Perspectives in Lung Cancer

Keyvan Moghissi, Jack Kastelik, Phillip Barber

• Publisher: Bentham Science Publishers
• Year: 2020
• ISBN:
  9789811459566
• Topic: Medicine
• Subtopic: Pulmonary & Thoracic Medicine

Perspectives in Lung Cancer compiles basic and advanced topics on lung cancer pathology and treatment in a single volume. Chapters introduce the reader to chest and lung anatomy followed by the biology of lung cancer. Subsequent chapters delve into diagnostic methods for lung cancer while progressing into treatment options. The book culminates into an explanation of the concept of the Lung Cancer Centre, which is a representation of the editors' vision for organizing a lung cancer treatment unit. Key features: Organises key topics covering both standard and avante-garde topics related to lung cancer
All contributions are presented by experts in lung cancer treatment
Addresses basic biology of lung cancer
Provides information about 3D surgical planning, a relatively new concept in the field of thoracic surgery
Addresses the standard method of resection, VATS and Mini VATS
Covers the role of radiation and systemic anti-cancer therapies in lung cancer treatment
Provides a glimpse of modern methods such as image guided surgery and therapy, laser therapy, and photodynamic therapy
Covers the role of palliative care for lung cancer
Presents information about a visionary organization of a lung cancer unit and treatment centre. The combination of carefully organised chapters covering a wide array of topics make this reference an essential reference for healthcare professionals interested in acquiring a broad perspective on lung cancer treatment with the goal of improving patient outcomes.

Diagnostic Approach to Lung Cancer

Jack Kastelik^*

Castle Hill Hospital & Hull Royal Infirmary, Hull University Teaching Hospitals NHS Trust, Hull, UK

Abstract

Lung cancer is a common neoplasm. Diagnosis of lung cancer at an early stage is associated with the best prognosis. Therefore, early recognition of symptoms through increased awareness, systematic investigations and rapid diagnosis of lung cancer is of importance. Patients investigated for lung cancer would require a chest radiograph, computed tomography and Positron Emission Tomography. Imaging can provide a non-invasive approach to staging lung cancer. However, in a number of patients, more invasive methods may be required for accurate staging. Endobronchial ultrasound (EBUS) and Endoscopic ultrasound are techniques, which in conjunction with mediastinoscopy, form important techniques for mediastinal lymph node staging as well as sampling for histological diagnosis. Patients with more peripheral lesions may need biopsy using CT guidance or newer approaches such as radial EBUS or navigational bronchoscopy. Many patients with lung cancer would also require complex physiological fitness assessment, including lung function and exercise testing. A proportion of patients with lung cancer may develop pleural effusion, which would require careful assessment based on the use of systematic diagnostic protocols and understanding of the best interventional and therapeutic strategies. Therefore, investigations and management of patients with lung cancer have become complex and should be undertaken through the multidisciplinary team approach.

Keywords: Lung Cancer, Computed Tomography, Positron Emission Tomography, Endobronchial Ultrasound, Navigational Bronchoscopy, Lung Function testing, Pleural effusion, Thoracocopy.

---

^* Corresponding author Jack Kastelik: Castle Hill Hospital & Hull Royal Infirmary, Hull University Teaching Hospitals NHS Trust, Hull, UK; Tel: [phone]; Fax: [phone]; E-mail: [email protected]

INTRODUCTION

Each year, worldwide, approximately 1.8 million patients are diagnosed with lung cancer [1]. Unfortunately, a majority of the patients are diagnosed with advanced disease, which is not curable and has survival at 5 years in the range of 4% [1]. Only 15% to 20% of lung cancer cases are diagnosed with stage one disease, which carries a much better prognosis [2^-5]. The Office for National Statistics in

England has reported 5-year survival for lung cancer in men at 12.9% and slightly higher in women at 17.7%, with other countries such as Australia reporting dissimilar 5-year survival rates of around 16%. In order to provide curative options, lung cancer requires to be diagnosed at an early stage. This can potentially be facilitated by increasing the public awareness of lung cancer and the symptoms associated with it, together with work towards improving primary care identification and early investigations of patients with suspected lung cancer. This would allow the patients to seek medical advice earlier and for the primary care physicians to rapidly initiate investigations and referrals to a specialist. In addition, there is a drive towards developing systems and programmes, including lung cancer screening, which would allow for earlier detection of lung cancer. However, before any benefits of such interventions are appreciated, clinicians are left with relying on the early recognition of symptoms, leading to rapid imaging followed by appropriate investigational protocols.

