Daniel Raymond, MD, a thoracic surgeon at Cleveland Clinic takes a minimally invasive approach to find lesions in the lungs and remove them in an effective way.
We’re going to talk about lung cancer and lesions and detecting them. First of all, what is a lesion in your lung?
Raymond: One of the questions we commonly get is what is a lesion? What’s a nodule? What’s a mass? They’re really used interchangeably. Technically, a mass is something greater than three centimeters, but for the most part, it’s essentially an abnormality in the lung tissue, and it’s the way it’s described on a C.T. scan. We’re seeing more and more of this because of the frequent use of C.T. scanning for diagnostic purposes as well as the advent of C.T. screening for lung cancer.
Whenever you say lesion or mass, automatically, your mind goes to, oh, you have cancer.
Raymond: Right.
But that’s not always the case?
Raymond: No, it’s not. In fact, if you look at some of the data from the lung cancer screening trials, when you take a population of patients that have 30 pack year smoking history – meaning 30 years smoking one pack a day – between the ages of 55 and 75 and you do screening C.T. scans on those people, around 40% of them will have lung nodules. Of those nodules, only 3% are actual cancers. The majority of nodules that we see on C.T. scans are benign.
How could you tell the difference?
Raymond: There’s additional testing, but oftentimes, it comes down to trying to get a biopsy.
But now there’s a new way to do it with the microcoils?
Raymond: Yeah. The challenge is that biopsying lung lesions is an imperfect science. Essentially, we can either approach it from inside the airway with what’s called a bronchoscopy or we can stick a needle through the chest wall.
What’s a bronchoscopy?
Raymond: A bronchoscopy is an endoscopic procedure where they go through the airway and they can look out through the airway and try to biopsy lesions using various technologies, such as what’s called a navigational bronchoscopy. So those two options – meaning needles through the chest or a scope through the lung – are the two main ways of biopsying lesions that are less invasive. The challenge we often face in those circumstances is there’s this notion of what’s called a negative predictive value, and the negative predictive value is what is the chance that that lesion is not a cancer if the biopsy is negative? The negative predictive value of those studies, and there are a lot of parameters that go into it, but can be around 70%, meaning 30% of the time they’re wrong and they’ve missed the diagnosis. This is particularly true in very small lesions that can be very difficult to reach by a needle or a bronchoscope, and oftentimes we’re talking to patients about doing surgical biopsies and basically going in and removing the spot.
How much would you remove?
Raymond: You try to remove as little as possible, but you remove the spot itself, and that depends on how superficial the spot is in the lung and where it is in relation to other anatomic structures. We are frequently asked to go in and remove spots in the lung to determine, is it truly cancer or not? Because that is the definitive test. The challenge is that now, with the frequent use of C.T. scanning, we’re seeing these nodules that we don’t think we could feel in the lung. They’re so small that we probably could not find them surgically, and therefore we need to do something to localize those spots. There have been many different technologies that have evolved over the years to try to mark where a spot is in the lungs so the surgeon can go in and find it – and everything from radioactive tracers to putting little beads in next to them to putting dyes in – many different technologies, and none of them has really achieved the correct answer to the process. One of those is a technology that evolved out of the breast cancer technology for localizing breast lesions, where the radiologist put a wire into the breast lesion, and then the surgeon can follow that wire down and excise the area where the wire is. That same notion has been extrapolated into the chest. There are a few more challenges – the first and foremost being you’re sticking a needle into a balloon. You can have air leakage and it can pop and you can have lung collapse, and so it’s a little more complex of an issue. On top of it, the lung is constantly moving, and so when putting a wire in, you’re trying to hit a moving target. That technique, though, is an effective way of doing it, and the traditional way of doing that is to actually put the wire in while the patient’s down in radiology while the patient’s awake, and then transport that patient up to the operating room and then do a surgical procedure to remove the wire and the spot. What we’ve worked on is developing a technique where the patient basically comes in to the operating room, goes to sleep, the wire is placed in the operating room, the spot is removed, and then the patient wakes up afterwards after everything’s been completed. From a patient experience perspective, it’s a much more pleasant experience because they don’t have to go through that localization process while they’re awake, down in radiology, and then wait several hours for an operative room to become available.
Is there a difference in when the wire would go in and the microcoil?
Raymond: Not really. The microcoil specifically is a specific type of coil that can be seeded in the lung tissue and will stay in the lung tissue where you want it to be. The real big difference between the technique that we’ve developed and the more traditional technique is more based on the patient experience and the fact that, instead of having to go through the process of having a needle placed through your chest and a wire placed in your chest and then waiting for the operating room to become available, it’s all done after you go to sleep. There are a few advantages of doing that. Number one, there’s the risk of having lung collapse in the transition time between having the needle put in in radiology and making it up to the operating room. There’s also the unpredictability of operating rooms where, if some emergency comes in, that person can end up not having their case or delaying their case and leading to less desirable delays in treatment. The other is, in the operating room, the radiologist has complete control over the lung movement. What we can do is when the patient’s asleep and they’re on the ventilator, we can actually stop ventilation while they’re placing the microcoil so that there’s no movement. They don’t have to account for any movement during the procedure. Furthermore, because they are in the operating room and we are right there, if there’s any question of lung collapse, we simply treat it right away. I think there’s a safety factor.
