Content

Introduction

Introduction

Lung cancer is one of the most common and serious types of cancer (Video). Approximately 40,000 new cases are ascertained (diagnosed) each year in Italy, representing 11% of all cancer diagnoses in the population, 15% of new diagnoses in men and 12% in women.

Generally, in the initial stages, this type of tumor does not cause disturbances (symptoms), but as the disease progresses, the following may occur:

  • persistent cough
  • traces of blood in secretions from the respiratory system (sputum)
  • shortness of breath or "hunger for air"
  • unexplained fatigue and weight loss
  • pain when coughing or breathing deeply

When these symptoms appear, it is advisable to consult your family doctor for a check-up.

A tumor that originates in the lungs is defined primary tumor of the lung. A tumor that develops in another part of the body and spreads to the lungs is called secondary tumor of the lung.

There are two different types of primary lung cancer classified according to the type of cells they develop from:

  • non-small cell lung cancer, is the most common (about 80 of cases) and in turn is divided into three main types: squamous cell carcinoma, adenocarcinoma and large cell carcinoma
  • small cell lung cancer, (also called microcytoma, about 10-15% of cases) has a much faster growth than the non-small cell lung cancer and, generally, also a more severe evolution (prognosis)

Lung cancer mainly develops in older people. It is rare under the age of 40 and most common in the 70-74 age group, which is most affected.

Although people who have never smoked can also get lung cancer, cigarette smoking is the main cause of the disease (attributed to over 85% of cases). This cause-and-effect relationship is due to the different toxic substances inhaled regularly every time you smoke a cigarette. The risk increases according to the amount of cigarettes smoked and the duration of the smoking habit. The relative risk of smokers compared to non-smokers has increased by 14 times and reaches 20-25 in heavy smokers (read the Bufala).

People with lung cancer are treated differently based on the type of cancer, the stage of the disease (stage) and general health conditions. If the detection of the disease (diagnosis) is made in the early stages of its development, that is when the tumor is still confined to a very small area, surgery can be considered. More frequently, a combination of radiotherapy is used. and drug therapy, with chemotherapy and molecularly targeted drugs, since often at the time of discovery the tumor has already begun to expand very rapidly and, consequently, surgery can no longer be considered an effective therapy.

Lung cancer does not usually cause noticeable symptoms until the disease spreads to the lungs or other parts of the body. This, in general, means that the outlook for this type of disease is not as promising as it could be for other types of cancer. Overall, about 1 to 3 confirmed (diagnosed) cases live for at least one year after diagnosis and about 1 in 20 people live for at least 10 years. The 5-year survival rate has increased slightly in recent decades from 10 to 14% in men and from 12 to 18% in women. The 10-year survival is 12%, 11% among men and 15% among women. However, survival rates can vary greatly depending on the spread of the cancer at the time of its discovery. An early diagnosis, therefore, can make a big difference.

Symptoms

Symptoms

Lung cancer in its early stages generally does not cause symptoms (symptoms) but as the disease progresses, they begin to manifest.

The main ones include:

  • cough that does not go away after two to three weeks
  • persistent cough that gets worse
  • respiratory infections (bronchitis or pneumonia) that are frequent or that recur after some time
  • presence of blood in secretions coming from the respiratory system (sputum)
  • chest pain during deep breathing or when coughing
  • shortness of breath or shortness of breath
  • persistent fatigue, weakness
  • loss of appetite or unexplained weight loss

Less common symptoms of lung cancer are:

  • changes in the appearance of the fingers, especially the curved and swollen extremities
  • body temperature around 38 ° C or higher (fever)
  • difficulty swallowing or pain when swallowing
  • respiratory difficulties
  • hoarseness
  • swelling of the face and neck
  • persistent chest or shoulder pain

If one or more disorders of the type described above appear, it is advisable to consult the attending physician.

