Lung Cancer Treatment
Lung Cancer Surgery
Surgery is routinely performed as a treatment for primary lung cancer or secondary cancer of the lung (metastases). Surgical procedures involve wedge resections of the lesions, segmentectomy (removal of a segment of the lung, 1/10th of a lung usually), lobectomy (removal of a lobe, 1/3rd to one half of a lung), bi-lobectomy (removal of two lobes) or pneumonectomy (removal of the entire lung).
Depending upon the extent and type of disease, surgery usually requires a minimum of four to five days in hospital after a wedge resection or a lobectomy of lung and up to ten days after a pneumonectomy (resection of left or right lung).
Minimally invasive surgery as a lung cancer treatment is routinely performed at our Centre. You may be eligible for a keyhole Video-Assisted Thoracic Surgery (VATS) wedge resection, VATS segmentectomy (ablation of a segment of your lung) or a VATS lobectomy (removal of a lobe of your lung) depending upon the size and location of the tumour. We do perform all type of complex operations including sleeve resections, sleeve lobectomy and pneumonectomy (removal of the entire lung).
The possibility of having a minimally invasive procedure (keyhole surgery) will be discussed with our Consultant Thoracic Surgeon. This procedure is appropriate if you have got early stage lung cancer, with a tumour less than 3 cm in diameter and ideally no positive lymph nodes as assessed by PET-CT, EBUS-TBNA or mediastinoscopy. In that case, the pulmonary lobe involved will be removed through a 5 cm minithoracotomy. This procedure is less painful than a conventional thoracotomy and the recovery period is shorter. The in-hospital stay is usually three to four days following a VATS lobectomy or segmentectomy.
You may also have to discuss the possibility of having a paravertebral catheter or an epidural catheter for adequate pain relief after your thoracotomy or VATS with one of our consultant anaesthetists.
Alternatively, you may have advanced stage lung cancer and the operation may involve the resection of a great vessel, diaphragm, or part of the chest wall together with part of your lung. In that case the procedure is considered carefully and discussed with experienced radiologists and oncologists. At the present time, this kind of procedure is usually performed following a course of induction chemotherapy to reduce the size of the tumour and make it more easily resectible.
Bupa Cromwell Hospital has a high dependency unit (HDU) and an intensive care unit (ICU) supervised by a team of consultant critical care physicians allowing our team to perform complex cases. Your stay in HDU or ICU will be determined by the extensiveness of your lung resection and your co-morbidities (history of cardiac disease, diabetes, obesity, etc).
Most patients are transferred back to their room after an overnight stay in HDU following their lung resection.
Chemotherapy as a Lung Cancer Treatment
If the tumour is too large or is involving thoracic organs others than the lung, your consultant may recommend that you receive some chemotherapy before the operation to help reduce the size of the tumour. Sometimes, radiotherapy is administered along side chemotherapy to shrink the tumour further. This is called induction treatment and this is increasingly used to make inoperable tumours operable.
Alternatively, your consultant may recommend that you receive chemotherapy following your operation. This treatment is usually started six to eight weeks after surgery and is called adjuvant chemotherapy. This cancer treatment is normally recommended to reduce the risk of cancer relapse.
This treatment is recommended when the tumour is large, when the thoracic lymph nodes are involved by the cancer, or when other thoracic organs are involved. The chemotherapy is usually administered as an outpatient treatment over three to four months and consists in a combination of two drugs given intravenously over a few hours. Alternatively, your consultant may recommend a new drug targeting cancer cell receptors instead of the chemotherapy.
Radiotherapy as a Lung Cancer Treatment
Radiotherapy is used to treat the tumour when surgery is not possible due to high risk or multiple other medical problems. This treatment is usually administered over a few days or weeks depending on the location of the tumour and dose planned by your consultant.
There are different ways to administer radiotherapy and new techniques and advances in this field can now minimise the collateral damage to organs surrounding the tumour.
Radiotherapy is rarely used before surgery. It is sometimes used following the operation (six to eight weeks after) when the risk of local relapse is particularly high. It is mostly used as an alternative to surgery in patients with inoperable tumours.
