worked throughout the United States both NetCE designates this continuing education activity clinically and as an educator. Her continuing education for 12 hours for Alabama nurses. classes have focused on the case management aspects of the care of orthopedic and pulmonary patients, with NetCE designates this continuing education activity for particular focus on the long-term care needs of the 2 pharmacotherapeutic/pharmacology contact hours. elderly and disabled. AACN Synergy CERP Category A. Faculty Disclosure Individual State Nursing Approvals Contributing faculty, Marilyn Fuller Delong, MA, BSN, In addition to states that accept ANCC, NetCE is RN, has disclosed no relevant financial relationship approved as a provider of continuing education in nurs- with any product manufacturer or service provider ing by: Alabama, Provider #ABNP0353 (valid through mentioned. 11/21/2021); California, BRN Provider #CEP9784; Division Planner California, LVN Provider #V10662; California, PT Jane C. Norman, RN, MSN, CNE, PhD Provider #V10842; District of Columbia, Provider #50- 2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 (valid through 12/31/2019); South Carolina, Provider #50-2405. Copyright © 2015 NetCE A complete Works Cited list begins on page 57. Mention of commercial products does not indicate endorsement. NetCE • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 1 #30721 Lung Cancer: Diagnosis and Management _______________________________________________ About the Sponsor 5. Describe the lung cancer classification The purpose of NetCE is to provide challenging cur- and staging system. ricula to assist healthcare professionals to raise their 6. Discuss the treatment options available to levels of expertise while fulfilling their continuing the patient with lung cancer, including education requirements, thereby improving the quality potential adverse effects. of healthcare. 7. Discuss the clinical course of a patient Our contributing faculty members have taken care to with lung cancer. ensure that the information and recommendations are 8. Describe conditions caused by advanced accurate and compatible with the standards generally lung cancer and lung cancer treatments. accepted at the time of publication. The publisher dis- 9. Identify the vascular access devices (VADs) claims any liability, loss or damage incurred as a conse- commonly used in the treatment and quence, directly or indirectly, of the use and application management of lung cancer. of any of the contents. Participants are cautioned about 10. Define grief and loss and identify measures the potential risk of using limited knowledge when to facilitate the grieving process. integrating new techniques into practice. 11. Differentiate between advance directives, Disclosure Statement physician directives, and do not resuscitate It is the policy of NetCE not to accept commercial sup- (DNR) orders. port. Furthermore, commercial interests are prohibited 12. Explain the hospice concept. from distributing or providing access to this activity to learners. 13. Discuss nursing case management and clinical pathways of the patient with lung cancer. Course Objective 14. List patient teaching goals that are useful The purpose of this course is to address the various for patients with lung cancer. aspects of diagnosis, treatment, disease management and appropriate patient care for healthcare professionals caring for patients with lung cancer. Sections marked with this symbol include Learning Objectives evidence-based practice recommend ations. Upon completion of this course, you should be able to: The level of evidence and/or strength 1. Discuss the risk factors and incidence of lung of recommendation, as provided by the cancer. evidence-based source, are also included 2. Explain the pathophysiology of lung cancer. so you may determine the validity or relevance of the information. These sections may be used in conjunc- 3. Identify the signs and symptoms of lung cancer. tion with the course material for better application to 4. Discuss the various tests used to diagnose your daily practice. lung cancer. 2 NetCE • January 25, 2018 www.NetCE.com ________________________________________________ #30721 Lung Cancer: Diagnosis and Management INTRODUCTION EPIDEMIOLOGY Lung cancer is the second most common cancer Early in the twentieth century, lung cancer was affecting both men and women in the United rare. One report from 1912 found only 374 cases States, accounting for an estimated 13.3% of all of lung cancer described in international medical new cancer diagnoses [1; 2]. Although it has been literature; one man commented that it seemed of linked primarily with smoking and environmental little value to write about such an “insignificant factors, this disease can affect patients regardless problem” [3]. However, in the 1930s, cigarette of their occupation or lifestyle. Within the general smoking became a socially acceptable trend for diagnosis of lung cancer, there are several