If the diagnosis is lung cancer or when there is a high suspicion of lung cancer, the next step is to determine the stage of lung cancer (clinical staging).

The staging of lung cancer is based on:

• The size of the tumor (measured by the CT scan)
• The exact location of the tumor(as seen on the CT scan)
• If the tumor has spread to lymph nodes within the lungs itself
• If the tumor has spread to lymph nodes in the middle of the chest (lymph nodes in the mediastinum)
• If the tumor has spread elsewhere outside the chest – what we call metastasis.

Surgery is the preferred treatment for people with Stage 1and Stage 2 lung cancer who can tolerate surgery.  And in this day and age, surgery is done using minimally invasive thoracic surgery techniques instead of a wide-open cut in the chest.  This minimally invasive technique is referred to as Video Assisted Thoracoscopic Surgery or VATS; and in some hospitals a robot is used to achieve minimally invasive lung surgery.

The goal of surgery is to remove the section of the lung (lobe of the lung) that contains the tumor, and also remove the affected lymph nodes in that area.

How does your doctor know if the tumor has spread to lymph nodes, or elsewhere in the body?

The CT scan which showed the suspected tumor is usually able to give an idea of the size of the tumor, and usually can identify any suspicious lymph nodes in the lungs and any suspicious lymph nodes in the middle of the chest (mediastinum).  The CT scan can also pick up any suspected spread of cancer to the liver, or to the bones in the chest.

A better test is the PET scan (positron emission tomography).  It’s a special test that identifies unusual areas in the body that are “eating up” a lot of sugar.  Fast growing tumors such as lung cancer, usually “light up” on a PET scan because they “eat up” a lot of sugar;  and if it has spread elsewhere, those places will also “light up” on the PET scan for t

he same reason.  The only exception is the non-smokers lung cancer- bronchiolalveolar carcinoma (BAC) or adenocarcinoma in-situ (AIS) and carcinoids, which don’t “light up” on PET scan.  Your thoracic surgeon is usually aware of these exceptions and will pursue this based on clinical suspicion and other unique characteristics on CT scan and PET scan.  You also should know that areas of the body with infection, or pneumonia, or bone fractures also “light up” on PET scan and can confuse the picture.

What if the PET scan suspects the lymph nodes in the middle of the chest (mediastinum)?

In this case, the thoracic surgeon has to prove whether or not those lymph nodes in the mediastinum actually contain lung cancer or not.  The best way to prove this unfortunately involves a minor surgical procedure called “mediastinoscopy” (this is even before the lung cancer is treated).  It involves going to sleep under anesthesia.  The thoracic surgeon then makes a small incision at the base of the neck, and slides a narrow telescope (mediastinoscope) along the front of the windpipe.  Through this mediastinoscope, the thoracic surgeon can biopsy the lymph nodes in the middle of the chest (mediastinum) on both sides of the windpipe to see if they contain lung cancer or not.

An alternative to mediastinoscopy is a less invasive procedure called EBUS (Endo Bronchial Ultrasound Needle biopsy) in which the thoracic surgeon or pulmonologist inserts a flexible bronchoscope equipped with an ultrasound device into the windpipe and performs a needle biopsy of the suspicious lymph nodes in the middle of the chest.  BUT if the results are negative, then a surgical mediastinoscopy (as described above) is required to make sure the result is correct.

Why is it important to confirm whether or not the lung cancer has spread to the lymph nodes in the middle of the chest (mediastinum)?

This is a very important step to guide lung cancer treatment because the treatment for lung cancer is different if it has spread to lymph nodes in the mediastinum compared to if it has not yet spread to those lymph nodes.  For lung cancer that has not spread to the middle lymph nodes (stage 1 and stage 2 lung cancer), treatment is minimally invasive lung surgery, whereas the treatment for lung cancer if it has spread to those lymph nodes in the middle of the chest (stage 3A lung cancer) is chemotherapy to “dry up” the lymph nodes first before considering lung surgery (see lung cancer stages below for more details).

The next paragraphs go into details about the stages of lung cancer and which lung cancers require surgery.

STAGES OF LUNG CANCER AND TREATMENT (This is a simplified summary).

STAGE 1 LUNG CANCER–When the tumor is less than 5 cm and has NOT SPREAD to any lymph nodes within the lung itself.  Basically, this is cancer that was detected quite early and has not spread anywhere.

For those who can tolerate surgery, the preferred treatment for stage 1 lung cancer is minimally invasive lung surgery also known as Video Assisted Thoracoscopic Surgery or VATS.  You don’t need a large cut in the chest for this one, and you don’t need chemotherapy.

The goal of surgery is to remove the section of the lung (the lobe of the lung) that contains the tumor, and also remove the lymph nodes in that area to confirm if the tumor has spread into the lymph nodes or not.

STAGE 2 LUNG CANCER

When the tumor is between 5 and 7 cm or has spread to the lymph nodes within the lungs itself, or the tumor is now growing into the large branches of the windpipe (bronchus) or tumor is now touching nearby organs.

For those who can tolerate surgery, the preferred treatment for stage 2 lung cancer is surgery.  Most stage II lung cancer can be removed with minimally invasive lung surgery or Video Assisted Thoracoscopic Surgery (VATS).  However in some cases the old-fashioned large cut in the chest (thoracotomy) may be necessary- especially when the tumor is stuck to the surface of nearby organs.  If the tumor is located in such a place that the surgeon was unable to get it all out, then radiation therapy and chemotherapy after surgery will be necessary to burn-out any left-over tumor.

As mentioned before, the goal of surgery is to remove the section of the lung (lobe of the lung) t

hat contains the tumor, and also remove the affected lymph nodes in that area.

STAGE 3A LUNG CANCER – The tumor is larger than 7 cm or has spread to lymph nodes in the middle of the chest (mediastinum), or is stuck to the rib cage or to the heart, or the esophagus (swallowing tube).

Patients with stage 3A lung cancer require upfront chemotherapy and radiation therapy to “dry up” the lymph nodes and shrink the tumor before going through with surgery.  Unfortunately after chemotherapy, it becomes more difficult to perform minimally invasive lung cancer surgery safely because the lung tissues become tougher and sticky to the large blood vessels.  In these situations, it is safest to do lung surgery using the old fashioned large cut in the chest (thoracotomy).

Again, the goal of surgery is to remove the section of the lung (lobe of the lung) that contains the tumor, and also remove the affected lymph nodes in that area.

In STAGE 3B LUNG CANCER the tumor has spread to the lymph nodes on the other side of the windpipe and in STAGE 4 LUNG CANCER, the tumor has spread to the other lung, or elsewhere outside the chest (metastasis).  Stage 3B and stage 4 lung cancers are considered “advanced stage” lung cancers; and because the cancer is already widespread, surgery is not effective as a form of treatment.  Rather, chemotherapy with radiation therapy become the best options in stage 3B and stage 4 lung cancers.

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Read about the author: Ugo Ogwudu, M.D. Thoracic surgeon.

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