Lung cancer


Lung cancer develops most often in the lining of the bronchi, but it can start from any place in the respiratory system - alveoli, trachea or small bronchioles.


What can be the manifestations of lung cancer

Because in the beginning, lung cancer does not show any special symptoms, when they are available, the disease is already in an advanced stage.

  • Appearance of a new persistent cough, refractory to treatment
  • A change in the character of the usual smoker's or chronic cough
  • Appearance of blood in the sputum, even in small quantities
  • Shortness of breath - to a different degree expressed and/or changed compared to before
  • Pneumonia due to bronchial obstruction and superimposed bacterial infection
  • Pleural effusion
  • Change in voice - decreased strength (intensity) and height (frequency) due to affecting the so-called. recurrent laryngeal nerve from the tumor process

Symptoms and signs after metastasis depending on the location of the metastasis. In case of bone metastases - pain, pathological fractures (fractures) and suppression of bone marrow function. In brain metastases – neurological symptoms, headache etc.

Paraneoplastic syndromes - due to the large amount of active substances and hormones produced by the tumor, which mimic other diseases and divert diagnostic attention to another type of pathology.

All the listed symptoms and syndromes can have a completely different reason for their appearance. The presence of one, two or more of these does not make a diagnosis, but only directs clinical and diagnostic thinking to perform more specific investigations to clarify the condition.

Risk factors

Risk factors for the development of the disease:

  • Smoking is a proven risk factor for the accumulation of such mutations.
  • Air pollution with industrial waste, heavy metals, gases normally present in the air such as radon, radioactive elements and others are only a small part of the factors, for which it is considered, that they are related to the development of lung cancer. All these factors act in their totality against the background of genetic predisposition (inherited and accumulated mutations).

Recognized and proven risk factors are:

  • Smoking - the risk of developing lung cancer is directly proportional to the number of cigarettes smoked per day and the duration of the habit in years
  • Secondary exposure to cigarette smoke - passive smoking
  • Exposure to radon gas, which is a normal product of the soil and water cycle and is also found in residential buildings
  • Working with asbestos
  • Family history of lung cancer
  • Emphysema and other inflammatory-destructive lung diseases

The medical community has focused on establishing the genetic profile of malignancy and therapeutically attacking tumors at the molecular and genetic level..

Diagnostics and screening

Imaging studies are the first, but an insufficient step towards a diagnosis of lung cancer. While radiography is an indicative study, the scanner (computed tomography), magnetic resonance imaging (MRT) and positron emission tomography (FRI/CT) provide a more detailed image of the structures and processes in the thorax.

After the localization of the process and the assessment of its distribution in the body, the last decisive step in the diagnostic process is the biopsy of an accessible formation and histological assessment- of the biopsy material by a specialist pathologist. The performance of fibrobronchoscopy with a clip biopsy provides sufficient material in terms of quantity and quality to perform both histological, as well as genetic studies, which is of decisive importance for the formation of an individual therapeutic plan for patients.

Diagnostic procedures:

  • Clinical examination with physical examination
  • Examination of sputum - microscopic and cytological
  • Blood tests - hematological, biochemical and tumor markers
  • X-ray of lungs
  • CT
  • Magnetic resonance
  • Bronchoscopy and biopsy
  • Transthoracic biopsy for peripherally located tumors
  • Bronchial lavage
  • Mediastinoscopy with biopsy of lymph nodes
  • Thoracoscopy
  • Positron emission tomography
  • Bone scan to rule out metastases
  • Spirometry

The malignant entity is accepted to be characterized according to complex indicators, determining the degree of its development.

The presence of a tumor and its size is considered in four grades - denoted by T- 1, 2, 3 or 4; отбелязва се дали са засегнати лимфни възли – N, respectively with an index 1, 2 or 3 depending on the extent of involvement; M is for metastases – 0 or 1 for absence or presence. The aggressiveness of cancer cells is characterized by G - from non-aggressive to increasing on a scale of 1 to 3.


There are several types of lung cancer. The formations are made up of different cells and occur in different areas of the lung. A general distinction is made between small cell and non-small cell cancer. This is very important, as the forecast, and their treatment are different.

Non-small cell - approx 85% of lung cancer cases are of this type. It unites several subgroups:

  • Squamous - usually centrally located
  • Large cell
  • Adenocarcinoma - in most cases peripheral and most common in smokers
  • Rare forms of the broncho-alveolar genus, a variety of ade- nocarcinoma.

