Most lung cancers are termed "carcinomas", which are tumors caused by uncontrolled reproduction of epithelial cells; these are the cells which form the linings and surfaces of most of the bodies organs and internal structures. There are two main types of carcinoma which are classified according to the size and presentation of the cancerous cells.

After a biopsy has been taken (which removes part of the tissue suspected to be cancerous), a laboratory specialist, known as a "histopathologist", places the biopsy sample under a microscope and is able to determine whether cancer is present and whether it is non-small cell or small cell cancer. The former accounts for the bulk of lung cancers (80%) but whatever classification is accorded, it is important because different treatment regimes are more effective at treating the different types (note that there are other classifications but these two are the major ones).

Non-small cell lung cancers (NSCLC) are themselves further classified into three different types though the treatment therapies are very similar for all of them:

Squamous cell lung carcinoma;

Adenocarcinoma; and

Large cell lung carcinoma.

Squamous cell cancer of the lung occurs in around a quarter of all lung cancer patients and is usually located near the central bronchus, this is the main airway leading into the lungs themselves. Fortunately, these types of cancer are less aggressive and grow slowly.

Adenocarcinoma occurs in approximately 40% of patients and starts in the outer lung tissue and is most closely associated with smoking, though many non-smokers also present this form of the disease. Whether a patient is male or female and whether they have smoked or not will determine different treatment paths for them under this category.

Small cell lung cancer (SCLC) is much less common and usually presents itself in the larger airways (the "bronchi"), but while less common they are unfortunately, much more aggressive. While this form lends itself to treatment by chemotherapy or radiation treatment, however, in many patients by the time it has been diagnosed the cancer has frequently spread (or "metastasized") to other parts of the body. The prognosis for SCLC is usually quite poor and is the type of lung cancer which is most commonly associated with smoking.

No matter what type of cancer a patient presents, it is vital that it is diagnosed as soon as is possible in order to maximize the chances of a positive outcome. Diagnosis and classification of the type of cancer is the first stage in the process of delivering effective treatment for patients, and as quickly as lung cancer has been diagnosed, it must then be "staged". Staging is the process by which the degree of spread and size of a cancer has gotten to; there are four stages, I through IV, with stage I being the best assessment and IV the worst. Staging is important because it directly impacts upon the treatment regime which must be delivered as well as classification of the cancer type.



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Early stage lung cancer (Stage I & II) is usually treated by surgical intervention and a combination of chemotherapy and radiation treatment. Stage II cancer may treated by surgery in certain instances, though generally later stage cancer is treated by chemotherapy alone or by combination of chemotherapy and radiation treatment - it is possible for tumors to be shrunk in size so a re-staging of the patient is warranted and surgery becomes a viable option.

The process of removing the cancer tumor is known as "resection", or the cutting away of the cancer mass and suspected diseased tissue. There are a variety of surgical options available but the standard techniques are:

Thoracotomy - an incision is made through the chest wall; and

Median Sternotomy -where the surgeon cuts through the breastbone to access the chest cavity and the lungs.

As both of these techniques involve considerable recovery periods and pain for the patient, alternatives have been devised to provide access to lung cancer tumors and allow for less discomfort for the patient;

Anterior Limited Thoracotomy - known as "ALT" is performed on the front of the chest and involves a much smaller incision than thoracotomy or median sternotomy;

Anterioraxilary Thoracotomy - known as "AAT" involves an incision on the front of the chest close to the underarm; and

Posterolateral Thoracotomy - known as"PLT" involves an incision through the back or side of the chest area of the patient.

ALT in particular provides a less invasive option than a standard thoracotomy, and certainly results in reduced blood loss for the patient with a much reduced recuperation period and pain.

Video-Assisted Thoracoscopy or Video-Assisted Thoracic Surgery (VATS)

VATS is a state-of-the-art surgical technique which allows for resection of tumors without the need for invasive, full-surgery. A video camera allows the surgeon to see the interior of the patient's chest and the location of cancer tumors using a high-powered television screen. This provides a skilled surgeon with the ability to operate without actually opening up the patient and involves a much smaller set of incisions.

