First, see what the guidelines say
Lung cancer with different strains and stages has a different course of treatment. According to the latest 2018 guidelines from the National Comprehensive Cancer Network (NCCN), the main recommendations for the comprehensive treatment of stage I non-small cell lung cancer (NSCLC) are as follows.
- Surgery is preferred, including lobectomy + systemic hilar and mediastinal lymph node dissection, either thoracoscopic or open-heart.
- Anatomic lung segmental or wedge resection (“less than lobectomy”) + systematic hilar and mediastinal lymph node dissection or sampling may be considered in a subset of stage IA patients who are elderly, or have poor lung function.
- Stage IA and IB patients with complete tumor resection usually do not require adjuvant chemotherapy, radiation therapy, and targeted drug therapy after surgery; however, in stage IB patients with high risk factors for recurrence, physicians may selectively consider adjuvant chemotherapy.
- Re-operation is recommended for stage I lung cancer with positive margins (margins with tumor residue in the naked eye, or microscopically); if for some reason re-operation is not possible, post-operative combination chemoradiotherapy is recommended.
- If there are severe medical comorbidities, advanced age that precludes surgery, or if the patient refuses surgery, radical radiation therapy, or image-guided radiofrequency ablation may be used.
If you would like to know what is going on with lobectomy, segmental lung, or wedge lung resection as described above, please read the related article:
See two more patients’ treatment
You may find these professional descriptions difficult to understand, so let’s take a look at two typical cases.
Case 1
Mr. Chen, 56 years old, had been a smoker for 30 years, and was seen in the outpatient clinic for a physical examination of his unit, which revealed a “pure ground glass nodule” (8 mm) in the right upper lung.
Mr. Chen had regular checkups for two years, and his most recent exam revealed an enlarged nodule (14 mm) with a partially solid component and “short burrs,” which are often suggestive of malignancy.
The doctor recommended surgery, and Mr. Chen was hospitalized, underwent a comprehensive fiberoptic bronchoscopy and cardiopulmonary function tests, and had no contraindications to surgery, so he underwent a partial right upper lung resection. Intraoperative cryopathology suggested: invasive adenocarcinoma, so right upper lung lobectomy + systemic lymph node dissection was performed. Postoperative pathology suggested: no metastasis in lymph nodes.
Mr. Chen recovered well and has been discharged from the hospital with regular follow-ups and no need for further radiation or chemotherapy.
Case 2
Aunt Zhao, 64 years old, presented to the hospital with a chest CT indicating a left upper lung nodule (2.8 cm*2.4 cm*2.2 cm) due to a recent severe cough with blood.
Aunt Zhao was hospitalized and underwent PET-CT, which suggested a hypermetabolic lesion in the left upper lung, which was considered malignant; no malignant manifestations were seen in the mediastinum, hilar lymph nodes, or the rest of the body.
Further refinement of fiberoptic bronchoscopy and cardiopulmonary function tests were performed, and she had no obvious contraindications to surgery. After discussion, the surgeon decided to perform a partial resection of the left upper lung (lobectomy + systemic lymph node dissection) with intraoperative frozen pathology suggesting adenocarcinoma, and performed a complete lung cancer resection with postoperative pathology suggesting no metastasis in the lymph nodes and stage T1cN0M0.
Auntie Zhao is also currently undergoing regular review and has not had further radiation or chemotherapy.
Frequently asked questions about early lung cancer treatment
After reading the stories of these two patients, you may have some questions, which are answered below.
Q1, why did Auntie Zhao have obvious coughing and coughing up blood, but Mr. Chen did not?
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A1, the vast majority of early-stage lung cancers are insidious and do not show abnormal manifestations; a few patients may have irritating dry cough, coughing up blood or chest tightness.
Epidemiological surveys in China show that most patients are already in the middle to late stages when lung cancer is diagnosed, so it is especially important for people at high risk for lung cancer to have regular medical checkups. Mr. Chen was diagnosed with a very early lesion on a chest CT during a physical examination and received timely treatment.
Q2, the same lung nodule was found, why didn’t Mr. Chen just have surgery, and would delaying the disease for two years cause a delay?
