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LUNG CANCER AND VATS – THORACOSCOPIC (CLOSED) SURGICAL TREATMENT OF LUNG CANCER

What is lung cancer?  It is caused by cells that surround the airways especially in the lung tissue.  It has two main types:Small – cell” and “Non – small cell“.  This distinction is related to how the cells are viewed under a microscope.

Causes Lung Cancer:

  Figure-1: (Lung cancer mass in the left lung)

  New cases and deaths estimated from “lung cancer” (America 2013):

New cases: 228,190

Deaths: 159,480

HOW DOES “Cigarette” Make “Lung Cancer”? *

Smoking contains both cancer-causing “chemicals” and destroys the “natural defense system” of the lungs.  Airlines are covered with structures called hairy “cilia”.  These hairy structures protect the airways by sweeping toxins, bacteria and viruses.  ** Cigarettes and tobacco products paralyze these hairy cilia and prevent them from performing their duties!  In this way, cancer-causing substances accumulate in the lungs and cause “lung cancer”!

LUNGS;

There are 2 lungs in the rib cage, right and left.  They are part of the “respiratory system.”  Air enters the nose and mouth and passes through the airways (trachea and bronchi) to reach the lungs.

  There are 3 parts (lobes) in the “right” lung and 2 lobes in the “left” lung.  There are 2 thin layers of cover (pleura) in the rib cage;  one covers the lungs (visceral pleura) while the other covers the inner face of the rib cage (parietal pleura).

Figure-2: Lungs

CANCER CELLS

Cancer” starts at the level of “cells” that make up all tissues and organs;  the same happens in the lungs.

Normal cells” grow when needed and divide to form new cells .;  when normal cells age, damage, and die.

Sometimes, this process works “wrong”!  Cells grow uncontrollably and form mass (tumor), when they are not needed.

Tumors can be either “benign” or “malignant”:

Benign tumors:

• They rarely threaten life

• They do not enter the surrounding tissues, that is, they do not hold.

• They do not spread to other parts of the body.

Usually they do not need to be removed

Malignant tumors (lung cancer):

• They may threaten life

• May invade neighboring organs and tissues (invasion)

• They can spread to other parts of the body (metastasis)

• They can be removed frequently, but they may grow again (recurrence)

Lung cancer” can spread throughout the body through “blood and / or lymph vessels”.  These cancer cells can settle in other tissues and organs and cause cancer (metastasis) there.  * This is not treated like cancer of the organ in which it is located, but as a metastasis of lung cancer.

Types of Lung Cancer (Figure-3)

In 2013, 228,000 Americans are expected to be diagnosed with “lung cancer”.

According to the “appearance of cancer cells” under the microscope, the most common:

• SMALL CELL: The cells appear “small” under the microscope.  1/8 of lung cancers are in this group.

• NON-SMALL CELL: Cells seen under a microscope are larger.  Most lung cancers (7/8) are in this group.  (They do not grow and spread fast like small cell cancer, and their treatment is different).

Figure 3: Types of Lung Cancer

** STAY AWAY FROM SMOKING AND PROTECT YOURSELF OF PASSIVE SMOKING (SECOND HAND SMOKERS)! **

* ALSO TAKE PROFESSIONAL SUPPORT FROM YOUR DOCTOR TO QUIT CIGARETTE!

STAGING TESTS

After lung cancer is detected, some detailed tests are required for the “correct treatment decision”.

  Staging tests” show the extent (stage) of the disease and show whether cancer cells have spread to another part of the body.

When lung cancer spreads, cancer cells can spread to neighboring or distant lymph nodes, and many other organs and tissues (other lung, liver, brain, bone, adrenal gland, etc.).

Staging Tests:

  • CT (Computed Tomography)
  • PET (Positron Emission Tomography);  It shows how much cancer cells hold a special sugar marked.
  • MRI (Magnetic Resonance Imaging)
  • Bone scan (Scintigraphy)

* Sometimes, suspicious lymph nodes need to be removed for pathological examination.

At this stage, you can ask your doctor:

• What is the type of my lung cancer?

• Has the cancer spread to another organ other than the lung?  Which organs?

• Can I get a copy of the test results?

Stages (Figure-4 a-b- TNM Cancer Staging):

  Figures 4 a-b (Staging)

* STAGING mainly depends on:

• Mass size

• How much has spread to neighboring tissues

• Cancer cells spread to lymph nodes and / or other distant organs

NON-SMALL Cell Lung Cancer (NSCLC)

Stages are expressed in Roman numerals (I, II, III, and IV).  Stage I – early stage, while Stage IV – is defined as advanced stage.

