Lung cancer ranks first among cancer-related deaths worldwide.
Lung cancer is the most common type of cancer in men, and it has also become frequent in women due to the rising rate of smoking.
Since lung cancer develops primarily due to smoking, the risk of lung cancer can be reduced and prevented if smoking is ceased.
It is our country's most common type of cancer and is usually centrally located.
Smoking is responsible for approximately 80-85% of lung cancer cases. It is more common in smokers, especially for squamous cell lung cancer and small cell lung cancer. There is a linear relationship between the number of cigarettes consumed daily, the duration of smoking, and the risk for lung cancer.
The incidence of lung cancer is slightly higher in individuals with a family history of lung cancer.
The scar tissue in pulmonary tuberculosis, empyema, interstitial fibrosis, and other lung diseases with tissue destruction may form a basis for lung cancer. These patients are at high risk of adenocarcinoma than different lung cancer types.
Asbestos exposure, the most important known risk factor for mesothelioma (lung membrane cancer), also increases the risk of lung cancer.
Note: Especially people with a family history of cancer are at high risk with the addition of other threats. Smoking status plays a significant role in this kind of patient.
Small cell lung cancer: The incidence of small cell lung cancer among all lung cancers is approximately 15-20%.
The most common type in our country and is usually centrally located.
Adenocarcinoma of the Lung is the most common type in some countries. Its frequency has also started to increase in our country. It is generally located peripherally.
The course and treatment approach of small and non-small cell lung cancer is entirely different.
Lung cancer symptoms can be examined in 2 groups, local signs and extrapulmonary symptoms:
Computed tomography of the thorax (Thorax CT) scanning is performed
If a tumor or other appearance associated with the cancer is detected in the chest X-ray, CT should be performed for further diagnosis.
CT also shows nodules that are not visible on chest X-rays.
After the standard chest X-ray and computed tomography examination, the regional spread of the disease can be estimated, and its localization is revealed. The physician can now decide which biopsy method will be required for a definitive lung cancer diagnosis.
Biopsy: A biopsy is performed to diagnose lung cancer and determine the cell type if cancer is suspected.
Bronchoscopy: it is preferred in lesions that are located centrally.
Trans Thoracic Needle Biopsy: In tumors located at the more extreme points of the lungs, a biopsy can be taken by entering the skin with a needle under ultrasonography or computed tomography guidance. Cells are aspirated.
Tru-cut biopsy: In tumors located at the more extreme points of the lungs, excisional biopsy is performed by entering through the skin under the guidance of computed tomography. These biopsies are much more valuable for genetic studies for smart drug treatments.
Navigational bronchoscopy and endobronchial ultrasonography; Due to technological developments in recent years, tumors located at the endpoints of the lung can also be reached with navigational bronchoscopy.
Sputum cytology.
Lung cancer treatment requires a multidisciplinary approach.
In lung cancer, different approaches can be applied according to the stage of the disease, location, and histopathologic examination. Each patient should be evaluated individually for an accurate decision on treatment methods. This way, the patient’s more precise treatment method is determined, and the chance of treatment success increases. All international treatment guidelines underline the need for a multidisciplinary approach in determining lung cancer treatment.
Note: This evaluation aims to prepare the patient for surgical intervention, determine the possible risks, and prevent them.
Surgery is performed if the patient does not have distant metastases and no cancer spread in the lymph node.
During the operation, mediastinoscopy is performed, and lymph nodes are sampled and sent to the pathology laboratory for a frozen section procedure to make a rapid microscopic analysis. Pathologists report the result of the frozen section procedure while the operation is still ongoing; if cancer spreads in the lymph node, the surgery is terminated. If no cancer is distributed in the lymph nodes, the surgery continues.
The surgery can be performed in 2 ways:
The open method removes the cancerous lung lobe with an incision between the ribs.
Minimally invasive surgery is performed without opening the chest cavity, instead with a keyhole procedure by inserting a tiny video camera through small incisions. The surgeon operates from outside the chest. This procedure requires advanced surgeon experience. The aim is to reduce the risk of metastasis and recurrence.
(Described in detail in another section)
Segmentectomy
Lobectomy
Only that lobe is removed if the tumor is located solitarily in one lobe.
Sleeve resections
To resect less lung tissue, the bronchi are sutured end to end. For example, when a whole lung needs to be removed, only one lobe is removed by sleeve resection, and the rest of the lung tissue is preserved.
Pneumonectomy
An entire lung is removed if the tumor mass is gross and involves both lobes.
Patients with lung cancer with metastasis do not generally undergo surgery. There are two exceptions to this.
Brain metastasis: If lung cancer has a single metastasis located in the brain, firstly brain surgery and then lung surgery can be performed (N2, if there is no cancer involvement in mediastinal lymph nodes)
Adrenal gland metastasis: If there is only one adrenal gland, surgery can be performed if there is no lymph node metastasis (N2).
Suppose the patient is inoperable and his cancer has metastasized. In that case, we consider the disease systemic rather than local, and the treatment consists of chemotherapy and radiotherapy combined.
Chemotherapy; It is a treatment course that activates the death of fast-growing cancer cells.
