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Lung Cancer

Lung cancer, which is rapidly spreading in the world and in our country , is defined as the second most common cancer type after prostate cancer in men and breast cancer in women. Lung cancer, the most important cause of which is shown as smoking; It can manifest itself especially with shortness of breath, wheezing, sudden weight loss or various pains. This cancer, which is among the most frightening types of cancer, can be successfully treated and prolonged its lifespan, thanks to developing medical and technological opportunities.

What is lung cancer?

Lung cancer occurs as a result of uncontrolled proliferation of tissues and cells in the lungs, the most important task of which is to take oxygen into the body and to ensure the removal of carbon dioxide formed during vital activities from the body. These uncontrolled proliferating masses grow in their environment and can spread and damage the surrounding tissues. Lung cancer is divided into small cell (oat cell) lung cancer and non-small cell lung cancer. 

Non-small cell lung cancer: There are many types of non-small cell lung cancer. The type of cancer cells of each type is different. Each cancer cell grows differently and spreads in different ways. The types of non-small cell lung cancer are determined by the type of cells in the cancer tissue and the appearance of the cells when examined under a microscope. Small cell lung cancers comprise roughly 15% of all lung cancers. It is usually seen in patients who smoke. Compared to other types of lung cancer, its spread to the body through the lymphatic system and blood is faster. 

Squamous cell carcinoma: It arises from squamous cells that appear thin and flattened like herringbone. Also called epidermoid carcinoma. 

Adenocarcinoma: It originates from cells with glandular (secretory) characteristics. 

Large cell carcinoma: Cancer that shows large and abnormal cells when viewed under the microscope. 

Adenosquamous carcinoma: Cancer that starts from cells that appear flattened under the microscope and also shows glandular features. 

Pleomorphic, sarcomatoid, or sarcomatous carcinoma: A group of cancers that present with different types of cancer cells under the microscope. 

Carcinoid tumor: It is a slow growing, neuroendocrine (starting from cells that secrete hormones as a result of nervous stimulation) cancer.

What are the symptoms of lung cancer?

Lung cancer symptoms may vary depending on the location. A mass located in the upper part of the lung can compress some nerves and cause pain in the arm and shoulder, hoarseness, and drooping eyelids. Since these symptoms can be seen in many diseases, they can be neglected. Any upper respiratory tract infection, lung infection, musculoskeletal pain can cause these complaints. If the duration of these symptoms exceeds a few weeks, a doctor should be consulted without delay.  

Some of the symptoms of lung cancer are:

  • Persistent shortness of breath, wheezing

  • Cough that does not go away and gets worsebloody sputum

  • Loss of appetite and weight loss

  • chest pain

  • hoarseness

  • difficulty swallowing 

The most common symptom of lung cancer is persistent cough. In addition, chest pain, shortness of breath, fever, hoarseness, swelling in the face and neck, shoulder and arm pain, back pain, difficulty in swallowing and bloody sputum are also symptoms of lung cancer. Bloody sputum accompanying cough is seen in a quarter of lung cancer patients. Head and bone pain, fatigue and weakness are also common symptoms of lung cancer.Lung cancer symptoms are sometimes quite insidious. In almost a quarter of patients, cancer occurs without any symptoms. Most people find out they have lung cancer when they have a chest X-ray for another disease. For this reason, routine controls are of vital importance in detecting lung cancer at an early stage. If lung cancer is detected in the early stages, the chances of success in its treatment are quite high. Today, with the advances in imaging techniques such as low-dose spiral computed tomography, lung cancer can now be detected at an early stage.

What are the causes of lung cancer?

Although smoking is the biggest cause of lung cancer, lung cancer can also be found in non-smokers. When we look at all lung cancer cases, 15% of them are people who have never smoked. Being in smoking environments also increases the risk of developing lung cancer. By avoiding smoking, the risk of lung cancer can be reduced by 50 percent for 10 years. Products such as cigarettes, pipes, cigars and hookahs are the most important risk factors proven to be a cause of cancer. Apart from cigarettes; genetic transmission, asbestos, radon gas, and air pollution are also causes of lung cancer. Some lung diseases, such as tuberculosis, may increase the risk of radiotherapy to the lungs. The high level of arsenic in drinking water is also an important reason. There has been an increase in lung cancer in recent years, with women consuming more and more cigarettes.

