Lung Cancer Treatment Options PDF

removal of some affected lymph nodes Brachytherapy and Gamma (stereotac Surgery for lung cancer - major surgery that requires hospitalization, upon tic) hospitalization we have to secure consent, IV line, pr...

removal of some affected lymph nodes Brachytherapy and Gamma (stereotac Surgery for lung cancer - major surgery that requires hospitalization, upon tic) hospitalization we have to secure consent, IV line, pre op teaching, advise client Are among the options on NPO depending on order (8-12 hrs). Follow up care that last for weeks to months. BRACHYTHERAPY Radiation is introduced inside the lungs of the patient with the use GA for the procedure. of bronchoscope Patient may experience difficulty of breathing, shortness of breath, pain, Preparation: and weakness following the procedure. o Same as preparing patient for bronchoscopy Nursing consideration in proper positioning to prevent atelectasis. o Additional protective measures: wearing of LEAD APRON o Safer option of brachytherapy Risk of surgery: bleeding, infection, GA and atelectasis o More discomfort and costly o VATS (Video Assisted Thoracic Surgery) - laparoscopic procedure GAMMA KNIFE / STERIOTACTIC SURGERY ▪ For wedge resection Used if lung cancer has metastasized to the brain ▪ Minimally invasive Knife because it slices off tumor in the brain like a knife using ▪ Thoracoscope gamma rays ▪ Video cam ▪ Laparoscopic suction irrigation NURSING MANAGEMENT (Chemoradiation Therapy) ▪ Laparoscopic retractor Additional protective measures thru lead apron ▪ Under GA ▪ Removal of tumor assisted with TB monitor Manage the ff side effects: o Esophagitis (bcs of adjacency of trachea to the lungs) NURSING MANAGEMENT: ▪ Food and nutrition administered thru NGT or TPN Dyspnea ▪ NGT can cause irritation of esophageal lining, o WOF pulmonary complications such as: TPN might be ordered ▪ Atelectasis, bronchospasm, pulmonary ▪ NPO can also be placed embolism, etc. ▪ PEG - too invasive to be an option unless really o Closely monitor O2 sat and delivered according to needs indicated Dysrhythmias and Arrhythmias - due to vagal irritation o Pneumonitis o Prescription of cardiac medications ▪ If client underwent surgical resection of the lungs ▪ Heart complication is possible CHEMO RADIATION THERAPY ▪ Medication (prednisone or dexamethasone) SCLC o Radiation myelopathy o Cornerstone of treatment ▪ Damaged of spinal cord due to ionizing radiation o LD - Etoposide and cisplatin (limited disease) o ED - platinum based - monotherapy (single drug used) o Relapse: Week 16 – UGIT Cancer ▪ < 3 mos - etoposide taken every 3 weeks for 4 weeks. (oral) UPPER GASTROINTESTINAL TRACT ▪ > 3 mos - topoisomerase (teniposide, eronotican REVIEW OF ANATOMY &PHYSIOLOGY and topotican) - oral + IV Depending on severity and it occurs after 3 mos IV infusion then oral medication the client visit for the IV chemo drug o Most of It is not operable, no localization and very small. o Prevent recurrence and as palliative measures for metastatic type o Standard care for limited disease NSLC o As adjuvant o For unresectable tumors o Platinum-based (cisplatin, carboplatin and oxaliplatin) - (1st line) ▪ first line (with platinum compound) causes changes in DNA structure which results to Gi tract starts from mouth down to small intestine cancer cell death. Upper Gi tract (esophagus, stomach, liver, pancreas) o Docetaxel (2nd line) - inhibit mitotic spindle fiber STOMACH ▪ Option for clients who does not want surgery or There are several risk factors for a client to develop cancer of CI surgery (oncologic emergencies: superior the stomach but generally common affected are those exposed vena cava syndrome, cardiac tamponade, and to gastric acid, enzymes and certain chemicals from the food spinal cord compression) that we eat. ▪ Palliative care for metastatic This area may include the cardia, body and pylorus of the ▪ Radiation (external beam therapy, gamma and stomach. brachytherapy) ✓ The body and pylorus of the stomach and their cell morphology After chemo drug, the patient goes back to radiation but sometimes it is used is altered kasi nga eto yung areas na expose sa gastric acid, simultaneously enzymes at chemicals EBRT - External Beam Radiation Therapy Paano naapektuhan? By law of gravity the stomach contents together with the acids and chemicals settles in these areas kasi eto yung lower portion ng Can affect other organs such as heart stomach automatic dun sya mapupunta hindi sa fundus. Additionally in the absence of food, continuously pa