Causes

Causes

Most cases of lung cancer are caused by cigarette smoking, but people who have never smoked can also be affected.
The main causes are:

  • smoke, tobacco smoke is the most important risk factor for the onset of lung cancer and is believed to be responsible for 85-90% of observed cases. It contains more than 60 different carcinogenic substances, ie substances that can cause lung cancer. cancer, and is known to cause several other cancers (esophagus, mouth). Those who smoke more than 25 cigarettes a day are 25 times more at risk of lung cancer than a non-smoker. Those who smoke half a pack a day have a risk about 10 times higher, and even those who smoke "only" 5 cigarettes a day have five times greater risk. The risk does not change if the cigarettes are prepared by the consumer himself. The consumption of tobacco in the form of other products also increases the risk of developing lung cancer and other cancers. These products include: cigars, pipe tobacco, a form of powdered tobacco, chewing tobacco
  • passive smoke, Frequent exposure to tobacco smoke in the environment (secondhand smoke) increases the risk of developing lung cancer in non-smokers. Research has shown that sharing a home with smoking partners increases the likelihood of developing lung cancer by 25% (read the hoax)
  • radon, radon is a radioactive gas that comes from uranium present in small quantities in all rocks and soils. Radon is able to penetrate into buildings, where it can also be found at high levels, given the limited volume of internal air. On the contrary, the radon that escapes to the open is dispersed and the concentrations in the external air are generally very low. The possible risks associated with radon inhalation of developing a tumor are higher in smokers since smoking and radon have a multiplicative effect
  • work exposures, Exposure to certain chemicals and minerals used in various workplaces, especially in industries, increases the risk of developing lung cancer. These substances include:
    • arsenic
    • asbestos
    • beryllium
    • cadmium
    • coal fumes
    • silica
    • nickel
  • outdoor air pollution, recent studies suggest that prolonged exposure to diesel engine exhaust can increase the risk of lung cancer by up to 50%. Another study showed that the risk of developing lung cancer increases by about a third if you live in an area with high levels of nitric oxide in the air (mostly produced by cars and other vehicles).

Some other possible risk factors:

  • cannabis smoke, to date there are no clear and definitive results on the relationship between cannabis and lung cancer. The risk of getting cancer seems slightly increased, in particular recent studies have indicated an "association between cannabis and adenocarcinoma, but not with squamous cell lung cancer. Certainly the use of cannabis has an inflammatory effect on the airways and can be the cause of persistent cough and shortness of breath. Most cannabis smokers mix weed with tobacco, tend to smoke less than tobacco-only smokers, but usually inhale more deeply and hold the smoke in their lungs longer.
Diagnosis

Diagnosis

In the event that any symptoms (symptoms) attributable to lung cancer, such as shortness of breath or a persistent cough, it is advisable to consult your doctor.

In addition to examining the general health conditions and inquiring about the type of disturbance, he could propose to undergo the examination of the spirometer, a device that is used to measure the amount of air that enters (inhalation) and exits (exhalation) from the lungs. In addition, they may order blood tests to rule out other possible causes of the disorders such as, for example, a respiratory infection and other tests which may include:

      • chest x-ray, the first test usually used when lung cancer is suspected. The tumor typically appears on the x-ray film as a grayish-white spot. However, radiography often gives an uncertain result as it cannot distinguish cancer from other formations such as, for example, a lung abscess (accumulation of pus). In this case, it will be necessary to rely on a specialist who will prescribe further tests to ascertain the presence or not of lung cancer and, if so, check what type of cancer it is and how advanced it is.
      • CT scanComputed tomography (CT) is usually done after a chest X-ray. It uses X-rays and produces a series of images in sequence which, suitably processed with computer programs, give a detailed picture of the internal structures of the examined organ. It can include the administration of a contrast agent, a liquid usually containing iodine. , which makes the image of the lungs clearer. In order to perform a CT scan with contrast medium, it is necessary to have fasted for at least 6 hours and to undergo some blood tests to evaluate the functionality of the kidneys and liver. The scan is painless and takes approximately 10-30 minutes
      • PET-CT, positron emission tomography is a type of investigation performed, generally, when the results of the CT scan indicate the presence of cancer at an early stage. The PET-CT scan gives a much more detailed picture from the functional point of view allowing to visualize the areas in which active tumor cells are located. This may be relevant to the choice of therapy. It involves the intravenous administration of a mildly radioactive substance. The person to be examined is made to lie down and undergo a painless scan lasting about 30-60 minutes
      • bronchoscopy and biopsy, in the event that the CT scan detects the presence of a tumor in the central part of the chest, the patient will undergo a bronchoscopy. It is a procedure that allows you to view lung tissue and take a small sample of cells from inside the lungs. During the examination, a thin, flexible tube, called a bronchoscope, is gently introduced through the mouth or nose. in the trachea up to the bronchi and lungs. The examination may be slightly annoying and, for this reason, a light sedative administered in advance and a local anesthetic are required to make the throat numb. The procedure is very simple and takes only a few minutes
      • other types of biopsy, surgical biopsy, such as a thoracoscopy or mediastinoscopy it is performed in doubtful cases or when the mass is not reachable with the bronchoscope. Alternatively, the fine needle aspiration technique can be practiced.
        • fine needle aspiration, is performed by inserting a needle through the skin, treated with local anesthetic, guided by a CT scanner to the suspicious mass in the lung. The needle will be used to take a sample of tissue to be examined in the laboratory for the presence of cancerous cells
        • thoracoscopy, is performed under general anesthesia by making a small incision in the chest to introduce a tube, similar to a bronchoscope, which allows you to directly observe the suspicious area and take a sample of tissue. After a thoracoscopy, a short hospital stay may be required
        • mediastinoscopy, is an endoscopic examination that allows the doctor to explore the area between the lungs (mediastinum) and the regional lymph nodes, areas where cancer cells usually spread. It is performed under general anesthesia, making a small cut in the lower part of the neck to introduce a thin tube and let it continue up to the mediastinum. This technique allows both to observe and to take small quantities of tissue to be analyzed to check for the presence of cancer cells. A short hospital stay may be required

