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Denise Brock

Lung Cancer Video Library – Spanish Language: Video #10 How a Lung Cancer Diagnosis is Made

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GRACE Cancer Video Library - Lung

 

For our 10th video in the GRACE Spanish Lung Cancer Library, Dr. Brian Hunis, Medical Director, Head and Neck Cancer Program, Memorial Cancer Institute, Miami, Florida, joined GRACE to discuss the basics of Lung Cancer for Spanish-speaking patients and caregivers, in this video Dr. Hunis reviews how a lung cancer diagnosis is made. 


 

 

 

 


 

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TRANSCRIPTS – Spanish and English
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¿Cómo se realiza el diagnóstico de cancer de pulmón?

El diagnóstico de cancer de pulmón, por lo general, comienza con un paciente que tiene algún tipo de anormalidad en un estudio de diagnóstico por imágenes, por ejemplo: una placa de tórax o una tomografía computada de tórax. El paciente puede o no tener síntomas, porque estos son ciertamente inespecíficos como la tos, cansancio, baja de peso etc.

Cuando un paciente tiene una lesión que es sospechosa para cáncer de pulmón, lo que se necesita hacer es una biopsia para tener tejido por análisis. De la manera por la que se obtiene ese tejido puede ser por tomografía computada, biopsia percutánea con aguja fina o más grande (para tener mejor tejido) o biopsia quirúrgica en donde se usa si la sospecha es grande y los pacientes van directamente a cirugía.

 La otra opción es por broncoscopía, que ahora se está usando menos de lo que se usaba anteriormente, este procedimiento es por medio de un tubo que va por la garganta hasta los bronquios y el árbol bronquial para tomar tejido. La broncoscopía es beneficioso para tumores centralizados en el mediastino (parte entremedia de los pulmones), pero no están beneficioso en la periferia que está en los costados de los pulmones.

Otra opción que está usando cada vez más en el mundo, es una biopsia con broncoscopía con ultrasonido endobronquial. Es similar a un broncoscopio, pero tiene una cámara de ultrasonido que nos permite localizar ganglios linfáticos, con lo cual podemos tener biopsia y confirmación de enfermedad en ganglios linfáticos en el mediastino.


 

How is lung cancer diagnosed?

Lung cancer diagnosis, in general, starts with a patient presenting some kind of abnormality in a medical imaging like a chest x-ray or a chest computed tomography. Patients could be or could be not presenting the following symptoms: cough, fatigue, weight loss and others, but they are nonspecific. 

When a patient has a suspicious injury or sign of lung cancer, a tissue biopsy should be analyzed. There are many ways to obtain this tissue like computed tomography, percutaneous biopsy with thin or larger needle (for better-quality tissue), or surgical biopsy that is done when the doctor thinks the injury has a higher risk for lung cancer.    

The other option is bronchoscopy, which is less used than it was before. Here you use a tube in the throat to get to the bronchioles and then to the bronchial tree and take the sample. Bronchoscopy is great for centralized tumors in the mediastinum (middle part of the lungs), but is not good for the periphery area in the side of the lungs.

Another option that it’s been used more, is a bronchoscopy biopsy with endobronchial ultrasound. It is similar to a bronchoscopy, but it has an ultrasound camera that helps us find lymph nodes, where we can make a biopsy and confirm lymph nodes disease in the mediastinum.


GRACE Video

Bronchoscopy and EBUS

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GCVL_LU-B05_Bronchoscopy_EBUS

 

Dr. Jed Gorden, Swedish Cancer Institute, describes the differences between bronchoscopy and endobronchial ultrasound, highlighting the advantages of EBUS in diagnosis and staging.

