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New Procedure for Diagnosing Lung Cancer -- April 12, 2010 -- Dr. Susan Garwood and Dr. Stacey Vallejo

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New Procedure for Diagnosing Lung Cancer
April 12, 2010
Susan Garwood, MD, pulmonologist
Stacey Vallejo, MD, pulmonologist
SAINT THOMAS HOSPITAL

Lung Cancer Symptoms

One fourth of all people with lung cancer have no symptoms when the cancer is diagnosed. These cancers are usually identified incidentally when a chest x-ray is performed for another reason. The other three fourths of people develop some symptoms. The symptoms are due to direct effects of the primary tumor; to effects of metastatic tumors in other parts of the body; or to malignant disturbances of hormones, blood, or other systems.
Symptoms of primary lung cancers include cough, coughing up blood, chest pain, and shortness of breath.

  • A new cough in a smoker or a former smoker should raise concern for lung cancer.
  • A cough that does not go away or gets worse over time should be evaluated by a health care provider.
  • Coughing up blood (hemoptysis) occurs in a significant number of people who have lung cancer. Any amount of coughed-up blood should cause alarm.
  • Chest pain is a symptom in about one fourth of people with lung cancer. The pain is dull, aching, and persistent and may involve other structures surrounding the lung.
  • Shortness of breath usually results from a blockage in part of the lung, collection of fluid around the lung (pleural effusion), or the spread of tumor through the lungs.
  • Wheezing or hoarseness may signal blockage or inflammation in the lungs that may go along with cancer.
  • Repeated respiratory infections, such as bronchitis or pneumonia, can be a sign of lung cancer.

Symptoms of metastatic skin rashes depend on the location and size. About 30-40% of people with lung cancer have some symptoms or signs of metastatic disease.

  • Lung cancer most often spreads to the liver, the adrenal glands, the bones, and the brain.
  • Metastatic lung cancer in the liver usually does not cause any symptoms, at least at the time of diagnosis.
  • Metastatic lung cancer in the adrenal glands also typically causes no symptoms at the time of diagnosis.
  • Metastasis to the bones is most common with small cell type cancers but also occurs with other lung cancer types. Lung cancer that has metastasized to the bone causes bone pain, usually in the backbone (vertebrae), the thighbones, and the ribs.
  • Lung cancer that spreads to the brain can cause difficulties with vision, weakness on one side of the body, and/or seizures.

Types of Lung Cancer

What are the types of lung cancer?

Lung cancers, also known as bronchogenic carcinomas ("carcinoma" is another term for cancer), are broadly classified into two types: small cell lung cancers (SCLC) and non-small cell lung cancers (NSCLC). This classification is based upon the microscopic appearance of the tumor cells themselves. These two types of cancers grow and spread in different ways, so a distinction between these two types is important.

SCLC comprise about 20% of lung cancers and are the most aggressive and rapidly growing of all lung cancers. SCLC are strongly related to cigarette smoking with only 1% of these tumors occurring in non-smokers. SCLC metastasize rapidly to many sites within the body and are most often discovered after they have spread extensively. Referring to a specific cell type often seen in SCLC, these cancers are sometimes called oat cell carcinomas.

NSCLC are the most common lung cancers, accounting for about 80% of all lung cancers. NSCLC has three main types that are named based upon the type of cells found in the tumor. They are:

  • Adenocarcinomas are the most commonly seen type of NSCLC in the U.S. and comprise up to 50% of NSCLC . While adenocarcinomas are associated with smoking like other lung cancers, this type is especially observed as well in non-smokers who develop lung cancer. Most adenocarcinomas arise in the outer, or peripheral, areas of the lungs. Bronchioloalveolar carcinoma is a subtype of adenocarcinoma that frequently develops at multiple sites in the lungs and spreads along the preexisting alveolar walls.
  • Squamous cell carcinomas were formerly more common than adenocarcinomas; at present they account for about 30% of NSCLC. Also known as epidermoid carcinomas, squamous cell cancers arise most frequently in the central chest area in the bronchi.
  • Large cell carcinomas, sometimes referred to as undifferentiated carcinomas, are the least common type of NSCLC.
  • Mixtures of different types of NSCLC are also seen.