types, men in the United States. By the 1950s, lung can- each with its own clinical course and prognosis. It is cer rates had risen significantly in the male popula- important that healthcare professionals understand tion. In the 1960s, women began to embrace the these differences as they care for patients with the trend and started smoking cigarettes in increased diagnosis of lung carcinoma. numbers. Ten years later, the rate of lung cancer among women had increased as well [2]. Multiple treatment options are available to the patient with lung cancer. Traditional methods, Among men in the United States, the number of such as surgery, chemotherapy, and radiation, new lung cancer cases and the number of deaths continue to be the mainstays, but alternative from lung cancer have decreased over the last methods are being increasingly developed and several decades due to a decline in the number used. Many of the treatment options available of men who smoke. Although men develop lung to patients with lung cancer have extensive side cancer more often than women, the incidence of effects, which should be discussed and minimized new lung cancer cases among men has declined as much as possible. 28% over the past 37 years [4]. The death rates for U.S. men are lower than the death rates for men By first understanding lung cancer and how it is in several other countries, but more men die from diagnosed and treated, healthcare professionals lung cancer than do women [2; 5]. In 2012, 86,740 will best know how to implement measures to save men died from lung cancer, compared with 70,759 costs. The realities of healthcare costs in the last women [4]. Among women in the United States, few decades have caused changes in the practice reductions in smoking began in the late 1970s. The of medicine. Perhaps now more than ever before, incidence of lung cancer among women decreased the nurse has a vital role as patient advocate. 1.1% per year from 2005 to 2009, whereas the When concerns exist about quality of care, the death rates increased from 1999 to 2012 [4]. Lung case manager can be a pivotal influence to keep all cancer death rates for women in the United States components of the process functioning. are among the highest in the world [6]. Also, large state and regional variations in lung cancer trends among U.S. women persist [1; 4; 5; 7]. NetCE • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 3 #30721 Lung Cancer: Diagnosis and Management _______________________________________________ The American Cancer Society estimates that The role of particulate air pollution in the inci- 221,200 new cases of lung cancer (115,610 men dence of lung cancer has been the source of serious and 105,590 women) will be diagnosed in the debate and contention for many years. Between United States in 2015; lung cancer deaths for the 1982 and 2006, the American Cancer Society same year are estimated to be 158,040 (86,380 men conducted a study (the Cancer Prevention Study II and 71,660 women), accounting for approximately [CPS-II]) to examine the impact of environmental 28% of all cancer deaths [4]. and lifestyle factors on cancer etiology in men and women in the United States. Researchers deter- ALTERABLE RISK FACTORS mined that fine particulate and sulfur oxide-related Several risk factors for lung cancer have been pollution, from vehicle and industrial sources, was associated with lifestyle choices, meaning that the associated with an increased incidence of cancer, risks can be either managed or avoided in many heart disease, and all-cause mortality. Long-term cases. The most common lifestyle risk factor in the exposure to these pollutants was determined to be development of lung cancer is smoking. A 1954 a significant environmental factor in lung cancer study was one of the first to substantiate the con- incidence and mortality [13]. nection between smoking and lung cancer. This Those who work around certain industrial sub- study demonstrated that a person who had smoked stances, such as asbestos, have been found to have for 20 years, the equivalent of two packs per day an increased risk for developing lung cancer, as for 10 years or one pack per day for 20 years, was, well as mesothelioma and nonmalignant lung and on average, 20 times more likely to have died from pleural disorders [14]. In the late 1970s, the U.S. lung cancer than a nonsmoker [8]. One in four Consumer Product Safety Commission imposed a lung cancer deaths in the United States each year limited ban on the use of asbestos. This was fol- is related to smoking [9]. lowed by a 1989 ban on all new uses of asbestos There are several other risks that contribute to by the U.S. Environmental Protection Agency the development of lung cancer besides smok- [15]. Studies have shown that cigarette smoking ing, including involuntary or secondhand smok- combined with asbestos exposure is particularly ing, industrial and environmental hazards, and hazardous. Smokers who are exposed to asbestos