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Stages of Lung Cancer

Occult Carcinoma

Occult lung cancer means that cancerous cells are present in the sputum, but as yet, no cancer can be found in the lung. The diagnostic evaluation of occult lung cancer most often includes a chest x-ray and selective bronchoscopy with follow-up CT scan if necessary, to define the site and nature of the primary tumor. Once the primary tumor is found and stage is established, treatment choices are based on the stage of disease.

Stage 0 (Carcinoma in situ)

Stage 0 lung cancer is that found only in the layer of cells that line the air passages, and is generally discovered through “sputum cytology”. Since most lung cancer patients are diagnosed at a later stage, Stage 0 patients are generally those who have either participated in a lung screening trial, or have sought out special screening tests because they are considered to be at high risk.

Carcinoma in situ tumors are by definition, noninvasive and incapable of metastasizing, however, they do frequently progress to invasive cancer. Patients may be offered surveillance bronchoscopies, and if lesions are detected, potentially curative therapies.

Standard treatment options may include surgical resection using the least extensive techniques possible (segmentectomy or wedge resection) with the goal of preserving maximum normal pulmonary tissue because of the high incidence of second primary cancers. If lesions are centrally located, a lobectomy may be required. Patients with central lesions may also be candidates for endobronchial therapies including photodynamic therapy, electrocautery, cryotherapy and Nd-YAG laser therapy.

Stage I Non-Small Cell Lung Cancer

Stage I non-small cell lung cancer is located only in one lung and has not spread to nearby lymph nodes or outside of the chest. For patients diagnosed at this early stage, surgery is the treatment of choice traditionally, however, many doctors now recommend a multi-modality approach in which two or more types of treatment are combined. Because every patient’s circumstances are different, the type of surgery recommended (segmentectomy, lobectomy, pneumonectomy) as well as whether the addition of chemotherapy or radiation is appropriate, is evaluated on a case by case basis. Once treatment options have been given, patients should then weigh the potential benefits versus risks for each option.

Surgery

Surgical removal of the cancer may be accomplished through various techniques including segmentectomy (removal of a small segment of the lung), lobectomy (removal of a lobe of the lung) or pneumonectomy (removal of the entire lung). Careful pre-operative assessment of the patient’s age and overall health status, as well as where the cancer is located is critical in making this decision. Generally speaking, the less lung removed, the greater the preservation of lung function and the lower the risk of complications from the surgery. On the other hand, if too little lung is removed there is an increased risk of local recurrence. Before committing to surgery, patients should discuss all possibilities thoroughly with their medical team. More on lung cancer surgery.

Chemotherapy

Although the cure rate for Stage 1 non-small cell lung cancer is approximately 60% with surgery, it should not be assumed that surgical removal will account for the containment of every single cancer cell. It may be possible that even in early stage cancer some cells have spread outside the lung and may not be detectable with current testing methods. In order to improve the odds of a cure, chemotherapy given before surgery (neoadjuvant) or after surgery (adjuvant) is often suggested. It is the opinion of some medical professionals that using both neoadjuvant and adjuvant chemotherapy helps to reduce the likelihood of recurrence. More on chemotherapy for lung cancer.

Radiation

Some Stage 1 non-small cell lung cancer patients are not surgical candidates based on their age or on concurrent health conditions that would make surgery too risky. For these patients, the use of newer imaging techniques such as positron emission tomography (PET) can more precisely stage their cancer so that radiation can be used. In a recently conducted clinical trial in which patients who were either not able to, or did not wish to undergo surgery, were given radiation twice daily for five weeks, results demonstrated that radiation alone produced an average survival time of over 34 months. More on radiation therapy for lung cancer.

Although the treatments listed above are “standard” care options for which specific cancer patients may be eligible, not every treatment is appropriate for every patient, nor does every patient wish to pursue aggressive treatment. In addition, there may be other newer techniques or clinical trials still under investigation for which a patient may qualify. It is highly encouraged that a solid doctor/patient relationship be established so all potential options can be evaluated, and a course of action determined.