Do you think there’s more instances of lesions and nodules and everything in the lung, or are you just now able to see it?
Raymond: I think we’re just seeing more of them because we’re using C.T. scans more, and that’s why we’ve been seeing trends towards decrease in lung cancer mortality. One of the reasons for that is because lung cancer is being diagnosed earlier at a curable stage. In classic lung cancer stats, 85% of lung cancers are diagnosed at stage four, meaning that they have metastasized somewhere else in the body. If we can start diagnosing them earlier and treating them earlier, we can save a lot of lives. The more frequent use of C.T. scanning is one of the reasons why we’re doing that. In addition, too, a lot of advances in chemotherapeutic measures that have had a big impact as well.
Now I was watching the animation on it just a minute ago and it does look like you take a chunk out the lobe.
Raymond: Yes, that’s true.
But it’s really not that big, right?
Raymond: No, it’s not. It can be large, but essentially the amount we’re taking out usually is not physiologically impactful to the patient. They won’t notice the difference in that small amount of lung being removed. They will notice, after surgery, that they have the typical discomforts of having surgery, which tends to be the bigger challenge in breathing. It hurts to breathe after a chest surgery. Once you’ve gone through that period, though, they won’t miss that small piece of lung tissue.
Okay. We’re using the patient that you had, David Sherman. Can you tell me a little bit about him?
Raymond: Well, David came to us as a classic – found a spot in the lung, don’t know what to do about it. He was very concerned about the diagnosis of lung cancer. The classic answer in a circumstance like his was to say, we will just watch this nodule because it’s too small to get, and he did not like that answer. He was very anxious that this was a cancer that would evolve while we were watching. He wanted something more aggressive done, and that’s where the microcoil technique was used so that we could localize the lesion. We had decided, before his case, that if we were to identify a cancer, he wanted a definitive cancer operation, meaning to take the lobe of the lung out, which is this gold standard operation. In his circumstance, we were able to localize the lesion, we took that down to pathology, they identified a cancer, and then we did a lobectomy. The choice of whether or not to do a lobectomy is an area of controversy right now because these lesions are so small, that we don’t really know what the right answer is. Can we just stop at just doing a wedge resection of the lesion? There’s a lot of data that would suggest that probably just stopping at a wedge resection is acceptable, but that’s a discussion you have with the patient and you discuss that data with them and you say, if we find a cancer, should we stop at a wedge resection and preserve lung tissue? Or should we do the gold standard lung cancer operation? He chose the latter because he was very concerned about the possibility of cancer spreading.
When you take it out, when you microcoil it, when you take out the lesion and then you take to the lab, the patients still on the operating table?
Raymond: Yep.
It’s all one thing?
Raymond: Yeah. They are asleep, and we simply wait for the pathologist to tell us cancer or not.
How long does that usually take?
Raymond: 20 minutes.
Cool. That’s nice, right?
Raymond: Yeah. That’s standard in every hospital. It’s called a frozen section. Frozen sections take about 20 to 30 minutes. They can only provide limited information. They can tell you it’s cancer or is it not. The other thing is is the margin negative? If you do just a wedge resection, you have to make sure you have a good margin of normal tissue around the cancer so that you’re assured that it’s completely resected.
When you started doing this, before the microcoil, and now, how many cancers have you found more than you would have?
Raymond: I would say, at this point, the majority of the lesions we’ve taken out are cancers. What that suggests to us is when radiologists and surgeons and pulmonologists look at lesions and they have an inkling that this is malignant, that we’re pretty good at our educated guesses as to what it is. What I would say, even in the circumstances where we don’t identify a cancer, is sometimes we identify other things that require treatment. In one case in particular, we identified a type of fungal infection that was unusual and required antifungal treatment. In another case, we identified a type of lymphoma. So not a classic lung cancer, but another type of cancer that had gone undiagnosed prior to that. The rate of diagnosis of cancer with this procedure is quite high. The real question comes down to, how do you blend this – this is a new way to practice. The standard answer is, this nodule is small, we’ll just follow it. The big question comes in is when do you use this technique and when you don’t? Basically, I offer this technique to patients with small peripheral nodules, meaning on the outside of the lung. You can’t go deep into the lung with this technique. We could either go after it with the microcoil technique or we could watch it with a three-month interval scan and see if it grows, and let them decide. It just gives us another option for patients, and I think the fact that we can, one, give them another option, and two, we can do it with them totally asleep so that they don’t have to go through that experience. It’s a nice thing to be able to offer.
END OF INTERVIEW
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