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:
  • Cancer is generally found in one lung. There may be cancer in nearby lymph nodes on the same side of the chest.
  • Cancer has spread beyond the primary tumor in the lung into other parts of the body.

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
• Prior radiation therapy to the chest
• Diet
• Air pollution
• Secondhand smoke
• Exposure to cancer-causing substances:
  • Asbestos
  • Radon
  • Chromium
  • Nickel
  • Radioactive ores, such as uranium and plutonium
  • Arsenic
  • Vinyl chloride
  • Silica
  • Coal products
  • Mustard gas
  • Chloromethyl ethers
  • Diesel exhaust
  • Soot
  • Tar
• Personal or family history of lung cancer (first degree relative who developed lung cancer under the age of 60)
• Prior radiation therapy to the chest
• Diet
• Air pollution

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

Diagnosis of lung cancer often includes a number of different tests and procedures, many conducted by your thoracic surgeon:

• Medical history
• Physical examination
• Blood and urine test
• Chest X-ray to look for any mass or spot on the lungs.
• Computerized tomography scan(CT scan) uses a combination of X-rays and computer technology to produce horizontal, or axial, images of the body.
• Sputum cytology studies phlegm (mucus) cells under a microscope.
• Thoracentesis, where a hollow needle is inserted through the skin in the chest wall to remove fluid (when present), which is then sent to the lab to be checked for cancer cells.
• Biopsy performed using either a closed or an open method. Closed methods are performed through the skin or through the trachea (windpipe). An open biopsy is performed in the operating room under general anesthesia.
  • Needle biopsy, a thin, hollow needle is guided into the mass while the lungs are being viewed on a fluoroscopy or CT scan. A sample is removed and evaluated under a microscope. Also called a closed, transthoracic, or percutaneous (through the skin) biopsy. A needle biopsy may also be performed during a bronchoscopy (see below).
  • Thoracoscopic biopsy, also referred to as video-assisted thoracic surgery (VATS) biopsy, is an operation where the surgeon makes one or more small cuts in the side of the chest wall, under anesthesia, through which a small telescope with a video camera on the end is inserted. This allows the doctor to look at the outer part of the lungs and chest wall and to sample any abnormal areas for viewing under a microscope. Therapeutic procedures, such as the removal of a nodule or other tissue may be performed. Depending on the results of the biopsy, more extensive surgery, such as the removal of a lobe of the lung, may be performed during the procedure.
• Bronchoscopy, which is the examination of the bronchi (the main airways of the lungs) using a flexible tube (bronchoscope) passed down the mouth or nose. Bronchoscopy helps to evaluate and diagnose lung problems, assess blockages, obtain samples of tissue and/or fluid, and/or to help remove a foreign body.
  • Navigational bronchoscopy: This new procedure creates a GPS-type guidance system combined with a bronchoscope to biopsy deeper and smaller spots in the lung.
  • Transbronchial biopsy is performed through a fiberoptic bronchoscope (a long, thin tube that has a close-focusing telescope on the end for viewing) through the main airways of the lungs (bronchoscopy).
  • Endobronchial ultrasound, a specialized technique combining bronchoscopy with an ultrasound that enables clinicians to visualize lymph nodes with high sensitivity, and allows a biopsy without an incision.
  • Mediastinoscopy, a small incision is made in the neck above the top of the sternum under general anesthesia and a mediastinoscope is inserted to see into the chest cavity and obtain tissue samples of mediastinal lymph nodes. This procedure helps in staging the cancer or making the diagnosis of the cancer.
  • MRI, PET, or bone scans determine if the cancer has spread from where it started into other areas of the body.

Thoracic surgeon Michael Jaklitsch, MD and thoracic radiologist Francine Jacobson, MD have developed a tool for the American Association for Thoracic Surgery to determine if a patient should be screened for lung cancer.