Stage II Non-Small Cell Lung Cancer

Stage II non-small cell lung cancer is located only in one lung and may involve lymph nodes on the same side of the chest that do not include lymph nodes in the mediastinum. For patients diagnosed with Stage II non-small cell lung cancer, surgery is considered to be the best first-line treatment for those who qualify, however, Stage II patients often require more than one therapeutic approach to increase effectiveness and to control microscopic disease that can lead to recurrence.

Surgery

Surgical options for Stage II non-small cell lung cancer patients are basically the same as for Stage I patients. The initial objective of doctors is to determine, based on the size and location of the tumor, whether it is possible for the cancer to be removed surgically and how well the surgery will be tolerated by the patient. In general, the surgical removal of Stage II cancers results in over 25% to 30% of patients being alive with no evidence of recurring cancer within five years of treatment.

Chemotherapy

Since the optimal treatment of Stage II non-small cell lung cancer often includes treatment regimens beyond surgery, this “multi-modality” approach may be best carried out at a major cancer center where the patient has access to surgeons, medical oncologists and radiation oncologists that work in a team setting. As with Stage I chemotherapy options, treatment may be neoadjuvant, adjuvant or both. Studies are being conducted on a continual basis to determine what treatment or combination of treatments provides the most benefits with the fewest risks for the largest patient population.

Radiation

Patients with potentially operable tumors but who have other medical contraindications to surgery or those with inoperable Stage II disease but with sufficient pulmonary reserve may be candidates for radiation therapy with curative intent. Careful treatment planning with attention to the precise definition of target volume and the avoidance of critical normal structures is necessary to achieve the best results.

An alternative staging methodology is known as TNM (Tumor, Nodes, Metastasis). This staging system provides more information about the tumor and how it has spread. See the following table to compare TNM Stages to Stages 0 to 2:

Stages 0 to 2 of Lung Cancer
Stage TNM (Tumor, Nodes, Metastasis) Definition
Occult carcinoma TX, N0, M0 TX = Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy.

N0 = No regional lymph node metastasis.

M0 = No distant metastasis.
0 Tis, N0, M0 Tis = Carcinoma in situ.

N0 = No regional lymph node metastasis.

M0 = No distant metastasis.
IA T1a, N0, M0

T1b, N0, M0
T1a = Tumor =2 cm in greatest dimension.

T1b = Tumor >2 cm but =3 in greatest dimension.

N0 = No regional lymph node metastasis.

M0 = No distant metastasis.
IB
T2a, N0, M0
T2a = Tumor >3 cm but =5 cm in greatest dimension.

N0 = No regional lymph node metastasis.

M0 = No distant metastasis.
IIA T1a, N1, M0

T1b, N1, M0

T2a, N1, M0

T2b, N0, M0
T1a = Tumor =2 cm in greatest dimension.

T1b = Tumor >2 cm but =3 cm in greatest dimension.

T2a = Tumor >3 cm but =5 cm in greatest dimension.

T2b = Tumor >5 cm but =7 cm in greatest dimension.

N0 = No regional lymph node metastasis.

N1 = Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension.

M0 = No distant metastasis.
IIB T2b, N1, M0

T3, N0, M0
T2b = Tumor >5 cm but =7 cm in greatest dimension.

T3 = Tumor >7 cm or one that directly invades any of the following: parietal pleural (PL3) chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura or parietal pericardium.

Tumor in the main bronchus (<2 cm distal to the carina, but without involvement of the carina.
Associated atelectasis or obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe.

N0 = No regional lymph node metastasis.

N1 = Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension.

M0 = No distant metastasis.

 

Clinical Trials

Clinical trials are investigative studies that evaluate the safety and effectiveness of new techniques or drugs. Participation in a clinical trial can offer cancer patients access to potentially better treatments than are currently available. Crizotinib (PF-02341066), a drug currently in the clinical trial system, has shown remarkable response rates in advanced stage non-small cell lung cancer patients who exhibit a specific mutation. Two other drugs that are now approved by the Food & Drug Administration, erlotinib (Tarceva) and gefitinib (Iressa) have also provided high response rates. Patients who are interested in participating in a trial should discuss the possible benefits and risks with their doctors. The National Cancer Institute, which can be accessed online at www.cancer.gov maintains a clinical trial database that is updated on a monthly basis.

Compensation information is available for those diagnosed with lung cancer. Call us toll-free at 1-800-258-1054.

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