What are the risk factors for lung cancer?

Risk factors that increase lung cancer can be listed as follows:

  • Air pollution

  • Coal, carbon etc. use of

  • Chronic lung diseases

  • Tobacco and tobacco products

  • Exposure to certain chemicals such as arsenic and radon gas by breathing

  • Genetic causes

Stages of lung cancer

Lung cancer stages are divided into 4 stages. It is defined as stage 1 if the cancer is in the lung, stage 2 if it has spread to the nearest lymph nodes, stage 3 if it has spread to the space between both lungs and the pleura, and stage 4 if it has spread to organs such as bone, liver, and adrenal glands. The treatment plans of lung cancer stages are also different from each other. If lung cancer is detected at stage 1, the success rate in treatment is higher. Tumor cells in the lung tissue are removed by surgery and preventive treatment is planned according to the doctor's decision. If the disease is in advanced stage; In chemotherapy and radiotherapy treatments, which drugs will be used according to the cell type and for how long are determined by the doctor.

Staging in non-small cell lung cancer

In order to determine the treatment method for lung cancer, the stage of the cancer must be determined. The stage is determined according to the tumor and its spread.

Stage 1: The cancer is 5 cm or less in size and has not spread to the lymph nodes.

Stage 2: The cancer has not spread to the lymph nodes but is larger than 5 cm or close to the rib cage or diaphragm (the membrane that separates the chest cavity from the abdominal cavity). If the cancer is 7 cm or smaller and has spread to the lymph nodes or near the bronchi, it is also considered stage 2.

Stage 3A: The cancer has spread to the lymph nodes between the lungs or is close to the part of the windpipe that splits in two. This spread is quite common. In addition, it has been observed that it spreads to organs such as the heart, trachea, and other lung lobes without spreading to the lymph nodes or bronchi in the lungs or close to the lymph nodes.

Stage 3B: The cancer appears in the lymph nodes on the other side of the chest or above the collarbone or larger (such as the heart, trachea) and lymph nodes in the middle of the chest or near the part where the trachea divides.

Stage 4: Cancer appears to have spread to both lungs, the fluid surrounding the lungs and heart, or to other parts of the body such as liver, brain, bone.

The choice of treatment is related to the extent of the disease. Surgical intervention is the most common form of treatment in stages 1 and 2. In stage 3, the choice of treatment changes according to stages 3A and 3B. Stage 3A is a stage that needs to be evaluated very comprehensively. At this stage, considering the PET-CT result, sampling is performed in the lymph nodes in the chest cavity by mediastinoscopy or bronchoscopy. Based on this sampling result, a decision is made about the treatment. Radiotherapy alone or concurrently with chemotherapy can be offered to patients in stage 3D. In stage 4, radiotherapy or chemotherapy can also be used to slow the duration of the disease and control symptoms. The most important development in recent years is the use of smart molecules (targeted drugs) in appropriate patients. The appropriateness of the use of these drugs is determined by a detailed pathological examination of the patient's tumor. Today, it is extremely important to test whether the methods called individual treatment in advanced non-small cell lung cancer will be suitable for each patient and to use this chance for the patient when necessary.

Staging in small cell lung cancer

In small cell lung cancer, the stage of the disease is determined to determine the definitive treatment. This staging; It is evaluated under two headings as diffuse disease limited to the lung and extended beyond the lung. Treatment methods for limited and extensive small cell lung cancers are different. The stage of the disease is determined as a result of certain tests and the treatment method is decided. If the cancer is seen in one side of the lung, limited stage, if it has appeared in both lungs or has spread to other organs, advanced (diffuse) stage is diagnosed. Recurrence of the disease is possible. In treatment that includes chemotherapy, it is applied by targeting tumors in the lung or tumors in other parts of the body. In some patients, radiotherapy to the brain can be applied for preventive purposes even if there is no cancer. This treatment is called protective “brain irradiation”. This, It is given to destroy invisible cells in the brain and to prevent tumor formation. Surgical treatment is not a preferred method in small cell lung cancer.