geography. Smoke that is breathed in from the have a risk of developing lung cancer that is greater environment is not as concentrated as if it was than the individual risks from asbestos exposure inhaled directly, but it contains the same harm- and smoking added together [14; 15]. ful materials. Secondhand smoke, also known In addition to asbestos, many other materials have as environmental tobacco smoke, is a complex been linked to the development of lung cancer, mixture of gases and particles that includes smoke including [11; 16]: from the burning cigarette, cigar, or pipe tip (side- stream smoke) and exhaled mainstream smoke. • Radioactive ores (e.g., uranium) Secondhand smoke contains at least 250 chemicals • Inhaled chemicals or minerals (e.g., arsenic, known to be toxic, including more than 50 that beryllium, cadmium, vinyl chloride, nickel cause cancer. Secondhand smoke exposure causes compounds, chromium compounds, coal lung cancer in nonsmoking adults. Nonsmokers products, mustard gas, chloromethyl ethers) who are exposed to secondhand smoke at home • Myristic acid or work increase their lung cancer risk by 20% to • Petroleum products 30% [10; 11; 12]. Secondhand smoke exposure also causes respiratory symptoms in children and slows • Wood dust their lung growth. There is no risk-free level of • Radon secondhand smoke exposure. Even brief exposure • Diesel exhaust can be dangerous [10]. 4 NetCE • January 25, 2018 www.NetCE.com ________________________________________________ #30721 Lung Cancer: Diagnosis and Management These substances are handled in many occupations, Significant racial and ethnic differences in the including by workers in chemical factories, auto- smoking-related incidence and progression of lung mobile maintenance, uranium mining/processing, cancer have been reported [17]. Tobacco use varies copper smelts, foundries, shipyards, mines, and within and among racial/ethnic minority groups. glass, pottery, and linoleum factories [17]. Individu- African Americans bear the greatest health bur- als in any of these occupations who also smoke den. Among adults, American Indians and Alaska cigarettes have an increased risk of developing Natives have the highest prevalence of tobacco lung cancer [11]. use, and African American and Southeast Asian men also have a high prevalence of smoking. Asian Geography has also been shown to be a significant American and Hispanic women have the lowest risk factor for lung cancer. A report compiled prevalence. Differences in the magnitude of disease by the American Cancer Society, the Centers risk are directly related to differences in patterns of for Disease Control and Prevention (CDC), the smoking. No single factor determines patterns of National Cancer Institute, and the North Ameri- tobacco use among racial/ethnic minority groups; can Association of Central Cancer Registries these patterns are the result of complex interac- found large geographic variations in smoking that tions of multiple factors, such as socioeconomic are delaying a decrease in lung cancer death rates status, cultural characteristics, acculturation, in women and slowing the decrease in men. For stress, biological elements, targeted advertising, example, the average percentage decrease in the price of tobacco products, and varying capacities lung cancer death rate among men in California of communities to mount effective tobacco control was more than twice that of many Midwest and initiatives [19]. Southern states during the period 2008 through 2012 [18]. In women, the lung cancer death rate There seems to be an identifiable trend of lung increased in 3 states (Vermont, South Dakota, cancer in persons who have a family history of and North Dakota) and decreased in 28 states for lung cancer, particularly in those cases where the the same time period [18]. Rates remained stable patient was young. Studies have shown that there in 20 states. State variations have been attributed may be a specific gene that predisposes a person to to several factors, including the level of public lung cancer. Researchers studying the genetics of awareness about the harmful effects of smoking, familial lung cancer have found strong evidence social norms (e.g., acceptability of smoking), state linking a major lung cancer susceptibility region educational levels, racial/ethnic variations among of chromosome 6, specifically 6q23-25, to lung and states, tobacco control activities, industry promo- other tobacco-related cancers [20; 21]. tional activities, and economic dependency on tobacco farming and production [7]. PREVENTION AND SCREENING NONALTERABLE RISK FACTORS Most risk factors can be minimized by establishing The risk factors mentioned so far have all been goals to prevent the disease whenever possible. manageable or preventable (i.e., the decision to The majority of these efforts have been focused smoke or where to work is generally a personal on educating the public to never begin smoking, choice). Race, gender, socioeconomic