Lung cancer

Chest radiography (X-ray) is often the first examination which is performed to ascertain the presence of any suspicious lung lesions. If pulmonary lesions are suspected, further investigations should be requested in order to better investigate their morphological features and extent.

Computed tomography (CT) of the chest with contrast medium defines the size and morphological characteristics of lung lesions..

Morphological study helps distinguish a cancerous lesion from pneumonia or inflammatory disease. It also allows for the evaluation of the relationship of the lung lesion to other organs within the chest (such as the heart and large vessels or esophagus) and the study of possible lymph node involvement.

In the presence of suspected lung cancer, CT scans of the abdomen and encephalon are also required in conjunction with a CT scan of the chest to assess any extension of disease outside the lung.

Positron Emission Tomography (PET) is an examination that allows lung lesions identified in CT scans to be studied metabolically. It uses a different contrast agent than that used in CT, which is fluoridesoxyglucose, a radiolabeled sugar that is picked up by tumor cells.

PET scanning is an examination useful for completing staging (and thus better defining the extent of the disease and the involvement of any other organs). Sometimes it can be false-positive in the presence of inflammatory disease (e.g., pneumonia), or false-negative (in certain subtypes of lung cancers whose cells do not pick up fluorodeoxyglucose, such as low-grade neuroendocrine tumors or mucinous adenocarcinoma) .

CT scans of the brain, chest, and abdomen with contrast medium and PET scans with FDG are complementary examinations that allow characterization of the morphology and metabolic behavior of lung lesions, possible involvement of hilar and mediastinal lymph nodes, or other distant organs. They are not, however, examinations to define the histologic nature of a lung lesion, but are a necessary step in planning a possible biopsy.

When an imaging examination (CT scan or PET scan) shows the presence of a suspicious lung lesion, it is necessary to schedule a biopsy and subsequent histologic examination in order to obtain tissue for microscopic analysis to define the diagnosis (tumor or nontumor lesion, histology, and biological features) and determine the type of treatment.

Biopsy on obtained by taking a sample of tumor tissue for microscopic analysis to confirm the presence of the lesion, establish its type and eventual stage. There are several modes:

• Bronchoscopy: a thin flexible instrument is introduced under local anesthesia through the nose or mouth to visualize the lungs from the inside and take a tissue sample for histological and cytological examination;
• Echoendoscopy via EBUS-TBNA: involves endoscopically guided transbronchial ultrasound needle aspiration and also allows cytological samples of lymph node tissue to be taken through the airway. This procedure is performed under deep sedation;
• Needle aspiration and needle biopsy: a fine needle is introduced under local anesthesia into the tumor, lymph node, or other tissue in order to take a sample of cells. This examination is performed under CT or ultrasound control to monitor the path of the needle to the target;
• Thoracentesis: if fluid is present in the thoracic cavity, a sample can be taken by introducing a fine needle into the intercostal space for the purpose of determining, through cytological examination, the possible presence of neoplastic cells. In cases where plenty of fluid is present, this procedure can also be used to remove enough fluid to improve the patient’s breathing;
• Mediastinoscopy: is an examination performed under general anesthesia and involves the introduction of an instrument through a small incision made at the base of the neck to biopsy the lymph nodes in the thoracic cavity. In this way, the stage of the tumor can be defined and it can be determined whether surgery is a treatment option;
• Video-assisted thoracoscopy (VATS): a procedure performed under general anesthesia, which involves the introduction through a small incision in the chest of a micro-camera to visualize the pleural surface and take tissue samples for histological examination.

Histologic examination for lung cancer consists of microscopic analysis of a tissue sample (taken by biopsy) to determine whether the lesion is cancerous (benign or malignant), what histotype it presents (e.g., adenocarcinoma, squamous cell carcinoma, etc.), and to define its stage and grade, indicative of its extent and aggressiveness, respectively.

Histologic examination often makes use of immunohistochemical analysis both for diagnostic framing purposes (diagnosis of the nature of the lesion) and for the purpose of predicting response to specific medical therapies: for example, analysis of PD-L1 (Programmed Death-Ligand 1) protein is essential for all lung cancers.

This test helps determine whether a patient is a good candidate for immunotherapy, a therapy that aims to “unlock” the patient’s immune system to attack cancer cells. The results are often expressed as a percentage and can influence the choice of therapy to be undertaken.

The examination with in-depth imunohistochemicals takes a variable amount of time depending on the complexity of the case (at least 7 working days for reporting by the Anatomic Pathologist).

With this method, DNA and RNA extraction is performed on tissue samples (see histologic examination) or liquid biopsy (peripheral blood sampling), and somatic genetic analysis of a series of genes is performed to search for mutations, fusions, and amplifications.

The method used isnext-generation sequencing (NGS) with a gene panel that allows simultaneous analysis of hundreds of genes (up to 517), providing a complete picture of the molecular changes present in the tumor.