How is lung cancer diagnosed?

For the diagnosis of lung cancer, first of all, it is necessary to reach a mass determined on x-ray. It is questioned whether the person has any diseases, tobacco use (cigarette, pipe, cigar, etc.), environmental or occupational exposure to substances and whether there is cancer in other family members. If lung cancer is suspected, sputum examination (sputum cytology; examination of the material coming out of the mucous membrane of the lungs with a deep cough under a microscope) may also be requested by the doctor. This test is a simple and useful test for detecting lung cancer. The doctor may need to examine the lung tissue to be sure of cancer. This examination includes the type of cancer (non-small cell or small cell) and the extent of its spread (metastasis) or to determine the stage of cancer. Then, a computerized tomography is taken to determine how to reach the mass. The most appropriate way of reaching the mass is decided from fine needle biopsy or bronchoscopy. The diagnosis of lung cancer is made as a result of the examination of the biopsy. If the disease has spread to other organs, the diagnosis can be made by taking parts from those organs. After the diagnosis is made, it is the turn of the lung cancer stages.​

Since lung cancer is a type that cannot be evaluated in cancer screening programs, it can rarely be detected in the early stage, that is, before it spreads from the lung to the lymphatics or other organs. The probability of catching the disease in the early period is around 15%. In cases that have not spread to the lymph nodes, the 5-year survival rate is 50%. However, when cancer is diagnosed in these patient groups, this rate falls below 15% since the disease has spread to nearby organs other than the lung. Early diagnosis of lung cancer occurs during routine tests or examinations for another health problem.

Imaging methods in lung cancer

Chest X-ray: After the detailed history and physical examination of the patients, a two-way chest X-ray is taken as the first step for diagnosis. In some cases, with this imaging method, the damage to the lungs due to the tumor can be detected with this film. However, since chest radiography does not always give a clear response, any small change to be seen on the film should be detected by lung tomography.

Computed tomography (CT): It provides information about the size, shape and location of the tumor. It shows lymph nodes that have become enlarged due to disseminated lung cancer. With the diagnosis of early-stage lung cancer, it shows the condition of the liver, adrenal glands, brain and other internal organs where lung cancer can spread.

Magnetic Resonance Imaging (MRI): It provides visualization by separating the lung into sections by computer together with magnetic and radio waves. Since x-rays are not used in MRI examination, there is no radiation hazard.

Positron Emission Tomography (PET): The procedure is done using a low-dose radioactive substance attached to a sugar molecule that collects in cancerous tissues. It is applied in determining whether the tumor has spread in patients who have been diagnosed with cancer rather than cancer, and in planning the treatment by staging lung cancer.

Bone Scintigraphy: It is determined whether the cancer cells show any spread to the bones, thanks to the radioactive substance given to the patient through the vein. It is a method that is routinely applied especially in small cell lung cancer and in cases where bone metastasis is suspected in non-small cell lung cancers.  

Biopsy methods in lung cancer

Lung cancer may progress locally in the lungs or may have spread (metastasized) to other parts of the body, including the lymph nodes, bone, and brain. For this reason, a tissue sample is taken from the lung to determine the lung cancer and its type. The tissue sample taken by biopsy is examined under a microscope. Taking a biopsy of the tissue seen in the lung and believed to be cancer does not cause the tumor to spread and the disease to worsen.

The methods used to retrieve this piece of tissue are:

Bronchoscopy in Lung Cancer: The airways are examined through a thin lighted tube inserted orally into the bronchi and trachea, and small tissue samples are taken.

Needle Aspiration Application in Lung Cancer: A sample is taken from the cancerous tissue by entering the needle through the chest wall for the mass in the lung. This sample is examined under a microscope.

Thoracentesis Application in Lung Cancer: In order to detect cancer cells, a sample is taken from the fluid surrounding the lungs with a needle.

