Lenox Hill Thoracic Surgery
National Leaders in Minimally Invasive Thoracic Surgery
Richard Lazzaro, MD FACS
Byron Patton, MD

Lung Cancer Treatment

Overview:  Lung cancer can be detected on routine chest xray (CXR), or cat scan (CT scan) in up to 25 % of patients. CT scan screening is being evaluated for early detection of lung cancer in high risk patients (current and former smokers, ages 55 to 74 with a smoking history of at least 30 pack years, as defined by the National Lung Screening Trial, NLST.

Symptoms may be related to the lung, surrounding structures, spread to other areas of the body (metastasis) or related to hormones produced by the lung cancer, which cause other syndromes (paraneoplastic syndromes). Cough, wheezing, hoarseness, hemoptysis (coughing blood), shortness of breath, chest pain, back pain, weakness, stroke, bone fracture, jaundice, hypertension, swelling, facial swelling (superior vena cava syndrome), mental status changes, eye changes (ptosis, miosis, anhydrosis - Horner's syndrome) as well as fatigue, depression and weight loss.

Lung cancer develops when genetic changes occur in a normal cell within the lung. As a result, the cell becomes abnormal in shape and behavior, and reproduces endlessly. The abnormal cells form a tumor that, if not surgically removed, invades neighboring blood vessels and lymph nodes and spreads to nearby sites. Eventually, the cancer can spread to locations throughout the body.

Symptoms: Lung cancer can be detected on routine chest xray (CXR), or cat scan (CT scan) in up to 25 % of patients. CT scan screening is being evaluated for early detection of lung cancer in high risk patients (current and former smokers, ages 55 to 74 with a smoking history of at least 30 pack years, as defined by the National Lung Screening Trial, NLST).

Symptoms may be related to the lung, surrounding structures, spread to other areas of the body (metastasis) or related to hormones produced by the lung cancer, which cause other syndromes (paraneoplstic syndromes). Cough, wheezing, hoarseness, hemoptysis (coughing blood), shortness of breath, chest pain, back pain, weakness, stroke, bone fracture, jaundice, hypertension, swelling, facial swelling (superior vena cava syndrome), mental status changes, eye changes (ptosis, miosis, anhydrosis - Horner's syndrome) as well as fatigue, depression and weight loss.

Diagnosis: Diagnosis can occasionally be made from cytologic or pathologic analysis of the sputum. Frequently, patients require bronchoscopy - a lighted camera can be placed inside the trachea (airway) for obtaing a biopsy. Other possibilites include CT guided biopsy, EBUS (endobronchial ultrasound), videomediastinoscopy, and VATS (video assisted thoracic surgery). Once a specific type of lung cancer is identified (small cell lung cancer or non- small cell lung cancer), additional testing is performed to assess the stage (also know as extent of disease). Types of non-small cell lung cancer include squamous and adenocarcinoma.

Chest X-Rays: In a small percentage of cases, a routine chest x-ray reveals the first signs of lung cancer. Usually, however, symptoms of existing lung cancer, such as coughing, chest pain, and blood in the sputum, will lead to a chest x-ray.

Computed Tomography: Computed tomography (CT), particularly the specific technique called low-dose spiral (or helical) CT, is more effective than x-rays for detecting cancer in patients with suspected lung cancer. It is the standard imaging procedure for determining if and where the cancer has spread (metastasized). Surgeons also use CT scans to evaluate patients before lung surgery.

Staging: Physicians use physical examination, blood testing (CBC - complete blood count, CMP - complete metabolic profile), radiographic imaging (CT Scanning and PET - positron emission tomography) to determine a stage of the lung cancer.

Non-small cell lung cancers are assigned a number from 1 to 4, which is utilized to determine the best treatment plan.

