LUNG CANCER IS deadliest form of cancer for a few reasons. First, it's the second most commonly diagnosed form of cancer behind only skin cancer. The American Cancer Society reports that about 14 percent of all new cancers are diagnosed in the lungs and estimates that in the United States in 2018, 234,030 new cases of lung cancer will be diagnosed and about 154,050 people will die of the disease. That accounts for more than a quarter of all cancer deaths in the U.S.

Second, lung cancer is hard to detect early. Unlike with some other cancers, such as breast cancer, where it's relatively easy to screen for tumors and treat surgically, the lungs lie deep inside the body. It's difficult to see what's happening inside these highly-vascularized organs. Screening has risks associated with it and is therefore usually reserved for people who are at elevated risk of developing the disease. Plus, people with lung cancer may not develop symptoms until the disease has progressed, and later stage disease is less treatable than earlier stage cancers. The current five-year survival rate for stage 4 lung cancer is less than 10 percent.

Although a lung cancer diagnosis is often a grim affair, it's not all doom and gloom. With World Lung Cancer Day arriving on Aug. 1, it's worth noting new advances in lung cancer treatment that are leading to better results for patients through research-driven innovation. "In the last couple of years, it seems every six months, something is changing," says Dr. Nathan Pennell, director of the lung cancer medical oncology program at the Cleveland Clinic's Taussig Cancer Institute. "It's a very exciting time to be an oncologist," he says, because a variety of new drug and surgical treatment protocols are offering patients better outcomes and dramatically longer survival times in some cases.

Revolutionary immunotherapies have doubled life expectancy in some lung cancer patients by leveraging the body's own immune system to fight the cancer. Discoveries of new molecular biomarkers, such as EGFR, are helping doctors find better ways to target variations among lung cancer tumors, leading to more effective drug treatments. And combination therapies that use a mix of traditional chemotherapies and cutting-edge immunotherapies are making big inroads in treating lung cancer, especially among patients with later stage disease that has spread beyond the lungs.

Amid all these developments, less attention has been paid to new advances in surgery for lung cancer. Surgery to remove lung cancer tumors is often a major component of a patient's treatment protocol, especially for people with early stage disease. There are big strides being made in that arena, which offers more patients a better chance of beating the deadliest of all cancers.

Surgery has typically been reserved for patients with stage 1 or stage 2 lung cancer. This is sort of a sweet-spot in detection that can be challenging to hit. Very small tumors may not cause symptoms and may not be detected until they have grown larger. And traditionally, when very small tumors, called nodules, have been detected, often through the use of CT screening, sometimes the patient is told a "wait-and-see" approach is the best option. It may be "too small" to remove, and thus the cancer is given more time to progress before a surgical intervention takes place.

But patients with very small nodules may now be getting a different answer from doctors about when it's time to try surgery. Dr. Daniel Raymond, a cardiothoracic surgeon at the Cleveland Clinic in Ohio, has been using a technique called microcoil localization in some patients and says this approach may be a good option for patients with very small lung nodules. "The statement, 'it's too small to be biopsied' isn't always accurate," he says. "Following the nodule," and waiting to see whether it grows, "may be entirely appropriate, but simply being too small is no longer a reason not to pursue a biopsy because we have technology that can guide us."

Microcoil localization uses CT images to help the radiologist place a small wire coil into the nodule so the surgeon can find it and remove it. "Presently, the most common way of removing lung nodules is by using video surgery, VATS techniques, or robotic surgery," in which the surgeon uses video and remote robotics equipment to determine where to cut. But "some of the nodules have less solid components to them and are smaller and deeper in the lung tissue and you can't be confident you can feel the thing," Raymond says.

"Previously, the best option if you took someone to the operating room with a smaller nodule and you couldn't feel it, you'd have to make a bigger incision and put your hand in and try to feel with your fingers," Raymond says. This could move the surgery from a minimally invasive technique to a larger "open surgery," which Dr. Bernard J. Park, deputy chief of thoracic surgery at Memorial Sloan Kettering Cancer Center in New York, says is more traumatic to the patient. "The advantage with minimally invasive techniques is that there's less trauma to the patient," which can lead to faster healing.

But if the nodule is hard to locate or to find in the operating room, the surgery is likely to become more complicated, and that's part of why new techniques like microcoil localization are being pioneered. It's also a means of treating cancers earlier when survival rates are higher; the American Cancer Society reports that the five-year survival rates for patients with stage 1 non-small cell lung cancer ranges from 68 percent to 92 percent depending on the cancer's sub-stage. The five-year survival rate for patients with stage 4 metastatic NSCLS ranges from 1 to 10 percent.

"This is a technique that evolved out of a need to reliably identify smaller nodules in the lung for removal," Raymond says. It may be applicable for patients with earlier stage cancers, but also for patients who have had cancer elsewhere in the body – a new nodule in the lungs (or a tumor elsewhere in the body) could signal metastasis of that previous cancer, which would dictate the patient needs chemotherapy. The technique may also be offered to high-risk patients, such as those who are immunosuppressed or those who've had a lung transplant or are being assessed for one. "And then there's another population of patients, where it's an anxiety issue. If they have a small nodule and the knowledge of that small nodule is really impacting their quality of life, this provides an alternative means of determining what it is and providing therapeutic options," Raymond says.

Placing a microcoil wire into the nodule using imaging technology at the same time surgery is being conducted can help remove some of the guesswork the surgeon faces while creating a better patient experience. Raymond says the microcoil is a special wire that's been designed to coil on both ends. The radiologist places the wire at the right depth using a CT scanner that shows exactly where the nodule is. This can be done without having to make any incisions; rather the coil is placed using a needle that's loaded with a flexible platinum wire. "The wire is built so that it will coil and form a ball on one end and then the goal is to try to get the other end of the wire to coil outside of the lung but not in the chest wall, so in the space outside of the lung." After this wire has been placed by the radiologist, the surgeon takes over, using a camera to find the wire. The surgeon then conducts a wedge resection, removing a wedge-shaped portion of tissue surrounding the nodule. The removed tissue is tested immediately and if the patient needs additional surgery, it can be done right then and there.

Other techniques also attempt to make it easier for the surgeon to find the nodule during surgery. "Various different centers have different means of localizing [marking] small nodules," Raymond says, noting that some surgeons use a bronchoscope to implant a small metal seed next to a nodule. "Then you can find that seed with an X-ray in the operating room." In some cases, the surgeon may inject a radioactive protein into the nodule and "then use a Geiger counter to find the nodule," in the operating room, Raymond says.

In still other cases, patients may visit the radiology suite prior to surgery to have a wire coil implanted in the nodule. Then, they go upstairs to the operating room to have the nodule removed. "With a lot of those techniques, the patient experiences can be not so pleasant because they have to have the [localization] procedures done while they're awake." Patients will be given an anesthetic to numb the area, but being put under general anesthesia in a radiology suite may pose risks because often general anesthesia requires the use of a ventilator that forces air into the lungs. "If you then put a needle hole in the lung and you're pushing air into the lung, you can cause the lung to collapse."

So, these placements typically need to be done while the patient is awake and able to breathe without the assistance of a ventilator. But that means these localization procedures can be very uncomfortable. "Anything that's on the surface of the lung that rubs the chest wall causes a lot of pain, and so that's one of the complaints patients have when they have wires placed down in radiology and have to wait for surgery," Raymond says.