Lung cancer is a complex disease, and is treated by an extensive team of doctors including a pulmonologist, oncologic thoracic surgeon, medical oncologist, and radiation oncologist. Close collaboration of your doctors is required to ensure the best treatment. At Continuum Cancer Centers of New York, all new patients’ cases are routinely discussed at our weekly Multidisciplinary Thoracic Oncology Conference where all of the specialists involved in lung cancer treatment collaborate to discuss and recommend the appropriate treatment for our patients.
In many patients, the team of physicians may decide that your cancer should be treated with radiation therapy, either by itself, or as part of a combined treatment plan. At Continuum Cancer Centers, we have many physicians in each discipline specializing in the treatment of lung cancer.
Lung cancer comes in several forms and how a patient is treated depends on what form of lung cancer is diagnosed, and at what stage the cancer is found. There are two major types of lung cancer - non-small cell lung cancer and small cell lung cancer. There is also a non-small cell subtype of lung cancer called bronchoalveolar carcinoma, which is difficult to diagnose. Its treatment can be complex depending on the individual patient.
Most forms of lung cancer, especially small cell lung cancer, are caused by smoking or from being exposed to second-hand smoke. People who are exposed to asbestos or radon also increase their risk of developing lung cancer.
Non-Small Cell Lung Cancer
There are six types of non-small cell cancers. These types are determined by how the cancer cells look under a microscope. They are:
1. Squamous cell carcinoma, which occurs in the thin, flat squamous cells.
2. Adenocarcinoma, which occurs in cells that secrete.
3. Adenosquamous carcinoma, which occurs in cells that secrete and are flat.
4. Large cell carcinoma, which occurs in cells that are abnormally large.
5. Undifferentiated carcinoma, which occurs in cells that do not look like normal cells and multiply uncontrollably.
6. Bronchoalveolar carcinoma, which can resemble a lung infection.
Small Cell Lung Cancers
There are three types of small cell lung cancer. These types are determined by how the cancer cells look under a microscope. They are:
1. Small cell carcinoma or oat cell cancer, which occurs in cells that are flat, small and oval, and resemble oat grains.
2. Mixed small cell/large cell carcinoma, which occurs in cells that are a mix of small and large cancer cells.
3. Combined small cell carcinoma, which is small cell lung cancer combined with squamous and/or secreting cells.
Diagnosing and Treating Lung Cancer
Depending upon the type and stage of the lung cancer, our experts treat patients with surgery, chemotherapy, radiation therapy, or combinations of the three. Specialists in thoracic surgery, pulmonary medicine, and medical and radiation oncology work together to develop an individualized treatment plan for each lung cancer patient. Surgical techniques can include such advanced approaches as video-assisted thoracoscopic surgery (VATS), robotic assisted surgery, and minimally invasive brachytherapy (radiation seed implants). The full range of supportive services available are pain management, integrative medicine, reiki, yoga, acupuncture, social work, nutrition, and psychological support.
What is radiation therapy?
Radiation therapy is the use of high powered x-rays to kill cancer cells. It is sometimes known as radiotherapy. There are many forms of radiation therapy, and your doctor will discuss with you which is the most appropriate type of radiation therapy for your cancer.
Types of radiation therapy
External Beam Radiation Therapy.
Conventional External Beam Radiation Therapy
External beam radiation therapy uses a high powered x-ray machine called a linear accelerator to deliver radiation therapy precisely to the cancer. Treatments are usually delivered daily Monday through Friday, and the entire treatment course may last between 5 and 9 weeks. The amount of time the daily treatments will take will depend on the kind of radiation plan your physician has determined is best for you, but treatments usually last between 15 and 30 minutes. At Continuum Cancer Centers, we have the most up-to-date technology to deliver cutting edge treatments. Types of external beam radiation therapy that your radiation oncologist they recommend for your treatment may include:
-Intensity Modulated Radiation Therapy [IMRT].
Intensity modulated radiation therapy is a form of external beam radiation therapy that uses a constantly varying radiation beam to accurately target to the cancer cells, while protecting the normal tissue. Your radiation oncologist will determine whether this form of external beam radiation therapy is appropriate for you.
- Image Guided Radiation Therapy [IGRT]
Image Guided Radiation Therapy uses a CT scanner built into the radiation treatment machine to perform a CT scan prior to each radiation treatment in order to ensure pinpoint accuracy of daily radiation treatments.
