What Treatment of Malignant Lung Tumors Is Available?
Innumerable pulmonary nodules are discovered each year during Chest X-rays or CT scans.
Most nodules are noncancerous (benign). A solitary pulmonary nodule is found on up to 0.2% of all chest X-rays films.
Lung nodules can be found on up to half of all lung CT scans.
How Is The Cause Of Pulmonary Nodules Diagnosed?
Though most lung nodules are not malignant, it is very important that those representing cancer are identified early in their course, when they are curable.
Chest X-rays and CT Scans
Usually the first sign that a pulmonary nodule is present is a spot on the lung that shows up on a chest X-ray or a CT scan. These tests are usually done when a person sees the doctor for a respiratory illness.
If the X-ray film or CT scan indicates there is a pulmonary nodule, your doctor will ask you about your medical history, including whether you have had cancer in the past. He or she will want to know whether you are a smoker or former smoker and about any exposure to environmental chemicals that may be toxic.
The doctor will look at the X-ray to evaluate the size and shape of the nodule, its location, and its general appearance. Single pulmonary nodules seen on chest x-rays are generally at least 8 to 10 millimeters in diameter. If they are smaller than that, they are unlikely to be visible on a chest X-ray. The larger the nodule is, and the more irregularly shaped it is, the more likely it is to be cancerous. Those located in the upper portions of the lung are also more likely to be cancerous.
If you have any older chest X-rays, you should let your doctor look at them for purposes of comparison. This may allow the doctor to determine the growth rate of the nodule. In general, malignant nodules double in size every 1 to 6 months. Nodules with a slower or faster growth rate are less likely to be cancerous.
Your doctor may recommend that you undergo a CT scan to obtain a more detailed image of the nodule, or your nodule may have first been identified by a CT scan. CT scans can give information about the specific features of the nodule, including its shape, size, location and internal density. CT scans are more accurate than chest x-rays in determining the nature of the nodule. A CT scan can find very small nodules, as small as 1-2 mm in diameter.
If the nodule is small enough or if its features suggest a very low likelihood that it represents a cancer, your doctor is likely to follow the nodule over time with repeated chest imaging. If the nodule does not grow over time, it is confirmed to be benign. If a concerning pace of growth is noted, then additional evaluation would be suggested. The interval between scans and the length of follow-up depends on the size of the nodule and the risk of malignancy.
Positron Emission Tomography (PET)
A PET scan can also help to find out if a nodule is malignant or benign. A PET scan uses a radiolabeled substance such as glucose that is absorbed by the nodule, and able to be imaged, providing a picture of the nodule’s activity level. Malignant cells have a faster metabolic rates than normal cells, so they require more energy and thus absorb more of the radiolabeled substance. Nodules can light up on PET imaging if they are malignant or if there is active inflammation. Nodules smaller than 8-10 mm are not seen well by PET imaging.
Biopsy
A biopsy is a procedure in which a small tissue sample is removed from the nodule so it can be examined under a microscope. It may be performed when other tests are inconclusive to rule out the chance that a growth is malignant.
There are two ways, short of going through surgery, to collect samples from lung tissue. The method used depends on the size and location of the nodule, as well as the comfort of the medical team with these procedures.
Bronchoscopy
This procedure is used if it appears the nodule can be reached through the breathing tubes. It uses a bronchoscope, which is a thin, lighted flexible tube that can be inserted into the mouth or nose and through the windpipe (trachea) into the bronchus (airway) of the lung. The bronchoscope has a very small camera at its end. Biopsy tools can be passed through the camera to reach the nodule.
Needle biopsy (also known as transthoracic needle aspiration)
This test is most successful when the nodule is towards the edge of the lung, near the chest wall. A needle is inserted through the chest wall and into the nodule, usually under the guidance of a CT scan.
If the nodule has a very concerning appearance or growth pattern, or its nature is not able to be clarified by the above tests, the best step may be to remove the nodule. This will clarify its nature while treating it. This requires the patient be fit enough to undergo the surgery.
THE PROCEDURE
If the nodule is malignant, there does not appear to be any spread of the cancer, and the patient is fit, then the cancer should be surgically removed. If a non-surgical biopsy of a nodule with high concern for malignancy is done and the results are inconclusive, it is still recommended that the nodule be taken out.
Surgical techniques to remove Pulmonary Nodules include:
Thoracotomy
This procedure is considered open lung surgery.
A cut is made in the wall of the chest in order to remove pieces of diseased lung tissue.
Patients usually have to remain in the hospital for a few days after the operation.
The mortality risk is low, however when possible, a mini-thoracotomy that is less invasive may be performed.
