Due to various symptoms (e.g. cough, coughing up mucus or blood, shortness of breath, fever, weight loss, pain), the treating doctor will order an X-ray examination or, if necessary, a computer tomography of the chest. If there is an abnormal finding, it could be due to various diseases, such as inflammation, a benign or even malignant tumor.
In the Pulmonology Clinic, a number of tests are carried out in order to be able to make an accurate diagnosis without delay. As a rule, an examination of the airways (bronchoscopy) is first carried out in order to take tissue samples from the bronchi and/or lungs. If the presence of a tumor is suspected, in most cases an ultrasound examination (EBUS, endobronchial ultrasound) and, if necessary, a needle puncture of the mediastinal lymph nodes are carried out during the first bronchoscopy to more precisely assess the spread of the disease (staging). All tissue samples are examined under a microscope in the Institute of Pathology; further immunohistochemical or molecular tests on the material obtained may then be necessary. Surgical clarification of the mediastinal lymph nodes using a so-called mediastinoscopy is only necessary in a few cases.
In most cases, position emission tomography (PET-CT) is carried out to search for scattered foci (distant metastases) of the disease. Evaluation with bone scintigraphy, neck and abdominal ultrasound, and head magnetic resonance imaging may be necessary. If a diagnosis cannot be made from the tissue sample taken during bronchoscopy, samples may be taken from the outside through the chest wall with the support of ultrasound or computer tomography.
When planning treatment for the disease, the performance of the body, especially the lungs, heart and kidneys, is crucial and must be taken into account. For this purpose, various functional examinations are carried out, such as lung function (body plethysmography), blood circulation examination of the lungs (perfusion scintigraphy), an ultrasound examination of the heart (echocardiography) and, if necessary, an exercise test on a bicycle. Once all examination findings and information are available, they are presented and discussed at a large tumor conference. Representatives of all departments involved in the diagnosis and treatment of the disease are present at this tumor conference. All further therapy steps will be determined together. These are explained in detail to the patient and, if requested, in the presence of their relatives. Right from the start, we can make it easier to deal with the illness and offer psychological support in collaboration with the Clinic for Psychosomatic Medicine and Psychotherapy.
If, in the course of an advanced disease, persistent shortness of breath occurs due to narrowing of the airways, these can be widened or reopened as part of a lungoscopy. All modern techniques for interventional pneumological endoscopy are available at any time:

• Rigid bronchoscopy, possibly combined with a flexible technique
• Bronchial dilatation
• Cryotherapy, cryorecanalization
• Argon plasma coagulation (APC)
• Airway stents
• endobronchial radiation therapy (brachytherapy) in cooperation with the clinic for radiation therapy.

If the shortness of breath is caused by a recurring accumulation of fluid in the chest (pleural effusion), a permanently inserted catheter tunneled under the skin may be used to drain the fluid. This enables care under home conditions.

If there is a suspicion of a lung tumor, the patient is first examined comprehensively with the aim of classifying the stage. It will be clarified what type of tumor it is and whether there are already lymph node or distant metastases. For this purpose, positron emission tomography (= PET) and an endobronchial puncture (= EBUS) of the lymph nodes are carried out. If the PET indicates an infestation of the lymph nodes and at the same time the cytological puncture results of the lymph nodes are negative, the surgeon performs a so-called procedure under general anesthesia. Video mediastinoscopy. As part of this procedure, the lymph nodes are biopsied under view. The surgeon thus makes a valuable contribution to correct staging in diagnostics. This is essential for planning further treatment and estimating the prognosis.

Along with chemotherapy and radiation therapy, surgery is an essential pillar of lung cancer treatment. If there is a locally operable tumor without lymph node involvement, surgical removal of the tumor is the treatment of first choice. These cases can usually also be carried out using the keyhole method (= minimally invasive). The goal is always to preserve as much lung tissue as possible. In advanced cases that show central lymph node involvement, we pursue a so-called neoadjuvant concept. This means that chemotherapy is first carried out before the tumor is surgically removed. This approach has proven successful in international studies. In these stages we usually operate through an open approach (= thoracotomy), as removing the tumor in a healthy person can be quite challenging. The development of surgery has progressed to such an extent that extended resections are also possible with good results. This includes not only the removal of the actual tumor, but also the neighboring anatomical structures such as the pericardium or the chest wall. Our center has great expertise in this area, which extends to operations using a heart-lung machine. Our goal is to sensibly integrate surgery into the overall treatment concept in supposedly advanced cases in order to achieve the best results for our patients. Even in palliative situations, when malignant pleural effusions quickly develop, we can improve patients' shortness of breath through minimally invasive talcum pleurodesis.