This unique program offers eligible patients CT scans to screen for lung cancer. Eligible patients must be between the ages of 55 and 79 who smoked one pack of cigarettes a day for 30 years.

Learn more about lung cancer screening.

Learn more about a BWH clinical trial utilizing CAT scans during surgery to better target lung tumors.

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. Learn more about the stages of 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. Treatment options include:

Surgery

Surgery is usually the best option for treating early-stage lung cancer and may be used to remove a portion of the lung or the entire lung. Our thoracic surgeons have 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.

Dana-Farber Brigham Cancer Center is home to one of the few dedicated thoracic surgery intensive care units in the country, with sub-specialized nursing staff and state-of-the-art healthcare resources.

Types Of Surgery

• Segmental or wedge resection: Removal of only a part of the lung. There are 10 segments in each lung.
• Lobectomy: Removal of an entire lobe of the lung. There are 3 lobes in the right lung and 2 in the left lung.
• Pneumonectomy: Removal of an entire lung.
• Sleeve resection: Removal of a piece of bronchus, after which the lung is reattached to the remaining part of the bronchus.
• Open-chest surgery: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.

Minimally Invasive Surgery

Using minimally invasive surgery techniques over traditional surgeries offers patients many benefits: improved accuracy and visualization, minimized trauma to tissue, less bleeding, decreased pain, less scarring and a shortened recovery.

• 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:
• Video-assisted Thoracic Surgery (VATS), a minimally invasive procedure that involves the insertion of a thoracoscope (a tiny camera) and surgical instruments into small incisions in the chest. Open lung resection for cancer often requires a large thoracotomy incision with spreading of the ribs. VATS lobectomy uses three small incisions without any spreading of the ribs. 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.
• Image Guided Video Assisted Thoracoscopic Surgery (IVATS), a new technique pioneered at BWH where minimally invasive thoracic surgery is combined with live CT scanning in the operating room to precisely pinpoint the location and margins of the nodule or tumor to be removed. This is particularly appropriate for very small suspicious nodules which are otherwise difficult to find during conventional surgery.
• Endoscopic Stent Placement: An endoscope is a thin, tube-like instrument. It may be used to place a stent in an airway blocked by abnormal (cancerous) tissue, helping a patient to breathe more easily.

Read about Image Guided Video Assisted Thoracic Surgery (iVATS)

Non-Surgical Cancer Treatments

• Radiation therapy uses high-energy rays to kill or shrink cancer cells. Radiation is often used in conjunction with chemotherapy before surgery to shrink the tumor. The Radiation Oncology service at Dana-Farber Brigham Cancer Center uses the most advanced equipment and techniques to deliver radiation to cancerous areas, while avoiding exposure to normal tissues. More importantly, radiation experts work closely with your surgeon to create a specialized treatment plan just for you.
• Brachytherapy: Radiation therapy can be delivered with catheters to a precise location to radiate small areas using high energy.
• Stereotactic Body Radiation Therapy(SBRT): Radiation therapy can be delivered into specific small areas with high intensity using innovative computerized machines.
• Chemotherapy uses anticancer drugs to kill cancer cells throughout the entire body. Chemotherapy is often used before or after surgery or alone in the most advanced cases of lung cancer. The purpose is to shrink the tumor so it can be surgically removed. Chemotherapy is often used in conjunction with radiation, and chemotherapy experts work closely with your surgeon to create a personalized treatment plan.
• Clinical trials and targeted therapy Biological drugs now exist that target specific lung tumors based on their genetic makeup. Dana-Farber Brigham Cancer Center has developed some of these approaches and every tumor is analyzed for its genetic make-up in order to maximize patient benefit and tailor the best therapy for each patient.
• Photodynamic therapy (PDT)is a type of laser treatment that involves injecting photosensitizing chemicals into the bloodstream. For lung cancer, the light is delivered through a bronchoscope inserted through the mouth or nose. PDT is generally used for very early bronchial cancers or advanced cancers blocking an airway.