As the incisions and surgical-invasion is significantly reduced, the patient experiences far less pain and enjoys a much reduced recuperation period post-operation. The technique is not universally employed for two main reasons - firstly, the level of surgical skill required is very high and only highly skilled surgeons can utilize the technique successfully. In addition, as the surgeon is not provided with a full view of the area where the diseased tissue is located, it is possible to miss other cancer tumors or evidence of diseased tissue which a standard operation may uncover.

VATS is usually most appropriate for early stage lung cancer where there is no evidence that the disease has metastasized to other parts of the body or lungs themselves.

The Use of Other Therapies

Depending on the nature of the disease and the overall health of the patient, it is common for patients to undergo treatment pre and post-operation with chemotherapy and radiation treatment. In certain instances, where surgery is not advisable, a patient may undergo such alternative therapies in combination or as stand-alone treatments, but the exact treatment regime which is advised for a patient depends on individual circumstances and the findings of the oncology team providing treatment.


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Lung cancer is classified by the type of tumor and the stage which the disease has progressed to, which is important because the classification determines the treatment regime which will be followed.

There are four stages of cancer - Stage I to IV and a catch-all category, Occult (which describes those cancers which are known to be present but cannot be seen using diagnostic tools).

The earliest, and least dangerous cancers are Stage I progressing to stage IV which represents very serious danger to the patient's life and the last stage of the disease.

Stage I & II Treatment Regimes

The main form of treatment is surgery and the removal (or "resection") of the cancer tumor.

It is common for additional treatment to be administered in the form of radiation treatment to follow up the surgery. Where a patient is unable to withstand surgical intervention due to their state of health, then radiation therapy alone may be used to destroy the tumor tissue.

Stage III Treatment Regimes

Physicians usually further classify Stage III patients into three further sub-groups:

1. Patients with obvious Stage III disease with abnormally large lymph nodes presenting on X-Ray or CT Scan;

2. Patients with normal looking lymph nodes but still cancerous; and

3. Classic Stage 3b patients with tumors of any size and presenting diseased lymph nodes.

Patients in group 1 probably have cancer in the enlarged lymph nodes and surgery is not likely to benefit them in this instance. A combination of chemotherapy and radiation treatment may benefit them more than any surgery. Treatment is usually done concurrently rather one after the other, as this produces a better response from patients but side effects are worse for patients.

Patients in group 2 may benefit from surgical resection but where the nodes are in fact cancerous, treatment as group 1 may be followed before any surgical intervention to remove visible tumors.

Patients in group 3 are not likely to receive surgery in any event and will be advised to follow a combination therapy as per group 1 if they have noncancerous effusion (fluid which is free of cancer cells). If cancerous effusion is presented, patients may consider receiving chemotherapy alone rather than no therapy and comfort care (unfortunately, such patients tend not to survive any longer than Stage IV patients, i.e. around 8 months).

Stage IV Treatment

Patients at this stage have two options - to receive chemotherapy or receive no treatment with comfort care. Chemotherapy alone improves overall survival rates and also helps with managing the symptoms of the disease for many patients.

Summary

While staging the disease is crucial in formulating an effective treatment regime, the precise nature and timing of any treatment must also be managed with precision and great care. Only the patient and the oncology team are able to make the determination as to when and what exact treatment therapies should be employed. In many instances, the aggressive use of combination therapies may allow for re-staging of the lung cancer whereby the tumor is shrunk to allow effective surgical intervention to take place.


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Lung cancer may be treated by a variety of therapies including surgery, but chemotherapy and radiation treatments are used extensively to treat the disease whether surgery takes place or not.

Chemotherapy

Chemotherapy involves drug medication which is designed to kill fast growing cells in the body - cancer cells are fast growing and it is this uncontrolled growth which causes tumors to develop. Unfortunately, the medications which are administered are unable to differentiate between cancer cells and other fast growing cells, such as the red blood cells and hair. As a consequence, there are side effects involved in receiving chemotherapy which includes hair loss and other debilitating symptoms.

Many patients do not like the idea of receiving chemotherapy because they have heard of the side effects usually associated with receiving the treatment. Management of the side effects has come a long way and in many instances, patients do not experience them to as great an extent as they originally anticipated.

