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Lung Cancer

In the US, lung cancer kills more people than breast cancer, colon cancer, and prostate combined. For the last few decades, survival for other cancer has significantly improved, and in just the last few years, screening and new treatments have finally started to improve survival for lung cancer. The treatment is determined by the type and stage of lung cancer. These days, treatment may be surgery, chemotherapy, radiation therapy, immunotherapy, or targeted drug therapy.

The American Cancer Society’s estimates for lung cancer in the United States for 2016 are:

– About 224,390 new cases of lung cancer (117,920 in men and 106,470 in women)
– About 158,080 deaths from lung cancer (85,920 in men and 72,160 in women)

Overall, the chance that a man will develop lung cancer in his lifetime is about 1 in 14; for a woman, the risk is about 1 in 17. Black men are about 20% more likely to develop lung cancer than white men. The rate is about 10% lower in black women than in white women.

Both black and white women have lower rates than men, but the gap is closing. The lung cancer rate has been dropping among men over the past few decades, but only for about the last decade in women.

At Providence St John’s Health Center, our physicians work closely together as a team to provide all the clinical resources you need during your cancer treatment. Your health care team includes distinguished thoracic surgeons, radiation oncologists, pathologists, pulmonologists and medical oncologists. The appropriate members of the Providence St John’s lung cancer screening team or the Thoracic Tumor Board will review the CT scan and make recommendations.

Types of Lung Cancer

 

There are two major types of lung cancer:

  • Non-small cell lung cancer accounts for 85 to 90 percent of lung cancers. The main types of non-small cell lung cancer are:
    • Squamous cell carcinoma (also called epidermoid carcinoma) often begins in the bronchi near the middle of the lungs.
    • Adenocarcinoma usually begins along the outer edges of the lungs. It is the most common type of lung cancer in people who have never smoked.
    • Large cell carcinomas are a group of cancers with large, abnormal-looking cells related to hormone secreting glands. These tumors may begin anywhere in the lungs and grow quickly.
  • Small cell lung cancer is sometimes called oat cell cancer. It grows rapidly and spreads to other organs. There are two types:
    • Limited. Cancer is generally found in one lung. There may be cancer in nearby lymph nodes on the same side of the chest.
    • Extensive. Cancer has spread beyond the primary tumor in the lung into other parts of the body.
Risk Factors for Lung Cancer

 

Smoking tobacco is the most significant risk for developing this type of cancer, typically affecting people older than 45. Factors that contribute to an increased risk for developing lung cancer include:

  • Smoking cigarettes, pipes, or cigars, now or in the past causes 80% of lung cancer
  • Secondhand smoke
  • Exposure to cancer-causing substances:
    • Radon: after smoking, radon is the next leading cause of lung cancer in the US Link to radon areas in LA.
      Radon causes 20.000 cases of lung cancer per year in US (http://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm). On the following maps, the red areas show where high concentrations of radon are found:
      • Radon Potential Zone Map
      • Radon Potential Zone Map
      • Radon Potential Zone Map
    • Asbestos
    • Chromium
    • Nickel
    • Radioactive ores, such as uranium and plutonium
    • Arsenic
    • Vinyl chloride
    • Silica
    • Coal products
    • Mustard gas
    • Chloromethyl ethers
    • Diesel exhaust
    • Soot
    • Tar
  • Family history of lung cancer (relative with lung cancer under the age of 60)
  • History of radiation therapy to the chest
  • Air pollution

 

Symptoms of Lung Cancer

 

Lung cancer may not cause any symptoms and may be found on a routine chest X-ray or low-dose chest CT-scan. Signs and symptoms of lung cancer may include:

  • Cough that doesn’t go away and worsens over time
  • Trouble breathing
  • Chest pain
  • Wheezing
  • Coughing up blood or rust-colored mucus
  • Hoarseness
  • Loss of appetite
  • Weight loss for no known reason
  • Feeling very tired
  • Pneumonia or bronchitis
  • Shoulder pain
  • Bone pain
  • Yellowing of skin and eyes (jaundice)
  • Headache, seizures, or confusion
  • Enlarged lymph nodes in the neck
Stages of Lung Cancer

The staging system for any cancer was created to put cancers into groups that correlate with the prognosis and into categories that determine treatment. A simplified description of the 4 stages of lung cancer and possible treatment is seen below.

Lung cancer staging 2

Diagnosis of Lung Cancer

CT scans and PET scans do not prove that a patient has cancer. Diagnosis of lung cancer requires a biopsy. This may include a number of different tests and procedures:

Blood and urine test for cancer:
Providence St John’s Health Center is a leader in  liquid biopsies (checking a patient’s blood to look for cancer cells).  This can be used for diagnosis, staging, and follow up.