Video-Assisted Thoracoscopy
This procedure uses a thorascope, a flexible tube with a miniature camera on its end. The thorascope is inserted through a small cut into the chest wall. The camera allows the surgeon to view an image of the nodule on a television screen. This technique requires a smaller cut and a shorter recovery time than a thoracotomy does.
After completing a thorough evaluation and diagnosis, your surgeon will determine the safest surgical approach to treat your medical condition. While some types of mediastinal tumors and lymphomas (cancerous growths) usually respond best to medical treatments such as chemotherapy or radiation, other types of masses, including neurogenic tumors or thymomas, may be best managed with surgery.
Surgical approaches to remove Mediastinal tumors or masses include:
Sternotomy
A traditional open-surgery approach that uses an incision to divide the breast bone to resect or remove large mediastinal masses or tumors. A sternotomy allows access to the entire chest cavity including the heart, great vessels and lungs, and may be necessary for larger tumors and masses.
Thoracotomy
A traditional open-surgery approach that uses an incision to divide the ribs to resect or remove large mediastinal masses or tumors. Similar to a sternotomy, this procedure allows access to the entire chest cavity and enables the thoracic surgeon to safely and effectively remove the tumors or masses.
Minimally Invasive Surgery
While Sternotomies and Thoracotomies are commonly used to treat larger mediastinal masses, a Mediastinoscopy or Videothoracoscopy may be used to treat smaller mediastinal tumors.
Minimally invasive surgical techniques decrease postoperative pain, reduce the length of stay in the hospital, and allow a more rapid recovery and return to work and regular activities. Other possible benefits include reduced risk of infection and less bleeding. Minimally invasive approaches include:
Mediastinoscopy
During a Mediastinoscopy a small cut (incision) is made in the neck just above the breastbone or on the left side of the chest next to the breastbone. Then a thin scope (mediastinoscope) is inserted through the opening.
A tissue sample (biopsy) can be collected through the mediastinoscope and then examined under a microscope for lung problems, such as infection, inflammation, or cancer.In many cases Mediastinoscopy has been replaced by other biopsy methods that use computed tomography (CT), Echocardiography, or Bronchoscopy to guide a biopsy needle to the abnormal tissue.
Mediastinoscopy may still be needed when these methods can't be used or when they don't provide conclusive results.
Video-Assisted Thoracoscopy
Video-Assisted Thoracoscopy is a procedure that uses video-assisted technology to minimize trauma. This procedure is performed in the operating room under general anesthesia. A Thoracoscope (small video-scope) is inserted through a small incision between the ribs to view the mass. Special instruments are inserted through two other small incisions to remove the mass.
While Thoracoscopic surgery offers benefits over the more Traditional Sternotomy or Thoracotomy procedures, video-assisted techniques are most successful when completed by advanced thoracoscopic and minimally invasive thoracic surgeons.
Risks
There are risks of any surgical procedure, including mediastinal surgery. However, the rate of complications from mediastinal surgical procedures is low, with various Mediastinoscopy studies reporting overall complication rates of 1.3 to 3 percent.
PREPARATION FOR SURGERY
Before traveling to Cyprus, as part of your surgery preparation we require detailed medical information in the form of a medical questionnaire, ECG, Pulmonary tests and blood work. In some cases an Angiogram is required.
Although not all the tests may be required for each patient, they usually include:
All of this information will allow the doctors that we work with to determine your eligibility for the procedure. Your surgeon will give you specific instructions about any dietary changes or activity restrictions you should follow before surgery.
Tell your surgeon what medications you are taking, especially aspirin or an anticoagulant ("blood thinner"). Your surgeon will tell you if you should stop taking them. Also bring a complete list of your current medications (including over-the-counter drugs, vitamins and herbal supplements), allergies, your medical records and any health insurance information.
If you smoke, stop immediately to improve your blood flow and breathing.
If you develop a cold, fever or sore throat within a few days of your surgery, or have other questions or concerns, contact our offices immediately.
Ten days prior to your arrival in Cyprus, you will receive all the necessary pre operative instructions, to prepare yourself both physically and mentally for your chosen procedure.
Upon arriving in Cyprus, as part of the pre-surgery tests done at our partner hospitals you will again receive chest X-rays, blood tests, an electrocardiogram and any other pre operative tests your surgeon feels necessary.
Your surgeon and anesthetist will also go through you medical and surgical issues with you. During this visit, your surgeon will discuss your procedure and answer any questions.
Getting Your House Ready Before Your Surgery
It is also important to get your house ready for after you come home from the hospital. At first it will be harder for you to move around, so arrange your furniture and household items ahead of time to make it easier for you during your rehabilitation.