din expose ang stomach sa acids and enzymes. Intraoperative Radiation therapy Risk din yung mga may inappropriate or unbalanced diet at may eating disorders Radiation is administered during surgery Delivered in tumor bed while area is exposed 46 like anorexia and bulimia because it puts the gastric cells at risk in developing GERD mutation or abnormal cell proliferation. yung gastric acids, enzymes narereach yung esophagus kapag umakyat. Sa may Paano naman naapektuhan ang cardia eh nasa taas sya ng stomach? The mga chronic GERD naman naglelead to barretts esophagus wherein yung lining stomach is connected to the esophagus by the gastro-esophageal junction (this ng esophagus resembles the lining of the intestine dahil yung sobrang exposure serves as the sphincter and is supposed to close when we ingest the food, and ng esopaghus sa gastric acids, enzymes nagkakaroon ng accidental when the food goes inside the stomach) kapag may conditions like GERD yung regurgitation patient, umaakyat yung food from the stomach to esophagus nagkakaroon ng Absorption of chemicals contact yung acids, enzymes at chemicals sa cardia. absorption of chemicals from the foods such as nitrates or mga processed foods Obesity Obesity can cause the body to produce more insulin thus increase in number of LIVER fat cells Consumption of aflatoxin B eto yung mga contaminated food products Chronic liver injury Liver cancer is characterized by hepato cellular carcinoma and it develops through the presence of chronic liver injury which produces inflammation Take note: Kapag disease related yung risk factor this include those clients with diabetes mellitus Smoking (Pancreas) Bakit naman may risk factor ng smoking sa pancreas? According to evidences, cigarette contains nicotine but yung nicotine hindi sya nagcocontribute sa cancer, it is the nitrosamine that is toxic content of cigarette that contributes to cellular changes. Play a role in metabolism including metabolizing the medication Anong nangyayare? During smoking yung nicotine reaches the lungs tapos we take naabsorb yan ng blood stream at dahil sa longer period ng exposure sa nicotine Kapag nagkaroon ng cancer sa liver, maapektuhan ang metabolism of waste, nagkakaroon ng higher retention ng nicotine sa esophagus, spleen, cecum, and storage of different vitamins that our body needs such as vit. A,B,D, and iron and pancreas. Study shows that nicotine levels are found in pancreatic juices 7x also impaired digestion kasi yung liver also aids in digestion higher in smokers than in none smokers. Since the liver metabolizes the drugs we take, Chemotherapeutic drugs are less effective because of the first SCREENING / DIAGNOSTIC TESTS: pass hepatic effect wherein yung drug effectivity is less kaya Radiological Studies: Barium Swallow ang option for therapy is surgery. o Fluoroscopic procedure or X ray examination wherein patient Because liver and pancreas are connected with the stomach drinks a certain amount of radiation which serves as contrast through duodenum, if the patient has a stomach cancer the dye particularly with a barium solution. chance to metastasize to these areas are high don’t forget to secure consent kasi gagamit ng contrast dye dahil dun sa mga ducts pancreatic duct, hepatic duct etc. madaling kumalat) o Pre-test: NPO postmidnight Pancreas has two parts: ▪ for about 6-8hrs depending on the protocols but o Head (yung rounded part) normally ranges 6-12hrs ▪ Head of the pancreas is the most common ▪ Prior the x-ray procedure pt will drink 250-300ml of site of cancer cell formation barium solution atleast hourly for 4x pero mahirap madiagnose kung may pancreatic cancer kasi yung manifestations because the mucosal lining of GI tract is smooth, kapag smooth it will make the may be confuse with diabetes mellitus. barium solution not to be absorbed immediately so it takes time kaya kelangan Bakit? because the head of the pancreas is the part that produces most of the atleast 4x ang pag inom nung solution.) pancreatic enzymes and hormones which is important in regulating the insulin. TAKE NOTE: yung last dose ng barium solution is drunk when the pt is already in So kapag may tumor sa head ng pancreas naapektuhan yung regulation ng the xray room, it is drunk by the pt when the technician takes a series of xray to sugar so nagkakaroon ng confusion kung may cancer ba sa pancreas or due to determine any abnormal movement of the esophagus during swallowing. diabetes lang. So ang trinetreat is yung manifestation ng diabetes at kapag ▪ Include in health teaching that the solution may not nalaman na malignant na yung tumor. taste good o Tail kasi sabi daw ng mga pasyente lasang mapait daw na lasang chalk. And yung iba nagcocomplain na nagka nausea habang umiinom. RISK FACTORS o Post-test: Laxative; instruct that stools will turn white, monitor for obstruction Instruct the uminom ng maraming tubig para maeliminate yung barium EGD-(ESOPHAGOGASTRODUODENOSCOPY) o VISUALIZATION OF THE UPPER GIT BY ENDOSCOPE Smoking (esophagus)Bakit may smoking under ng esophagus? Yung smoke na nalalanaghap hindi lang yan napupunta sa lungs, some of it we ingest upon the closure of glottis so we inhale by the mouth, yung ibang usok napupunta sa esophagus. 