Typically, chemotherapy will involve a combination of drugs which will target specific types of cancer cell - not all cancer cells are fast growing, and different drugs will attack different types of cancer cell depending on the stage it has reached.

Radiotherapy or Radiation Treatment

Radiation treatment uses ionizing radiation such as gamma rays to kill cancer cells. The radiation can be targeted very precisely at the area where the cancer has occurred within the body and in some instances is capable of being delivered so that it affects only the tumor and not healthy tissue.

Radiation treatment may also be used to reduce the size of a tumor so that it becomes operable.

Radiation stops cells from undergoing division and forming new copies of the DNA which they contain. If a cell is reproducing quickly, it is likely to be susceptible to radiation which will interfere in its development and as cancer cells are fast growing, they are especially vulnerable to the treatment. Unfortunately, cancer cells are not the only cells which are fast growing as we have already seen, and radiation therapy affects blood cells, hair and skin.

Side effects include hair loss, redness of the skin, itching, loss of skin through the outer layers sloughing off, pain and heightened sensitivity, skin pigmentation and swelling (known as "edema").

Both therapies may cause a loss in appetite, changes in how your sense of taste and heart issues as well as nausea and vomiting. Patients undergoing these treatments tend to become tired very easily while receiving treatment and there is an increased risk of infection as the white blood cells are also adversely affected by the treatment.

We have already noted that radiation treatment may be used to shrink a tumor so it may be removed, but they also are used to tackle cancers which do not lend themselves to surgery in the first instance. Small Cell Lung Cancer (SCLC) is usually inoperable and is treated by these joint therapies while operable lung cancers use these treatments both before and after surgery to ensure that any cells which have not been removed by surgery are killed off to prevent recurrence of the condition.



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Many patients find that they have lung cancer either because they present symptoms such as persistent coughing and wheezing, sometimes coughing up blood or pain the chest and stomach. This usually prompts further investigation of the chest, typically calling for an x-ray (which may also occur as part of a routine health check) and the testing of sputum samples.

At this point more investigations will be called for dependent upon the results.

Detailed Diagnosis

The purpose of a chest radiograph or x-ray, is to detect enlarged lymph nodes in the chest or the existence of a mass in the lungs. More advanced techniques can be used to provide much more detailed information and include the following:

CAT Scan or CT Scan - a CT Scan is a computer assisted examination which provides a cross-sectional image of the body under examination;

MRI Scan - a Magnetic Resonance Imaging (MRI) scan uses hydrogen ions within the patient's body which respond to magnetic fields when they are applied to the body or in this case, the chest. A computer then uses the results to create a chest image which allows for precise location of any mass which has been detected and whether it involves the lungs;

Bronchoscopy - this involves an examination of the airways (the windpipe and lung branches) and is usually conducted by a pulmonologist ( a physician who specializes in respiratory diseases). The examination may involve the taking of a swab from these areas or a biopsy (the removal of a tissue sample);

Needle Biopsy - a physician inserts a needle using the results of a CT Scan to guide where the needle, so a sample of tissue may be removed from the mass which has been detected; the tissue samples obtained are then "smeared" on a microscope slide and examined by a histopathologist to detect whether the cells are cancerous; and

Bone Scan - this test may be undertaken to check whether any cancer cells have spread (known as "metastasized") to the bones from the original tumor.

A technological advancement is the CT/PET fusion imaging scan - this diagnostic tool uses an injected sugar solution which contains a radioactive element to highlight any cancerous mass. Cancer tumors are very fast growing and use a lot of energy so they rapidly absorb the sugar solution which is accumulates around and within the tumor. When a scan is then performed, the concentration of the radioactive sugar is detected and provides the location and detail of the cancer tumor. It should be borne in mind that there are other tissues which will cause the sugar solution to accumulate such as a bacterial infection, so even this test is not conclusive.

Once lung cancer has been diagnosed, the team of oncology physicians treating the patient will review the results to assess the treatment options for the lung cancer and to check whether any spread of the disease has occurred to other parts of the body. Where it is found the disease has not spread to other parts of the body, then a surgical inspection may take place to assess the disease in detail around the lungs, heart, windpipe and tissues of the chest. In addition, extensive blood tests will take place to look for cancer "markers" which are usually proteins that are associated with the development of lung cancer.



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