Lung Cancer, Non-Small Cell

Lung Cancer, Non-Small Cell: General Information

Lung Cancer, Non-Small Cell

Stages of Non-Small Cell Lung Cancer

Recurrent Non-Small Cell Lung Cancer

There are several types of non-small cell lung cancer. Each type of non-small cell lung cancer has different kinds of cancer cells. The cancer cells of each type grow and spread in different ways. The types of non-small cell lung cancer are named for the kinds of cells found in the cancer and how the cells look under a microscope:

Squamous (SKWAY-mus) cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that look like fish scales. This is also called epidermoid carcinoma.
Large cell carcinoma: Cancer that may begin in several types of large cells.
Adenocarcinoma: (A-den-oh-KAR-sih-NOH-muh) Cancer that begins in the cells that line the alveoli and make substances such as mucus.

Other less common types of non-small cell lung cancer are: pleomorphic, carcinoid tumor, salivary gland carcinoma, and unclassified carcinoma.

Smoking can increase the risk of developing non-small cell lung cancer.

Smoking cigarettes or cigars is the most common cause of lung cancer. The more years a person smokes, the greater the risk. If a person has stopped smoking, the risk becomes lower as the years pass, but is never completely gone.

Anything that increases a person's chance of developing a disease is called a risk factor. Risk factors for lung cancer include the following:

Smoking cigarettes or cigars, now or in the past.
Being exposed to second-hand smoke.
Being treated with radiation therapy to the breast or chest.
Being exposed to asbestos, radon, chromium, arsenic, soot, or tar.
Living where there is air pollution.

When smoking is combined with other risk factors, the risk of developing lung cancer is increased.

Video (Dr. Frederick Grannis, Section Head of Thoracic Surgery at City of Hope Medical Center, discusses lung cancer and the effects of smoking.)

Possible signs of non-small cell lung cancer include a cough that doesn't go away and shortness of breath.

Sometimes lung cancer does not cause any symptoms and is found during a routine chest x-ray. Symptoms may be caused by lung cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

A cough that doesn’t go away.
Trouble breathing.
Chest discomfort.
Wheezing.
Streaks of blood in sputum (mucus coughed up from the lungs).
Hoarseness.
Loss of appetite.
Weight loss for no known reason.
Feeling very tired.

Tests that examine the lungs are used to detect (find), diagnose, and stage non-small cell lung cancer.

Tests and procedures to detect, diagnose, and stage non-small cell lung cancer are often done at the same time. The following tests and procedures may be used:

Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits, including smoking, and past jobs, illnesses, and treatments will also be taken.
Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
Sputum cytology: A procedure in which a pathologist views a sample of sputum (mucus coughed up from the lungs) under a microscope, to check for cancer cells.
Fine-needle aspiration biopsy of the lung: The removal of part of a lump, suspicious tissue, or fluid from the lung, using a thin needle. This procedure is also called needle biopsy. Ultrasound or another imaging procedure is used to locate the abnormal tissue or fluid in the lung. A small incision may be made in the skin where the biopsy needle is inserted into the abnormal tissue or fluid. A sample is removed with the needle and sent to the laboratory. A pathologist then views the sample under a microscope to look for cancer cells. A chest x-ray is done after the procedure to make sure no air is leaking from the lung.
Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope (a thin, lighted tube) is inserted through the nose or mouth into the trachea and lungs. Tissue samples may be taken for biopsy.
Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs, and a thoracoscope (a thin, lighted tube) is inserted into the chest. Tissue samples and lymph nodes may be removed for biopsy. This procedure may be used to remove parts of the esophagus or lung. If certain tissues, organs, or lymph nodes can’t be reached, a thoracotomy may be done. In this procedure, a larger incision is made between the ribs and the chest is opened.
Thoracentesis: The removal of fluid from the space between the lining of the chest and the lung, using a needle. A pathologist views the fluid under a microscope to look for cancer cells.

Videos (Dr. Claudia Henschke, a Radiologist at Weill Cornell Medical College, discusses her group's study of early lung cancer detection. In a later episode she returns to provide a follow-up of her study.)

Certain factors affect prognosis (chance of recovery) and treatment options.

The stage of the cancer (the size of the tumor and whether it is in the lung only or has spread to other places in the body).
The type of lung cancer.
Whether there are symptoms such as coughing or trouble breathing.
The patient’s general health.

For most patients with non-small cell lung cancer, current treatments do not cure the cancer. If lung cancer is found, taking part in one of the many clinical trials being done to improve treatment should be considered. Clinical trials are taking place in most parts of the country for patients with all stages of non-small cell lung cancer.