In summary, thoracic surgery is an integral part of the treatment of lung cancer. Our center offers all common surgical procedures, which are carried out with appropriate expertise and routine for the benefit of the patients.

Drug tumor therapy plays a major role in the treatment of lung cancer. The so-called systemic therapy is used in both metastatic and localized stages. Chemotherapy and immunotherapy are most often administered as infusions, but certain targeted therapies come in oral form (tablets or capsules). The majority of chemotherapy/systemic therapies can now be administered on an outpatient basis.

Inpatient chemotherapy/systemic therapies
Inpatient therapy usually only takes place if outpatient therapy is not possible for clinical reasons or if the type of therapy makes inpatient administration absolutely necessary. Even if side effects occur, inpatient treatment is sometimes necessary.
For this purpose, you will find an experienced team of senior physicians, specialists, assistant physicians and oncological nurses in our hematology/oncology wards 331a and 331b. On our wards 331a and 331b, in addition to trained nurses, three oncology nurses, a palliative care nurse, three nurses with additional training in wound management and two pain nurses work in the nursing area. On the medical side, you will be looked after by at least two doctors from hematology/oncology in each ward.

Interdisciplinary outpatient chemotherapy
In interdisciplinary outpatient chemotherapy (IAC), it is possible to carry out chemotherapy, antibody therapies and blood transfusions on an outpatient basis.
This has the great advantage for patients that they can leave the clinic on the same day and remain in their home environment. In addition to the hematology/oncology outpatient clinic, several specialist disciplines carry out their outpatient therapies in the IAC rooms. The main advantage of combining outpatient therapies from different disciplines is the uniform organization while maintaining a high standard to ensure therapy planning, implementation and further monitoring. Further information about the IAC can be found here.

Radiation therapy plays a major role in the treatment of lung tumors. Depending on the type of tumor (histology) and size, radiation therapy is often used in combination with chemotherapy as the only method of healing. But radiation therapy is also used after surgery to reduce the occurrence of a recurrence (reappearance of the tumor).

What does “percutaneous” radiation therapy mean?
With percutaneous radiation therapy, the tumor is irradiated from the outside “through the skin”. This technique is also called teletherapy. The very high-energy radiation is generated using a linear accelerator. This directs the photon beams, more precisely ultra-hard, high-energy X-rays, onto the tumor. The goal is to destroy the cancer cells. Technical developments such as intensity-modulated therapy (IMRT), stereotaxy, image-guided radiation (IGRT = image guided radiotherapy), breathing-controlled radiation and particle therapy now make it possible to irradiate the tumor with ever greater precision.

How does radiation therapy work?
A single radiation session usually lasts a few minutes, but many sessions are usually carried out over several weeks until the tumor has received the necessary total radiation dose. Depending on the type and size of the tumor, in special cases around 5 sessions or even just one individual session may be sufficient (stereotaxy, radiosurgery). In order to ensure precise planning, doctors need a lot of information. The more information doctors have about the tumor, the more precisely they can plan the radiation treatment.

How is the preparation for radiation therapy carried out?
As a rule, a computer tomography (CT) of the lungs is carried out first. At this point, the first markings are made on the skin with a waterproof pen, which will later be used to correctly adjust the patient's position during irradiation. The images from the computer tomography are then transferred to the computer system for radiation planning. The doctors determine the volume to be irradiated on the computer and the radiation physicists calculate the best setting of the accelerator (number and size of the radiation fields, etc.) individually for each patient.

How is the healthy tissue surrounding the tumor protected during radiation?
Multiple irradiation fields from different directions are used. The radiation fields are chosen so that the rays do not hit the tissue to be protected, such as the spinal cord, or that they penetrate the tumor through the tissue to be protected, such as when irradiating a tumor in the lungs, with the lowest possible effective dose from different directions so that the total radiation dose reaching the tumor can be delivered to different parts of the lung with the lowest possible single dose that does not destroy the healthy tissue.

