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Lung Cancer

Although not the most common tumor, lung cancer is the primary cause of death from cancer in the United States.¹ Recently, there have been improvements in the management of patients with this disease. These advances include refinements in lung cancer staging, the use of positron emission tomography (PET) and the emergence of minimally invasive pulmonary resection.

Diagnosis
The most common symptoms related by lung cancer patients are cough, shortness of breath or hemoptysis; however, complaints or physical findings from any organ system may herald this disease. Diagnostic tests usually include a hemogram, urinalysis, serum electrolytes, liver enzymes, a chest roentgenogram and computed tomographic (CT) scan. Complete pulmonary function tests are needed if ablative therapy such as surgery or radiation is planned.

Because of low yield or potential false positive results, laboratory evaluations for metastatic disease are recommended only if the patient has metastatic symptoms. Various biopsy techniques may be appropriate depending on their ease of use, which is dependent on tumor location and the patient's physical reserve.

Staging and PET scanning
Surgical staging by mediastinoscopy, thoracoscopy or limited thoracotomy is useful to exclude metastases or unresectabil-ity before proceeding with thoracotomy.

Recently, the use of PET has become more practical. Using the tracer fluorine-18 fluorodeoxyglucose (FDG) to mark areas of excessive metabolic activity, this technology offers tomographic reconstructions of the body by showing areas that are "hot" because of high sugar uptake. This reaction can confirm the nature of a pulmonary nodule as well as show metastatic mediastinal lymph node activity.

Bone and other distant metastases apart from the brain also can be confirmed. Inflammatory conditions can create false positives, yet false negatives are uncommon. This exclusion is helpful in differentiating tumor from scar -- something that conventional CT scanning cannot do.

The staging system for lung cancer recently was modified to better categorize patients.² Figure 1 shows the new staging system. Stages I and II now are subdivided into A and B, with B reflecting the poorer prognosis associated with larger tumors. A tumor with chest wall invasion but no lymph node metastases now is graded IIB instead of IIIA, because the prognosis in such cases is better than for other IIIA tumors. Satellite spread within the same lobe now is considered T4. The survival rate for each stage is shown in Figure 2 (back). An important exception to Stage IV disease is the localized lung cancer and an isolated brain metastasis. If both can be treated definitively with surgery or radiation, the cure rate may be as high as 25 percent.

Treatment
The poor prognosis of lung cancer comes from the inability to detect it early. Stage IA ( 3 cm tumor) patients have a cure rate as high as 80 percent and usually are treated with resection followed by observation. However, patients who have larger tumors without lymph node metastases (IB) have survival rates as low as 50 percent.

A randomized trial of chemotherapy vs. observation now is offered for these patients, who also may have occult lymph node metastases not detectable by standard light microscopy. Ellis Fischel is one of 10 cancer centers offering a study designed to correlate the presence of tumor DNA in lymph nodes with survival for clinical Stage I patients.

Patients with more advanced tumors (from Stage IIA to IIIB) are offered some combination of surgery, chemotherapy or radiation therapy, usually on a protocol through a multidisciplinary thoracic oncology team. The value of surgery for stages higher than 2B is controversial. Patients with metastatic disease (IV) and adequate physical reserve are offered promising chemotherapy agents.

Minimally invasive surgery now is practical for operations as complex as pulmonary lobectomies, provided that the anatomy is favorable (Figure 3). University Hospital and Ellis Fischel just completed a retrospective review of the first 20 attempted cases. Many of these cases were high risk, prone to complications and prone to prolonged hospitalizations. Three were converted uneventfully to the standard method. The remaining cases were matched with standard thoracotomy controls for age, sex, lobe and FEV1.

Patients undergoing VATS recovered faster (discharge at 6.0 ± 1.8 vs. 11.9 ± 2.7 days, p=0.05), despite the standard group having fewer high-risk patients. The low-risk VATS patients were discharged in 3.5 ± 0.5 days (range 2 - 5). Three weeks after surgery, most patients who underwent VATS had markedly less pain (Figure 4) than the standard open patients. There were no intraoperative complications, and the resected specimens were indistinguishable from those removed the standard way.

Conclusion
With more accurate staging, improvements resulting from new treatments will be more clearly defined, allowing studies to finish more quickly. For appropriate patients, operations for lung cancer are becoming less morbid, optimizing the quality of life and maximizing the chance for cure.

References

1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. Ca: A Cancer Journal for Clinicians. 1998;48:6-29.

2. Mountain CF. Revisions in the international system for staging lung cancer. Chest. 1997;111:1710-1717.