Staging

From a "careful evaluation of the results of all the tests carried out, it should be possible to understand what type of tumor it is and what its stage of development (staging) is, important elements for assigning the patient the most correct type of treatment.

Non-small cell lung cancer

Non-small cell lung cancer (the most common type) usually spreads more slowly than small cell lung cancer and responds differently to treatment. The stages of non-small cell lung cancer are:

      • phase 1: the cancer is contained within the lung and has not spread to the local lymph nodes. Stage 1 can also be divided into two sub-stages:
        • stage 1A - the tumor is less than 3cm in size
        • stage 1B - the tumor is 3-5 cm
      • phase 2: two sub-phases are distinguished: 2A and 2B.
        Phase 2A has the following characteristics:
        • the tumor is 5-7 cm
        • the tumor is less than 5 cm and the cancer cells have spread to nearby lymph nodes
        Phase 2B has the following characteristics:
        • the tumor is larger than 7 cm
        • the tumor is 5-7 cm, and the cancer cells have invaded nearby lymph nodes
        • the tumor has not spread to the lymph nodes, but has spread to surrounding tissues
        • the cancer has spread to one of the main airways (bronchi)
        • the tumor caused the lung to collapse
        • presence of smaller tumors in the lung
      • step 3: phase 3 is divided into two sub-phases: 3A and 3B.
        In stage 3A, the cancer has spread either to the lymph nodes in the center of the chest or to the following surrounding tissues:
        • lining of the lungs (pleura)
        • rib cage
        • mediastinum
        • other lymph nodes near the affected lung
        In stage 3B, the tumor has spread to one of the following compartments:
        • lymph nodes on both sides of the chest above the collarbones
        • other organs or tissues, such as the esophagus, trachea, heart, or major blood vessels
      • step 4: in stage 4 the cancer has spread to both lungs or to a "different distant part of the body (such as bone, liver or brain)

Small cell lung cancer

Small cell lung cancer is less common than non-small cell lung cancer. When examined under a microscope, cancer cells are smaller in size than the cells that cause non-small cell lung cancer.
There are only two stages:

      • limited disease, the cancer has not spread beyond the lung
      • extensive disease, the cancer has spread beyond the lung
Therapy

Therapy

Determining which treatment (therapy) is most suitable for a lung cancer patient is the task of one team of specialists, who will take care to formulate a diagnosis and develop a treatment plan that also takes into account:

      • type of cancer (non-small cell or small cell cancer)
      • tumor size and location
      • progress phase (Stadium)
      • general state of health

The choice of therapy can be a very difficult task. The team of specialists will recommend a type of treatment but, ultimately, the decision will rest with the sick person. The main types of therapies include surgery, radiotherapy, chemotherapy and, where possible, molecularly targeted therapy. Depending on the type of cancer and the degree of progress, it is possible that they are prescribed in combination with each other.

Non-small cell lung cancer

If non-small cell lung cancer is confined to one lung and general health is good, surgery to remove the cancer cells may be indicated. This may be followed by a course of chemotherapy to destroy any remaining cancer cells. .