Radiofrequency Ablation and Cyberknife Stereotactic Radiosurgery as a Lung Cancer Treatment
CT-guided radiofrequency ablation (RFA) and Cyberknife stereotactic radiosurgery are new minimally invasive image-guided technologies available for patients who cannot have surgery due to severe co-morbidities or poor lung function.
These techniques are safe and their role is currently evaluated in the treatment of early stage lung cancer and solitary lung metastases and in patients who are not fit for surgical resection.
RFA has been used for more than ten years at pilot centres and Cyberknife radiosurgery has been used for more than three years with excellent success rates.
Your treatment would be discussed and delivered by a team involving a consultant radiologist, a clinical oncologist and a thoracic surgeon. Treatment planning is mapped out on a computer with the aid of a PET-CT fusion scan to outline the tumour that is to be targeted.
RFA is mainly used to treat small lung tumours (ideally less than 3 cm, but up to 5 cm) or pulmonary metastases. This is always done under general anaesthetic in the interventional radiology suite. The procedure is performed by an interventional radiologist, with a thoracic surgeon attending.
The Cyberknife is used to irradiate small lung tumours (ideally less than 5 cm) and is currently being evaluated as an alternative to lung resection in patients unfit for surgery with stage I lung cancer. This treatment is administered in the radiotherapy suite and no anaesthetic is needed.
Personalized Biomedicine, Biomarkers and Targeted Therapies
The landscape of thoracic oncology is changing. At present the treatment of specific tumours such as lung cancer is based on large clinical trials (thousands of patients) and the rule is of 'one size fits all' with all patients with a similar cancer type receiving the same chemotherapy / drugs.
Response to chemotherapy is highly variable. Some types of cancers are known to respond well to chemotherapy, some others are notoriously resistant to chemotherapy. Moreover, chemotherapy drugs can cause life threatening side effects. Therefore, it is essential to find drugs that are active on the cancer, without causing too many side effects.
Translational research is essential in thoracic oncology to bring the basic science discoveries to the patient’s bedside. In the last 10 years, researchers have discovered that gene expression and tumour biology may be more important than the anatomical staging of a cancer.
Gene expression, profiling, genotyping and biomarkers are progressively becoming an essential step in the analysis of thoracic cancers. In the past 10 years, new drugs have been developed to target specific gene mutations and have transformed the prognosis of lung cancer and other thoracic cancers. Mutations in the EGFR gene, Alk gene, HER-2 gene, BRAF gene and others can now be efficiently targeted with drugs like tyrosine kinase inhibitors and provide better control of the tumour, together with significant prolongation of life.
Once a diagnosis of lung cancer, malignant mesothelioma, tymoma or any other thoracic cancer has been made, it is essential to find out which genetic abnormalities cause the cell to grow uncontrollably.
Targeting specific abnormalities proved very effective in certain types of breast or lung cancer and targeted agents such as trastuzumab, erlotinib or gefitinib are now used routinely to treat patients whose cancers express specific genetic abnormalities.
Most of these genetic abnormalities can be found on a tiny sample of tumour (a biopsy) which is either fresh, frozen or fixed in Formalin, embedded in paraffin and sent to the scientist for analysis.
Our team will offer you a personalized service. Our thoracic surgeon or our interventional radiologist will perform the biopsy and send all biological material to our pathology and molecular biology teams.
No matter whether you have early-stage or advanced-stage lung cancer, the tissue analysis will help your doctors decide which treatment is best for you i.e. a combination of surgery and targeted therapy or a specific chemotherapy agent.
We will provide you with a pathology report and a genetic analysis within a few days (maximum three weeks for a complex analysis). These reports will be used to decide which therapy is best for you and more likely to result in a regression of the cancer.
Immunotherapy for Lung Cancer, Thymic Tumours and Malignant Mesothelioma
In the past fews years, both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have approved the use of new immunotherapy drugs aiming at increasing patient's immune response against cancer. Some of these drugs (Pembrolizumad, Nivolumab, Atezolizumab) have been used routinely in the past three years at the Bupa Cromwell Hospital to treat patients with lung cancer, thymoma and malignant mesothelioma. These drugs are administered intravenously at regular intervals (two or three weekly) in our dedicated chemotherapy day unit.