Symptoms

Symptoms related to lung cancer usually occur in more advanced stages of the disease and therefore, many patients with the early stages of lung cancer may remain asymptomatic. One of the important barriers in early diagnosis is the recognition by the primary care that the symptoms that patients are presenting with may be related to lung cancer. A study from the UK revealed that the average time from the presentation and the diagnosis of lung cancer was 3 months and for patients diagnosed with the early stages of the disease, it was much longer, around 5 months [6]. Lung cancer can present with different symptoms, many of which may be non-specific. More specific symptoms of lung cancer, such as haemoptysis, may be present in only 20% of patients. The investigations are usually initiated when the symptoms become apparent typically in the form of cough, breathlessness, haemoptysis or pain. The breathlessness may occur due to the lobar collapse or mechanical compression resulting in the narrowing of the lumen of the bronchi or endo-bronchial obstruction. Voice hoarseness or breathlessness due to diaphragmatic paralysis can be a manifestation of the phrenic nerve involvement. Other presentations may be in the form of the superior vena cava obstruction syndrome or Horner’s syndrome due to Pancoast’s or superior sulcus tumour. The clinicians require to be aware of the modes of presentations related to so-called paraneoplastic syndromes, which may include endocrinological abnormalities such as a syndrome of inappropriate anti-diuretic hormone secretion (SIADH), hypercalcaemia or Cushing’s syndrome as well as haematological abnormalities including deep vein thrombosis (DVT), superficial thrombophlebitis, disseminated intravascular coagulation (DIC) and cutaneous and musculoskeletal disorders including hypertrophic osteoarthropathy or dermatomyositis. Moreover, patients may present with neurological disorders due to the Lambert Eaton syndrome, peripheral neuropathy, cerebellar degeneration or limbic encephalitis. These syndromes may require biochemical testing to assess serum calcium, serum and urine osmolality and sodium levels or measuring serum specific anti-neuronal nuclear antibodies such as anti Hu, Yo or Ri, which may be detected in paraneoplastic neurological syndromes.

The main hurdles for early diagnosis are related to the patients’ awareness of lung cancer and the reluctance to seek a medical assessment when the symptoms become apparent with studies showing a median delay of 99 days from the onset of the symptoms and the patients seeking medical opinion [7]. There is evidence that the introduction of the campaigns that increase public awareness of lung cancer and training within the primary care may result in increased referral rates for a chest radiograph and a resulting rise in the diagnosis of lung cancer. For example, a recent report of such a campaign in Leeds, a large city in the north of England, revealed an 81% rise in the community ordered chest radiographs and a shift towards diagnosing of a higher proportion of earlier stages I and II of lung cancer [8]. Another example would be the CHEST Trial, which showed an increase in consultation for new respiratory symptoms [9]. Similar findings have been reported recently from the CHEST Australia study, which showed a 40% increase in respiratory consultations within the high-risk lung cancer population [10]. Early initiation of investigations is of importance as there is evidence to suggest that the time to diagnosis for patients with lung cancer may determine the outcomes [11]. For this reason, the awareness of the symptoms of lung cancer within the population and the primary care remains an important factor for early initiation of the investigations. Once the patients are referred to a specialist centre, it is paramount that there are systems in place that would allow for systematic and timely investigational pathways, which are individualised according to each patient’s requirements.

Initial Investigations

The current guideline suggests that in the UK, patients with suspected lung cancer are referred to a fast track lung cancer clinic usually as these allow for rapid investigations and diagnosis and are associated with less anxiety to the patients [12]. This is not dissimilar to the settings within the other health systems. The fast track clinics are working within the multidisciplinary team settings with a chest physician usually providing the initial assessment and the choice of investigational pathway. Cancer clinical nurse specialists form an important part of the multidisciplinary team and provide support to patients with suspected lung cancer through the investigational pathway and the diagnosis. The guidelines suggest that the investigational pathway for lung cancer should include investigations that involve the least risk to the patient and provide information on both the histological diagnosis and the staging. There is, therefore, drive towards the optimal investigational pathway that would result in rapid diagnosis and staging of the disease. There is evidence that the timely diagnosis of lung cancer can improve the outcomes. For example, a Lung-BOOST trial showed that a rapid diagnostic pathway compared to the standard care reduced time from the referral and diagnosis by 15 days and increased the median survival by 191 days [13]. In the UK, in order to improve the time interval from the referral to diagnosis and the treatment of lung cancer, the national optimal lung cancer pathway has been promoted and is being implemented [14]. Patients with suspected lung cancer should have a chest radiograph and if this is suspicious for lung cancer computed tomography (CT) of the thorax ideally on the same day (Table 1). The staging CT scan should include imaging of the liver, the adrenals and the lower neck as this would allow to assess for any distal metastases. However, the chest wall involvement may require further imaging in the form of ultrasound or magnetic resonance imaging (MRI) [15]. Similarly, an MRI may be required to assess patients with the superior sulcus neoplasm, as this may provide more information regarding the extent of the disease. The majority of the patients with suspected lung cancer would also require a Positron Emission Tomography (PET) scan, which provides more accurate staging. PET scan compared to the CT is more accurate in assessing the mediastinal lymph nodes involvement with sensitivity and specificity of 77.4% (95% CI 65.3 to 86.1) and 90.1% (95% CI 85.3 to 93.5), respectively [16]. The PET scan may also be helpful in diagnosing distal metastases. Therefore, all patients who are considered for radical treatment should have a PET scan. However, as the PET scan is not sensitive for the brain metastatic disease d...