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A2, in the specialty, pulmonary nodules can be classified as pure ground glass nodules (pGG0), partially solid nodules (mGGO), and solid nodules, depending on their density. According to the guidelines, pGG0, which is less than 20 mm in diameter, is considered relatively “safe” and can be followed up, with interventions if it becomes larger and more solid during the follow-up process.
There are many international studies that have demonstrated the safety of pGG0. A follow-up study of 1046 pGGO patients at the National Cancer Center in Japan showed that after almost 4 years of observation, only 56 cases turned into partially solid nodules, and most pGG0 remained unchanged.
A Korean study showed that of the 19919 people screened for small pulmonary nodules from 1997 to 2006, 122 were screened for GGO, and after nearly 5 years of observation, 90.2% of the GGOs were unchanged or even shrunk.
Overall, therefore, there is no need to panic if pGG0 is found, and it is important to follow up regularly and treat it with surgery and other treatments if there is any change. The early stages of lung cancer evolve more slowly, and good follow-up does not delay the disease, but can prevent many unnecessary surgeries.
Q3, how can I determine if a lung nodule is malignant when it is found on physical examination? Do I have to have surgery if I don’t know if it’s good or bad?
Q3.
Stage I lung cancer has certain specific manifestations in imaging examinations such as chest CT and PET, such as lobar short burrs and vacuolation signs. Mr. Chen was considered as a possible malignant because of these types of changes in the nodes.
At present, the only means of confirming a diagnosis of lung cancer is pathological examination. In addition to surgery, biopsies can be taken by invasive means such as fiberoptic bronchoscopic biopsy and CT-guided lung puncture. If the malignant manifestation is not obvious, the diagnosis can be confirmed by taking a biopsy and doing pathological tests instead of surgery.
There are different voices in the profession on how to handle cases of highly considered malignancy on imaging. Others believe that invasive procedures carry risks such as pneumothorax and bleeding, and may result in misdiagnosis if the puncture happens to be around the tumor and the tumor is not obtained; also, puncture may create a risk of tumor metastasis along the puncture track (although this risk is very low). In the era of minimally invasive surgery, stage I lung cancer surgery has become much less invasive, and early surgery can help avoid these risks.
For both patients, because the tumors showed a high probability of malignant presentation, the final decision was made after discussion to operate directly, with the extent of resection determined intraoperatively based on frozen pathology to minimize trauma.
Q4. Do patients considered to have stage I lung cancer also need a “whole body workup”? What specific tests are needed?
Q4.
A4. When a doctor considers lung cancer, he or she will do two things: a whole-body tumor assessment and a functional assessment.
Systemic tumor evaluation: Because lung cancer has a tendency to metastasize in the mediastinal lymph nodes and in the brain and bone, the diagnosis of lung cancer should be followed by an exploration for metastatic disease throughout the body. If the high cost of PET is unaffordable, a cranial MRI and bone scan can be done separately to clarify the presence of brain and bone metastases.
Functional assessment: The main purpose is to determine whether the patient can tolerate the surgery, and tests such as cardiac ultrasound and pulmonary function can be done. A detailed preoperative evaluation is helpful to reduce the risk of perioperative complications.
Q5, if diagnosed with stage I lung cancer, is it okay to treat conservatively, take medications, etc.? Do I need chemotherapy even after surgery for stage I lung cancer?
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A5, currently, surgery is the preferred treatment for stage I lung cancer. If a patient is finally diagnosed with stage I lung cancer, after radical surgery, there is usually no need to continue radiation or chemotherapy, but the tumor is still at risk of recurrence, so it is important to follow medical advice and have regular checkups. For individual patients who are judged by their physicians to be at high risk of recurrence after surgery, the physician may recommend postoperative chemotherapy.
Disclaimer:
Tumor disease and treatment options are extremely complex, and treatment should be fully individualized, and this case does not represent a “like patient” treatment decision. Please seek professional advice from a competent physician regarding your specific treatment plan.
Co-authors: Dr. Zheng Shaopeng, Guangdong Provincial People’s Hospital, Guangdong Lung Cancer Institute