There are 43,500 new cases of cancer in Switzerland every year. Lung cancer accounts for around 11% of cases and is one of the most common forms of cancer after breast and prostate cancer. Every year, this means that around 4,700 patients are diagnosed with lung cancer. Men are more frequently affected than women. The patient is over 50 years old when first diagnosed with the disease.
Smoking is considered the greatest risk factor. The chances of recovery from lung cancer depend heavily on the stage at which the cancer is discovered. Lung cancer is often detected late, which is why the mortality rate is the highest compared to other types of cancer. As lung cancer causes few symptoms in the early stages, intensive research is being carried out into new methods for early detection.
Test subjects wanted for our pilot study on the early detection of lung cancer
Smokers between the ages of 55 and 74 who have smoked at least 1 pack of cigarettes a day for 30 years can take part in the study. The test subjects undergo computer tomography to detect early forms of lung tumors.
As part of the webinar for patients and relatives, the Lung Thoracic Oncology Center gave lay insights into various topics relating to lung cancer under the motto “Meet the experts”.
Careful staging is of the utmost importance for prognosis and treatment.
The effort involved in determining the stage is significant in that the recommended therapy depends crucially on the tumor stage. Any unclear shadowing in the lung X-ray should be clarified by means of computer tomography (CT). It makes sense to examine the liver and adrenal gland at the same time in a CT scan so as not to miss a metastasis there.
Depending on the location of the tumor, fine tissue examination (histology) or cell collection (cytology) is performed using bronchoscopy (bronchoscopy) with brush cytology, aspiration, fine needle aspiration, endobronchial ultrasound (EBUS) with transbronchial needle aspiration (EBUS-TBNA) or by means of lung pleural puncture in the case of effusion.
A CT-guided puncture can also be performed in the case of a suspected tumor focus in the lung margin area, although the rate of false-negative results is still high. In this case, minimally invasive keyhole surgery for wedge tissue resection with intraoperative tissue examination (followed by correct tumor-oriented surgery in the same session or at a later date) is an option.
In addition to the lung tumor, a CT scan looks for lymph node involvement. The tumor usually first spreads via the lymph channels into the lymph nodes of the lung root (hilus: hilar lymph nodes) or the space between the lungs (mediastinum: mediastinal lymph nodes).
The aim must be to differentiate between negative lymph node involvement, hilar involvement, same-sided mediastinal involvement and reciprocal mediastinal involvement, as this is important for further treatment. A PET/CT is performed for this purpose. The detection rate of lymph node metastases in combined PET and CT examinations is higher than that of CT alone and generally avoids invasive examinations in patients with negative mediastinal findings.
In the case of PET-positive lymph nodes (signal enrichment), invasive clarification using EBUS-TBNA (endobronchial ultrasound with transbronchial needle aspiration) or mediastinoscopy is recommended.
Even the smallest peripheral lung foci can be localized using navigation bronchoscopy and various procedures (cryobiopsy, forceps biopsy) can usually be used to clearly puncture the tissue and often provide evidence of a tumour. Sometimes, however, no tumor cells can be detected, which does not necessarily rule out a tumor because only one puncture was made. If the findings are negative, a mediastinoscopy with biopsy should be performed.
For greater patient comfort, we at the USZ are the first center in Switzerland to offer the option of combined diagnostics and treatment under anesthesia (hybrid procedure). For this purpose, the patient’s unclear pulmonary focus is wire-marked under anesthesia after appropriate preparation, a wedge resection is connected and, depending on the microscopic rapid assessment, the correct oncological tumor operation is connected (Hybrid-OPS image).
Correct treatment can only be given after exact staging, which must be discussed and coordinated in an interdisciplinary tumor board. In principle, the more advanced stages should be treated on a multidisciplinary basis, at least with the recommendation of an experienced tumor center such as ours at the University Hospital.
From stage II, a skull MRI is routinely performed preoperatively to rule out a brain metastasis.
Minimally invasive surgery for lung cancer (TV show praxis gesundheit from May 1, 2017)
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Treatment
Treatment decisions are made in a weekly interdisciplinary committee, the tumor board, consisting of specialists from radiology, pathology, pneumology, surgery, radiotherapy and medical oncology and are adapted to the respective tumor stage.
Modern lung cancer therapy concepts generally include a multimodal approach, i.e. several forms of therapy are used in combination: in addition to local therapies such as surgery and radiotherapy, systemic drug therapy is also used. In the latter case, so-called “targeted therapies” of specific drugs, or rather “targeted therapies”, are used today. immunotherapies, mostly in the context of clinical trials.
Nowadays, surgery plays a role in all tumor stages.
Stage I can be treated with surgery alone. This again shows the importance of preoperative PET/CT examinations, as a positive lymph node involvement was relatively frequently found in the tissue preparation in the early stages, which was not recognizable on CT alone.