Identifying these molecular alterations is critical to accessing molecularly targeted drugs (so-called precision cancer therapy or target therapy), which offer rapid and durable responses with often a better tolerability profile than traditional chemotherapy.

This examination is complex, is performed immediately after confirmation of histological examination, and takes about 10-15 working days to report.

Surgery, when possible, is thetreatment option of choice for resectable non-smallcell nonmetastaticlung cancer.

Surgery may be preceded or followed by chemotherapy, immunotherapy, or radiotherapy and followed by another antineoplastic treatment depending on the histologic-molecular features and definitive stage of disease.

Types of surgery for lung cancer include various lung resection procedures, including open surgery and minimally invasive approaches, such as video-assisted thoracoscopy (VATS) and robotic surgery.

Surgical techniques can be divided according to the extent of lung tissue removed into:

• Wedge-shaped (or wedge-shaped) resection: removal of a small portion of lung tissue in a wedge shape
• Segmental resection: removal of one or more lung segments, parts of a lobe
• Lobar resection (Lobectomy): removal of an entire lobe. The right lung has three lobes, while the left lung has two lobes.
• Complete lung resection (Pneumonectomy): removal of a whole lung.

Removal of lung cancer tissue is associated with removal of adjacent lymph nodes (hilar and mediastinal).

The choice of the type of surgery and approach depends on various factors, including the stage of the tumor, the patient’s health condition, and the patient’s ability to breathe.

In small cell lung carcinoma (SCLC) , surgery is only rarely used as part of the main treatment because at the time of diagnosis the cancer has usually already spread.

Radiation therapy for lung cancer is a localized, noninvasive therapy, performed mostly on an outpatient basis, that can destroy tumor cells through the use of high-energy radiation called high-energy ionizing radiation.

It is delivered by dedicated equipment (linear accelerator and tomotherapy) and can be used to treat early-stage cancer or in local recurrences (as an alternative to surgery or after surgery), in combination with chemotherapy for larger local tumors, or as palliative therapy to relieve symptoms of the tumor or its metastases.

In addition to conventional radiotherapy, a special type of radiotherapy used in our institute is stereotactic radiotherapy for the treatment of primary or metastatic lung lesions, which is able to intervene, with a limited number of sessions, on small lung lesions, striking extremely precisely the volume to be irradiated and reducing the involvement of healthy tissues. All with an intervention that takes into account the movements of the lungs caused by breathing acts.

Radiation therapy is generally well tolerated, but some acute or late side effects may occur. Acute toxicity includes symptoms such as coughing, difficulty breathing, fatigue and skin irritation, burning and problems swallowing (dysphagia); later toxicity may include pneumonia or pulmonary fibrosis. These effects depend on radiation dose and should be managed by referring physicians; severity may be increased by smoking.

Chemotherapy for lung cancer is a medical treatment that uses drugs (cytostatics) to destroy cancer cells, preventing them from growing and spreading throughout the body. Chemotherapy can be given intravenously or orally, in cycles interspersed with recovery breaks, and can be used before surgery (neoadjuvant), after surgery (adjuvant or “prophylactic”), or to reduce symptoms in advanced stages.

The drugs can be administered in combination with each other or individually. The choice of chemotherapeutic agents, especially in advanced stages, depends on the type of lung cancer, so accurate histologic definition is essential at the diagnostic stage. Today, chemotherapy is often combined with other therapies (target therapies or immunotherapy) to increase its effectiveness.

Side effects of chemotherapy for lung cancer vary depending on the drugs used, but the most common include nausea and vomiting, fatigue (asthenia), temporary reduction of certain blood components ( red blood cells, white blood cells, platelets), hair loss, oral cavity pain and ulcers, diarrhea or constipation, and numbness or tingling in the extremities (peripheral neuropathy).

Other effects may include reduced immune defenses, fever, and skin reactions. It is important to report any symptoms to the oncologist, who can provide supportive therapies such as antiemetics for nausea medications to manage neuropathy, or blood transfusions.

Precision therapy(targeted therapy) uses drugs that target specific molecular alterations (often genetic mutations) present in cancer cells, blocking their growth and survival more selectively than traditional chemotherapy.

To assess whether a patient with non-small cell lung cancer is suitable to receive treatment with biologic therapy, it is necessary to perform appropriate molecular characterization(Next Generation Sequencing NGS) of the tumor sample obtained by biopsy.

For some of these potential molecular markers of cancer, it is now possible to intervene through targeted drugs deliverable by the national health care system or through experimental therapies (e.g., EGFR, ALK, ROS1, BRAF, NTRK, RET, KRAS, METex14, HER2).

Treatment is usually administered as tablets or intravenous infusion and can be combined with chemotherapy and other treatments.

By acting on specific molecular targets of cancer cells, these drugs can leave healthy tissue intact, potentially reducing side effects compared with traditional chemotherapy.However, depending on the drug agent administered, side effects may still occur. The most common of these include skin manifestations such as rash and dryness, gastrointestinal disorders (diarrhea), and fatigue, but also heart problems, hypertension, thyroid changes, and, in some cases, pneumonia.