status, and decrease exposure to secondhand smoke, and/ family history are not factors that can be changed, or stop smoking if already smoking. Educational but they nevertheless influence an individual’s efforts to prevent new smokers from beginning likelihood of developing lung cancer. have been heavily aimed at teenagers and young adults. Many programs have been established in schools, on television, and in print media. NetCE • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 5 #30721 Lung Cancer: Diagnosis and Management _______________________________________________ Smoking cessation is beneficial in the following There is little evidence that chest x-ray or sputum ways [19; 22]: cytology affect lung cancer mortality [26]. However, low-dose helical CT scans in high-risk patients do • It lowers the risk for lung and other types result in reductions in lung cancer-specific (20% of cancer; the risk declines with the reduction) and all-cause (nearly 7% reduction) number of years of smoking cessation. mortality, mostly due to cancers being at an earlier • It reduces an individual’s risk of dying stage at the time of diagnosis [27]. Based on these prematurely. findings, the U.S. Preventive Services Task Force • It reduces respiratory symptoms (USPSTF) recommends that adults 55 to 80 years (e.g., coughing, wheezing, dyspnea). of age who have a 30 pack-year smoking history • It slows the rate of decline in lung and currently smoke or have quit within the past function and may improve lung tissue. 15 years be screened annually with low-dose CT scan [28]. Screening should be discontinued once Patients who stop smoking continue to have a a person has not smoked for 15 years or develops greater risk of developing lung cancer than those a health problem that substantially limits life who never smoked at all, and the benefits are expectancy or the ability or willingness to have greater the earlier cessation occurs; however, ces- curative lung surgery. sation is beneficial at all ages. Among adult U.S. smokers, more than 70% report that they want to quit completely [19; 23]. Brief PATHOPHYSIOLOGY clinical interventions by healthcare providers can OF LUNG CANCER increase the chances of successful cessation, as can counseling and behavioral cessation therapies [24]. To understand the pathophysiology of lung cancer, Treatments with more person-to-person contact it is necessary to examine normal tissue cells and and intensity (e.g., more time with counselors) how they function. Normal cells are differenti- have been shown to be more effective. Effec- ated. That is, they undergo structural changes that tive pharmacological therapies include nicotine make them different from cells in other parts of the replacement products (e.g., gum, inhaler, patch) body; these differences allow the cells to operate and non-nicotine medications, such as bupropion optimally in a given environment. SR (Zyban) and varenicline tartrate (Chantix); Malignant cells divide at an uncontrolled rate; however, the U.S. Food and Drug Administra- they may grow at a frenzied pace, accumulating tion (FDA) has required manufacturers to add a many more cells than are needed and disrupting black box warning regarding a reported association homeostasis. They also have the ability to undergo between the use of these medications and neuro- innumerable doublings without dying. These psychiatric adverse effects [19; 24; 25]. new cells are not the same as the original cells. Several screening tools have been explored for Therefore, they cannot perform the same tasks, the early detection and subsequent treatment of and function is altered. One example of malignant lung cancer, the most common being chest x-rays, cell reproduction causing abnormal function is sputum cytology, and computed tomography (CT) small cell lung cancer (SCLC) cells, which can scans of the lungs. The tests involve risks, such produce adrenocorticotropic hormone (ACTH) in as false-positive diagnoses, which may account such large amounts that the patient may develop for as much as 4% to 15% of total diagnoses [26]. Cushing’s syndrome, characterized by upper body False-positive results may lead to overtreatment weight gain, hypertension, and loss of potassium and unnecessary procedures. Other risks presented [29]. Cells that are close in appearance and func- by the use of these screening tests include false- tion to healthy cells are well-differentiated, while negative results and exposure to radiation. tumor cells that are dramatically unlike healthy lung cells are undifferentiated or anaplastic. 