Stages of Non-Small Cell Lung Cancer

After lung cancer has been diagnosed, tests are done to find out if cancer cells have spread within the lungs or to other parts of the body.

The process used to find out if cancer has spread within the lungs or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Some of the tests used to diagnose non-small cell lung cancer are also used to stage the disease. (See the General Information section.) Other tests and procedures that may be used in the staging process include the following:

Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time.
Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. This procedure is also called nuclear magnetic resonance imaging (NMRI).
Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography. EUS may be used to guide fine needle aspiration biopsy of the lung, lymph nodes, or other areas.
Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells.
Mediastinoscopy: A surgical procedure to look at the organs, tissues, and lymph nodes between the lungs for abnormal areas. An incision (cut) is made at the top of the breastbone and an endoscope (a thin, lighted tube) is inserted into the chest. Tissue and lymph node samples may be taken for biopsy.

mediastinoscope is inserted into the chest through an incision above the breastbone to look for abnormal areas between the lungs. Enlarge

Anterior mediastinotomy: A surgical procedure to look at the organs and tissues between the lungs and between the breastbone and spine for abnormal areas. An incision (cut) is made next to the breastbone and an endoscope (a thin, lighted tube) is inserted into the chest. Tissue and lymph node samples may be taken for biopsy. This is also called the Chamberlain procedure.

Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.

The following stages are used for non-small cell lung cancer:

Occult (hidden) stage

In the occult (hidden) stage, cancer cells are found in sputum (mucus coughed up from the lungs), but no tumor can be found in the lung by imaging or bronchoscopy, or the primary tumor is too small to be checked.

Stage 0 (carcinoma in situ)

In stage 0 (carcinoma in situ), cancer is in the lung only and has not spread beyond the innermost lining of the lung.

Stage I

Stage I is divided into stages IA and IB:

Stage IA: The tumor is in the lung only and is 3 centimeters or smaller.
Stage IB: One or more of the following is true:
- The tumor is larger than 3 centimeters.
- Cancer has spread to the main bronchus of the lung, and is at least 2 centimeters from the carina (where the trachea joins the bronchi).
- Cancer has spread to the innermost layer of the membrane that covers the lungs.
- The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or developed pneumonitis (inflammation of the lung).

Stage II

Stage II is divided into stages IIA and IIB:

Stage IIA: The tumor is 3 centimeters or smaller and cancer has spread to nearby lymph nodes on the same side of the chest as the tumor.
Stage IIB:
- Cancer has spread to nearby lymph nodes on the same side of the chest as the tumor and one or more of the following is true:
  - The tumor is larger than 3 centimeters.
  - Cancer has spread to the main bronchus of the lung and is 2 centimeters or more from the carina (where the trachea joins the bronchi).
  - Cancer has spread to the innermost layer of the membrane that covers the lungs.
  - The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or developed pneumonitis (inflammation of the lung).
  or
- Cancer has not spread to lymph nodes and one or more of the following is true:
  - The tumor may be any size and cancer has spread to the chest wall, or the diaphragm, or the pleura between the lungs, or membranes surrounding the heart.
  - Cancer has spread to the main bronchus of the lung and is no more than 2 centimeters from the carina (where the trachea meets the bronchi), but has not spread to the trachea.
  - Cancer blocks the bronchus or bronchioles and the whole lung has collapsed or developed pneumonitis (inflammation of the lung).

Stage IIIA

In stage IIIA, cancer has spread to lymph nodes on the same side of the chest as the tumor. Also:

The tumor may be any size.
Cancer may have spread to the main bronchus, the chest wall, the diaphragm, the pleura around the lungs, or the membrane around the heart, but has not spread to the trachea.
Part or all of the lung may have collapsed or developed pneumonitis (inflammation of the lung).

Stage IIIB

In stage IIIB, the tumor may be any size and has spread:

To lymph nodes above the collarbone or in the opposite side of the chest from the tumor; and/or
To any of the following:
- Heart.
- Major blood vessels that lead to or from the heart.
- Chest wall.
- Diaphragm.
- Trachea.
- Esophagus.
- Sternum (chest bone) or backbone.
- More than one place in the same lobe of the lung.
- The fluid of the pleural cavity surrounding the lung.

Stage IV

In stage IV, cancer may have spread to lymph nodes and has spread to another lobe of the lungs or to other parts of the body, such as the brain, liver, adrenal glands, kidneys, or bone.

Treatment Option Overview

There are different types of treatment for patients with non-small cell lung cancer.