Sputum cytology
looks for cancer in sputum tests.

Thoracentesis:
a needle passes between the ribs into the chest cavity to drain fluid which can be checked for cancer cells.

  • Biopsy to obtain a sample of a tumor to make a diagnosis:
    Needle biopsy, a needle guided by CT scan passes between the ribs into a  lung mass.  Tissue is evaluated under a microscope.
  • Surgical biopsy, often performed by video-assisted thoracic surgery (VATS) under general anesthesia, is obtained through a small incision in the chest.   A video camera is inserted so the surgeon can see what to biopsy.  The patient usually stays in the hospital for 1-2 days.  Sometimes the procedure is expanded to remove the whole mass for a cure.

Bronchoscopy:  a flexible tube (bronchoscope) passes into the trachea to look for narrowed windpipes or tumors, and to get biopsies.
o Navigational bronchoscopy:  uses a computer as a GPS guidance system to direct the bronchoscope where to get a biopsy
o  Transbronchial biopsy: uses fluoroscopy to direct the bronchoscope where to get a biopsy

Biopsy and staging of mediastinum (middle of the chest):

o Endobronchial ultrasound (EBUS), uses an ultrasound to direct the bronchoscopy where to get a biopsy of lymph nodes or lung masses.
o   Mediastinoscopy: under general anesthesia, an instrument, called a mediastinoscope, passes into the mediastinum to obtain biopsies of mediastinal lymph nodes.

Radiology
    • Chest X-ray to look for a mass in the lungs.
    • Computerized tomography scan (CT-scan) combines X-ray and computer technology to create very detailed images of the inside of the chest.
    • radiology
    • PET scan positron emission tomography, is an x-ray which is usually used to evaluate and stage patients with a lung mass. The PET scan provides the following information:
      • Lung Mass: If a lung mass does not light up on the PET, there is about a 5% chance it is cancer. If the mass does light up on the PET, there is an 80% chance it is cancer. The OPET does not prove that a mass is or is not a cancer
      • Lymph Nodes: If nodes light up on the PET, they usually contain cancer (Table 1), but we see a 20% false positive rate (20% of nodes that light up have no cancer in the node) so a biopsy is usually performed to determine if cancer is really present in nodes that light up on PET.
      • Distant Metastases: The PET is often used to determine if a cancer has spread from the lung to other parts of the body.
      • MR: MR and CT scans can both image all parts of the body. They have many similarities and differences, as seen in the Table:
CT scan MR
Method Radiation

Fast with high resolution

Magnetic field
Slow, noisy, in smaller tunnel
Better test for Lungs, bones, chest, arteries Soft tissue, tendons, spinal cord, brain tumors
Time for test 5 minutes > 30 minutes
Contra-indicated Pregnant women, children, Obesity (>450 lbs)
Allergies kidneys Kidneys, liver
Cost Less More expensive
Biopsy for Lung Cancer
  • Sputum cytology looks for cancer in sputum tests.
  • Thoracentesis: a needle passes between the ribs into the chest cavity to drain fluid which can be checked for cancer cells.
  • Biopsy to obtain a sample of a tumor to make a diagnosis:
    • Needle biopsy, a needle guided by CT scan passes between the ribs into a lung mass. Tissue is evaluated under a microscope. A needle biopsy may also be performed during a bronchoscopy
    • Surgical biopsy, often performed by video-assisted thoracic surgery (VATS) under general anesthesia, is obtained through small incision in the chest. A video camera is inserted so the surgeon can see what to biopsy. The patient usually stays in the hospital for 1-2 days. Sometimes the procedure is expanded to remove the whole mass for cure.
  • Bronchoscopy: a flexible tube (bronchoscope) passes into the trachea to look for narrowed windpipes or tumors, and to get biopsies.
    • Navigational bronchoscopy: uses a computer as a GPS guidance system to direct the bronchoscope where to get a biopsy
    • Transbronchial biopsy: uses fluoroscopy to direct the bronchoscope where to get a biopsy

Biopsy and staging of mediastinum (middle of the chest):

  • Endobronchial ultrasound (EBUS), uses an ultrasound to direct the bronchoscopy where to get a biopsy of lymph nodes or lung masses.
  • Mediastinoscopy: under general anesthesia, an instrument, called a mediastinascope, passes into the mediastinum to obtain biopsies of mediastinal lymph nodes.

