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The Basics of a Lung Cancer Workup

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GCVL_LU-B00_Lung_Cancer_Workup_Basics

 

Dr. Gerard Silvestri, Medical University of South Carolina, describes the steps necessary to work up a lung cancer diagnosis, from initial scan to choice of treatment.

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What are the basics of working up a lung cancer? When I see a patient in my clinic, usually they haven’t had anything done yet. They’ve been referred to me with a “spot” or lesion, or a mass on their lungs, and again, the first thing I need to do is take a good history and physical. How long have you had your symptoms, have you had weight loss, do you have bone pain, have you had headaches, what are some of the things going on — what diagnostic workup have you had? Sometimes they’ll already have had a biopsy. My job though is to do these three steps, absolutely simultaneously and sometimes in order — what is it, where is it, what I can do about it — diagnosis, stage and treatment.

The first visit is almost always trying to review the imaging and decide whether you need more imaging, do a good physical exam, do a good smoking history, find out what other health issues the person may have like heart disease, that can give us a challenge in terms of how we’re going to treat the cancer. So that’s the first part.

Sometimes I have to say that some patients are — it’s thought they may have a lung cancer, and in fact it’s something else. It could be a fungal infection or something else going on in the lungs. So usually what happens over sort of the course of the next ten working days is, either some more imaging, or a biopsy, and then perhaps a PET scan to help us with the staging portion of this. So sometimes we get a PET scan that will help us both direct the biopsy, but also help us with the stage. Over the next ten days or so we’ll try to get those tests done.

In addition, we always present our new cases at a multidisciplinary tumor board. What’s that? A multidisciplinary tumor board is where all the different specialties get together to look over the imaging, the biopsy results, the pathologic results, and come up with a better treatment plan. So who’s in the room during the tumor board? A pulmonologist usually, a chest surgeon or a thoracic surgeon, a medical oncologist, a radiation therapist, a pathologist, sometimes you’ll have a dedicated chest radiologist who will help review the films, and then also people from other ancillary services that are extremely helpful like clinical trials staff, like palliative care nursing. So we have all those people in the room at the same time, and they’re either reviewing brand new cases, or difficult and challenging cases that are coming back to the tumor board for consideration.

So that kind of happens in that first ten days and for us, we know how anxious patients can get during that time period that they just want to get something started, but I would urge anyone listening to this to consider is, if you don’t get it right, if you don’t give the person the correct stage and the correct treatment options, you won’t get the best care. Yes, speed is important, but you’ve got to get it right — what is it, the diagnosis, where is it, the appropriate stage, and then what are your treatment options, which really differ depending on stage. For stage I it’s usually surgery, for stage II, surgery followed by chemotherapy, for stage III, chemotherapy and radiation, and for stage IV, chemotherapy alone or some of the targeted agents. So if you don’t get that right, you’re going to get the wrong treatment, so be patient with that and if your doctors need to biopsy in a different area, as long as they’re explaining it appropriately to you, you should try to stay with that program.

So that’s the general workup of a patient. I will say, every patient gives a little bit of a nuance and so sometimes a patient seemingly needs something that’s a bit unusual in terms of a biopsy or the location of a biopsy or how to best go about getting that biopsy, and I can also say that sometimes the tumor board is split. Sometimes there’s no right answer about whether we should do it via a needle biopsy through the chest wall, or a bronchoscopy, and sometimes talking that through with a patient, they can help us – you can help us as patients make a decision about which way we would go next. That’s the general workup of a lung cancer.


GRACE Video

PET Scan Imaging: What Does It Tell Us?

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GCVL_LU-B02_PET_Scan_Imaging_Lung_Cancer_Workup

 

Dr. Gerard Silvestri, Medical University of South Carolina, discusses the use of PET scans in lung cancer workup.

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You may be asked when you’re diagnosed with lung cancer to have something called a PET scan. Unlike a CT scan, a PET scan tells us not where it is, but is it active — so a PET scan works on this idea that if it “lights up,” it’s an active lesion. Now things that are active tend to be rapidly dividing cells, and so PET is actually not useful in the brain where we are thinking all the time, we have very rapid metabolism. If a lesion lights up in the lung it’s rapidly dividing cells and it may be cancer, although sometimes infections in the lung can cause the PET scan to light up and even changes after radiation treatments can cause a PET scan to “light up.”

The PET scan can tell us if and where lesions are active, and they sometimes pick up disease we didn’t suspect outside the chest, for example in the bone, or the adrenal gland, or the liver, so the PET scan is useful if it’s positive and it tells us that a lesion is active. It’s also incredibly useful if it’s negative — so sometimes we have benign spots in our lung and if the PET scan is negative in that area it means, by and large, it’s not cancer.

One strong recommendation in this area though is if you have a positive PET scan it doesn’t always mean cancer; 20% of the time it’s falsely positive, especially in patients that have infections around a certain area. We often recommend doing a biopsy to confirm that the PET scan is in fact really cancer, or could it be something else. Sometimes we’re really surprised at the results of the biopsy in patients who have a positive PET scan and it turned out not to be cancer, which is good news for our patients.


GRACE Video

How a Diagnosis of Lung Cancer is Made: The Biopsy

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GCVL_LU-B01_Diagnosis_Lung_Cancer_Biopsy

 

Dr. Gerard Silvestri, Medical University of South Carolina, describes several procedures used to obtain biopsy tissue in order to diagnose lung cancer.

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When I meet with patients who have a new spot on their lung, I tell them I want to do three things and I do it in lay terms and then describe what that means in medical terms. So I ask the question, what is it — that’s the diagnosis, where is it — that’s the stage, and then what can we do about it — those are the treatment options.