Different types of treatments are available for patients with non-small cell lung cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Six types of standard treatment are used:

Surgery

Four types of surgery are used:

Wedge resection: Surgery to remove a triangle-shaped slice of tissue. Wedge resection is used to remove a tumor and a small amount of normal tissue around it. When a slightly larger amount of tissue is taken, it is called a segmental resection.

Lobectomy: Surgery to remove a whole lobe (section) of the lung.

Pneumonectomy: Surgery to remove one whole lung.

Sleeve resection: Surgery to remove part of the bronchus.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

Radiosurgery is a method of delivering radiation directly to the tumor with little damage to healthy tissue. It does not involve surgery and may be used to treat certain tumors in patients who cannot have surgery.

The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Video (Dr. Kemp Kernstine, Director of the Lung Cancer Program in City of Hope, discusses an article where a test can determine if chemotherapy would benefit a lung cancer patient.

Video (Dr. David Harpole, a Professor of Thoracic Surgery at Duke University Medical Center, explains how researchers at Duke have developed the first genomic test which can predict which patients with lung cancer would benafit from chemotherapy.)

Laser therapy

Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. Fiberoptic tubes are then used to deliver the laser light to the cancer cells, where the drug becomes active and kills the cells. Photodynamic therapy causes little damage to healthy tissue. It is used mainly to treat tumors on or just under the skin or in the lining of internal organs.

Watchful waiting

Watchful waiting is closely monitoring a patient’s condition without giving any treatment until symptoms appear or change. This may be done in certain rare cases of non-small cell lung cancer.

New types of treatment and prevention are being tested in clinical trials. These include the following:

Chemoprevention

Chemoprevention is the use of drugs, vitamins, or other substances to reduce the risk of developing cancer or to reduce the risk cancer will recur (come back).

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

New combinations

New combinations of treatments are being studied in clinical trials.

Treatment Options By Stage

Occult Non-Small Cell Lung Cancer

Treatment of occult non-small cell lung cancer depends on where the cancer has spread. It can usually be cured by surgery.

Stage 0 Non-Small Cell Lung Cancer

Treatment of stage 0 non-small cell lung cancer may include the following:

Surgery (wedge resection or segmental resection).
Photodynamic therapy using an endoscope.

Stage I Non-Small Cell Lung Cancer

Treatment of stage I non-small cell lung cancer may include the following:

Surgery (wedge resection, segmental resection, or lobectomy).
External radiation therapy (for patients who cannot have surgery or choose not to have surgery).
Surgery followed by chemotherapy.
A clinical trial of photodynamic therapy using an endoscope.
A clinical trial of surgery followed by chemoprevention.

Stage II Non-Small Cell Lung Cancer

Treatment of stage II non-small cell lung cancer may include the following:

Surgery (wedge resection, segmental resection, lobectomy, or pneumonectomy).
External radiation therapy (for patients who cannot have surgery or choose not to have surgery).
Surgery followed by chemotherapy, with or without other treatments.
A clinical trial of external radiation therapy following surgery.

Stage IIIA and Stage IIIB Non-Small Cell Lung Cancer

Treatment of stage IIIA non-small cell lung cancer may include the following:

Surgery with or without radiation therapy.
External radiation therapy alone.
Chemotherapy combined with other treatments.
A clinical trial of new ways of giving radiation therapy and chemotherapy.
A clinical trial of new combinations of treatments.

Treatment of stage IIIB non-small cell lung cancer may include the following:

External radiation therapy alone.
Chemotherapy combined with external radiation therapy.
Chemotherapy combined with external radiation therapy, followed by surgery.
Chemotherapy alone.
A clinical trial of new ways of giving radiation therapy.
A clinical trial of new combinations of treatments.

Stage IV Non-Small Cell Lung Cancer

Treatment of stage IV non-small cell lung cancer may include the following:

Watchful waiting.
External radiation therapy as palliative therapy, to relieve pain and other symptoms and improve the quality of life.
Chemotherapy.
Laser therapy and/or internal radiation therapy.
A clinical trial of chemotherapy with or without biologic therapy.

Recurrent Non-Small Cell Lung Cancer

Recurrent non-small cell lung cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the brain, lung, or other parts of the body

Treatment of recurrent non-small cell lung cancer may include the following:

External radiation therapy as palliative therapy, to relieve pain and other symptoms and improve the quality of life.
Chemotherapy alone.
Surgery (for some patients who have a very small amount of cancer that has spread to the brain).
Laser therapy or internal radiation therapy.
Radiosurgery (for certain patients who cannot have standard surgery).
A clinical trial of biologic therapy or other new treatments.

Source: National Cancer Institute