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Today I’m going to talk to you about bronchoscopy with endobronchial ultrasound. It’s an interesting technology — bronchoscopy in its form that we know it now, flexible bronchoscopy, has been around since about the late 1960s. This allowed us to move bronchoscopy from an operating room into outpatient settings and allow us to navigate through the airways. For those of you that have heard of colonoscopies or upper endoscopies, these are all cameras that allow us to snake through the airway or other orifices and get a much clearer picture of what’s going on inside. The challenge though with traditional bronchoscopy is it allows you to only see what’s directly in front of you — what is in the airway, and the overwhelming majority of the time the airways are normal.

A tremendous advantage to us in the field of lung cancer, lung cancer diagnosis, and lung cancer staging has been bronchoscopy coupled with ultrasound, creating what’s called endobronchial ultrasound or EBUS. This is a very small ultrasound probe coupled at the end of a bronchoscope. It enters into the airway in the exact same fashion that bronchoscopy does for traditional procedures, but what it allows us to do is look through the airway wall. This is critical because looking through the airway wall now allows us to identify lymph nodes, abnormalities that are around the trachea, the bronchi which are the divisions of the airway that go to the left lung and the right lung, and this is critically important because we know that with staging where we’re not only diagnosing those that have cancer, but where the cancer is and whether it has spread to the lymph nodes is crucial to an understanding and developing a treatment plan.

Some we now have a tool in our armamentarium to, in a very minimally invasive way, go into the airways, see what’s in the airways, and see through the airways into the lymph nodes that live in and around those airways. Once we’ve identified these very specific structures, we can sample them with small needles allowing us to puncture through the airway wall directly into a lymph node, collect a sample, have a pathologist look at it under a microscope, and tell us whether that lymph node is involved in cancer or that lymph node is not involved with cancer. Critical are the decisions that will be made for creating a treatment algorithm.

The advantage of this is that it’s minimally invasive; it’s done in the outpatient setting. It allows us to sample most of the lymph nodes that are present and are critical to decision making around lung cancer and lung cancer staging. Complications of it are very rare — sometimes after bronchoscopy and bronchoscopy with ultrasound, people can experience a fever, or maybe a sore throat, but larger complications like bleeding and infection are very rare.

The most important thing though to understand is that this is a partnership with your physician and that they explain to you what procedure you’re going to have, and how this procedure is going to benefit you, whether it’s bronchoscopy or bronchoscopy with ultrasound.

The final thing that I’m going to talk about with bronchoscopy and bronchoscopy with ultrasound is how you’ll be during the procedure. Most patients ask, “am I going to be awake; am I going to know what’s going on?” There are two ways to do bronchoscopy and bronchoscopy with ultrasound. One is what’s called conscious sedation — this is sort of a twilight phase where people are sleeping, they’re breathing on their own, responsible for their own vital signs, but a bronchoscopist is allowed to do procedures without it causing too much disturbance to the patient. This is good for procedures that last about 25 to 30 minutes and allows people to sample in the airways in a very safe fashion. Another way that bronchoscopy with ultrasound is performed is with anesthesia — this is where an anesthesiologist takes over the safety of the patient and the control of their airway. A breathing tube or a small cap over the back on the airway is placed allowing air to pass in and out and control the breathing and ensure safety during the procedure.

So when you talk with your physician about this, it’s important to understand how you will feel during the procedure, what is going to be going on in terms of your safety, sedation, and your comfort. It’s also important to know that there’s data for this; the data for this suggests that the procedures are equal. Bronchoscopy and bronchoscopy with ultrasound can be done safely in the setting of conscious sedation and in the setting of general anesthesia, and you should feel confident that you can have a safe and effective procedure.

So in summary the most important thing is that you partner with your physician in order to get the most information possible from any procedure. In this case the procedure will be bronchoscopy. Bronchoscopy is an inspection of the airway. We couple that with ultrasound which is not only inspection of the airway, but visualization through the airway wall, identifying the lymph nodes and structures. Biopsying those gets tissue which is staging and telling us how much cancer there is, and this can be done safely and effectively with you sleeping in either a conscious or twilight phase, or with general anesthesia.


GRACE Video

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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Transcript

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.


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