If the cancer has not spread to other areas but, for various reasons, surgery cannot be applied (for example, if general health does not allow it), radiation therapy is usually prescribed to destroy the cancer cells. In some cases, it can be associated with chemotherapy.

In cases where the cancer has spread remotely (metastasized) but both surgery and radiotherapy are not effective solutions, chemotherapy is recommended. If the cancer recurs again after the first chemotherapy treatment, another course should be done.

Biological therapies, or molecularly targeted drug therapies, are treatments that can control or stop the growth of cancer cells. In some cases, they may be recommended as an alternative to chemotherapy, or after chemotherapy.

Small cell lung cancer

Small cell lung cancer is usually treated with chemotherapy, alone or in combination with radiation therapy. This can have an effect on both survival and ailments caused by the disease.

Surgery is usually not indicated in the treatment of this type of lung cancer as the disease has often already spread to other areas of the body by the time it is diagnosed. However, if the cancer is at a very early stage, surgery can be applied. In these cases, chemotherapy or radiotherapy can be given after surgery to reduce the risk of the cancer returning.

Surgery

There are three types of lung cancer surgery:

      • lobectomy, consists of "removing one or more parts of the lung (called lobes). Doctors suggest this if the tumor is only in one section of a lung.
      • pneumonectomy, consists of the removal of the entire lung. It is applied when the tumor is in the center of the lung or has spread throughout the lung
      • segmentectomy or wedge resection, consists in the removal of a small piece of lung. This procedure is uncommon and indicated only if doctors consider the tumor to be small enough and limited to one area of ​​the lung, a situation that usually occurs at a very early stage

A frequent concern among patients undergoing surgery is the possibility of not being able to breathe regularly after surgery. In fact, it is possible to breathe normally even with only one lung. However, if you have breathing problems before the operation, such as shortness of breath, these symptoms are likely to persist even after the surgery.

Test before surgery, before surgery, the patient undergoes a series of tests to check the general health and lung function, including:

      • electrocardiogram (ECG), an examination performed with the application of electrodes to monitor the activity of the heart
      • spirometry, examination carried out by making the patient breathe through an instrument, called a spirometer, which measures the amount of air introduced and expelled from the lungs

Surgery is usually performed by making a cut in the chest, or to the side, to remove part or all of the affected lung. Nearby lymph nodes may also be removed if cancer cells are thought to be likely.

In some cases, video thoracoscopy (VATS) is performed. It is a type of surgery performed by means of small incisions made in the chest. Through one of them, a small fiber optic camera is inserted that allows the surgeon to see the images of the inside of the chest on a monitor.

The hospital stay after surgery could range from 5 to 10 days. However, in some cases it may take up to a few weeks in hospital to allow for a good recovery.

After the operation, the patient will be encouraged to move as soon as possible. This is especially important for blood circulation and to prevent the formation of clots. He will also be followed by a physiotherapist who will show him the breathing exercises to be performed daily to prevent complications.

Once at home, it will be necessary to dedicate time to physical and breathing exercises to regain physical shape. Walking and swimming are good forms of exercise suitable for most people after lung cancer surgery. In any case, it will be up to the team of caregivers to direct the patient to the most suitable exercises.

ComplicationsAs with all surgeries, lung surgery carries a risk of complications. It is estimated that one in five people suffer from it. They can be treated with drugs or with additional surgeries that involve a longer hospital stay.
Complications of lung surgery can include:

      • inflammation or infection of the lungs (pneumonia)
      • excessive bleeding
      • formation of blood clots in the leg (deep vein thrombosis) which could travel to the lung (pulmonary embolism)

Radiotherapy

Radiation therapy is a type of treatment that uses radiation to destroy cancer cells. Includes:

      • radical radiotherapy, an intensive course of radiation therapy is used to treat non-small cell lung cancer when the patient cannot undergo surgery. For very small tumors, a special type of radiation therapy, called stereotaxic radiotherapy, in place of surgery. Radiation therapy can also be used to control symptoms and slow the spread of cancer when no other type of therapy is possible (palliative radiotherapy)
      • prophylactic cerebral radiotherapy (PCI), is sometimes used during the treatment of small cell lung cancer as a preventative measure against brain metastases. PCI involves treating the whole brain with low doses of radiation

The three main types of radiation therapy are:

      • conventional external beam radiotherapy, uses a machine to deliver radiation beams from the outside to the parts of the body to be treated
      • stereotaxic radiotherapy, an innovative technique that allows you to send a "high dose of radiation directly to the tumor mass with extreme accuracy and precision, saving the surrounding healthy tissue as much as possible
      • internal radiotherapy, uses a catheter (thin tube) inserted into the lung. A source of radioactive material is placed inside the catheter and placed in close contact with the tumor and then removed after a few minutes.