It is important to report any symptoms to the oncologist, who can provide supportive therapies

In recent years,immunotherapy has revolutionized the treatment of lung cancer: it is a treatment that does not directly attack cancer cells, but uses drugs to stimulate the patient’s immune system to recognize and eliminate the tumor. This is often done by blocking the immune system’s “brakes,” called immune checkpoints, which cancer cells exploit to escape attack by T lymphocytes, thereby restoring the body’s ability to fight the cancer.

Immunotherapy is used in nonmicrocytoma lung cancer either in the earliest stages in combination with chemotherapy (neoadjuvant therapy) or after surgery (as adjuvant therapy to reduce the risk of recurrence), or in locally advanced disease after chemotherapy and radiation therapy, and finally in metastatic disease (alone or in combination with chemotherapy to increase treatment efficacy).

Biomarkers: the presence of PD-L1 protein on cancer cells is a key factor in estimating the likelihood of response to immunotherapy, and determines its therapeutic application.

In advanced small cell cancers, the combination of chemotherapy and immunotherapy is the standard first-line treatment.

Theside effects of cancer immunotherapy in the lung are varied and result from overactivation of the immune system, which can affect even healthy cells. The most common include thyroid-related endocrine toxicities (hypothyroidism), skin symptoms (rash, itching, dryness), gastrointestinal problems (diarrhea, abdominal pain), fatigue, muscle and joint pain, and flu-like symptoms (fever, chills). Less common, but more serious, are other endocrine (hypophysitis), pulmonary (pneumonia), and liver (hepatitis) toxicities, which require careful and timely medical monitoring.

It is important to report any symptoms to the oncologist, who can provide appropriate supportive therapies.

The management of lung cancer-related oncology emergencies requires a multidisciplinary approach involving pulmonologists, surgeons, oncologists, dieticians, palliativists, psychologists, nurses, and other specialists to ensure rapid and effective care.

These professionals are all represented within the institute and can be contacted during business days and hours by calling the relevant oncology area phone numbers or by contacting the secretary of the Interdisciplinary Lung Cancer Care Group at: 0119933069.

In case of non-deferrable emergencies (or during night/holiday hours), it is essential that the patient be sent to the emergency room of the hospital of territorial competence.

Maintenance therapy in lung cancer is a treatment that follows first-line therapy (often chemotherapy or chemo-radiotherapy) to control the disease and prevent progression, sometimes administering the same drug used in the first-line setting, but also other treatments such as immunotherapy, molecular-targeted ( target) therapies, or maintenance chemotherapy, depending on the histologic type and previous therapy and stage of the tumor.

The palliative care are available at the institute.

The impact of cancer in a person’s life also affects the psychological sphere: falling ill with cancer is in fact always a traumatic event that affects all dimensions of the person and can generate anxiety, fear, anger, depression.

At the Candiolo Institute, alongside cutting-edge therapies, the treatment and care pathway always includes a qualified psycho-oncological support that helps the patient cope positively not only with treatment but also with the delicate phase of physical and psychological recovery.

It is also possible to participate in support groups psychological to compare with other people who have gone through or are going through the same experience.

The Social Service of the Candiolo Institute conducts information and orientation interviews to patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. (phone: 011 9933059).

Follow-up of lung cancer is a post-treatment follow-up phase that includes periodic medical and instrumental examinations, such as CT scans with or without contrast and blood tests, to monitor any recurrence of the disease or the emergence of a new tumor.

The duration and frequency of checkups, which begin with close visits (every 4-6 months) and then taper off over time, vary according to the stage of the disease and the patient’s characteristics, and are agreed with the referring specialist.

Due to the high number of cases treated each year, the Candiolo Institute is a national reference for taking care of these cancers. Ourexperience enables us to deal with even the most complex situations, always with a personalized approach built on the clinical and personal profile of each patient.

Establishing the treatment plan always starts with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies that allow accurate assessment of the extent of the disease.

In addition, the Institute offers advanced and sophisticated laboratory investigations, including molecular and genomic analyses, which are critical for identifying biological features of cancer and guiding therapeutic decisions

When indicated, surgery is performed using minimally invasive techniques (thoracoscopic or robotic), which reduce operative trauma, promote faster recovery, and improve postoperative quality of life. Every treatment choice is defined within the GIC, ensuring a consistent and integrated approach.

As an IRCCS, the Candiolo Institute combines clinical practice with astrong mission toward scientific research. Patients can be evaluated forinclusion in active clinical trials active, which represent a real chance to access innovative therapies not yet available in standard practice. Collaboration between care and research is a distinctive value that translates into concrete opportunities for the patient.

The Interdisciplinary Care Group takes care of the person at every stage: from diagnosis to treatment to follow-up, with attention to nutritional support, psychological health, and reintegration into daily life. The organization of checkups, visits and treatment is designed to ensure continuity and serenity, always valuing the human dimension of care.