Radiology:

PET scan, positron emission tomography, is an xray which is usually used for several reasons to evaluate patients with a lung mass.

  • Lung Mass: If a lung mass does not light up on the PET, there is about a 5% chance it is cancer. If the mass does light up on the PET, there is an 80% chance it is cancer.
  • Lymph Nodes: If nodes light up on the PET, they usually contain cancer, but we see a 20% false positive rate (20% of nodes that light up have no cancer in the node) so a biopsy is usually performed to determine if cancer is really present in nodes that light up on PET.
  • Distant Metastases: The PET is often used to determine if a cancer has spread from the lung to other parts of the body.
  • MR: MR and CT scans can both image all parts of the body. They have many similarities and differences radiation vs Magnetic field fast high resolution, less radiation. MR no radiation, slow noisy, small tunnel
  • CT better bone, lung, chest problems, arteries. < 5 minutes 2 to 10 mSv, which is about the same as the average person receives from background radiation in 3 to 5 years. Usually, CT is not recommended for pregnant women or children unless absolutely necessary. Rare allergies kidneys
  • MR: 30+ minutes, cost more than CT, primarily used for soft tissue evaluation, e.g., ligament and tendon injury, spinal cord injury, brain tumors, very rare allergies kidney/ liver < 350 more claustrophobia to look for cancer in the brain.
  • Bone Scan: nuclear medicine test to look for cancer in the bones

Stages of Lung Cancer
The process used to find out if cancer has spread within the lungs or to other parts of the body is called staging. The stage is determined from the results of physical exams, imaging tests and biopsies that have been done.

Treatment for Lung Cancer

Depending on its type and stage, lung cancer may be treated with surgery, chemotherapy radiation therapy, local ablation including laser therapy, or a combination of treatments. Table shows common treatment for the different stages of lung cancer.   Treatment options include:

Surgery
Surgery is usually the best option for treating early-stage lung cancer.  Operations are performed to remove a portion of the lung or the entire lung.  It is the gold standard for treatment of lung cancer with the hope of a cure.     In 1992, our thoracic surgeons pioneered the use of minimally invasive video-assisted thoracic surgery (VATS), and  continue to develop innovative approaches to achieving the best outcomes for lung cancer patients.
Through demonstrations locally, around the US and around the world, we have taught hundreds of thoracic surgeons.
Types of Surgery

  • Wedge resection: The lung is cut like cutting a piece of pie to remove a piece of lung.
  • Segmentectomy:  There are 10 segments in each lung. Removal of a segment is called a segmentectomy. In selected cases, segmentectomy can provided as good a chance for cure as removal of a lobe.
  • Lobectomy: There are 3 lobes in the right lung and 2 in the left lung.   Removal of an  entire lobe of the lung is the most common operation to remove a lung cancer in the hope of a cure.
  • Pneumonectomy: Removal of an entire lung.
  • Sleeve resection: Removal of a piece of bronchus, and then reattach the remaining part of the bronchus.
  • Open-chest surgery (Thoracotomy):
    For many years, chest surgery was performed through incisions 6 to 10 inches long.   The ribs are spread open to allow a thoracic surgeon to get hands in to the chest to perform an operation.    Currently,Open procedures are less common, as minimally invasive surgeries are easier on the
    patient and equally effective. Sometimes, major open surgery is required, such as when the tumor is very large. 
  • VATS (Video-Assisted Thoracoscopic Surgery):  Minimally invasive operations have been performed in the chest since about 1990.     Currently, smaller, less complicated procedures, such as wedge resections, are usually performed with  VATS.   At Providence St. John’s, our thoracic surgeons perform over 90% of their lung cancer operations with minimally invasive surgery.   Our papers in medical journals have shown this reduces complications and length of stay in the hospital  without compromising the chance of a cure.   We pioneered this technique.
    • Segmental/wedge resection and lobectomy are both done with minimally invasive surgical procedures that use small incisions and specialized  instruments with video-scopes to guide the surgical process. Many patients come to us after learning they are not candidates for traditional surgery, and we are able to provide innovative surgical options that are safe and effective. Surgical techniques include:
    • VATS is a minimally invasive procedure that involves the insertion of a small camera and surgical instruments through small incisions in the chest.   This is less invasive than big chest incisions that require spreading the ribs. VATS lobectomy usually involves three small incisions without any spreading of the ribs, although in selected cases we use only 1 incision (Uniport). A camera is used to assist the dissection of sensitive blood vessels and lung structures. Less pain and quicker recovery are the goals. If chemotherapy is necessary after surgery, patients are healthier and can more reliably begin their adjuvant additional therapy.