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Source: Frieze DA, Adams VR. Lung Cancer. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed.http://accesspharmacy.com/content.aspx?aid=8008333. Accessed August 4, 2012.

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  • Solid tumor originating from bronchial epithelial cells

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  • Malignant transformation of normal epithelial cells

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  • Arises from normal bronchial epithelial cells that have acquired multiple genetic lesions and capable of expressing a variety of phenotypes.
  • Cellular proliferation and malignant transformation due to:
    • Activation of proto-oncogenes
    • Inhibition or mutation of tumor suppressor genes
    • Production of autocrine growth factors Molecular changes affect disease prognosis and response to therapy.
  • Histologic classification
    • Non–small cell lung cancer (NSCLC)
      • Includes adenocarcinoma (~50%), squamous cell carcinoma (<30%), and large cell carcinoma
    • Small cell lung cancer (SCLC) (~15% of all lung cancers)

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  • Leading cause of cancer death in men and women
  • Incidence increases with age; peak age of diagnosis between 55 and 65 years

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  • No screening test currently recommended.
  • Smoking cessation
    • Gradual decline in lung cancer risk

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  • Cigarette smoking responsible for ~80% of lung cancer cases.
    • Spouses of smokers have ~25% higher risk of lung cancer than spouses of nonsmokers.
  • Other risk factors include:
    • Exposure to respiratory carcinogens (e.g., asbestos and benzene)
    • Genetic risk factors
    • History of other lung diseases (e.g., chronic obstructive pulmonary disease [COPD] and asthma)

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  • Location and extent of tumor determine presenting signs and symptoms.
  • Thorough history and physical examination necessary to detect:
    • Signs and symptoms of primary tumor
    • Regional spread of tumor
    • Distant metastases
    • Paraneoplastic syndromes
    • Ability to withstand aggressive surgery or chemotherapy

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Signs and Symptoms

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  • Most common initial signs and symptoms:
    • Cough
    • Dyspnea
    • Chest pain or discomfort, with or without hemoptysis
  • Other systemic symptoms:
    • Anorexia
    • Weight loss
    • Fatigue
  • Disseminated disease:
    • Neurologic deficits from central nervous system (CNS) metastases
    • Bone pain or pathologic fractures secondary to bone metastases
    • Liver dysfunction from hepatic involvement
  • Paraneoplastic syndromes may be first sign of underlying malignancy.
    • Cachexia
    • Hypercalcemia
    • Syndrome of inappropriate antidiuretic hormone secretion (most common with SCLC)
    • Cushing’s syndrome

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Means of Confirmation and Diagnosis

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  • Pathologic confirmation of lung cancer established by examination of sputum cytology and/or tumor biopsy by bronchoscopy, mediastinoscopy, percutaneous needle biopsy, or open-lung biopsy.

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Laboratory Tests

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  • Metabolic panel

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Imaging

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  • Valuable diagnostic tests:
    • Chest radiography
    • Endobronchial ultrasound
    • Computed tomography (CT) scan
    • Positron emission tomography (PET) scan
  • Integrated CT–PET technology appears to improve diagnostic accuracy in staging NSCLC over CT or PET alone.

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Diagnostic Procedures

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  • Sputum cytology
  • Tumor biopsy by bronchoscopy, mediastinoscopy, percutaneous needle biopsy, or open-lung biopsy

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Staging

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  • NSCLC
    • Stage (anatomical extent of disease) based on:
      • Extent and size of primary tumor (T1–4)
      • Presence and extent of lymph node involvement (N1–3)
      • Presence or absence of distant metastases ...

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