Small cell cancer – found in approx 10-15% of patients diagnosed with lung cancer. This is a very aggressive form, develops very quickly.

On a national and global scale, lung cancer is the oncological disease with the highest morbidity and mortality. Despite these facts, a diagnosis is not a verdict. Modern medicine provides patients with a variety of therapeutic options, through which disease control can be achieved.


The stage of lung cancer determines the degree of spread of the oncological disease in the body, which is relevant to optimal choice of therapy and prognosis.

The stages are numbered I to IV with corresponding subdivisions. The judgment for surgical treatment is based on the type of tumor (small cell or non-small cell), the stage of the disease and the condition of the patients.

Standard treatment for lung cancer involves three main methods: surgery, radiotherapy and chemotherapy. The choice of treatment methods depends on the type of tumor and the stage of the disease. To improve the treatment results, the combined application of these methods is used. Chemotherapy after surgery aims to reduce recurrence rates in early-stage cases and increase survival in advanced cases.

Metastatic stage

In patients with metastatic lung cancer, the goal of treatment is disease control, symptom prevention, maintaining a good quality of life and potentially prolonging life.


Приложението на метода в контекста на комплексното лечение на рака на белите дробове може да бъде с лечебна или палиативна цел. The need for radiation therapy, as well as its volume and place in the treatment algorithm are specified at General Hospital Committees at AJIBADEM CITY CLINIC Oncology Center. Before lung radiation therapy, a functional breathing test is performed, assessment of patients' condition and precise calculations of doses and sites of irradiation.

Radiation therapy, similar to other treatment methods in oncology (such as surgery or chemotherapy), has an effect on both tumor cells, as well as on the normal structures of the body. However, the body is able to regenerate healthy cells, which were damaged, and they to restore their proper functioning. Successful radiation therapy is the result of applying ionizing radiation through a personalized treatment plan to the tumor cells in the best and most efficient way so, that they be destroyed, and healthy tissues are minimally affected.

One of the most advanced methods of lung cancer treatment, stereotactic radiosurgery has a role in the radical treatment of early-stage lung cancer, as well as in the aggressive treatment of metastases in certain cases. Radiation therapy is very effective in affecting a number of symptoms, related to cancer, such as pain relief from bone metastases, improving breathing by shrinking the tumor, when it has blocked the airways, stopping bleeding or reducing symptoms, caused by brain metastases.

For which patients brachytherapy is suitable

This therapy may have a positive impact in the complex treatment of prostate cancer in patients with low, medium risk and in some cases selected groups of high risk patients.

Is there a risk with brachytherapy?

Although the irradiation is carried out in a small volume, due to the proximity of the prostate to the urethra, brachytherapy may cause more severe irritation during urination than external beam radiation therapy. Some patients require temporary catheterization. Patients, undergoing brachytherapy, they don't have to drive.

Systemic antitumor drug treatment includes: chemotherapy, chemotherapy and targeted (aimed) therapy

Neoadjuvant chemotherapy - drug treatment, previous surgery or radiotherapy. Most often, the goal is to achieve tumor volume reduction and thus make subsequent surgical or radiation treatment technically feasible and successful.

Adjuvant chemotherapy (prophylactic) - treatment, which occurs at certain stages in some types of tumors, to destroy the remaining single cells in the body after surgery, which can settle somewhere and after a while begin to actively divide and form the so-called metastases - re-development of the tumor in the place of its primary development.

Modern targeted chemotherapy is often added to classic chemotherapy in adjuvant treatment (aimed) therapy.

There are various technical variations of the exterior (percutaneously) irradiation. Some of them include:

  • High dose, three-dimensional radiation therapy (3DCRT)
  • Intensity modulated radiation therapy (IMRT); its dynamic rotational form called VMAT with or without image guidance of radiation therapy (IGRT)

Organ movement during radiation therapy

Internal organs are not immobile during radiation treatment and the prostate sometimes moves outside the intended radiation area due to differential filling of the bladder and rectum during radiation.

Specialized innovative system (CBCT) for precise patient positioning

A specialized innovative CBCT system is applied daily for each patient exposure, allowing precise positioning of the patient. This technology makes it possible to determine the position of the prostate during irradiation and allows the necessary corrections to be made in order to achieve maximum accuracy.

