Recommended reading: Advances in Lung Cancer

this 2012 article by Hannon & Yendamuri explains the newest methods and modalities of treating nonsmall cell lung cancer (NCLC) as well as the importance of accurate staging for diagnosis and evidence-based treatment.

A layperson’s guide to “Advances in Lung Cancer,” by Hannon & Yendamuri

In addition to providing links to the full article text, we have also provided a highlighted pdf version  – with additional notes, links and information contained in this post.

What is staging?

Staging is the diagnostic process of determining how much/ how far cancer has spread.  Staging usually involves several tests and procedures such as PET/CT scans, mediastinoscopy or bronchoscopy (with endobronchial biopsy).  Some of these tests may have been done at the time of initial diagnosis.  Others will be done as part of the work-up after doctors suspect or have diagnosed lung cancer.

More about mediastinoscopy:

Mediastinoscopy as explained by Dr. Carlos Ochoa

WebMd article on mediastinoscopy

when mediastinoscopy is done with a camera, it is called video-assisted mediastinoscopic lymphadenectomy (VAMLA)

Transcervical extended mediastinal lymphadenectomy: is an extended version of a traditional mediastinoscopy, allowing for more extensive lymph node dissection.

article at CTSnet

The jury is still out on whether the newer technologies are superior to traditional mediastinoscopy. The most important thing is for a patient to have a mediastinoscopy-type procedure for accurate tissue diagnosis.  The more lymph nodes sampled – the more accurate the staging.

This procedure may be combined with other procedures like bronchoscopies with needle biopsy (EBUS) to be able to sample more nodes from more locations in the mediastinum.  (Each procedure samples a different area of the mediastinum.)

Why is staging important?

Staging provides doctors and patients with information about the extent of cancer present.  Is the cancer in a small area of the lung alone?  Has it spread to the lymph nodes?  Is there distant metastasis to other organs?

Knowing the answers to these questions will determine the course of treatment (surgery versus chemotherapy alone, surgery plus chemotherapy/ radiation).  Staging also gives us information about anticipated or expected survival – which is important for patients to know when deciding on treatment options.

Lung cancer 101 – article on staging of lung cancer, small and non-small at

Non-small cell lung cancer staging – National Cancer Institute. Also have information about the diagnostic testing used for accurate staging.

Staging is done, now what?

Once the cancer has been staged accurately, doctors can begin to discuss treatment options.  Treatment options can include surgery, chemotherapy and radiation.  Surgery is usually the most effective for early stage cancers (IA to IIIB in most cases).  More advanced cancers may require chemotherapy regimens or palliation alone.

Treatment Modalities discussed in Hannon & Yendamuri:

Brachytherapy – this is a type of radiation treatment that is implanted into the patient at the time of surgery.

American Brachytherapy Society (ABS)

Radiation therapy – has a section on brachytherapy

Single port thoracic surgery – archives for related posts on single port thoracic surgery

Robotic surgery – posts on robot surgery and the DaVinci surgical system.

Dr. Buitrago and robotic surgery – with short YouTube clip

Dr. Mark Dylewski – master of robotic surgery

Dr. Weksler – robotic surgery

The Davinci Robot

Awake thoracic surgery with Dr. Mauricio Velaquez

Palliation – including treatment for malignant pleural effusions

What is palliative care?

Reference article:

Hennon, M. W., & Yendamuri, S. (2012). Advances in lung cancer.  Journal of Carcinogenesis 2012, 11:21.

Dr. Mark Hennon and Dr. Sai Yendamuri  are board-certified thoracic surgeons, and assistant professors of thoracic surgery at the State University of New York – Buffalo.  They currently practice at the Roswell Park Cancer Institute in Buffalo, New York.

Intrathoracic Hyperthermic Chemotherapy (Hithoc) in advanced non-small lung cancer: the Nara Experience

As part of a continuing discussion of HITHOC (Hyperthermic IntraThoracic intraOperative Chemotherapy), today we are talking about the results of a small study conducted at the Nara Medical University, School of Medicine in Nara, Japan.

As part of a continuing discussion of HITHOC (Hyperthermic IntraThoracic intraOperative Chemotherapy), today we are talking about the results of a small study conducted at the Nara Medical University, School of Medicine in Nara, Japan.

While the study is small (just 19 patients in three groups), it’s important because the patients involved all had advanced lung cancer, with malignant pleural effusions or disseminated disease discovered at the time of surgery. This is important, as readers know, because lung cancers are often diagnosed late, (after patients develop malignant effusions), and that the prognosis for patients with malignant effusions is grim.

Population: 19 patients.

Notably, the treatment group C consisting of seven patients (which received no intrathoracic thermic treatment) who were treated during an earlier period (2001 – 2003). Group C had an average age of 64. Essentially a control group.

The remaining patients were treated during 2006 – 2008 and are divided into two groups;

Group A which received hyperthermic (hot) saline infusion with a 30 minute dwell time – consisted of seven patients.  This group was also older (average age 72).

Group B, consisting of five patients who received hyperthermic chemotherapy (cisplatin) infusion into the chest cavity with a 30 minute dwell time.

Note: Infusion in this post refers to instillation of fluid into the chest cavity, not an intravenous treatment.    All patients received post-operative adjuvant chemotherapy.

The grouping of A and B serves to distinguish whether the mechanism of treatment is related to the application of heat alone, or the application of heated chemotherapeutic agents.  Current theories about the effectiveness of HITHOC suggest that the heat of the chemotherapy allows the drugs to penetrate more deeply into the tissues compared to application of chemotherapy alone, but requires studies such as this to support this theory.

Interestingly, the pre-operative staging of these patients differed significantly from intra-operative findings with 8 patients diagnosed with early disease (stage I), five patients with stage II and only six patients as stage IIIA pre-operatively.  (Presence of a pleural effusion denotes stage IV).  Malignant effusions were not seen during pre-operative workup. (It is not uncommon to find more advanced cancer at the time of surgery.)

Surgery: All of the patients underwent a VATS procedure (video-assisted thoracoscopy).  The majority of patients of patients (16) underwent surgery to remove the primary lesion (cytoreductive surgery) with ten patients undergoing lobectomy and six patients undergoing wedge resection.

Intra-operative findings:  16 patients found to have malignant effusions, 10 patients with disseminated disease.

Results: No intra-operative/ post-operative deaths.

Group A (hot saline group): no deaths during follow-up period, with a median follow-up period of almost 20 months.  No recurrence of pleural effusions.

Group B (heated chemotherapy group): 4 deaths in follow-up period; median survival time was 41 months, one patient with recurrent pleural effusion 26 months after treatment.

Group C: (VATs alone): 5 deaths (during follow-up period) median survival 25 months, 4 patients with recurrent pleural effusions (average time to recurrent effusion: 3 months).

While this study is too small (with only five patients receiving intrathoracic chemotherapy) to generalize the results – it should prompt researchers into conducting more studies and trials into the use of hyperthermic intrathoracic chemotherapy in patients with late stage lung cancers.

The decreased incidence of pleural effusion in the treatment groups (A and B) is important also for quality of life issues.  However, these findings are also limited by the small study size.

I have written to Dr. Naito (corresponding author on this article) for further comment and information.


1. Kimura, M., Tojo, T., Naito, H., Nagata, Y., Kawai, N., & Taniquichi, S. (2010). Effects of a simple intraoperative intrathoracic hyperthermotherapy for lung cancer with malignant pleural effusion or dissemination. Interactive Cardiovascular & Thoracic Surgery 2010, April, 10 (4); 568 -71.  (linked to pdf).