47  o PRE-TEST: ensure consent, npo 8 hours, pre-medications under the side of insertion to provide pressure thus like atropine and anxiolytics prevent bleeding. ▪ The procedure involves insertion of endoscope through the mouth CANCER STAGING Dapat walang laman yung stomach aside sa mga gastric juices kaya STAGE 0 or STAGE I need mag npo ni pt o If the involve layer is the mucosal lining, and there are ▪ Atropine to reduce secretions to prevent aspiration no evidences of any invasion we can classify them ▪ Anxiolytics to reduce the anxiety of the pt into stage 0 or stage I ▪ Prior to the insertion of flexible endoscope, to prevent STAGE II gag reflex and promote easy insertion of flexible o If nagpenitrate na sa submucosa, or the muscle layer endoscope maglalagay ng local anesthesia “lidocaine and the side of the tumor is 5cm and reaches the serosa, and that is to prevent aspiration definitely involvement of lymph nodes already it is para maremove yung secretions classified stage III ▪ Prepare oxygen STAGE IV o INTRA-TEST: position : left lateral to facilitate salivary o Classified stage IV if there is definitely lymph node drainage and easy access involvement and there is larger size of the tumor and ▪ Left lateral position also brings more comfort to the pt a distant metastasized has occurred o POST-TEST Unlike sa gi tract walang mucosal lining ang pancreas at liver so paano ▪ npo until the gag reflex return nacacategoriza ang stage ng cancer? With regards to the liver, divided into 4 ▪ sims position until the client awakens. segments yan. ▪ monitor for signs of perforation (bleeding, pain, Stage I kapag yung tumor nag arise lang sa isang segment ng liver kahit saan pa unusual difficulty swallowing, elevated temp. yan naka locate sa liver ▪ maintain bedrest for the sedated client until alert. ▪ Lozenges, saline gargles, or oral analgesics can Stage II kapag nag arise yung tumor sa border ng segment kasi naoocuppy na relieve minor sore throat, after the gag reflex returns. nyan yung dalawang segment ng liver also kung malaki yung tumor at nacocover nya na yung dalawang segment.= ERCP – ENDOSCOPIC RETROGRADE Stage III kapag more than 2 segment na ang involve and also kapag may 2 tumors CHOLANGIOPANCREATOGRAPHY in 1 segment and o a procedure to diagnose and treat conditions of biliary or Stage IV kapag marami na din at nagmemetastasize na yung tumor. pancreatic ductal systems. Paano nadedetermine yung tumor sa liver, pancreas as well as their ducts? Since ✓ With regards to pancreatic tumor, the size is the considerable factor Walang direct visualization ng endoscope to these organs and ducts, the in determining the stage. endoscope is use as a manner to inject the dye directly into the duodenal papilla ✓ If the cancer is confined and has not invaded deeper tissues and no that is located in the duodenum. Yung duodenal papilla na yan is an opening lymph node involvement, there is no metastasize, and only a that originates from the pancreatic duct and common bile duct wherein yung carcinoma in situ it is classified into stage 0. biliary enzymes and pancreatic enzymes flows into the duodenum. ✓ if the cancer is confined and the tumor size is 4cm, there is Sa duodenal papilla tumatagos yung mga enzymes na nangagagaling sa liver, no lymph node involvement and has no metastasize, it is classified into pancreas papasok sa small intestine sa duodenum. And bec. the dye is injected stage 1. into the duodenal papilla and into the ducts to determine any abnormalities or tumors in the liver, pancreas xray will be performed. ✓ if the cancer is confined and the tumor size is >2cm , there is no lymph node involvement and has no metastasize, it is classified into stage 2 or Summary: Yung endoscope ang magiinject ng dye directly sa opening ng stage 2A. duodenal papilla papasok sa liver and pancreas through their ducts (pancreatic duct, hepatic