Thoracotomy Application in Lung Cancer: This method, which is used for the diagnosis of lung cancer, is the opening of the chest cage with a surgical intervention. It is applied if all other methods are not suitable or if success cannot be achieved with all methods.

Sputum Cytology Application in Lung Cancer: It is the method of examining the material coming out of the mucous membrane of the lungs with a deep cough under the microscope. The sputum sample taken from the patient is examined under a microscope to detect cancer cells.

When the patient is diagnosed with lung cancer as a result of the examinations, the samples taken from the patient are subjected to a series of tests in order to determine the stage and spread of the cancer and to determine the best treatment method. According to the stage of the cancer and the results of these tests, the treatment of lung cancer is personalized.

How is lung cancer treated?

Lung cancer treatment, as in all other cancers, varies depending on many factors such as the general health status of the disease, the stage of the disease and the type of cancer. In many stages, different treatment combinations and personalized treatments are applied. For this reason, it is very important to choose a fully equipped hospital and specialist doctor in the treatment of lung cancer.​

A small number of cancer cells that are likely to be left behind after lung cancer surgery are destroyed by adjuvant treatment . This treatment method is planned according to the patient's diagnosis report, age and general health status. After lung cancer surgery, patients can receive only chemotherapy or only radiotherapy or both chemotherapy and radiotherapy as adjuvant treatment. Sometimes, post-operative adjuvant treatment may not be required in early stage patients.

Treatment methods for lung cancer

Surgery in lung cancer

Lung cancer surgery is one of the lung cancer treatment methods. The type of surgical intervention depends on the location of the cancer in the lung. It is an operation to remove a small piece of the lung. If the entire lobe is surgically removed (lobectomy), it is called as either right or left lung removal (pneumonectomy). Some tumors cannot be operated due to their location, size and general health status of the patient.

Chemotherapy in lung cancer

Chemotherapy treatment in lung cancer is the destruction of cancer cells with drugs. Chemotherapy usually consists of 2 drugs. Chemotherapy can only be given by nurses who have received special training in this regard. The number of times that chemotherapy is given is expressed as a "cure" and is usually repeated every 21-28 days. Chemotherapy in lung cancer is usually administered in the form of intravenous fluids or oral pills in fully equipped outpatient centers. In some cases, chemotherapy is given as an inpatient, depending on the condition of the patient or the nature of the drugs given. After each chemotherapy course, patients are checked in the medical oncology clinic. In these controls, patients are examined, their complaints are listened to, the side effects of drugs are questioned, and some blood tests are requested to investigate whether they cause any harm to other organs in the body.

Pathology determines whether a patient will receive chemotherapy after surgery, and if so, how many cures.determines the characteristics of the tumor in the report. However, the age and general condition of the patient also play an important role in making these decisions. Chemotherapy is not suitable for patients whose general condition is poor enough to spend more than 12 hours in a day, as they cannot tolerate side effects. If patients who are planned to undergo chemotherapy have had surgery, it is preferable to start chemotherapy within 3 weeks after surgery. Patients receiving the first chemotherapy should have their blood and general condition checked in the medical oncology clinic approximately one week after chemotherapy. In this control, the general conditions of the patients, their tolerance to the treatment and blood tests are examined, and their complaints, if any, are listened to. In the subsequent cure applications, the blood controls and general conditions of the patient are examined before each treatment.

Smart drugs and smart molecule therapy

It is a form of treatment with oral pills given to suitable patients after extensive pathological examination of non-small cell lung cancers in recent years for non-squamous cell carcinomas. Smart pill therapy is not suitable for small cell and squamous cell lung cancers. In treatment guidelines around the world, smart therapies are used as the first-line treatment of small and non-squamous cell lung cancers in advanced-stage patients, if the pathology reports are appropriate. Further pathological examinations in these patients are called EGFR mutation test and ALK fusion test. The rate of positive (positive) detection of these tests in non-smokers is higher. However, even in smokers, the rate of one of the two tests being positive is around 20%.