6 NetCE • January 25, 2018 www.NetCE.com ________________________________________________ #30721 Lung Cancer: Diagnosis and Management Carcinogenesis is the process by which a normal Cellular Pathophysiology cell is changed into a malignant cell. Many steps of Small Cell Lung Cancers are involved, beginning with damage to the genes SCLC accounts for approximately 10% to 15% of that regulate cell growth or inactivation of tumor all lung cancers [32]. It initiates in the basal cell suppressor genes. The substance or factor that lining of the bronchial mucosa, often in the central initiates these cellular changes is referred to as a part of the chest. Because the cells resemble oat carcinogen. In some cases, an oncogene may be grains, SCLC was once called “oat cell carcinoma.” the initiating agent. These bits of genetic code SCLC is aggressive and grows rapidly, causing post- within the cell may allow the cell to be altered. obstructive pneumonia and atelectasis. It produces When this is the case, a cocarcinogen enhances arginine vasopressin (AVP) and ACTH, which the work begun by the oncogene initiator [30; 31]. causes Lambert-Eaton syndrome, the syndrome of inappropriate antidiuretic hormone secretion The second stage of carcinogenesis is promotion. (SIADH), and Cushing’s syndrome. SCLC metas- In this phase, cells have an increased opportunity tasizes very early and to distant sites such as the to become malignant. The effects of promotion brain, liver, and bone marrow. It is more responsive are linked to the level and duration of exposure to chemotherapy and radiation than other types of to the cocarcinogen (e.g., the number of years as a lung cancer; however, because it has a tendency to smoker and number of cigarettes smoked per day). be widely disseminated by the time of diagnosis, it This step of the process is reversible, so cancer is difficult to cure [35; 36]. prevention efforts are most effective when aimed at evading promoters. The length of time between Cellular Pathophysiology of exposure to the cocarcinogen and the development Non-Small Cell Lung Cancers of the malignancy is referred to as the latency Squamous cell carcinoma accounts for approxi- period [30; 31]. mately 25% to 30% of all lung cancers. It can The next step is progression, during which the be well-differentiated, moderately differentiated, tumor cells proliferate and undergo changes in or poorly differentiated. The cells are stratified their microscopic structure. Progression occurs as squamous epithelium that line the airways and the malignant cells divide faster and develop the have receptors for growing epidermal tissue. This ability to invade, metastasize, and resist normally carcinoma tends to begin in the medial portion of limiting agents [30; 31]. the lung, which makes it difficult to detect with a chest x-ray. Squamous cell carcinoma of the lung TYPES OF LUNG CANCER also produces a substance similar to parathyroid According to the World Health Organization hormone and may cause sudden hypercalcemia (WHO), there are two main categories of lung can- [32; 33; 37]. cer: small cell lung cancer (SCLC) and non-small The non-squamous cell carcinoma of adenocarci- cell lung cancer (NSCLC), each with their own noma accounts for approximately 35% to 40% of pathology. NSCLC accounts for approximately all lung cancers and may manifest as a “scar carci- 85% of all lung cancers and is further divided into noma.” It has a glandular appearance when viewed two types: non-squamous carcinoma (this includes under a microscope and is comprised of acinar, adenocarcinoma, large cell carcinoma, and other papillary, solid, and bronchoalveolar types of cells. cell types) and squamous cell (epidermoid) carci- This cancer type begins, and usually remains, in noma, each with distinct histologic and clinical a peripheral site of the lung, which makes it easy characteristics [24; 32; 33; 34]. to visualize on chest x-ray, but difficult to reach through bronchoscopy. It metastasizes easily, often to the brain, liver, adrenal glands, or bones [32; 33; 38]. NetCE • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 7 #30721 Lung Cancer: Diagnosis and Management _______________________________________________ Approximately 10% to 15% of all lung cancers are SYMPTOMS OF LUNG CANCER large cell anaplastic carcinoma, which is clinically Cough, especially one that changes or becomes similar to adenocarcinoma. Microscopically, the productive large cells lack distinctive features. It can start in Unilateral wheezing any part of the lung, and it tends to grow and spread Dyspnea quickly, which makes it difficult to treat [32]. Pneumonia Chest pain or pain in shoulder and arm Hemoptysis SIGNS AND SYMPTOMS Vocal cord paralysis Lung cancer rarely gives an early indication of its Atelectasis presence. It may be detected accidentally, when Neurologic changes viewing a routine chest x-ray, or it may be suspected Weight loss by symptoms presented by the patient (Table 1). Source: [39] Table 1 One of the most common symptoms experienced by patients with lung cancer is cough, which occurs when the airways become irritated (as from smok- Pain that arises from lung abscess or tumor is ing) [2; 32; 35]. Those patients who have a cough often difficult to describe. It may not be severe, if related to their smoking may recognize a change present at all. With metastasis