For lung cancer, external beam radiation therapy is used more often than internal radiation therapy, particularly if the cancer is thought to be 'curable'. Stereotaxic radiotherapy can be used to treat tumors in the initial stages, when they are very small, given the effectiveness of the technique compared to that shown by standard radiotherapy. Internal radiotherapy is, on the other hand, used mainly as a palliative treatment to relieve disorders in the cases in which the tumor causes obstruction of the airways.

The courses of radiotherapy treatment can be planned in several ways. Radical radiation therapy usually involves five administrations per week and a weekend break. Each session lasts 10-15 minutes and the cycle is repeated for 4-7 weeks.

Continuous accelerated hyper fractional radiotherapy is an alternative method that involves dividing the daily dose into three doses per day, for 12 days, without interruption.

For stereotaxic radiotherapy, fewer sessions are required as the single dose is more concentrated than a standard dose and the cycle usually comprises 3 to 10 total sessions.

Palliative radiotherapy usually takes 1 to 5 sessions.

Side effects of chest radiation therapy are:

      • chest pain
      • nausea and fatigue
      • persistent cough and increased sputum with streaks of blood (usually)
      • difficulty swallowing (dysphagia)
      • redness and pain of the skin (symptoms similar to sunburn)
      • Hair loss (it concerns only the treated area, therefore the chest hair for men and the hair in the case of patients undergoing brain radiotherapy)

In any case, the undesirable effects (side effects) disappear once the course of radiotherapy is completed.

Chemotherapy

Chemotherapy uses powerful drugs that can destroy cancer cells. There are several ways in which it can be used to treat lung cancer:

      • chemotherapy before surgery, the patient is subjected to therapy to reduce the volume of the tumor. This could increase the likelihood of the surgery being successful
      • post surgery chemotherapy, the patient is treated after surgery in order to prevent relapses
      • palliative chemotherapy, used to relieve ailments and slow down the spread of the tumor when it is incurable because it is too advanced
      • chemotherapy in combination with radiotherapy

A course of chemotherapy includes the administration of one or more drugs for several days, with a break of a couple of weeks to allow the body to overcome the side effects.

The total number of chemotherapy courses varies according to the type of cancer and the degree of progression. For the most part, it includes four to six cycles over a three to six month period.

Lung cancer chemotherapy is usually based on a combination of several drugs. They are usually given into a vein through a drip (intravenously) or through a tube connected to one of the blood vessels in the chest. More rarely, they are given by mouth (orally) in the form of tablets.

Side effects of chemotherapy can include:

      • fatigue
      • nausea
      • He retched
      • mouth ulcers
      • hair loss

These disorders can be reduced through the use of appropriate drugs and should gradually disappear at the end of the treatment.

Chemotherapy can weaken the body's defense system (immune system) increasing the vulnerability to infections. It will be necessary to notify the team of specialists and / or the oncologist as soon as possible if any signs of infection are detected, such as, for example, a temperature over 38 ° C (fever) or if you suddenly feel a general malaise.

Besides surgery, radiation therapy and chemotherapy, there are a number of other treatments that are sometimes used to treat lung cancer.

Biological therapies

Biological therapies consist of innovative drugs directed, generally, against a molecular target present on tumor cells. They are only suitable for people with cancer cells that produce particular proteins. It will be the task of the oncologist to prescribe specific tests on a small sample of cells taken from the lung (biopsy) to determine if these drugs can be used. In lung cancer, in cases difficult to treat with conventional therapies, such as surgery or radiotherapy, recent studies have shown a significant increase in responses and survival thanks to molecularly targeted therapies and immunotherapy (which uses each person's immune system to fight cancer).

Examples of biological therapies are drugs that inhibit the growth of cancer cells, or the formation of the vessels that support tumor growth, and monoclonal antibodies.