Radiotherapy in lung cancer

Radiotherapy is the use of high-energy rays to kill cancer cells. It is applied to a limited area and affects cancer cells in that area. Radiotherapy can be administered before surgery to shrink a tumor or after an intervention to destroy the cancer cell. Doctors usually use radiotherapy as the first alternative in patients with cancer that cannot be operated along with chemotherapy in patients who have regionally advanced but have not spread to a distant site (metastasis). In patients with advanced stages, radiotherapy can also be used to relieve symptoms such as shortness of breath or pain.

Vaccine therapy in lung cancer

There have been significant developments in the treatment of lung cancer, especially in recent years. One of the most important of these developments, which mostly concerns patients with stage 4 lung cancer, is immunotherapy, also known as lung cancer vaccine. Immunotherapy means that the patient fights cancer cells by using his own immune system. Therefore, it has fewer side effects than other chemotherapy drugs. Until a few years ago, other chemotherapy drugs were tried for patients with stage 4 lung cancer, and lung cancer vaccine was used when successful results were not obtained. Today, patients with stage 4 lung cancer in America and Europe can be treated with this cancer vaccine from the very first moment.

In order to use the lung cancer vaccine, some tests are required from the patient first. According to the type of lung cancer, it is determined whether it is a candidate for this vaccine. If he is a candidate for the vaccine, lung cancer vaccine treatment can be started as soon as the diagnosis is made. Although the vaccine does not have typical side effects such as nausea and vomiting, it has the ability to cause temporary inflammation  in the intestines and thyroid gland.

Since the lung cancer vaccine is currently used only in the fourth stage patient groups, it has a feature that affects life expectancy. In stage 4, all treatments are applied to prolong the life of the patient.

What are the ways to prevent lung cancer?

Lung cancer cannot be attributed to a single cause. As a result of researches, many causes of lung cancer have been found. Various factors may play a role in the development of lung cancer. Most of these are related to tobacco use. Lung cancer is not contagious. Some people may have a greater risk of developing lung cancer than others. The risk of cancer increases in the following situations.​

Smoking and lung cancer:

Smoking causes lung cancer. Harmful substances (carcinogens) in tobacco damage cells in the lung. Over time, these effects can cause cancer in the cells. a smoker's lung cancer; At what age he started smoking, how long he has been smoking, the number of cigarettes he smokes per day, how deeply he inhales the cigarette. Quitting smoking greatly reduces a person's risk of developing lung cancer. 

Cigar, pipe and lung cancer:

Cigar and pipe smokers are at a higher risk of developing lung cancer than non-smokers. How many years a person has smoked a cigar or pipe, how many times he smokes a day and how deeply he inhales are factors that affect the risk of cancer. Although they do not inhale, cigar and pipe smokers are also at risk for other types of lung and mouth cancer. The risk of lung cancer in passive smokers (those exposed to tobacco smoke) is also increased in the case of secondhand smoke. 

Asbestos and lung cancer:

It is a mineral group that is used in some industries as an insulation material and is naturally found in fiber form. Asbestos fibers tend to break up into particles and circulate through the air and adhere to clothing. These particles settle in the lungs when inhaled. There it damages the lung cells and thus increases the risk of developing cancer. Studies have shown that workers exposed to asbestos are 3-4 times more likely to develop lung cancer than those not exposed. This increase is greater for those working in industries such as shipbuilding, asbestos mines, insulation work, and brake repair. The risk of developing lung cancer is greater if asbestos workers smoke. Asbestos workers must use protective materials provided by their employers and follow recommended work and safety warnings.

​Air pollution and lung cancer:

An association has been found between lung cancer and exposure to air pollution. But this relationship has not been clearly described and further research is needed. 

Lung diseases: 

Some lung diseases, such as tuberculosis, increase a person's risk of developing cancer. Lung cancer tends to develop more in areas affected by tuberculosis. 

The patient's history:

A person who has had lung cancer once has a higher risk of developing a second lung cancer than a person who has never had cancer. Quitting smoking after a lung cancer diagnosis can prevent a second lung cancer from developing.

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