duct) pag na inject na yung contrast dye to this ducts it will be ✓ if the cancer is confined and not bigger than 5cm may or may not involve followed by x ray. the lymph node and has no metastasize, it is classified into stage 2 or stage BIOPSY 2B. o definitive diagnostic test ✓ If the cancer is growing outside the pancreas, and is bigger than 5cm, with Liver biopsy yung nasa picture, removal lymph node involvement, there is still no metastasize, it is classified into of liver tissue and usually done through stage 3 needle aspiration which permits the ✓ Classified into stage 4 if cancer has metastasized, regardless of the size of examination of liver cells. Malapit sa the tumor. lungs ang liver kaya Prior insertion ng TAKE NOTE: in pancreatic cancer the most common stage that is not easily aspirating needle, dapat iinstruct si pt to diagnose is stage 1 because it is manifested by diabetes mellitus condition, ang exhale and hold so that lungs is in relax nangyayare kasi yung manifestations ng dm ang natetreat hindi yung mismo state during insertion of the needle to problem sa pancreas. Pancreatic cancer may only be suspected pag si patient prevent trauma to lung tissue. hindi pa din nagiimprove despite na nagbibigay ka ng nagbibigay ng treatment During procedure dapat naka supine sa diabetes nya. lying si pt at naka raise ang right arm since nasa right side ang liver. SIGNS AND SYMPTOMS Take note: Naglalagay din ng local Esophageal Cancer anesthesia sa insertion site Usually, esophageal cancer will not show symptoms In early stages. o Common complications: bleeding, leakage of bile which may Coughing or hoarseness lead to peritonitis due to the tumor in the esophagus that compresses the laryngeal nerve. o Nursing Considerations: Weight loss ▪ Make sure that coagulation studies are obtained Weight loss will occur dahil sa dysphagia (difficulty swallowing dahil sa tumor) ▪ values are noted and abnormal results are treated Regurgitation or undigested food before a liver biopsy is performed Regurgitation occurs especially to pt with hx of GERD ▪ secure a consent, and after the biopsy the patient is positioned to their right side, may also apply pillow 48 Stomach Cancer Dyspepsia – pain or discomfort in the abdomen Early satiety – mabilis mabusog Hematemesis – vomiting of blood Liver Cancer Abdominal pain 90% of pt complain of abdominal pain as initial sign of liver cancer characterized by a continuous dull ache in the right upper quadrant pain in the epigastrium, or pain that radiates to the back. After removal, end to end anastomosis (pagdidikitin yung dalawang dulo Weight loss, weakness, and anorexia ng pinagputulan) Anemia and Hepatomegaly depending on the location of the tumor is yung incision (pwedeng sa gitna Liver plays a role in hematopoiesis that means with liver cancer, anemia may or sa thoracic kapag lower part ng esophagus and kung upper part naman also occur and liver may be enlarged or “hepatomegaly” may feel irregular upon ay sa neck scar, another incision is (abdominal scar yung transhiatal is palpation. made to facilitate the manipulation of the stomach during the surgery kasi Jaundice itatataas yan kasabay nung anastomosis) Jaundice may occur if bile duct is compressed by large tumors and if bile ducts Remember those clients with cardio pulmonary complications bec of are occluded it may give white stools in return since bile gives the stools brown existing conditions may increase their morbidity color Post op. after 5-7 days, client will undergo barium swallow again. Bakit ano Ascites ang purpose after surgery, anastomosis? To determine the esophageal Tumor may also compress the portal vein, which causes the fluid from the liver structure again and determine if there is any leak. Kapag may leak and intestines to accumulate in the abdomen resulting in ascites. ibigsabihin hindi maayos yung pag perfrom ng anastomosis makikita kasi yun sa x-ray. Pancreatic Cancer Dark and white stools TAKE NOTE: esophagus is being close by layers, starting from the mucosal lining, muscle layers and the serosa. With pancreatic cancer, Jaundice may be evident because cancer may spread to the liver causing the urine to become dark and white stools because of the ✓ Before the incision is close (yang chest scar at abdominal scar na yan bago compression of the tumor against the biliary duct. isara) to ensure a successful anastomosis maglalagay si anesthesiologist ng Jaundice ngt it will be flushed by normal saline then oobserve kung magkakaroon ng Jaundice may also be associated with uncontrolled