- Stereotactic Body Radiation Therapy [SBRT]
Stereotactic Body Radiation Therapy is used for small lung cancers in patients who may not be candidates for surgery. It uses several small, highly-focused radiation beams to deliver large doses of radiation to the tumor, while sparing nearby normal organs. As opposed to conventional external beam radiation therapy, SBRT is given in 3-5 treatments over 1-2 weeks, with each treatment session lasting approximately 1 hour. Because of the need for precise and accurate treatment, specialized CT scans are taken several times before, during and after each treatment to identify the tumor and confirm millimeter precision. At Continuum Cancer Centers, we have several clinical studies that are available for patients who are receiving SBRT. These include studies for patients with both early stage lung cancer and for metastatic disease. Your physician may also choose to treat you using this technique even if you are not enrolled in a clinical trial, if appropriate.
Internal Radiation Therapy (Brachytherapy)
In certain cases, radioactive material is placed directly into or near the tumor. This is called internal radiation, or brachytherapy. By placing the radioactive material directly into the body, the tumor can be treated effectively, while sparing nearby normal organs from most of the radiation exposure. Typically, there are two types of internal radiation that is used in the treatment of lung cancer:
-Wedge resection and brachytherapy
The usual treatment for early stage lung cancer is to remove the entire lobe of the lung (lobectomy) where the cancer is located. However, when patients have poor lung function or other medical conditions, they may not be able to have the standard surgery. Patients who cannot have surgery can have a smaller surgery called a wedge resection, where only a portion of the affected lobe of the lung is removed. However, while this surgery may be tolerated by patients with poor lung function and is sometimes successful at removing the cancer, it is not as effective in preventing local tumor recurrence as the standard surgery. In patients who cannot undergo the standard lung surgery, a newer treatment technique using radiation implants [“seeds”] sewn into the lung at the time of the smaller wedge resection has been developed and used for patients with early stage lung cancer. This newer treatment gives a better chance of cure than using the more limited surgery alone. At Continuum Cancer Centers, we have a unique clinical trial investigating the implantation of radioactive seeds using a robotic-assisted technique.
- Endoluminal brachytherapy
Sometimes, a tumor is located in one of the breathing tubes such as the trachea or bronchus, and can cause symptoms including cough, shortness of breath, and bleeding. In these cases, your radiation oncologist, together with your pulmonologist, can place one or more thin plastic tubes through your nose and into the area where the tumor is located. A tiny radioactive source can travel through that tube to the area where the tumor is located, giving radiation directly to that area. This type of treatment usually is performed between one and five times and can be very effective in relieving airway obstructions by tumors.
Radiation therapy-based protocols
At Continuum Cancer Centers, we are dedicated to offering the best available treatment for our patients, both now and into the future. We therefore have several clinical trials open that aim to advance our understanding of lung cancer and the effectiveness of radiation treatment.
Role of Chemotherapy in Lung Cancer
Stage IB, II, III: Adjuvant Treatment: Non small cell lung cancer is often difficult to cure with surgery alone, as cancer cells may escape from the lungs and travel to other parts of body but goes undetected by Xrays or CT scans (termed “micro metastatic disease”),. Studies have now shown that chemotherapy given after surgery, referred to as adjuvant treatment, can significantly improve survival by theoretically removing micrometastic disease . Chemotherapy is a cancer treatment which uses “drugs” to stop the growth of cancer cells either by killing the cells or stopping them from dividing. When chemotherapy is given into a vein (injected) or taken thorough the mouth, the medication enters into the bloodstream, and can reach cancer cells throughout the body(systemic treatment).
Stage III: Concurrent Treatment: Often, lung cancer has spread to local lymph nodes in the chest, but has not moved to other parts of the body. In this stage, termed local-regional lung cancer (stage III), patients can be cured with a combination of chemotherapy with radiation. The type of chemotherapy given in these cases depends on the patient’s clinical condition and the specific type of radiation used.
Stage IV treatment: Palliative treament: Unfortunately, most patients (55-65%) with lung cancer present with stage IV, inoperable diseae. In this all too common scenario, the only options are systemic chemotherapy (chemotherapy given by IV) and oral, targeted agents. The type of chemotherapy, number of cycles and frequency of treatment is based on the patient’s clinical condition and certain features of the tumor . Some commonly used chemotherapy medications are Cisplatin, Carboplatin, Taxotere, Taxol, Gemcitabine, Navelbine and Alimta. Fortunately, we now have a new class of medications for lung cancer that work by blocking the signals that make cancer cells grow and spread (termed “molecular targeted therapy”) This new generation of medications includes anti-angiogenic agents such as bevacizumab (Avastin), which inhibit blood vessel supply and growth of the tumor and oral inhibitors of the epidermal growth factor receptor (EGFR), such as gefitinib (Iressa) and erlotinib (Tarceva). There is much promise in these drugs as they continue to be tested in lung cancer to improve clinical outcomes. In addition to those agents already approved for lung cancer we are investigating new treatment options in our ongoing clinical trials including two vaccine studies and as well as several trials using newer chemotherapy or molecularly targeted agents.