Increasingly, lung lobe resection with removal of the mediastinal lymph nodes is being performed using minimally invasive keyhole surgery. In terms of overall survival and local tumor recurrence, there is no difference to the open procedure. At the same time, there are fewer complications, with faster recovery and quicker integration into the work process. Inpatient rehabilitation is usually not necessary, and any necessary chemotherapy is not only better tolerated, but is also more likely to be carried out as planned. We now perform over 80% of lung cancer operations using minimally invasive techniques, around half of which are robot-assisted (advantages include 3D view, additional degrees of freedom for the instruments), which enables even greater precision.
Wedge resection
This procedure is primarily used for diagnostic purposes. In this case, only the lung nodule is removed with a safety margin; if malignancy is present, more lung tissue usually has to be removed afterwards.
In patients with impaired lung function (especially smokers’ lungs), a non-anatomical lung wedge resection can be performed on tumors located in a less functional part of the lung, thus removing the tumor and even improving lung function at the same time using the LVRS (Lung Volume Reduction Surgery) concept.
Segment resection
In the case of smaller tumors up to two centimeters in size, under certain circumstances it is possible to perform an anatomical resection of only one (or more) segment(s) of the lung, rather than the entire lobe, while preserving a greater reserve of lung function.
Lung lobe resection
The standard of surgical resection is lung lobe resection with radical mediastinal lymph node removal, whereby the latter is particularly essential for correct staging of all anatomical resections.
Pneumonectomy
In very rare cases, the entire lung must be removed.
Extended resections
If a lung tumor grows into the neighboring structures (chest wall, central vessels or organs), it is necessary (usually after preliminary treatment) to remove the tumor as a whole together with the structures involved.
The preservation of functional lung and other tissue is always the primary goal, provided that oncologically correct surgery is performed. Various techniques are available for this purpose:
Bronchioplastic / angioplastic resections
In the case of centrally located tumors, a lung tissue-sparing resection can be performed using special suturing techniques. In this procedure, the tumor-bearing part of the airway or vessels is removed and the remaining lung is reconnected.
Even in advanced stages, surgical interventions can help to alleviate symptoms and thus improve quality of life. For example, in patients with recurrent malignant pleural effusion, talcum adhesion of the lung pleura (thoracoscopic talc pleurodesis) is performed using keyhole surgery. If the lung does not unfold adequately under visualization, a catheter tunneled into the subcutaneous fatty tissue (e.g. PleurX catheter) can be inserted instead. This can be managed at home by the patient independently or with Spitex assistance and improves quality of life.
Solitary round lung focus
The solitary round lung tumor is defined as a round tumor <3-5 cm without other abnormalities such as enlarged lymph nodes, completely surrounded by lung tissue. At >5 cm one speaks of a “mass”. In the case of suspicious lesions or growing foci, the further clarification concept is based on the patient’s risk profile and the size of the solitary round lung lesion. Suspicious characteristics are a size of more than 1 cm with irregular edges, so-called spiculae and a long history of smoking
If the risk profile is high, a tissue sample can be taken and examined directly (biopsy). wedge tissue resection can be performed. This should be mandatory for high-risk patients with findings > 1 cm with spicular protrusions; a PET/CT is also essential here. For other foci, regular follow-up examinations can be carried out first.
Rare benign tumors of the lung
Benign lung tumors include bronchial adenomas (benign glandular tumors), chondromas (cartilage tumors), most commonly the subgroup of so-called hamartomas, osteomas (bone tumors), fibromas (connective tissue tumors), lipomas (fatty tissue tumors), tuberculomas (often calcified scar tissue after healing pulmonary tuberculosis). Apart from tuberculomas, the benign lung tumors mentioned are rare.
Symptoms
Benign lung tumors rarely cause symptoms. They are most frequently discovered by chance during a radiological examination for other reasons. Certain benign tumors can be identified with certainty using standard CT scans. However, it is not uncommon for the diagnosis to remain unclear at first, and the unclear lung tumor understandably causes concern.
Diagnosis
Computed tomography may already be able to differentiate between benign and malignant tumors in certain cases. Follow-up imaging is useful for small, unclear tumors. If there is no growth in size, malignancy can often be ruled out after a certain period of time. Depending on the appearance and growth of the findings, invasive diagnostics may be necessary. CT-guided or sonography-guided punctures often do not lead to the desired result, as they usually cannot definitively rule out malignancy. Accordingly, wedge resection of the tumor is recommended in many cases. If it is a malignancy, the oncologically correct operation can be performed in the same session.
Treatment
Treatment is not necessary if the tumors do not cause any symptoms and can already be identified as benign by imaging. Otherwise, a parenchyma-sparing resection is performed, which is usually minimally invasive. In the case of an intraoperatively diagnosed malignant tumor, the correct cancer surgery is performed.
For patients
You can either register yourself or be referred by your primary care physician or gynecologist.