ID/CC A 64 year old female smoker presents to the ER after coughing up a
cupful of bright red blood.
HPI The patient has a 35 pack year smoking history. Recently, she has
coughed up blood streaked sputum. In addition, she reports fatigue,
decreased appetite and 25 pound weight loss over 3 months. She
drinks 2 martinis every day and takes one aspirin daily.
PE Vitals: thin, mildly anxious woman, BP 150/90, HR 88 bpm, RR
16 breaths per min. and temp. 99.2F
Neurologic: alert and oriented
Neck: no lymphadenopathy, thryomegaly or carotid bruit
Chest: scattered rhonchi bilaterally with no wheezes or crackles
CV: regular rate and rhythm, no rubs, gallops or murmurs
Abd: benign with no hepatosplenomegaly
Extremities: No cyanosis but has digital clubbing









Pathophysiology of human neoplasia is a spectrum of disease involving abnormal growth of tissue that does not follow cell death or apoptosis instead undergoes cell division to replace damaged tissue with mutated DNA. Cellular function is altered leading to proliferation, invasion and metastasis. Tumors take in these defects in unlimited numbers of genes that can cause an increase in growth. Exposure to carcinogens or ionizing radiation can accelerate the accumulation of these mutations. Several genes give tumor cells a growth advantage. Two mechanisms that allow tumors to grow is through the loss of function by the tumor suppressor genes and the mutation of proto-oncogenes to oncogenes (McChance & Huether, 2006, p.343)
Tobacco smoke contains 20 documented lung carcinogens which are responsible for 80-90% of lung cancers. These chemicals, along with any genetic predisposition to cancer, cause many genetic abnormalities in bronchial cells. These cellular changes progress from metaplasia to localized and then invasive
carcinoma (McCance & Huether, p. 1240-1241).
Most common genetic mutation associated with lung cancer is the deletion of tumor-suppressor gene p53, present in about 45-55% of non-small cell lung cancer and 75-100% of small cell cancer. Growth factors, such as epidermal





growth factor, promote tumor development once the process is started.
Primary lung tumors arise from the bronchi and are termed bronchogenic. Two major categories were adopted in 1999 by the World Health Organization to
classify lung cancers. Non-small cell lung carcinoma makes up 75% of all lung cancers. This group is then subdivided into 3 categories:
1. Squamous cell carcinoma: This accounts for about 30% of bronchogenic
cancers. Normally, squamous cell carcinoma is located near the hilus and project into the bronchi causing nonspecific obstructive symptoms such as cough or hemoptysis that may lead to atelectasis or pneumonia. These tumors are fairly well localized and do not metastasize until late in the disease. Treatment for this is surgery.
2. Adenocarcinoma: This type of tumor accounts for 35-40% of the disease
and are usually located on the periphery of the lung. The tumors often cause no symptoms and are found on chest x-ray. The patient may present with pleuritic chest pain and shortness of breath. This category contains bronchioloalveolar cell carcinoma. These are slow growing tumors that may metastasize through the pulmonary arterial system and mediastinal lymph nodes and occurs early in the disease. Five year survival range is below 15% (McCance & Huether, 2006, p. 1238-39).
3. Large cell carcinoma (undifferentiated): This tumor makes up 10-15% of



bronchogenic cancers and is diagnosed by process of exclusion as its cells have no features of squamous cell or adenocarcinoma. The tumor cells are large, arranged in nests or clusters and located in the periphery but can be found centrally which can cause distortion of the trachea and widening of the carina. Once tumor spreads, surgery is palliative (McCance & Huethner, 2006, p. 530).
Small cell lung carcinoma represents 25% of all lung cancers and has the strongest
association with cigarette smoking. The tumor grows rapidly and metastasizes early
to a wide range of organs. Prognosis is poor even with treatment of only 10% 2-year
survival rate.
Other lung cancers include bronchial carcinoid tumors (about 1%), adenocystic
tumors and mucoepidermoid carcinomas (rare bronchial gland tumors) and
mesotheliomas ( as a result of asbestos exposure).
Worldwide, lung cancer is the most common cancer in terms of incidence and
mortality with 1.35 million new case per year and 1.18 million deaths, with the
highest rates in Europe and North America. With this being said, lung cancer is also
one of the most preventable kinds of cancer. At least 4 out of 5 cases are associated
with cigarette smoking and the cause and efect relationship has been extensively
documented. During the 1920’s, a large section of male population began to smoke




cigarettes. Twenty years later, the frequency of lung cancer in men rose sharply at
the same time women started smoking. Thereby, in the 1960’s, there was an increase
incidence of lung cancer in females. The population segment most likely to develop
lung cancer is over 50 years of age and has a history of smoking. Typically, men
have outnumbered women with deaths from lung cancer but currently statistics show
women have surpassed men due to increase female smokers.
Passive or second- hand smoke is increasingly being recognized as a risk for lung
cancer. Legislation across the country has decreased undesired exposure to smoke
in public spaces. Also, government is doing more with regulating harmful
carcinogens related to emissions from automobiles, factories and power plants.

The symptoms of lung cancer can be best categorized by the extent of the disease. With a primary lesion, the most common symptom is cough. Hemoptysis and longstanding history of smoking yields a high index of suspicion for lung cancer. Patient may complain of generalized chest discomfort and dyspnea. Once the cancer invades the intrathoracic area either by tumor or lymphatics, it can negatively impact several nerves like phrenic that operates the diaphragm or recurrent laryngeal nerve that allows left vocal cord to operate. Pancoast tumor interferes with brachial plexus, patient may have weakness or numbness of affected limb, Horner’s syndrome, pleural effusions and SVC obstruction due to lymphatic


blockage or compression. Distant metastasis involve bone, liver, adrenal glands, brain, spinal cord and intraabdominal lymph nodes.

Paraneoplastic syndromes are a group of problems that are not directly related to
biological process of the tumor. It is hypothesized that these syndromes occur
because of the active hormones or peptides released by the tumor or response to the
tumor. These are a few of the disease processes that affect the following systems:
Endocrine: SIADH, Cushing syndrome
Neurologic: Lambert-Eaton syndrome, sub-acute sensory neuropathy
Skeletal: Digital clubbing, hypertrophic osteoarthropathy
Renal: Glomerulo-nephritis, nephritis syndrome
Metabolic: Lactic acidosis, hypourcemia

The 64 year old woman fits the epidemiological pattern for lung cancer, she is greater than 50 and has a 35 year history of smoking. Her symptoms include hemoptysis and chronic cough for 3 to 4 months. Her lung cancer may be further advanced because of multitude of symptoms such as fatigue, decreased appetite, significant weight loss and digital clubbing. Although she needs extensive work-up to diagnose and stage her expected lung cancer, the objective and subjective data presented may show that she has squamous cell carcinoma that is a form of non-small cell lung cancer.





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McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis for
disease in adults and children (5th ed.). St. Louis, MO: Elsevier Mosby.
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Copstead, L.C. and Banasik, J.L. (2000). Pathophysiology: Biological and behavioral
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McPhee, S.J. and Ganong, W.F. (2006). Pathophysiology of disease: An introduction to
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Beckles, M.A., Spiro, S.G., Colice, G.L., Rudd, R.M. (2003). Initial evaluation of the
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OncoNurse.com.fact sheet,(2000). Adapted from lung cancer, Johnston, L.