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The Types And Stages Of Lung Cancer Explained By Dr. Harsh Vardhan Puri

What is lung cancer?

Lung cancer is when cells of lungs mutate (change abnormally) and begin growing out of control. These cells grow in an unregulated manner.

They are divided into benign (noncancerous), meaning they do not grow into surrounding areas or spread in the body an malignant (cancerous) tumours grow into nearby tissues or spread to other parts of the body (metastasize).

A biopsy is required to determine the diagnosis of a tumour that appears suspicious on imaging.

How does lung cancer develop?

This is a matter of debate but in general, cancer develops after the genetic material in cells changes abnormally and there is unregulated growth of these cells. When there are enough of these abnormal cells, they can form a tumour.

Lung cancer often is a result of chronic exposure to tobacco smoke, either from smoking or from being around second-hand smoke. It also is linked to exposure to certain substances like radon gas or asbestos, or from prior radiation treatment to or over the lungs. These days a very prominent cause of lung cancer specially in India which is rising at a rapid rate is air pollution and there are many studies corelating lung cancer to air pollution.

What are the types of Lung Cancer?

There are two main types

Non-small cell lung cancer

Squamouscell carcinoma

Adenocarcinoma

Bronchoalveolarcarcinoma

Large-cell undifferentiated carcinoma

Smallcell lung cancer

What are the Stages of Lung Cancer?

Staging is important to plan treatment and is based:

Size

Location

Metastasis

The stages of lung cancer are:

Stage 1: Confined to lung, not spread to the lymph nodes or distant organs. Surgery is the best modality at this stage.

Stage 2: Cancer has spread from to nearby lymph nodes. Surgery followed by adjuvant therapy is best treatment.

Stage 3: Cancer is in the lung and has spread to mediastinal lymph nodes. Chemotherapy may be recommended before and after surgery with adjuvant radiotherapy. Targeted therapies may be used after surgery.

Stage 4 (Metastatic): Cancer has progressed beyond the lung to distant organs. This advanced stage of cancer is commonly managed by non surgical methods like palliative chemoradiation and targeted therapies.

How is lung cancer diagnosed?

Diagnostic phase is tailor basedaccording to each individual patient. Tests may include:

Blood Tests (Blood Draws)

Several blood tests are required to help establish the diagnosis and plan the further course of treatment.

Imaging (Radiology)

To obtain the most precise understanding of your cancer, your doctor may schedule you for different types of imaging that diagnose cancer. This may include Contrast Enhanced Computed Tomography (CECT) or Positron Emission Tomography(PET) or Magnetic Resonance Imaging(MRI).

Lung Biopsy (Pathology)

If imaging or other screening tests show that there is atumour, a biopsy will be needed. This test takes a tiny sample of cells from abnormal areas of tissue. This of an image guidence depending on the location of the tumour.

Ultrasound guided Biopsy

CT (Computed Tomography) Guided biopsy

Endo Bronchial UltraSound Biopsy for Lymph Nodes or Centrally located tumours

What are the tests done to stage lung cancer?

The clinical staging is important to treat and to prognosticate. This will require

Whole Body PET/CT Scan

Positron emission tomography (PET) Scan is a special imaging modality wherein a small amounts of radioactive materials called radiotracers or radiopharmaceuticals are injected in to the veins. These radiotracers accumulate in areas where there may be tumour cells and will be detected using a special camera and a computer. By identifying changes at the cellular level, PET scan may detect the early onset of disease before other imaging tests can and also help in identifying whether the disease is limited to lungs or has spread beyond it.

MRI Brain

Certain patients will require MRI of the brain to rule out spread to brain which sometimes is not picked up by PET scan.

Endo-Bronchial Ultrasound Guided staging of Mediastinal Lymph nodes

This test is used to check for spread of the cancer to regional or Mediastinal Nodes. It involves the use of a special bronchoscope which has an ultrasound probe at its tip. This is used to visualise the lymph nodes from which needle biopsy is taken and which is then subjected to evaluation by Pathologists for presence of cancer cells

Mediastinoscopy

This is a surgical procedure which is advised in patients with Lung Cancer to conclusively rule out involvement of Mediastinal Nodes in the central part of the chest, which is the space between the heart, lungs, windpipe, and oesophagus.

How is lung cancer treated?

Small Cell Lung Cancer

Usually small cell lung cancer patients present at a stage where the cancer has already spread beyond the lungs. Such patients are treated with chemotherapy. Surgery is limited to very early stage disease in patients who have not yet have lymph nodal or distant spread. Radiotherapy may also be required in its management.

Non- Small Cell Lung Cancer (NSCLC)

This cancer is treated by Surgery, Chemotherapy, Radiotherapy and targeted therapy or in combination. If detected early Surgery appears to offer the best long-term results.

Treatment by Stage of Disease

Stage I

For stage I NSCLC, surgery should be the only treatment needed. This may Involve removal of piece of lung as described below

Lobectomy

The Right and the Left Lung is made up of parts which are called lobes.