Improved diagnostic tools, such as sophisticated imaging procedures and endoscopy (a thin, lighted tube is inserted through the mouth and down the throat into the esophagus, where tissue samples may be taken for biopsy), as well as new surgical procedures -- including robotic and other minimally invasive techniques -- bring new hope to patients with esophageal cancer. Our program offers all these latest diagnostic and treatment technologies, including radiation and chemotherapy, as well as a multidisciplinary approach to care.
For appropriate patients, we offer a totally minimally invasive approach using laparoscopy and a combination of video-assisted thoracoscopic surgery (VATS) and robotic surgery. Our multidisciplinary approach for the treatment of this condition involves the use of esophageal stents, endoluminal treatment and innovative radiation therapies.
The evaluation of mediastinal masses can be done through minimally invasive incisions and video assistance. While some tumors are benign and can be removed surgically, others need only a biopsy for diagnosis. Our less invasive diagnostic methods save the patient from larger, more painful incisions.
After complete evaluation and diagnosis, a number of treatment options may be available. Some types of tumors respond well to chemotherapy or radiation therapy. Others are better treated with surgery. In some situations, a combination of approaches is best.
If surgery is warranted, a number of minimally invasive approaches have been developed over the last decade. Video-assisted thoracoscopic surgery (VATS) is a procedure that uses a small camera and pencil-sized incisions to look into the chest cavity and to biopsy and/or surgically remove mediastinal tumors. ?More recently, robotic surgery has been used to treat many mediastinal diseases. In fact, our surgeons were among the first groups to develop, use and publish their results with robotic surgery for all forms of thoracic and cardiac surgery, including thymectomy (removal of the thymus gland) for myasthenia gravis, mediastinal evaluation of tumors, and complex posterior mediastinal
Meticulous preoperative diagnostic testing and planning is absolutely critical in treating paravertebral tumors. While some of these disorders require complex open surgeries, some of them can be corrected with Eliana Center's expertise in advanced minimally invasive techniques or video-assisted thoracoscopic techniques.
Lymphoma is a type of cancer that develops in the body's immune system or lymphatic system. The lymph system is made up of thin tubes that branch into all parts of the body. Lymph vessels carry lymph, a colorless, watery fluid that contains white blood cells called lymphocytes. Along the network of vessels are groups of small, bean-shaped organs called lymph nodes, found in clusters in the underarm, pelvis, neck and abdomen. The lymph nodes make and store infection-fighting cells. Several organs are also involved in the body's defense against infection, including the spleen (an organ in the upper abdomen), the thymus (a small organ beneath the breastbone), and the tonsils (an organ in the throat).
Since lymph tissue is found throughout the body, lymphoma can begin almost anywhere and can spread to almost any other part of the body. The multidisciplinary approach of the Comprehensive Thoracic Oncology Program is, therefore, especially well suited to the treatment of lymphoma.
Two Kinds of Lymphoma
Lymphoma comes in two common forms:
- Hodgkin's Disease, which most commonly affects young adults and sometimes people older than 55 years of age, and makes up about 15% of all lymphomas. The disease typically occurs in the lymph nodes above the collarbone, and in younger adults is more likely to appear on the chest cavity between the lungs.
- Non-Hodgkin's Lymphoma, which occurs mostly in older adults with an average age of about 67. It makes up about 85% of all lymphomas. While this form of the disease occurs most often in the lymph nodes above the collarbone, it can also appear in the nodes in the abdomen. The non-Hodgkin's lymphomas are less predictable and more apt to spread.
Diagnosing and Treating Lymphoma
The chance of recovery and choice of treatment depend on the stage of the cancer (whether it is just in one area or has spread throughout the body), the size of the swollen areas, the results of blood tests, the type of symptoms, and the patient's age, sex and overall condition. Typical treatment options available at the Eliana Center include chemotherapy and radiation therapy.
While not associated with the immediate presence of cancer in most cases, many benign esophageal diseases are risk factors for the development of esophageal cancer. Physicians at the Eliana Center for Healing and Treatment of Thoracic Cancer have extensive expertise with these diseases and their proper treatment. Such conditions include:
- Gastroesophageal reflux disease (GERD), which occurs when acidic stomach contents flow back into the esophagus. Common symptoms include heartburn, regurgitation, reflux-induced cough or asthma, and difficulty swallowing due to esophageal scarring and narrowing.