to the chest wall or in the type of cough but are not as likely to realize lymph nodes, the patient may feel some tightness the significance of that change, particularly if the or a constant ache, which may be mistaken for a change occurs slowly over decades [35]. The cough pulled muscle related to coughing. When a tumor may be more frequent, more irritating, of a different invades the brachial plexus, there is usually pain tone, or may feel as if it is arising from a different in the arm and shoulder. Pain that originates in site than a normal cough. A cough that has always the chest wall may worsen with deep breathing or been dry may suddenly become productive as the coughing [35; 39; 40]. obstructed bronchus develops an infection [2; 35; Smokers may have emphysema and therefore be 39]. Persistent wheezing that occurs in one location familiar with and accustomed to the feeling of in a smoker may also indicate lung cancer [35; 39]. dyspnea (shortness of breath) that accompanies that disease. The emphysematous patient may only feel a more frequent need for oxygen, or perhaps if For all lung cancer patients who have troublesome cough, the American College already receiving oxygen continuously, his or her of Chest Physicians recommends that rate of O flow may have to be increased. Because 2 they be evaluated for treatable causes this change is more subtle, it may not be brought in addition to cancer-related etiologies. to the physician’s attention as promptly. In con- (http://www.guideline.gov/content. trast, when an otherwise healthy person becomes aspx?id=46179. Last accessed August 21, 2015.) winded easily with exercise, he or she is more likely Strength of Recommendation: 1C (Strong to investigate the cause and/or avoid exertion. If recommendation based on low-quality evidence lung cancer is diagnosed, dyspnea may occur even that the benefits outweigh the risks/burdens) at rest as the disease progresses [35]. 8 NetCE • January 25, 2018 www.NetCE.com ________________________________________________ #30721 Lung Cancer: Diagnosis and Management Hemoptysis, bright red blood in the expectorant, is DIAGNOSIS a symptom that generally prompts a rapid response from patients. Infection is the most common cause; When lung cancer is suspected, a complete history however, lung cancer tumors account for approxi- and physical examination is required. The history mately 20% of cases of hemoptysis [35]. Symptoms should inquire into any health problems, work such as recurrent bouts of bronchitis or pneumonia history, smoking history, and family history. The that do not clear quickly may cause the patient physical examination should include listening to to question whether there is an immune response respiration, checking for fluid in the lungs, and problem but may never cause the patient to link feeling for swollen lymph nodes or swollen liver. the illness to cancer. If the exam results suggest lung cancer, additional Metastasis has been shown to produce hoarseness, tests should be done [32; 37]. vocal cord paralysis, dysphagia, head and neck RADIOLOGICAL IMAGING swelling, weakness, weight loss, loss of appetite, anorexia, and anemia [40]. Other symptoms that Chest x-rays help find masses or lesions on the are indicative of metastatic spread of the disease lungs. When anteroposterior and lateral films are include Horner syndrome, abdominal discomfort, taken, a peripheral tumor at least 1 cm in diam- nausea and vomiting, unexplained fever, jaundice, eter can be visualized. Additionally, there will and cardiac symptoms. Elevated liver function tests be evidence of a widened mediastinum or hilar may be signs of liver metastasis. Bone pain may adenopathy visible with this view [37]. signify bone metastasis, and severe, unrelenting CT scans film cross-sectional soft tissue images of headache may be caused by increased intracranial the body to analyze tissue for density and reveal pressure from metastasis to the brain [40]. tumors or displaced organs. A CT scan of the An estimated 10% to 20% of patients with lung chest with contrast has been recommended for cancer experience paraneoplastic syndromes. patients with known or suspected lung cancer who These symptoms may develop when substances are eligible for treatment [45]. A chest x-ray and (e.g., hormones, cytokines) released by cancer chest CT scan with contrast material has also been cells disrupt the normal function of surrounding recommended for staging locoregional disease [46]. cells and tissue [40; 41]. SCLC is the most frequent The patient may be asked to take nothing by mouth cancer histology associated with paraneoplastic (NPO) prior to the procedure and may be asked to syndromes, including [40; 42; 43; 44]: drink, or receive intravenously, a contrast solution • SIADH to help outline structures in the body. The images can provide precise information about the size, • Blood clots shape, and position of tumors and can help find • Cerebellar degeneration (e.g., loss of