What are the advantages of Volume Modulated Rotational Radiation Therapy?

Radiation therapy is an alternative to surgery in many cases of early prostate cancer. In more advanced forms of the disease, when the pelvic lymph nodes are involved, surgery is not usually indicated and radiation therapy is the only treatment, giving a chance for healing. In high-risk cases, radiation therapy is combined with hormonal treatment.

Compared to older equipment, MR imaging allows for a higher dose to be delivered to the target tumor volume, while achieving maximum protection of healthy tissues and organs.

What are the side effects of external beam radiation therapy?

General reactions

In the beginning, some general reactions of the body such as fatigue are possible, Lack of appetite, nausea. They usually pass in the first days without radiation. Therefore, increase the hours of daily rest. If the reactions intensify, contact your doctor for help.

The following local reactions are observed when the prostate is irradiated, which usually begin in the middle of the treatment course and can last until 1 month after its completion.

  • Nausea and less often vomiting – in some more sensitive patients it may last longer. The doctor is this one, who will prescribe medicines and a diet for you to complete the treatment without any problems.
  • Bowel rumbling, how big, diarrhea - appear after 10 – 15 session. You may have several bowel movements a day. Your doctor will prescribe special medicines to relieve your symptoms. Diet is essential.
  • Irritation of the anus, exacerbation of hemorrhoids - if you have hemorrhoids, they can become inflamed. More frequent bowel movements lead to irritation of the anus area. The doctor will prescribe suppositories or other medicines.
  • Frequent urination, at the end of which there may be a burning sensation – This is due to a small part of the bladder, which is irradiated, because the prostate is located between the bladder and the rectum. No matter how precise the radiation is even with the most advanced modern equipment available, a small part of the bladder receives some dose. Share with your doctor and you will get advice and medication to overcome this temporary effect.
  • Loss of appetite, slight weight loss. These side effects pass ten days after the end of the treatment.
  • The hair at the radiation site will thin or fall out at the end of the treatment, but they can recover after a few months.

A dietary regimen is essential for undergoing radiation therapy in this area. Categorically and necessarily stop smoking and drinking alcohol.

  • Drink more fluids, but not too hot. Limit foods, rich in animal fats - fat, oil, bacon, pork and mutton. Consume mostly chicken and fish meat. Avoid the foods, which have a laxative effect and lead to gas formation: foods rich in cellulose - salads, fresh cabbage, peppers, rap, consume tomatoes peeled. From fruits, avoid pears, grapes, plums, as well as dry fruits. Consume cooked vegetables and soups. Sauces are allowed. Avoid beans and lentils.
  • Do not consume spicy, hot and sour foods. Avoid nuts, as they irritate the intestines. Don't trust advice, who recommend nuts to increase the number of leukocytes.
  • Do not use laxatives, without consulting your doctor.

aims to slow down and/or stop tumor growth for a different period of time and is aimed at such patients, whose disease is no longer curable, but can be controlled for a long time - sometimes for many years.

Modern drug treatment of malignant- those tumors includes both classic cytotoxic and cytostatic drugs (chemotherapy - antitumor drugs), and drugs from the so-called target (aimed) therapy, which selectively attack specific targets in tumor cells, representing genetic mutations, which are established by genetic research.

Sometimes targeted therapy is administered alone, and in other cases together with classical chemotherapy. Medications are also used for some cancers, which have an immunological effect (vaccines, etc.).

It either destroys tumor cells, or slows / stops their division in the primary tumor and / or its scattering (metastases).

According to national standards, based on the golden rules of the European (ESMO) and the American one (DISGUST) oncology association (including NCCN).

Decisions about the need for administration and the type of chemotherapy are made by the Clinical Oncology Committee on Chemotherapy. The committee is made up of medical oncologists and meets several times a week. A written decision is drawn up for each patient, determining the type of chemotherapy, number of courses, rhythmicity, as well as the way of monitoring the patient and reporting the therapeutic effect. Every patient has an attending physician, dynamically tracking its state.

The antitumor drugs used in chemotherapy have a different mechanism of action, effectiveness and adverse drug reactions. Antitumor drugs are combined in lung cancer regimens, including biometric-based dose calculation standards (height, weight) and functional indicators, as well as strict requirements for the duration and sequence of individual infusions.

Chemotherapy is a major branch of systemic drug treatment for lung cancer.

Source: Bulgarian Oncological Scientific Society (BOND)


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