Occult Stage

Cancer cells are seen in sputum, but there are no tumors in CT or other imaging tests.

Stage 0

Abnormal cells are in the innermost covering tissue of the lungs.  It did not cross this line.  Also called the CIS (carcinoma in-situ) phase.

Stage I

Now, the lung tumor has received invasive character.  It started to grow into the lungs from the innermost cover tissue.  There is normal tissue around the tumor, it has not yet spread to surrounding tissues.  5 cm.  smaller than (Figure-5) and lymph nodes are not yet captured.

Figure 5:

Stage II

Lung tumor is less than 7 cm and cancer cells can be seen close to the lymph nodes.  Sometimes the chest wall, diaphragm, or bronchi may be involved.

Stage III

The tumor can be of any size.  More than one tumor can be in the lung.  Tumor cells held lymph nodes on the same side or neck.  Neighboring organs may also be involved (heart, esophagus, or trachea).

Stage IV

Cancer cells are found in both lungs.  It has reached other organs (brain, bone, liver, or adrenal glands, etc.) or can be found in the fluid collected in the chest cavity.

SMALL Cell Lung Cancer (SCLC)

Most doctors define “2 stages”:

Limited stage: Cancer is found only in one lung area

Extended stage: It is seen in both lung regions.  Or, it is located in distant organs (brain, fluid collected in the chest cavity, etc.)

Some doctors also classify using Roman numerals (I, II, III, and IV).

TREATMENT

  • Surgery
  • Chemotherapy
  • Radiation Therapy
  • Targeted Treatments
  • Immunotherapy

** The right treatment for you basically depends on the type and stage of lung cancer.  You can get more than one treatment.

** Pain control at every stage of treatment, effective treatment of side effects of treatments, psychological support are very important.

DOCTORS in the Lung Cancer Treatment Team

  • Thoracic Surgeons (will perform surgical procedures; Videothoracoscopic Surgery, etc.)
  • Medical Oncologist (Chemotherapy and Targeted Therapy)
  • Radiation Oncologist (Radiotherapy)
  • Immunothrapist
  • Others;  Oncology nurse, Social worker, Dietician, Pulmonologist (Chest Diseases Specialist), Respiratory Therapist.

The treatment team will give you detailed information about lung cancer, diagnosis, treatment, side effects and treatments, and outcomes.

* In this treatment plan, you and the medical team should work together.

* In lung cancer, control is sometimes difficult, especially in advanced disease, in this case, doctors encourage their patients to participate in clinical research groups where new treatment approaches are studied.

You can ask your doctor about the “treatment approach”:

• What are the treatment options?  Which and why do you suggest me?

• What are the expected benefits of each treatment?

• What are the possible risks and side effects of each treatment option?  How are these side effects treated?

• What can I do to prepare for treatment?

• Do I have to stay in the hospital?  How long?

• What are the treatment costs?  Does the insurance cover?

• How will the treatment affect normal activities?

• Is it right for me to attend clinical study groups?

Second Opinion

You may want to get a second opinion about your diagnosis and treatment before starting treatment.  Note that doctors will support this condition.

This way, you have more information and you feel that you are in control.  You have the chance to make your decision healthier.

Don’t let the second opinion take you some time to worry about your treatment.  But still share this with your doctor;  your medical oncologist will not want to delay more than 1-2 weeks, especially in ‘small-cell’ lung cancer.

SURGICAL TREATMENT (VATS – Video-assisted Thoracic Surgery)

It is a treatment option that should be applied first in “early stage liver cancer”.

The surgeon usually removes the lung part of the cancer.  Most cancerous patients undergo a “lobectomy” (VATS – video-assisted thoracoscopic surgery or open surgery), in which the lung lobe is removed.  Sometimes the ‘whole lung’ may need to be removed, this is called “pneumonectomy”.  The thoracic surgeon should also detach the relevant lymph nodes (mediastinal lymph node dissection).

** Closed VATS-lobectomy, namely, endoscopic, video-assisted thoracoscopy, surgical surgery is used more widely today.  It requires technical skills and experience, but it is advantageous for the patient to be less painful, less bleeding, return to normal activities more quickly.  Position of the patient and location of surgical instruments during VATS (Figure 6-7).

