Lung cancer treatment requires a multidisciplinary approach.
- Pulmonary diseases
- Thoracic surgery
- Pathology
- Radiology, Nuclear Medicine, and Oncology collaboration are required.
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.
1. Lung Cancer Surgical Treatment
- Since lung cancer spreads to distant organs and remains asymptomatic, we can only operate on 20-30% of patients.
- A preoperative evaluation of the patient is done.
- Pulmonary function tests of the patient are performed. If his pulmonary functions are sufficient, surgery is performed immediately.
- If pulmonary function tests fail, the underlying disease is treated, and the test is repeated after the treatment. If the condition regresses, surgery is performed.
- Perfusion scintigraphy can be done
- 6-minute walking test
- Cardiac evaluation (e.g., Echocardiography, angiography)
- Smoking cessation is encouraged.
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:
Open surgery
The open method removes the cancerous lung lobe with an incision between the ribs.
Minimally invasive surgery (VATS)
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.
Anatomical resections
(Described in detail in another section)
Segmentectomy
- Requires slightly more experience in minimally invasive surgeries.
- It is preferred if the tumor diameter is 2 cm or less.
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.
Exception in operational criteria
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).
2. Neo-adjuvant / Induction therapy (drug therapy) + Surgery
- Depending on the characteristics of the tumor, surgery is preferred after chemotherapy ± radiotherapy in some patients, such as:
- Pancoast tumors.
- N2 tumors, where mediastinal lymph nodes are involved.
- In tumors that are in proximity to vital organs.
- Surgery is performed 3-4 weeks after the last neoadjuvant chemotherapy course.
3. Surgery + Adjuvant therapy
Adjuvant therapy, meaning chemotherapy after surgery, is also between choices in lung cancer treatment.
4. Chemotherapy + Radiation Therapy (Definite treatment, that is, Chemotherapy ± Radiotherapy): Surgery + Adjuvant treatment
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.
5. Radiation Therapy in Lung Cancer Treatment – Radiotherapy
Radiotherapy is also a treatment choice for lung cancer.
6. Smart Medicines (Target-Oriented Therapy)
Today, targeted therapy models that have fewer side effects than classical treatment methods in lung cancer remain up to date. Various lung cancer treatment methods have been developed in current studies to treat advanced lung cancer.
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:
- EGFR
- ALK
- ROS.1
- C-MET
- B-RAF
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%.
7. Immunotherapy
- In recent years, it has been one of the essential methods in advanced-stage (3B and 4th stages) lung cancers.
- It is a treatment that affects the immune system.
- It is a form of treatment that acts by re-establishing the healthy functioning cells of the damaged immune system.
- With this method, patients can survive longer.
- It is used in stage 3 patients who cannot undergo surgery after chemotherapy and radiotherapy.
- In stage 4 patients, it can be used in combination with chemotherapy in the 1st line therapy or used alone and in combination with chemotherapy as a 2nd line therapy.
- While the frequency of side effects related to this treatment is shallow, some can be very severe.
- One of the most critical issues about immunotherapy is that it is not beneficial for all patients.
Note: As a result, we evaluate each patient's treatment individually, discuss them in the multidisciplinary oncology council, and decide accordingly.