Prepartion for teh hospital
Here are a few things to keep in mind as you pack and prepare for the hospital and recuperation:
Clothing
Getting dressed in the morning helps you feel better, so be sure to bring some comfortable clothing to the hospital:
Day Before Surgery
Your surgical nurse will provide you with these instructions the night before surgery:
Morning Of Surgery
On the day of your surgery, your designated SALUS Patient Concierge along with a nurse may talk with you and your loved ones. They shall tell you what to expect. You will most likely feel a little nervous before surgery, so the SALUS team and the hospital staff will do all they can to answer your questions and help you relax.
Make sure all your medicines in their original containers with you to the hospital.
You will meet with the anesthesiologist who will talk to you about general anesthesia. This is a controlled sleep while the surgery is being done so you will not feel any pain or remember the surgery.
You should leave jewelry, watches, money and other valuables with the person who accompanies you or with our staff member who will place them in our safe.
Proceed with your routine morning care:
You will have an IV or intravenous line put in to give you fluid and medicine during your surgery.
When it is time for you to go to surgery, your family/ companion will be asked to wait in the waiting area. Your doctor will talk to your family/ companion there after your surgery is done.
RECOVERY AFTER SURGERY
After surgery, the patient is moved to the Intensive Care Unit where family members can visit the periodically.
Immediately after the procedure patients are awakened from the general anesthetic and allowed to breathe on their own.
Pain medicine is given through an epidural catheter to help control postoperative discomfort.
Drainage tubes are left in the chest to drain any excess air or fluid from the chest after surgery. These are removed once the air and fluid leakage stops.
Physical therapy is reinstituted early during the recovery phase during the hospitalization.
Patients usually stay in our partner hospitals for about one week or ten days as necessary, after surgery. This time does give our surgeon adequate time to monitor post operative recovery. During this time, some tests will be done to assess and monitor the patient’s condition.
Hospital Discharge And Home Instructions
Your diet is slowly increased from ice chips to liquids to solid foods as your intestines start functioning.
Before leaving the hospital, our surgeon and staff will help you adjust to recovery in every way possible. You will receive specific instructions and precautions from your surgeon and nursing staff and they will show you safe techniques of simple activities like getting in and out of bed, bathing, going to the bathroom, managing steps at home and getting in and out of a car.
You will be able to leave the hospital when you are:
Patients who had minimally invasive mediastinal surgery may be able to go home 1 to 2 days after surgery. Patients who had a sternotomy or thoracotomy may be able to go home 3 to 5 days after surgery.
Your thoracic surgery team will follow your progress and help you recover as quickly as possible. During your recovery, you and your family will receive updates about your progress so you’ll know when you can go home.
LIFE AFTER SURGERY
These guidelines give you an overview of what you may expect as part of your care after you leave the hospital. Be sure to follow your doctor’s discharge instructions if they are different from what is listed here.
You will receive specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care and diet. If minimally invasive surgery was performed, you may be able to return to work within 3 to 4 weeks after surgery.
Many of these side effects usually disappear in four to six weeks, but a full recovery may take a few months or more. The patient is usually enrolled in a physician-supervised program of cardiac and pulmonary rehabilitation. This program teaches stress management techniques and other important lessons (e.g., about diet and exercise) and helps people rebuild their strength and confidence.
YOUR ACTIVITIES
Patients are often advised to eat less fat and cholesterol and to walk or do other physical activity to help regain strength.
Doctors also often recommend following a home routine of increasing activity- doing light housework, going out, visiting friends, climbing stairs. The goal is to return to a normal, active lifestyle.
Most people with sedentary office jobs can return to work in four to six weeks. Those with physically demanding jobs will have to wait longer. In some cases they may have to find other employment.
Lifting and Reaching
If your surgery required an incision on your sternum (breastbone), it will take about 6-8 weeks for your sternum to heal. During this time, you may do light household chores, such as laundry, shopping, cooking, light gardening, dusting, and washing dishes when you feel up to it.
Do not lift, push or pull objects heavier than 5 pounds until your doctor says it is okay to do so.
Try not to stand in one place for longer than 15 minutes. Do not sit for more than an hour; take a break for a few minutes and walk around or move your legs.
Physical Activities
You may do light, quick activities where your arms are above your shoulders, such as brushing your hair. But do not do any activities where your arms are above shoulder level for a long time, such as washing a window or dusting a high shelf. Do not do any activity that causes pain or pulling across your chest.
To get the most out of your day, plan to do the most important activities first. Don't try to do everything at once, and schedule unfinished activities for another day. Make sure that you get plenty of rest in between activities.