Stage 1:lung cancer confined to the lung
Stage 2:lung cancer involves the lung and surrounding lymph nodes
Stage 3:lung cancer becomes more extensive and spreads to mediastinal lymph nodes
Stage 4:lung cancer has spread outside the chest and become metastatic

Small cell lung cancer is staged slightly differently:

Very Limited:Confined to the lung
Limited:Involves lung and surrounding lymph nodes
Extensive:More extensive, precluding treatment with radiation

Work-up, staging and management follows guidelines, established by the National Comprehensive Cancer Network (NCCN). Multidisciplinary conferences, involving thoracic surgical onologists, medical oncologists, radiation oncologists, radiologists, and pathologists are utilized to determine the best treatment plan, which is individualized for each patient. In general, surgery is recommended for stage 1 and stage 2 disease as initial treatment, provided the patient is a good candidate for surgery. Consultants will frequently use objective tests to assess a patient's ability to undergo surgery - pulmonary function testing, stress tests, and echocardiography.

Treatment
Physicians from various clinical areas (pulmonology, oncology, radiation oncology and thoracic surgery) work as a team to evaluate your medical condition and recommend an appropriate treatment.

Lung cancer is generally diagnosed in older individuals so there’s an increased need for techniques that are well tolerated among the elderly. For a variety of reasons, seniors recover more easily following minimally invasive techniques.

Surgery
The type of surgery a patient needs depends on the amount of lung or other tissue that needs to be removed.

Wedge Resection or Segmentectomy. Wedge resection and segmentectomy remove only a small part of the lung. They preserve almost normal breathing function after the operation.

Lobectomy. Removal of one of the lobes of the lung is called lobectomy. The patient must have enough lung function to undergo this procedure. The patient has a 3 - 5% risk of death after this operation, with older patients having the highest risk.

Pneumonectomy. Pneumonectomy removes the entire lung. The patient has a 5 - 8% risk of death after this procedure. The oldest patients have the greatest risk, and they almost always have a recurrence.

Other Procedures
Surgical advances are allowing a wider range of options, including minimal surgeries for early cancers and surgeries that relieve cancer symptoms in the late stages of the disease.

Thoracoscopy. Thoracoscopy, also known as video-assisted thoracic surgery (VATS), is a less-invasive technique that uses a thin tube containing a miniature camera and surgical instruments. It involves much smaller incisions than open surgery and speeds recovery to the point that patients are up within hours. Though the procedure is not appropriate in all cases, it offers significant advantages, especially in older or frail patients. Our surgeons utilize robotic technology, daVinci, to perform complex surgeries with small keyhole icisions to provide faster recovery, less pain with the potential for better long term outcomes as well.

Laser Surgery. Laser surgery allows surgeons to remove small amounts of lung tissue. Laser surgery may also be beneficial in treating cancers that have spread to, and are obstructing, the throat.

Photodynamic Therapy. Photodynamic therapy uses bronchoscopy and special laser light beams combined with a light-sensitive drug, called porfimer sodium (Photofrin), to kill cancer cells.

Cryosurgery. Cryosurgery uses a probe chilled to below freezing to destroy the tumor cells on contact. It is being investigated in combination with radiation therapy. It may also be an alternative in early stage cancer for patients who cannot have surgery.

Electric Cauterization and Thermal Ablation. Electric cauterization, which uses electricity to produce heat that destroys tissue, is also under investigation as a treatment for early-stage disease.

Radiofrequency Ablation. This non-surgical technique that uses an x-ray guided electrode to deliver heat to tissues may benefit lung cancer patients who are not eligible for surgery, radiation, or chemotherapy.

Radiation Treatments
The goal of radiation treatment is to administer doses as high as possible to kill as many cancer cells as possible, without destroying surrounding healthy tissues or causing a dangerous reaction. Doctors may try different procedures for the same patient. The exact radiation procedure depends on the site of the cancer or how far it has spread.

External-Beam Radiation. External-beam radiation therapy focuses a beam of radiation directly on the tumor. It is generally used for cancer that has spread.

Brachytherapy. Brachytherapy implants radioactive seeds through thin tubes directly into the cancer sites. Brachytherapy may be used for lung cancers that have spread to the throat and caused obstruction. High-dose-rate brachytherapy may also have some value for patients with inoperable tumors in the central region of the lung.

Three-Dimensional Conformal Radiotherapy
Three-dimensional (3-D) conformal radiotherapy delivers external-beam radiation specifically to targeted organs or tissues. This allows doctors to administer significantly higher doses to attack the cancer, while reducing the risk to healthy cells. This technique is generally considered the standard method of delivering radiation to lung tumors.