As far as diagnosis is concerned, that means getting a tissue biopsy, and there are a number of ways that we can get tissue from patients’ lungs. One is by numbing up the skin on the chest and doing a needle biopsy through the chest wall and into the spot itself. Another is by a procedure called bronchoscopy. That’s where we take a look down into the lungs, the patient is given sedation medicine, and then we take a biopsy from the inside out. There are a number of other ways, including a surgical biopsy where a patient is asleep in the operating room, and the patient gets a small surgical biopsy of their lesion.

Now sometimes we direct our biopsy outside the chest so that we can make a diagnosis and a stage at the same time. For example, if a patient has a liver lesion on a CT scan, we may choose to numb the skin in the abdomen and do a needle biopsy that way, and that gives us both a diagnosis and a stage at the same time.

It’s critically important to make sure that we get those three things right before we embark on treatment: what is it — diagnosis, where is it — stage, what can we do about it — treatment options.


GRACE Video

Potential Advantages, Disadvantages and Limitations of Lung Cancer Screening

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GCVL_LU-A06_Potential_Advantages_Disadvantages_Limitations_Lung_Cancer_Screening

 

Dr. Gerard Silvestri, Medical University of South Carolina, discusses the benefits and drawbacks of lung cancer screenings.

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Lung cancer screening is something that’s quite new in the United States. In 2010, the data was published on a 50,000 person trial where patients were either randomly allocated to get a CT (CAT) scan of their chest, a low dose radiation CT scan, or a chest x-ray, and the study showed a 20% reduction in lung cancer mortality in the patients who got screened for lung cancer with a CT.

There are a few things that you need to understand about that trial. One, it only included patients between the ages of 55 and 74; two, you had to have smoked at least 30 pack-years — that’s 30 years at a pack a day, or for example, 15 years at two packs a day. So you need to have a certain smoking history and be of a certain age to enter into that trial, and now patients in that age range with that smoking history are eligible to be screened for lung cancer with a yearly CT.

The advantage is that you hope to get the cancer when it’s quite small, and so it can be resected with a surgery, taken out, and that patient will have a better chance of being cured of their cancer because as we get to more advanced stages like when the cancer has spread outside of the chest, the hope for a complete cure is lessened. Early stage cancer, screen-detected cancer, has a better chance for cure.

There are some disadvantages to screening though that people need to be aware of. About one quarter of the time, patients who have a scan will have a spot on their lung, or a nodule, or a lesion it’s sometimes called — a quarter of the time those spots are there, and 96% of the time they’re benign spots, but they still need to be evaluated. Sometimes they’re evaluated just with following up with a CT scan, sometimes they’re evaluated with a biopsy, and even sometimes it requires surgery to get those out. That can cause a lot of anxiety in patients and certainly put them at risk for unnecessary procedures, particularly if you’re taking out something that was going to be benign all along. So that’s some of the disadvantage of being screened for lung cancer.

Also, as folks get older, so when you get up into that 75-77 age range, you also have other comorbidities, other things, other health issues that make it difficult for you to undergo surgery, and so some patients may not want to be screened if they have other health problems that may preclude a long life expectancy.

Overall, screening is being implemented in the United States the same way breast cancer screening was implemented years ago in the United States, and we’re doing it very carefully to make sure the patients are of the appropriate setting. The other thing we’re doing is making sure that if patients are smoking, that they get some smoking cessation as part of their screening endeavor.


GRACE Video

Different Lung Cancer Subtypes – Histology

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GCVL_LU-A07_Different_Lung_Cancer_Subtypes_Histology

 

Dr. Edward S. Kim from the Levine Cancer Institute in Charlotte, NC defines the concept of cancer histology and gives examples of several lung cancer subtypes.

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Now we’re talking about histology. When you’ve identified a nodule on a chest x-ray, or a CAT scan, or maybe there’s something in the liver — as you know,  lung cancer likes to leave its home base and go to other places — we get a biopsy, and that biopsy is going to help us two ways. One: it’s going to tell us what the origin of the tissue is, and two is: what subtype of that tumor is it? So, in the case of lung cancer, we try to first, identify whether it’s a non-small cell, or small cell lung cancer, and then within the non-small cell lung cancer grouping, which consists of about 85% of all of lung cancer, there are multiple different histology subtypes. That means a pathologist looks at it under a microscope — is looking at it like you would look at artwork on the wall, and trying to identify whether it’s an impressionist period, or it’s a different period of time — and that’s how they’re doing it.

Sometimes, they’ll run some basic tests that they can do in their pathology lab to help further classify one or the other histology subtypes. The most common subtype is adenocarcinoma — again, this is just the name of a non-small cell lung cancer subtype. There are also subtypes called squamous cell cancer, and then — again, those are the two major types, there are then a whole host of others. You will hear terminology such as: large cell carcinoma, neuroendocrine carcinoma, there’s even a classification called NOS, meaning not otherwise specified, and about 10-15% of the time, we can see this.

What does that mean? Well, it still means it’s a lung cancer, and it usually means it’s non-small cell lung cancer, but there is not enough tissue, or the architecture was not preserved enough during the biopsy procedure, that the pathologist can completely classify this tumor. That’s problematic, because now we have therapies that are specifically tailored for some patients who have adenocarcinoma, or squamous cell carcinoma. There are not as many therapies out there tailored for the large cell or neuroendocrine tumors. Again, these just represent different cell types that exist in the lung, and those are the ones that decide to grow and become misbehaving, and they evolve into a cancer, and that’s why they have their particular names.


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