Mass Found During Lung Cancer Screening: What Comes Next?
By Steve Sullivan, Mary Greeley Medical Center (view original article)
Brad’s been smoking for more than 50 years, which made him the perfect candidate for lung screening.
The screening procedure indicated a mass, which made the central Iowa man a perfect candidate for an advanced lung biopsy procedure performed by Dr. Tamim Mahayni, a McFarland Clinic pulmonologist. The procedure was particularly suited to Brad because the mass was found in the lower part of his left lung.
“I was told it could be cancerous and was referred to him,” says Brad. “He explained that it was a simple procedure, non-invasive and worked great. Everything went great, I hardly knew anything had happened, and they got the little samples they needed.”
Brad was diagnosed with lung cancer, but, fortunately, it was discovered early enough that it can be addressed with surgery.
Navigating the Lung
In the center of an operating room at Mary Greeley Medical Center in Ames, a patient lies on a table surrounded by various machines and a team that includes a pulmonologist, anesthesiologist, respiratory therapist, radiology technologist, surgical nurses, and a pathologist.
This collection of medical professionals and advanced technology is in pursuit of a tiny piece of tissue that could define the health of that patient for years to come. The tissue, which may be cancerous, is deep inside the patient’s lung. The procedure the patient is undergoing is navigational bronchoscopy, which utilizes a robot to perform an intricately guided examination of the lungs, and it’s being performed by Dr. Tamim Mahayni, a McFarland Clinic pulmonologist. (Dr. Taher Sabobeh, a pulmonologist joining McFarland Clinic in July, will also perform the procedure.)
New to Mary Greeley, navigational bronchoscopy provides a range of benefits, the most important of which is early cancer detection.
“When I look at the most recent cancer statistics in terms of cancer diagnoses and death by cancer, lung cancer makes up 12% of all cancer diagnoses,” says Mahayni. “It also makes up 20% of all cancer deaths and is the leading cause in this country of cancer death. There’s a disproportionate amount of people who are dying from lung cancer. The treatments are there, but to improve those numbers, we have to rely on detection and early diagnosis. This procedure helps pave the way for early diagnoses. We can go after smaller lesions to get people at earlier stages, which then becomes treatable to get that number down.”
A More Detailed Look
A conventional bronchoscopy involves taking a scope through a patient’s vocal cords and into their airway to provide a look at their bronchial tubes. It is CT-guided, which still is appropriate in certain situations. The benefit of a CT-guided biopsy is that it is controlled by a radiologist, who can target the lesion with the CT scanner.
The challenge with a CT biopsy, however, is that it involves a needle going through the rib cage and then through lung tissue, which can increase the risk of bleeding and lung collapse. The scope can only go so far and “you don’t actually get to see the lung tissue,” says Mahayni.
Navigational bronchoscopy solves this problem by using a computer to map out the airway, which enables Mahayni to guide his instruments to get within a few millimeters of the lesion that he’s trying to target.
“It allows us to take a catheter out further into the airways so we can take biopsies of nodules or lung masses that otherwise were very difficult to access in other terms, and it’s a safer procedure,” Mahayni says. “It’s one of those things in medical technology that I think is going to advance the field, particularly as it relates to lung cancer.”
He adds, “If we think about our airway, we have a trachea, which is the center pipe, and that splits into two main pipes. From there, it’s more of just a bunch of tunnels that go out into the lung. If I were to put a catheter out into these tunnels, I can’t really tell where my catheter is going. But with this new computer-assisted program, it really directs me the right way to go, and for that reason, we’re having a much higher success rate with these biopsies.”
To provide patients with this advanced procedure, Mary Greeley invested in an Ion robot made by Intuitive, which is the same company that produces daVinci surgical robots the medical center has used for many years.
“The robot is creating stability for the catheter and the ability to go out further into the lung than conventionally we were able to go before,” Mahayni says. “In general, we should be able to go out as far as we really need to with this catheter because it is so flexible and so small, but the robot creates the stability necessary to do the procedure safely.”
How the new process works
During navigational bronchoscopy, the patient first has a CT scan, which could identify if a mass, tumor, or nodule exists in the lung tissue. From there, a computer planning program maps the best path to put an ultrathin catheter through the different airways to get as close to the lesion as possible. This planning will be used in the operating room to guide the robot’s instruments to the lesion.
“There’s a catheter that has a small ultrasound on it, and we’re able to see whether we’re in the right location,” he says. “From there, we do use a C-arm, otherwise known as fluoroscopy, to help guide us to make sure that we’re still in the right direction, that we’re not going too far, and that we’re going far enough.”
The patient, who is under general anesthesia, uses an endotracheal tube to help breathe. A catheter, which goes through the endotracheal tube, then goes out to the targeted lesions. During the procedure, a catheter with a camera allows Mahayni to watch a screen and navigate the catheter through various airways on the way to the lesion.
“We can actually use our tools in that catheter to collect the tissue samples we need to determine if the lesions are cancerous,” says Mahayni.
The biopsy samples are then handed off to members of the surgical team, who prepare them for the pathologist to analyze immediately at the bedside in the operating room.
“We look at a small sample of cells called a fine needle aspiration under the microscope. We determine if the cells are normal or if they represent tumor/malignancy,” says Dr. Trisha Andersen, a McFarland pathologist. “We can usually tell benign versus malignant quickly if the sample is good. Sometimes if the needle is not in the right spot, we will have some benign cells or an inadequate sample. In those cases, the needle must be redirected to get a new sample which we will then assess under the microscope.”
The value of screening
Former or current smokers should discuss getting a lung cancer screening with their primary care physician. Lung cancer screening eligibility is based on three criteria:
- 50 to 80 years old
- Twenty pack-year smoking history (one pack per day for 20 years or two packs per day for 10 years, etc.) Pack Year Calculator
- Currently smokes cigarettes or quit within the past 15 years
Someone who meets these criteria could qualify for a CT lung cancer screening, which provides detailed images of the lungs and can indicate potential signs of cancer or other concerns. “We also really need more lung cancer screening, which helps on the other end for earlier detection,” Mahayni says.
If a biopsy is recommended, the patient may be referred to Mahayni, depending on the size and location of the mass detected by the CT scan.
“If we confirm that it is cancer, it depends on the type of cancer and the stage that it is, and that’ll help determine the treatment plan,” Mahayni says. “This procedure helps diagnose and, in some part, helps with the staging as well. We do rely, once we confirm the diagnosis, on a PET scan to make sure that the cancer hasn’t spread anywhere else. In general, we refer to cardiothoracic surgery, oncology, and radiation oncology to determine the right treatment plan for the patient.”