  Figure 6 & 7 (surgical instruments during VATS & position of the patient)

It is possible to remove the air and fluid that can accumulate in the chest after surgery thanks to the ‘chest tubes’ placed during the surgery.

* The patient’s walking, breathing exercises speed up the healing process more than expected.  Chest tubes are usually removed within 2-3 days.

Although hospitalization generally may vary from person to person, it can take 3-5 days in surgeries with VATS and appr. 7 days in open surgery.

It will be correct to discuss the pain control with your doctor in detail before surgery.

About surgery, you can ask your doctor:

• What type of surgery do you recommend to me?

• How will I feel after the surgery?

• How will you check if I have pain?

• How long will I stay in the hospital?

• Will I experience any side effects?

• When will I return to my normal life?

RADIOTHERAPY

Radiotherapy can be used at any stage:

• For the destruction of cancerous tissue that is or is thought to be in the lungs after surgery

• With chemotherapy in advanced lung cancer

• To shrink the tumor that blocks the airway

• Spread to bone or other tissues and to relieve pain

• Frequently in the treatment of cancer that has spread to the brain

You can ask your doctor about Radiotherapy:

  • When will the treatment begin? 
  • When will it end?  How often will it be applied?
  • How will I feel during the treatment?  Will I be able to drive while coming and going to treatment?
  • What should I do before, during and after the treatment?
  • How will we know that the treatment is effective?
  • What are the side effects?  What should I explain to you?
  • Is there a permanent effect?

CHEMOTHERAPY

Chemotherapy is used alone, with radiotherapy or before / after surgery.

Drugs that kill cancer cells are used.  Chemotherapy drugs are administered intravenously.

You will usually receive Chemotherapy at a clinic or doctor’s office, usually there is no need to stay in the hospital.

Side effects depend on which drug is given and its dosage.  Chemotherapy kills cells that multiply rapidly, but also normal cells that divide rapidly are affected:

    • Blood cells: When healthy blood cells are affected, frequent infections, easy bleeding, weakness and feeling tired, your doctor will either decrease the dose or interrupt the treatment and allow normal cells to reproduce.
    • Cells in the hair follicles: Hair may fall out in chemotherapy.  They come out again after treatment, but their color and structure may change.
    • Digestive system cells: There may be appetite, nausea, vomiting, diarrhea.  There may be mouth and lip pain.  Your treatment team will help you.
    • Sometimes;  hearing loss, joint pain, stinging in the hands and feet, tingling, numbness.

NOTE: * If chemotherapy and radiotherapy are given together, the side effects may be more severe!

TARGETED TREATMENTS

In “non-small cell lung cancer”, which is a common disease, “targeted therapies” can be given.  It has many types.  Treatments are directed according to the results of genetic studies.  In this treatment, the growth and spread of lung cancer cells can be blocked.

Depending on the drug given, it is used either for intravenous or oral therapy.  These drugs join the bloodstream and act on all cancer cells in the body.

Your doctors will observe side effects during the treatment;  skin rashes, diarrhea (diarrhea), abdominal pain, high blood pressure, vomiting, swelling of the hands and feet.  These side effects will usually disappear after treatment.

You can ask your doctor about Targeted Treatments for:

    • Which drugs do you recommend to me?  How will they work?
    • What are the possible side effects?  What can be done for these?
  • When will the treatment begin?  When will it end?  How often will I be treated?
  • How will we know that the treatment is effective?
  • Will there be a permanent side effect?

NUTRITION

Good and proper nutrition” is very important before, during and after treatment.  The right amount of calories and protein must be taken to maintain body weight and strength.  Good food makes you feel good and you have more energy.

Nausea, vomiting, impaired taste can cause your eating habits to deteriorate.

Your doctor and dietitian will surely help you with good and proper nutrition.

SUPPORT RESOURCES

The appearance of your cancer will change your life and the lives of those close to you.  It is very normal that you need help when fighting cancer.  With the whole treatment process, many concerns will arise about your family and your business life.

The people you can get help from your environment are:

• Doctors, nurses, other healthcare professionals

• Social workers, consultants

Support groups;  cancer patients, family members

Cancer Treatment Research Studies

It is the best approach to share with your doctor the need to participate in such studies, if necessary, and which research studies you can participate in.

NOTE: * It is not always true that you will benefit from these studies.

REMEMBER!  “EARLY DIAGNOSIS SAVES LIFE”

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