Other types of cancers can arise in the lung; these types are much less common than NSCLC and SCLC and together comprise only 5-10% of lung cancers:

  • Bronchial carcinoids account for up to 5% of lung cancers. These tumors are generally small (3-4 cm or less) when diagnosed and occur most commonly in persons under 40 years of age. Unrelated to cigarette smoking, carcinoid tumors can metastasize, and a small proportion of these tumors secrete hormone-like substances. Carcinoids generally grow and spread more slowly than bronchogenic cancers, and many are detected early enough to be amenable to surgical resection.
  • Cancers of supporting lung tissue such as smooth muscle, blood vessels, or cells involved in the immune response can rarely occur in the lung.

As discussed previously, metastastatic cancers from other primary tumors in the body are often found in the lung. Tumors from anywhere in the body may spread to the lungs either through the bloodstream, through the lymphatic system, or directly from nearby organs. Metastatic tumors are most often multiple, scattered throughout the lung and concentrated in the peripheral rather than central areas of the organ.

 

NEW MINIMALLY INVASIVE PROCEDURE for Diagnosing and Staging Lung Cancer

 

The Endobronchial Ultrasound, or EBUS, is advanced technology offering a more precise way of assessing a patient's lymph nodes and determining if lung cancer has spread to other parts of the body. Saint Thomas Hospital is one of the FIRST to have this advanced technology for diagnosing lung cancer and other diseases involving the lymph nodes.

This new technology is changing the practice of cancer staging.

Less Invasive, Shorter Hospital Stay

With lung and esophageal cancers, treatment decisions and the patient's prognosis is directly related to the extent of the disease, or the "stage" of the cancer. Malignancies in the chest can easily spread through the body via lymph nodes. If tumors have invaded a patient's lymph nodes, this can dramatically change the initial "staging" of the cancer, as well as the options for initial treatment.

Lung cancer is typically diagnosed after it has already spread, and long-term prognosis for patients is usually poor. But with the innovation of endobronchial ultrasound and its ability to accurately show the cancer stage, patients with early-stage lung cancer may avoid more extensive surgery. With less-invasive procedures, such patients may then leave the hospital sooner and use less pain medication as they recover.

The type of treatment recommended for lung cancer patients depends to a large degree on the stage of their cancer. The great advantage of this technology is that people who will benefit from surgery will not be denied surgery or receive unnecessary chemotherapy because of less accurate conventional staging with CT and PET scans.

It also means people with advanced lung cancer will not need to undergo unnecessary surgery that may not help them..

The EBUS Procedure

The EBUS technology is a hybrid employing ultrasound guidance with a bronchoscope, enabling real-time transbronchial needle aspiration to be performed. This combination aids in the diagnosis and staging of lung cancer. In clinical trials, many patients evaluated with EBUS were able to forego more invasive procedures, such as mediastinoscopy, thoracoscopy or thoracotomy.

Using EBUS, biopsies are performed through the trachea using ultrasound rather than surgical incisions that must be made in other, more invasive procedures. The EBUS procedure is usually completed in less than half an hour.

In an endobronchial ultrasound, patients are placed under conscious sedation or general anesthesia and a small scope is passed through the mouth down into the windpipe. The scope has a small instrument at its tip called a transducer, which can be pointed in different directions to produce images of lymph nodes and other structures in the area between the lungs, called the mediastinum.  The technology allows you to look in areas that have traditionally been hard to biopsy. If suspicious areas are seen–such as enlarged lymph nodes–a hollow needle can be passed through the bronchoscope and guided by real-time ultrasound into the abnormal structures to obtain a biopsy.

Endobronchial Ultrasound is a well-designed system. In many cases, it offers better sensitivity and specificity without having to make an incision.

 

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