Climbing Stairs and Steps
Unless restricted by your doctor, it's okay for you to climb stairs and steps. Because you may be off-balanced after surgery, be careful and hold the handrail when walking up and down stairs. If you need to, stop and rest before you finish walking up or down a full flight. Try not to use the stairs immediately after surgery, and try to plan your activities so that you use the stairs only when necessary.
Fatigue
Fatigue is probably the number one patient complaint following surgery. Fatigue results from an extended lack of sleep while in the hospital, energy used by your body to heal its wounds, and energy used to fight off pain. To combat fatigue, listen to what your body is telling you. Space your activities to allow for rest periods. Take plenty of naps, walk regularly, eat well, and use your pain medication as needed. It's important that you rest and get a good night's sleep. Even if it's early in the night, if you feel tired, go to bed.
Driving and Riding in a Car
You should not drive for 3-4 weeks from the date of your surgery or while you are still taking narcotic pain pills. During this time your reaction time may be dulled, and if an incision was made on your sternum, your breastbone will still be healing. You may be a passenger in a car at any time. Make sure to wear your seat belt. You may cushion your incision with a soft towel or pillow.
Returning to Work
Returning to work depends upon the type of work you do and your energy level. It usually takes 4-6 weeks before most patients feel they have returned to their full energy level. The decision to return to work should be made jointly between you and your surgeon. You may want to consider working half days at first.
Traveling
Delay vacations or extended trips away from home for approximately 2-3 weeks, or until after the first post operative visit with your surgeon. Avoid air travel for two weeks from the date of your discharge. This restriction is designed to prevent you from being too far away from your surgeon should a problem arise.
Sex
Your surgeon will advise you accordingly.
Exercise
Proper exercise will help your healing and recovery, as well as increase your stamina, maintain your ideal weight by burning calories, and lower stress in your everyday life.
Tips for exercising:
Make sure you are not exercising too hard. Stop if you are exhausted, short of breath, feel dizzy, or have discomfort in your chest. Call your doctor if these symptoms persist and you are not able to do your regular exercises.
YOUR DIET
Along with exercise, eating healthy will speed up your recovery and healing. If your appetite is poor, try to eat smaller but more frequent meals.
Depending on your condition, your doctor or dietician may put you on a special diet. For example, patients with heart failure must follow a 2,000 mg low-sodium diet. Diabetic patients must follow a low-sugar, low-fat diet.
Tips to healthy eating:
Poor Appetite and Nausea
Many patients lose weight in the postoperative period. They complain of lack of appetite and mild nausea. Certain medications such as pain pills may cause nausea. Try eating small frequent amounts of food, and take medications on a full stomach unless otherwise directed. If you continue to experience nausea or lack of appetite, call your primary physician.
Constipation
Constipation is due to inactivity, limited fluid intake and lack of dietary fiber. It is aggravated by medications such as pain pills and iron. Eating plenty of fiber and fresh fruits, drinking 6-8 glasses of water daily and using your prescribed stool softener (Colace) as instructed can usually relieve constipation. If this does not work, Milk of Magnesia or Dulcolax may be helpful. Avoid Milk of Magnesia if you have kidney problems.
Caloric Restriction
Your total calories may be changed to increase, decrease, or maintain your weight as necessary. Being overweight increases the work of the heart. Your drug therapy may cause you to be hungry, you may eat more, and you may then gain weight. It is, therefore, very important that you pay attention to the total amount of food you take in. In addition to adding to the work of your heart, being overweight is associated with high levels of Triglycerides (fats) in the blood stream. Having a lot of fats in your blood increases the possibility of having the blood vessels of your heart become thickened. This will be described in more detail in the section on cholesterol and fats that follows.
Cholesterol and Saturated Fat Restriction
Cholesterol is a necessary fatty substance found in the body and many animal foods. Fats are concentrated sources of energy which occur in three forms: polyunsaturated, monounsaturated, and saturated. People who have large amounts of cholesterol and saturated fats in their blood are at increased risk of having thickening of their blood vessels throughout their bodies. This is because saturated fats and cholesterol in your blood will gather along the walls of your blood vessels causing them to narrow. If this narrowing becomes severe in the blood vessels of your heart, the blood supply to your heart will not get enough oxygen, and the cells of your heart will die. This is called "Coronary Artery Disease."
In addition to your diet, your medications may also increase the level of fats in your blood. Thus, in order to prevent coronary artery disease, your overall fat intake must be restricted after surgery. Generally, your overall fat intake should not be more than 30% of your total calories each day. Increasing the proportion of monounsaturated and polyunsaturated fat in your diet and decreasing your total saturated fat intake to less than 10% of your total fat intake will actually help to lower cholesterol and saturated fat levels in your blood. The aim of this diet is to keep the levels of fats in your blood within normal limits.