- Esophageal motility disorders, which are characterized by uncoordinated muscle contractions along the esophagus that prohibit efficient swallowing. One such disorder, achalasia, occurs when the muscle at the lower end of the esophagus prevents food from entering the stomach. Also, the muscle along the lower half of the esophagus may not contract properly to propel food down the esophagus. These abnormalities cause food to remain in the esophagus, which can lead to lung infections or breathing disorders.
- Esophageal diverticulum, which resembles a small hernia or pouch protruding through the wall of the esophagus. This protrusion traps food and can cause swallowing difficulties, bad breath, regurgitation, breathing disorders or infections.
- Benign esophageal cysts and tumors, which can cause chest pain and difficulty swallowing and breathing.
Treatment for Benign Esophageal Disorders
There are many ways that the surgeons of the Comprehensive Thoracic Oncology Program can help patients with benign esophageal diseases and conditions. Some examples include:
Patients who do not respond to medical therapy, and younger patients who want to avoid a life-long GERD medication program, may be candidates for surgical correction of the esophageal anti-reflux mechanism. Our surgeons typically perform this minimally invasive procedure through small incisions in the abdomen. For some patients with very advanced disease, however, more extensive procedures may be required. Our surgeons have the experience to employ these methods when necessary. In certain situations, daVinci Robotic assistance is used by our surgeons.
Our surgeons treat achalasia and esophageal diverticulum with minimally invasive and robotic techniques designed to remedy the disorder and alleviate the underlying causes. Benign esophageal cysts and tumors can be surgically removed by using minimally invasive techniques, such as video-assisted thoracoscopic surgery (VATS) and robotic surgery.
Sometimes, a lung cancer tumor will grow into the spine or other vertebral structures, such as the nerve roots. This growth is a difficult complication that can result in pain, weakness or paralysis, depending on the location of the tumor and whether it has invaded or compressed nerve roots or the spinal cord.
The Eliana Center for the Treatment and Healing of Thoracic Cancer has extensive experience in the surgical removal of mediastinal tumors and cysts, particularly using innovative minimally invasive procedure. This capability has been applied to other disorders, including the treatment of myasthenia gravis.
Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of muscular weakness. Myasthenia gravis is caused by a defect in the transmission of nerve impulses to muscles because of an abnormal antibody released by the body's own immune system.
Thymectomy and Myasthenia Gravis
Thymectomy, the surgical removal of the thymus gland (which often is abnormal in myasthenia gravis patients), improves symptoms in certain patients and may cure some individuals, possibly by re-balancing the immune system.
Previously, good candidates for thymectomy required complex, invasive surgeries to remove the thymus gland. Minimally invasive incisions and robotic technology now allow Eliana Center's surgeons to routinely remove the thymus gland for tumors or treat myasthenia gravis through smaller incisions and in a less invasive manner.
Our surgeons performed the world's first complete endoscopic robotic thymectomy for myasthenia gravis. Using the da Vinci Surgical System, a camera and two small pencil-sized instruments are placed inside the chest cavity. While this technique is similar to thoracoscopic or video-assisted thoracoscopic surgery (VATS), the robotic system allows improved visualization and improved dissection and suturing capabilities compared to VATS. These abilities may even be improvements over open surgery because of the increased magnification and precise dissection techniques.
There are many non-cancerous conditions in the lungs that can benefit from the expertise of the surgeons of the Comprehensive Thoracic Oncology Program. Such conditions include:
Spontaneous pneumothorax, which occurs when air leaks through weak spots into the space between the lung and chest wall. This leakage causes the lung to partially collapse and makes breathing more difficult. Treatment frequently includes surgically inserting a chest tube to relieve pressure on the lung and enable it to re-inflate. We can also surgically repair suspected weak spots or chemically treat the lung surface to prevent future collapse.
Emphysema, which is one of a group of lung disorders known as chronic obstructive pulmonary disease (COPD). Emphysema's predominant symptoms include shortness of breath and sensations of breathlessness. Over time, the effort to draw a breath becomes more labored. Emphysema sufferers may find relief from lung reduction surgery, which often eliminates the need for oxygen therapy and significantly enhances breathing. Many patients with cancerous diseases also have emphysema. Our knowledge of techniques to remove or repair areas of emphysema can significantly reduce the risk of surgery in these patients and improve their quality of life.
Interstitial lung disease, which is the general term for a diverse group of chronic disorders. When a surgical biopsy is necessary to identify the specific type of interstitial disease, our surgeons routinely use minimally invasive techniques to reduce risk and trauma, especially among extremely ill patients.