Radiofrequency ablation

Radiofrequency ablation is a new type of treatment applicable in non-small cell lung cancer discovered at an early stage. It is practiced using a needle that is guided through the use of a computed tomography (CT) scanner until it reaches the tumor. A series of radio waves are transmitted through the needle that generate heat, killing cancer cells. The most common complication of radiofrequency ablation is the formation of an air pocket between the inner and outer layers of the lungs (pneumothorax). In these cases, a tube is inserted into the lungs to allow trapped air to escape.

Cryotherapy

Cryotherapy is a treatment that can be used in the event that the development of the tumor begins to obstruct the airways. This phenomenon, known as endobronchial obstruction, can cause disorders (symptoms) such as difficulty breathing, cough, even with the expulsion of blood. Cryotherapy is performed in a similar way to internal radiotherapy which involves the use of a device known as cryoprobeinstead of a radioactive source. The cryoprobe, placed in close contact with the tumor mass, generates very cold temperatures which help to shrink the tumor.

Photodynamic therapy

Photodynamic therapy (PDT) can be used to treat lung cancer at an early stage when the patient is inoperable. It can also be used to remove a tumor that is blocking the airways.
Photodynamic therapy is carried out in two stages. In the first, a drug is administered which makes the cells very sensitive to light. In the second, 24-72 hours later, a thin tube is inserted, guided to the tumor and used to emit a laser beam that will destroy the cancerous cells, which have become more sensitive to light.

Side effects of photodynamic therapy include inflammation of the airways and accumulation of fluid in the lungs. Both of these side effects (side effects) can cause breathing difficulties and pain in the chest and throat. However, these disorders should gradually subside as the effects on the lungs normalize.

Prevention

Prevention

If you smoke, the best way to prevent lung cancer and other serious diseases is to quit smoking as soon as possible. It is always worth stopping smoking: from the moment of stopping the risk of developing lung cancer is reduced every year. After 10 years, the risk is equal to half of those who smoke.

Diet

Nutrition and cancer studies suggest that a low-fat, high-fiber, whole-grain diet with at least five servings a day of fresh fruit and vegetables may reduce the risk of lung cancer, as well as others. types of cancer and heart disease.

Exercise

The evidence that regular exercise can reduce the risk of developing lung cancer and other cancers is now more than convincing. The numbers speak for themselves: adults should do at least 150 minutes (2.5 hours) of moderate aerobic activity each week to have an advantage in this regard.

Living with

Living with

Lung cancer can affect everyday life in different ways, depending on the stage of the cancer and the treatment you are receiving.

To better deal with the problems that may arise, it could be useful:

      • talk to friends and family
      • talk to other people in the same situation
      • inquire about the disease
      • avoid overexertion
      • take time for yourself

Lung Cancer Nurses

The team of specialists who will have to take care of the patient should include at least one nurse who specializes in the care of people with lung cancer. It is important to make sure of this as it could be of great help as well as a source of information and advice for the patient.

Wheezing

Wheezing is a common symptom in people who have lung cancer, both as a direct consequence of the disease and as a side effect of treatment. In many cases, wheezing can be alleviated by taking a few simple measures:

      • breathe slowly through the nose and exhale through the mouth (once the treatments are finished, you can contact a physiotherapist who can show you some simple breathing exercises)
      • simplify daily activitiessuch as using a trolley when shopping or avoiding the stairs
      • use a fan to cool your face
      • eating small, frequent meals ingesting small amounts of food from time to time

If these tips do not help restore normal breathing, your doctor may prescribe specific medications that can help improve shortness of air (dyspnea). In severe cases, they may prescribe oxygen therapy at home.

If the wheezing is caused by another cause, such as a chest infection or fluid buildup around the lungs (pleural effusion), it will need to be eliminated to improve breathing.

Bibliography

Bibliography

Huang YH et al. An epidemiologic review of marijuana and cancer: an update. Cancer Epidemiology Biomarkers and Prevention. 2015; 24: 15-31

Further links

Further links

Higher Institute of Health (ISS). Radon and the National Radon Plan (PNR)

Smoking, Alcohol and Drugs Observatory (ISS). Smoke

Higher Institute of Health (ISS). Green phone against smoking

Italian Association of Medical Oncology (AIOM). AIOM 2019 guidelines. Lung neoplasms

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