Approaching Stage IV Lung Cancer - Episode 3
Philippa Cheetham, MD: Now, before I bring in Dr. Martin to talk about more advanced lung cancer, do we always need to biopsy lesions that look suspicious on a chest X-ray or as a lung cancer expert, can you make a diagnosis just looking at imaging without actually getting a tissue diagnosis?
Leora Horn, MD, MSc: So, no one should ever be treated without a tissue diagnosis, just because the treatments are so very different. And what we also know is that cancers can spread. Just because it’s in the lung does not mean that it originated in the lung. We need to get tissue to confirm what we’re treating, and the tissue can also help us figure out how to test and what to treat patients with.
Philippa Cheetham, MD: Summarize what a lung biopsy would involve. It sounds like quite a frightening procedure to go through, to have a needle put into your lung. What does that involve for the average patient? Do the risks of the biopsy depend on where in the lung the tumor is or is it the same for all patients, regardless of the location of the lesion?
Leora Horn, MD, MSc: The risk definitely differs, and we may not always biopsy the lung. So, for example, if someone has a tumor outside of the lung, we might go biopsy there to make sure that it is the same thing that we’re seeing within the lung. The risk really depends not only on the location but how healthy the lungs are. The biggest risk for a patient with a lung biopsy is either bleeding or the lung potentially collapsing temporarily at the time of the biopsy. But in the hands of an experienced pulmonologist or radiologist, those risks are really minimized.
Philippa Cheetham, MD: Nance, you went through a lung biopsy. What was that procedure like? Was it done while you were awake or asleep?
Nance Neshanian: No, I was asleep.
Philippa Cheetham, MD: You were asleep. And it was a f, was it?
Nance Neshanian: Yes.
Philippa Cheetham, MD: And did you have any discomfort after the procedure?
Nance Neshanian: No, none at all.
Philippa Cheetham, MD: So, it was quick procedure but you were asleep, a day-case procedure.
Nance Neshanian: Yes.
Philippa Cheetham, MD: And then afterwards, you felt quite well.
Nance Neshanian: As soon as I woke up and was aware, I could go home.
Philippa Cheetham, MD: Before you had the biopsy, did you already suspect that this was lung cancer and the biopsy was just confirming it, or no?
Nance Neshanian: No, had no clue whatsoever. Didn’t enter my mind.
Philippa Cheetham, MD: And then you had the biopsy results a few days later. Tell us about when you first heard about the diagnosis of lung cancer.
Nance Neshanian: Well, my son who lives in the Denver area was in visiting for my birthday, and I got the news for my birthday and Christmas that it was cancerous. It was a sad time, but because he was there, I think it minimized it a great deal. I was happy to have him and his wife, and that toned down the sad news so we got over it.
Philippa Cheetham, MD: And we’ve already heard from Dr. Horn that some patients have lung cancer that’s localized to the lung and other patients have disease that’s gone beyond the lung. Did you know early on whether the tumor was confined to the lung or whether it spread beyond that?
Nance Neshanian: No, I didn’t, but I was on the golf course one day, and I got a phone call from the hospital that there was a spot on my spine and that if it were not treated immediately, I could become paralyzed. So, that put the hiatus on the golf game and I found out about that, and Dr. Mark Stavas did some radiation, five consecutive days I think it was, and we got rid of that.
Philippa Cheetham, MD: So, you had treatment for the lung lesion and the secondary lesion on the spine without ever having symptoms from either.
Nance Neshanian: Right.
Philippa Cheetham, MD: Which is great that patients are detected before they become symptomatic. You talked about a lung biopsy to make a diagnosis, Dr. Horn. Once a patient has had a confirmed diagnosis and you know that there’s disease outside the lung, do you need to biopsy the secondary lesions or is imaging enough to treat those with treatments like radiation?
Leora Horn, MD, MSc: That’s a good question and it often depends on what the scans look like. So, for a patient who maybe has one area that looks fairly atypical, we may go and biopsy that to confirm that it’s the same tumor and make sure that we’re on the right page with treatment. Sometimes you’ll get a scan and there are multiple spots in the lung but there might be a spot, say, in the liver or the bone that is harder to biopsy. And we may take the biopsy from the lung and use that in selecting our treatment. But in the majority of cases, we want to biopsy the most distant site where the cancer may have spread to confirm that it’s the same tumor type.
Philippa Cheetham, MD: And I guess the lesions that you biopsy depend on where they are and what the risks are to the organ involved in terms of biopsying the risk of the biopsy itself. You’ve already talked about potential complications, but lesions close to the spine sound like a potentially high-risk area to biopsy.
Leora Horn, MD, MSc: Doing a biopsy of an area around the spine is often not as difficult as maybe getting an area that’s central in the lung that’s hard for a bronchoscopy to get to, which is what Nance had where you go down the throat. So, it really just depends on the safety and what’s the easiest area to get to. Because with lung cancer, you don’t just want to make a biopsy diagnosis, you don’t just want to make a diagnosis from the biopsy. You also need enough tissue to do all the additional testing we need in order to help us select the best therapy.
Philippa Cheetham, MD: Right, so you need to get a decent amount of tissue.
Leora Horn, MD, MSc: Exactly.
Philippa Cheetham, MD: To help use that to determine future management and how best to treat the cancer.
Leora Horn, MD, MSc: Exactly.
Transcript Edited for Clarity