In the classical treatment model, a standard treatment approach is applied according to the histopathological type of cancer. Suppose the selected treatment method is incompatible with the determined cancer genetic structure. In that case, the patient can be unnecessarily exposed to the side effects, resulting in metastasis via blood or lymph, which is associated with shorter survival.
In targeted lung cancer treatment methods, personalized treatment is formed according to the genetic characteristics of the tumor cells.
While the drugs given in routine chemotherapy kill tumor cells, they also damage other cells of our body. These drugs are given intravenously. Side effects are common, for example, nausea, vomiting, homeostasis imbalance, and hair loss.
But smart or targeted drugs are only intended to kill the tumor cells and are taken orally.
The smart drugs available today are not effective in all types of cancer. Therefore, treating lung cancer may vary from person to person.
They are generally effective in a type of lung cancer called adenocarcinoma.
It is determined whether the drug will be beneficial by performing genetic analysis from the biopsy or the specimen from surgery.
These genetic markers are:
Approximately 7-10% of patients with lung adenocarcinoma can be treated with this treatment. Especially in non-smokers and female patients, the applicability rate of this treatment can reach up to 30%.
Note: As a result, we evaluate each patient's treatment individually, discuss them in the multidisciplinary oncology council, and decide accordingly.
Today, targeted therapy models with fewer side effects than classical treatment methods of lung cancer are up-to-date. Smart drugs are one of them.
Various molecular-level targeted cancer treatment methods are being developed in current studies to treat advanced lung cancer.
In the classical treatment model, we prefer a standard treatment approach according to the histopathological type of cancer. When the selected treatment method is incompatible with the determined cancer genetic structure, the patient can face side effects that can affect cancerous cells. The cancer spreads to the body via blood or lymph during the time before treatment, causing death before the expected time. In targeted therapy methods, personalized medicine treats according to the gene mutations detected by examining the cancer cell.
While the drugs of routine chemotherapy kill tumor cells, they also damage other cells of our body. Side effects are common, for example, nausea, vomiting, and hair loss. This type of treatment is intravenous.
But smart drugs or targeted drugs are only intended to kill tumor cells and are taken orally.
The smart drugs available today are effective only in a specific type of cancer.
They are generally effective in a type of lung cancer called adenocarcinoma. Drug effectivity is predicted by performing genetic studies from the biopsy or surgical specimen.
Analyzed genetic markers are as follows:
Approximately 7-10% of patients with lung adenocarcinoma benefit from this treatment. The applicability rate of the smart drug can reach up to 30%, especially in non-smokers and female patients.
It is one of the most critical options in advanced stage (Stages 3B and 4) lung cancers in recent years. It is a treatment that affects the patient's immune system. It acts by re-establishing the healthy functioning of the damaged immune system. With this method, patients can survive longer.
It benefits stage 3 patients who cannot undergo surgery after chemotherapy and radiotherapy treatment.
In stage 4 patients, it can be used in combination with chemotherapy in the 1st line therapy or alone as a 2nd line therapy.
While the frequency of the side effect rate related to this treatment is low, some side effects can be very severe.
One of the most critical issues about immunotherapy is that it is not beneficial for every patient.
In our country, this treatment method is not covered within the scope of health insurance.
Note:As a result, we evaluate each patient's treatment individually, discuss them in the multidisciplinary oncology council, and decide accordingly.
Staging in lung cancer is critical in terms of the course of the disease and the determination of the treatment method.
1. Small cell lung cancer, there are two stages localized and diffuse stage;
Localized phase; In small-cell lung cancer, the disease is limited to one side of the chest without spreading to the opposite lung or other organs.
Diffuse stage; In small-cell lung cancer, the disease has metastasized to organs other than the lung or the opposite lung.
Treatment is different in localized and diffuse stages of small-cell lung cancer, and we stage the using the following:
2. Since surgery is the most effective treatment in the early stages of non-small cell lung cancer, staging is critical.
Lung cancer is staged according to the TNM system.
T is used to define many features, such as tumor size, the relationship of the tumor with neighboring tissues and organs, and the bronchoscopic appearance of cancer.
N defines the presence or absence of metastases in the tumor's regional or distant lymph nodes.
M is associated with distant organ metastases, and there is no metastasis in M0 cases.
Note: The main point to be considered here is that a biopsy should be performed in lymph nodes with PET-CT involvement or in places where there is a possibility of cancer. PET-CT positivity can also be detected in non-cancer diseases such as tuberculosis, other infectious diseases, and sarcoidosis, which are common in our country.
Deciding without a biopsy may lead to the wrong treatment regimen. N2 (mediastinal lymph nodes), that is, it is necessary to biopsy large lymph nodes with PET involvement on the trachea. The least harmful method to the lymph nodes is chosen.
The first choice for the patient is endobronchial ultrasonography (EBUS) or Endoesophageal ultrasonography (EUS). Endobronchial ultrasonography is a safe and outpatient bronchoscopic method that does not require hospitalization. With this method, the probability of accurate lung cancer staging is over 85-90%. If there is no success, more invasive procedures such as video mediastinoscopy or thoracoscopy (VATS), surgical staging methods, are preferred. Surgical staging methods are performed under general anesthesia, and a vast number of sampling is done.