The thoracic surgeons at CVTSA in Northern Virginia use state-of-the-art minimally invasive surgical techniques to treat lung cancer.
Lung cancer is the leading cause of cancer deaths in the United States. While many people believe that lung cancer only affects people who smoke, the reality is that about two thirds of cases, lung cancer occurs in patients who have never smoked or have quit smoking. Further, lung cancer affects more people than breast, prostate and colon cancer combined.
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Warner EE, Mulshine JL, "Lung Cancer Screening with Spiral Ct: Toward a work strategy." Oncology (Williston Park). 2004 May; 18(5):564-75, discussion 578, 583-4, 587.
Cancer (also called a tumor, nodule or mass) located in the lungs is either primary or metastatic. Primary cancer means that the cancer began in the lungs and is comprised of lung cells. Differently, metastatic cancer in the lungs means that a cancer located elsewhere in the body has spread to the lungs. Metastatic cancer is made of cells from the primary cancer site. Because of the differences in cellular make up, primary and metastatic cancers in the lungs are treated differently.
Diagnosing Lung Cancer
Lung cancer is diagnosed in several different ways. Often, an abnormality is spotted on either a routine chest x-ray, or one performed because a patient has a persistent cough or is coughing up blood. To confirm what the abnormality is, a patient will undergo one or all of the following tests:
CT Scan – Computed Tomography is a diagnostic, non-invasive examination that provides anatomic detail using x-ray technology.
PET Scan – Positron Emission Tomography (PET) is a diagnostic, non-invasive test which looks at the metabolic activity taking place in the body. Cancer is metabolically active, so PET scans are a good determinant of whether or not a tumor is cancerous, or malignant. You will receive an injection glucose which has a safe radioactive label. Metabolically active tissues that use glucose will take up the radioactive tracer and “light up” on the scan. These images are then correlated or fused, with the CT examination to localize areas of abnormal metabolic uptake. The lungs are largely composed air with very minimal metabolic activity. Therefore, it is easy to see cancer in the lungs via PET because cancer is very metabolically active. It is important to know that areas of infection, inflammation or trauma are also metabolically active and can be confused with cancer.
Bronchoscopy – During this minimally invasive procedure, a flexible fiberoptic scope is placed via the nose or mouth into the major airways where biopsies or washings for cells can be obtained.
Needle Biopsy – Using CT as a guide, a physician places a needle into the lungs at the site of the abnormal tissue. The physician then removes some of the abnormal tissue and sends it to pathology to determine its origin.
Surgical Biopsy – Sometimes a tumor is too small or in such a location that it cannot be accessed using a needle biopsy. In these cases, a surgeon makes a very small incision in between two ribs and, using specially designed instrumentation, removes a part of the lung on which the tumor is growing. Then, the entire piece of tissue is sent to pathology.
When a person is diagnosed with cancer, the next step is to stage it. Staging refers to determining how much cancer there is in the body and where it is located. This information helps doctors determine how to treat the disease and provides prognostic information. American Joint Committee on Cancer (AJCC) created a staging system for most cancers based on the extent of the tumor (T), whether or not it has spread to the lymph nodes (N) and if the cancer has metastized (M), or spread to the other areas of the body. Based on these three areas, staging is referred to as TNM. To learn about the various stages, click here.
Treating Lung Cancer
For patients diagnosed with lung cancer, there are a number of options including chemotherapy, radiation therapy and surgery. Often, patients will receive a combination of all three treatments. Chemotherapy and radiation can be administered before or after surgery, depending on the location and stage of the cancer. This decision is made by the surgeon and oncologist, in consultation with the patient.
Many patients with early stage lung cancer benefit from upfront surgery because the tumor appears confined to an area of the body that is removable (resectable). As the stage of the cancer at diagnosis increases surgery alone becomes less effective and multimodality therapy is most beneficial. Surgery may still be an important part of the treatment plan, however chemotherapy and or radiation therapy may need to come first. Patients with end stage lung cancer, i.e. stage IV may undergo palliative surgery. This means that while their cancer cannot be cured, a tumor or tumors can be removed to make the patient more comfortable, such as if a tumor is obstructing an airway.
For patients whose cancer is amenable to surgery, there are two kinds: minimally invasive or traditional, open surgery.
Minimally Invasive Surgery
When performing minimally invasive surgery, a surgeon makes two incisions which are about two to four centimeters long and then performs the operation without the need for rib spreading. A camera is inserted into one incision and projects the inside of the body onto a 26 inch flat screen high definition monitor. The surgeon watches the screen while inserting instruments through the second incision to perform the surgery. This surgery is sometimes called video assisted thoracic surgery, or VATS.