blood glucose levels and leak. Pero post-op maguundergo pa din ng barium swallow ang pt to impaired production of pancreatic enzymes. This pancreatic enzyme mixes with ensure again. liver enzymes that produces the bilirubin (so yung jaundice at uncontrolled glucose level often leads to the diagnosis of pancreatic cancer) ✓ Mapapansin din after anastomosis yung stomach tumaas sya, dahil na din sa shortening of the esophagus. Kaya possible risk na magkaroon ng GERD, Dull and constant abdominal pain aspiration, regurgitation si pt. Dull and constant abdominal pain which occurs in more than 80% of pt, yung characteristic of pain is mid upper abdominal pain, which sometimes radiates ESOPHAGEAL STENT from the back especially occurring after eating. Relief of pain may be obtained Tube or stent placed in the esophagus to keep a block area by sitting or leaning forward. open. To keep the tumors away that may hinder the passage of foods Week 16 – Upper GI Tract Cancers and fluids towards the stomach Commonly indicated for small tumors. For example, stage 1 SURGICAL MANAGEMENT cancer ESOPHAGECTOMY ENDOSCOPIC MUCOSAL RESECTION not necessarily mean removal of esophagus, removal of the It can determine tumor area that is being affected lang with tumor location, characteristic NURSING CONSIDERATIONS: Pwede nyang ma resect yung mga Ensure Consent small tumors as shown in the picture NPO kasi less bleeding lang yung pwedeng Pre-medications mangyare dito Prepare the chart Unfortunately, pede pa X-ray of the pt because of the result of the barium swallow (dadalhin rin mag recurrent kaya yun sa or) nakaschedule pa din for How the pt will be transported, wheelchair ba or stretcher radiation or Take note that the client will undergo general anesthesia chemotheraphy ang pt Post op client may undergo liquid diet, soft foods for 4-8 weeks depending on the doctors advise. And kapag nakabalik na sa normal diet ang pt advise them na magingat sa pagkain ng mga meat kasi mahirap para sakanila lunukin yun, kaya dapat slice muna nila bago iingest. Chew food properly prior swallowing and small frequent feeding Avoid eating 2 hrs before sleeping to avoid regurgitation Drink fluids 30 mins after the pt eat solid foods Sit while eating 49 ✓ If the tumor arises sa baba ng stomach, portion of the stomach will be if the color of the drainage is yellow to green that is bile meron leakage ng bile) removed and then the end of the duodenum is connected doon sa if the color is red meaning may bleeding remaining stomach (ang tawag dito ay billroth I or gastroduodenostomy) Monitor also the altered level of glucose ✓ If the tumor arises sa baba ng stomach, portion of the stomach will be WOF: leakage of pancreatic enzymes removed and then the end of the jejunum is connected doon sa remaining stomach (ang tawag dito ay billroth II or gastrojejunostomy) RADIATION THERAPY ✓ If the tumor rises doon mismo sa stomach and dapat iremove yung buong Pwede bang gamitin yung ngt for food? Pwede ba sila kumain? NO. Bec. It will stomach, ang tawag doon ay gastrectomy (due to gastric carcinoma) lessen the effectivity of the radiation therapy. Pero there are 2 options para ✓ Letter A portion ng stomach, letter B, C, D jejunum, magkaroon pa din ng source of nutrition ang pt: TPN, or via the peg (magcecreate ng opening sa stomach at magiinsert ng peg tube directly into the ✓ Roux-en-y or gastro jejunostomy/jejuno-jejunostomy stomach) ✓ yung remaining part ng stomach (which is yung letter A) and the esophagus SELECTIVE INTERNAL RADIATION THERAPY is connected dito sa letter C (which is yung jejunum) kaya A + C = gastro o delivered by blood vessels through a catheter jejunostomy (hepatic artery ang dadaanan ng catheter) sirt can be ✓ Yung letter B (first part ng jejunum) magiging connected sa letter D kaya B more effective if there are evident blood vessels that + D = jejuno- jejunostomy directly supplies the tumor called angiogenesis. The most common source is YTTRIUM 90 LIVER TRANSPLANT Remember radiation sources can be found in the clients excreted waste like sweats Another option is liver transplant, however not all pt is qualified for liver transplant. Kahit may resources pa sila, may MILAN kaya dapat hindi hawakan yung pt na nagpapawis during radiation therapy also CRITERIA kasi na sinusunod. kung umihi or tumae sila dapat iflush yung toilet 2-3x For example: may isang donor ng liver between young and CHEMOTHERAPY old, sa young na binibigay yung liver. Take note: antidote for methotrexate is leucovorin o #1 criteria, single tumor and the diameter is