enlarged, potentially cancerous lymph nodes. The balance, unsteady limb motion) test can also be used to detect masses in the adre- • Hypercalcemia nal glands, brain, and other internal organs [32]. These syndromes are common lung cancer compli- While CT of the chest is the reference standard for cations. They have been most frequently associated detecting focal lung disease, missing lung lesions with advanced stages of the disease but may also during CT is a well-recognized phenomenon. The occur at early stages [43; 44]. computer-aided detection system has been shown to increase the overall accuracy of lesion detection when used as a second reader on chest CT studies [47; 48]. NetCE • Sacramento, California Phone: 800 / 232-4238 • FAX: 916 / 783-6067 9 #30721 Lung Cancer: Diagnosis and Management _______________________________________________ Spiral CT uses a faster, continuously rotating Endobronchial ultrasound (EBUS) uses sound machine. The spiral CT allows for a more rapid waves to produce images [52]. EBUS has been collection of images than the standard CT. It also found to be a useful adjunct in the diagnosis of lung reduces blurred images, lowers the dose of radiation cancer, particularly when the lesions occur in the received, and produces thinner images that yield a periphery of the respiratory tract [53]. Additionally, more detailed picture for analysis [32]. EBUS has been shown to have a high sensitivity and specificity for node staging compared to CT or A CT-guided needle biopsy is another option PET scans and may be considered in staging lesions for analyzing suspected cancer. In this method, [54]. Endoscopic esophageal ultrasound is similar a CT scan is used to guide a biopsy needle into to EBUS, except it involves passing an endoscope the suspected area. The scans are repeated until down the throat into the esophagus. Ultrasound the physician is certain that the needle is within images taken inside the esophagus may help find the mass. A biopsy sample is then removed and cancerous lymph nodes inside the chest [55]. reviewed under a microscope [32]. Magnetic resonance imaging (MRI) is a nonin- LABORATORY ANALYSIS vasive radiological procedure used in some cases Blood work is done to assess the respiratory status to aid in diagnosing lung carcinomas. It is more and to look for metastasis to other organs. These commonly used to stage lung cancers and iden- tests may include arterial blood gases, complete tify possible metastases, particularly of the brain blood count, serum calcium, alkaline phosphatase, and spinal cord [33]. However, it may also be and liver function studies [33]. employed to visualize areas of the lungs not well Sputum specimens for cytology are completed demonstrated on axial images. Head CT or MRI in order to microscopically identify any malig- brain imaging has been recommended for use in nant cells that may have been sloughed off and patients with signs or symptoms of central nervous expectorated. This requires collecting three early system disease as well as for patients with stage III morning specimens in an attempt to obtain deep disease who are being considered for aggressive sputum production, not just saliva from the mouth. local therapy [33; 46]. Samples are placed in a fixative and processed Positron emission tomography (PET) scans may before viewing. Sputum cytology is not routinely also be useful in the diagnosis of lung cancer. An recommended and should be reserved to inves- 18F-deoxyglucose PET scan should be performed tigate patients with centrally placed nodules or to investigate solitary pulmonary nodules or mass, masses and who are unable to tolerate or unwilling particularly in cases where a biopsy is not possible to undergo bronchoscopy or other invasive tests or has failed, depending on nodule size, position, [33; 49]. and CT characterization [45; 46; 49; 50]. This VISUALIZATION AND BIOPSY study may also be useful in detecting metastatic spread of the disease but is not intended to replace A bronchoscopy is performed routinely on patients conventional imaging techniques. The American suspected of having lung cancer. This procedure College of Chest Physicians (ACCP) does not allows an opportunity to visualize the lung structure recommend PET scanning in the routine staging for possible narrowing, inflammation, bleeding, of SCLC, although the National Comprehensive or tumors (Table 2). The ability to actually see Cancer Network (NCCN) guideline recommends some tumors permits a more representative tissue combined PET-CT if limited-stage disease or sample to be obtained. A sample of the tissue may metastasis is suspected [49]. PET has been recog- be obtained through needle aspiration (transbron- nized as a valuable tool in developing a treatment chial), brush or forceps biopsy, bronchoalveolar plan in the management of lung cancer [49; 51]. lavage, or bronchial washings. There is some controversy regarding the use of bronchoscopy 10 NetCE • January 25, 2018 www.NetCE.com