For appropriate patients, minimally invasive surgery is advantageous because there are fewer complications, the hospital stay is decreased and the patient recovers faster. In addition, there is less pain because the ribs were not spread. A faster time to a complete recovery leads enables patients to return to their normal lives more quickly. In addition, if post operative chemotherapy is required, the minimally invasive technique allows for earlier and more successful initiation of chemotherapy.
Patients who undergo minimally invasive surgery get up and walk within 2 hours of surgery and generally stay in the hospital 24-48 hours.
Mr. Oglesby Talks about his Experience with Minimally Invasive Surgery.
Traditional, Open Surgery
Some patients are not candidates for minimally invasive surgery for various anatomical reasons. In these instances, a surgeon makes an incision on their side (flank) and spreads the ribs slightly to gain access to the tumor.
For specific questions about preparing for and recovering from surgery, please visit the Frequently Asked Questions portion of this website.
Treating Cancer that has Metastasized to the Lungs
When a cancer has metastasized to the lungs from another location in the body, surgery is only sometimes an option. If the cancer is not particularly aggressive or if the disease in the lung is limited, then a patient may be a surgical candidate. Patients undergoing surgery for metastatic cancer to the lungs can have either minimally invasive or traditional, open surgery.
Medical Articles About Lung Cancer
Mediastinal Staging of Non-Small Cell Lung Carcinoma Using Computed and Positron-Emission Tomography
Overall accuracy for computed tomography (CT) and positron-emission tomography (PET) is approximately the same which in our experience is 86 percent. False/negatives occurred three times more commonly with CT; false/positives occurred two times more often with PET. PET seems to achieve a high negative predicted value (93-95%) in the evaluation of mediastinal disease. PET seems to be particularly helpful in evaluating patients with bulky nodes that may persist after chemotherapy and/or radiation therapy as delivered neoadjuvantly.
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Pragmatic and Successful Approach to the Treatment of Non-Small Cell Carcinoma of the Lung
Carcinoma of the lung is the single leading cause of death from cancer for men and women combined, responsible for 31% of cancer deaths in men and 25% of cancer deaths in women. Based on the pioneering work of Nohl and Paulson there exists now near universal agreement upon the importance of staging for the selection of appropriate treatment of lung cancer.
Consistent with the experience of others, resection of tumors of smaller size and lesser (I and II) stage resulta in longer survivals. Our experience mirrors the literature and shows excellent long-term results. We have been more fortunate than most institutions when dealing with stage III and IV disease. Our operative (hospital) mortality rates are less (refer to Table 2 within the appended article), and our long-term survivals are greater stage for stage than the best of the reports in the literature (refer to Figure 9 in the appended article).
Based on the concept that incomplete resection precludes long-term survival, the authors have selectively and progressively utilized neoadjuvant (preoperative) chemotherapy or chemoradiation therapy to try to downstage disease, whereby a complete resection may then be feasible. With regard to late stage (III and IV) disease, our results match or exceed the best results reported to date anywhere.
Neoadjuvant chemotherapy, followed by surgical resection has resulted in Kaplan-Meier five-year survivals of 46%. The latter figure closely approximates a 42% five-year survival achieved in our earlier (1981-1989) experience where we de predominately with "occult" N2 disease. Yet, our neoadjuvant results have been achieved despite dealing with significantly more bulky and advanced disease.
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Late Stage (III and IV) Non-Small Cell Carcinoma of the Lung: Results of Surgical Resection at Inova Fairfax Hospital
One hundred seventeen patients underwent up-front surgery with respective hospital mortality rates and a five-year survival of 1.7 % and 31%. Twenty-five patients, most with bulky mediastinal disease, underwent neoadjuvant (preoperative) therapy followed by surgical resection with respective rates of hospital mortality, complete pathologic response, major pathologic response, and five-year survivals of 0%, 16%, 64%, and 34%.
Of the sixteen patients undergoing neoadjuvant therapy who had complete pathologic response with significant downstaging of disease, five-year survival was 61%. Among patients with an estimated postoperative FEV-1 < 1.0 liters, there were no five-year survivors (P < 0.0001).
Adjuvant (postoperative) therapy was associated with improved five-year survival (P = 0.03), particularly for combination chemotherapy and radial therapy (P = 0.02).
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