Right Lung – Upper, Middle & Lower Lobe

Left Lung – Upper & Lower Lobe

Surgical removal of a lobe is known as lobectomy. Based on the current evidence wherever feasible removal of the lung cancer containing lobe is considered as the standard treatment option. Along with the lobe lymph nodes around the lung and in the mediastinum will be taken out also. Everything removed is sent for histopathological diagnosis. This will help take decision regarding requirement of any additional treatment.

Segmentectomy or Wedge Resection

Done rarely and is generally reserved only for very small stage I cancers and for patients with other health problems that make removing the entire lobe dangerous.

Pneumonectomy

Pneumonectomy means removal of the entire lung of one side. Its is done only in cases where complete removal of the tumour is not possible with a lobectomy. Experienced surgical teams will avoid doing a pneumonectomy using there expertise wherein they can salvage the lobes by doing special surgeries like sleeve resection. However despite everything sometimes pneumonectomy is unavoidable.

After surgery, the removed tissue is checked to see if there are cancer cells at the edges of the surgery specimen (called positive margins). This could mean that some cancer has been left behind, so a second surgery might be done to try to ensure that all the cancer has been removed. (This might be followed by chemotherapy as well.) Another option might be to use radiation therapy after surgery. For people with stage I NSCLC that has a higher risk of coming back (based on size, location, or other factors), adjuvant chemotherapy after surgery may lower the risk that cancer will return. New lab tests that look at the patterns of certain genes in the cancer cells may help with this.

Non-Surgical Option for Stage I NSCLC

For patients with serious health problems that prevents them from having surgery, stereotactic body radiation therapy (SBRT) or another type of radiation therapy may be considered as an alternative main treatment. Radiofrequency ablation (RFA) may be another option if the tumour is small and in the outer part of the lung.

Stage II NSCLC

People with stage II NSCLC who are otherwise fit for surgery are treated by removal of the lung cancer by lobectomy or sleeve resection. Sometimes removing the whole lung (pneumonectomy) is needed. Any lymph nodes likely to have cancer in them are also removed. The extent of lymph node involvement and whether or not cancer cells are found at the edges of the removed tissues are important factors when planning the next step of treatment.

After surgery, the removed tissue is checked to see if there are cancer cells at the edges of the surgery specimen. This might mean that some cancer has been left behind, so a second surgery might be done to try to remove any remaining cancer. This may be followed by chemotherapy (chemo). Another option is to treat with radiation, sometimes with chemo.

Even if positive margins are not found, chemo is usually recommended after surgery to try to destroy any cancer cells that might have been left behind.

In case of serious medical problems that would keep you from having surgery, you may get only radiation therapy as your main treatment.

Treating stage III NSCLC

Stage IIIA NSCLC

Treatment may include some combination of radiation therapy, chemotherapy (chemo), and/or surgery. For this reason, planning treatment for stage IIIA NSCLC often requires input from a multidisciplinary team consisting of a medical oncologist, radiation oncologist, and a thoracic surgeon. Treatment options depend on the size of the tumor, its location, which lymph nodes it has spread to and the overall health and fitness for tolerating treatment.

These patients usually require chemotherapy to start the treatment which may or may not be combined with radiation therapy (also called chemoradiation). Chemotherapy in this setting that is before surgery is called Neo-Adjuvant Therapy (NACT or NACTRT). After a few cycles of NACT/RT the patient is revaluated and in patients with good response and absence of disease progression surgery is consoderd if the surgeon thinks the entire disease can be removed and the patient os fit to undergo such treatment. In some cases surgery may be offered as the first followed by chemo, and possibly radiation therapy if it hasn’t been given before.

Stage IIIB NSCLC

Patients with Stage IIIB NSCLC have lung Cancer that has spread to lymph nodes that are near the opposite lung or in the neck or the have tumour that has grown into / invaded nearby important structures in the chest. These cancers can’t be removed completely by surgery. As with other stages of lung cancer, treatment depends on the patient’s overall health. Most of such patients are not good surgical candidates and maybe offered definitive treatment by combination of chemo and radiotherapy. Some people can even be cured with this treatment. If the cancer stays under control after 2 or more treatments of chemoradiation, immunotherapy can be considered for keeping the disease stable.

In patients not fit to undergo combination of chemotherapy, either of the modality alone may be used and these patients can be considered for immunotherapy. These are difficult to treat cancers and have relatively worse prognosis.

Stage IV NSCLC

Spread of the Lung cancer beyond the confines of the chest corresponds to Stage IV NSCLC. At this stage Lung Cancer cannot be cured, however it can be controlled using chemotherapy (chemo), targeted therapy, immunotherapy, and radiation therapy. This may increase the life of the patients and may improve the quality of life by relieving symptoms but these are not likely to cure.

Prevention of Lung Cancer

The best prevention is to avoid exposure to tobacco smoke and to avoid exposure to certain workplace chemicals. A heathy diet rich in fresh fruits and vegetables and regular exercise are recommended for your overall health.

Treatment of Lung Cancer

The treatment of Lung cancer is guided by:

The Type of Lung Cancer

The Stage of Lung Cancer

Patient overall condition and Fitness level

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