How does the actual treatment work? What does image-guided radiation therapy (IGRT) mean?
The patient is placed on the treatment table and pushed into the treatment position. If necessary, IGRT is then carried out by checking the positioning of the patient using a control computer tomography taken on the radiation table, which is compared with the radiation planning computer tomography (IGRT). The irradiation table then moves to the planned irradiation position with millimeter precision in order to direct the rays exactly onto the tumor and the actual irradiation can begin. The actual radiation treatment is very quick and usually only takes a few minutes. Irradiation can occur via individual fixed irradiation angles (3D conformal therapy) or during the rotation of the accelerator around the patient with simultaneously changing field irradiation configurations (IMRT or VMAT technique).

How is breathing-controlled radiation carried out?
Tumors in the lungs move when you breathe, some very little, some a lot. To ensure that the tumor is always targeted precisely and that no healthy lung tissue is irradiated unnecessarily, a so-called 4D computer tomography is performed on all patients. For this purpose, a marker block is placed on the chest area during computer tomography and the patient's breathing movement is measured. The images from the computer tomography are then sorted into a breathing phase so that the movement of the tumor while breathing can be seen precisely. Tumors that have a very high mobility during breathing are then later only irradiated in a certain breathing phase, while no irradiation occurs in the other breathing phases. In this case, however, the irradiation lasts longer than just a few minutes. If a patient can breathe very well, there is also the option of irradiating with deep inspiration breath hold, as even then the tumor shows no mobility.

How is stereotaxy or radiosurgery carried out for lung tumors at Marburg University Hospital?
With stereotaxy, computer-assisted target guidance systems or image-guided (IGRT) enable precise localization of the tumor. Stereotaxy is often used in the lung area for a few high-dose irradiations of the tumor (fractionated stereotaxy). This high-precision radiation (stereotaxy) with a high single dose and reduced number of radiation sessions is also called hypofractionated radiation. The one-time, high-precision irradiation of a tumor or metastasis is also known as radiosurgery. Stereotaxy and radiosurgery are effective and safe alternatives to both conventional radiation and surgery. Both techniques are used in combination with breath-controlled radiation. No anesthesia is required to carry out the therapy. The risks of early and late side effects are usually minimal.

How is brachytherapy performed?
During brachytherapy, the tumor is irradiated from the “inside”. To do this, a tube is first brought down the trachea to the tumor (bronchoscopy). Then a radioactive substance, which is in a sleeve and attached to a wire, is brought through the tube to the tumor. This happens computer controlled. This process is called afterloading. This means that both the staff and the patient come into contact with the radioactive substance for as short a time as possible. The tube is placed in the body and the radiation is administered under anesthesia. The most time-consuming part of the treatment is inserting the tube and planning the radiation treatment. The actual radiation usually only takes a few minutes. The radioactive substance is then drawn in under computer control.

What side effects can occur with radiation?
Due to modern techniques, the occurrence of side effects has become much lower. Patients often react to radiation with tiredness, fatigue and exhaustion. Skin redness during therapy is now a rarity. If the esophagus receives a dose of radiation, slight difficulty swallowing may occur acutely. A very rare side effect is so-called pneumonitis, which can lead to an inflammatory reaction of the lung tissue within the high-dose ranges of radiation. This could present with coughing or shortness of breath and would be treated with cortisone. As a possible late change after radiation therapy, parts of the lung can become fibrotic (connective tissue) and participate less in air exchange. As with an operation, this is taken into account beforehand when planning the radiation treatment so that there is always enough lung tissue available for air exchange.

When do we use radiation therapy for patients with lung tumors?
If bone metastases have already occurred, percutaneous radiotherapy is used effectively to relieve pain. Fewer sessions are necessary, so the therapy is usually completed in 2-4 weeks. In individual cases, a single irradiation may be sufficient. When brain metastases occur, radiation therapy is usually used to shrink or completely destroy the metastases, as many systemic therapies such as chemotherapy often cannot overcome the blood-brain barrier and radiation therapy offers an effective, non-invasive treatment option.

How can you contact us?
You can reach us Monday - Thursday from 8:00 a.m. to 4:00 p.m. and Friday from 8:00 a.m. to 2:00 p.m. on the telephone number 06421/ 58-62833, at the email address Ambulanz.STT(at)uk- gm.de or by post to Radiation Therapy and Radiation Oncology, UKGM Marburg, Baldingerstr., 35043 Marburg

Nuclear medicine examination methods enable the visualization of various metabolic processes in the body through the use of radioactively labeled substances and therefore play an indispensable role both in the diagnosis of pulmonological diseases and in the preoperative preparation of surgical procedures.

Lung scintigraphy is also based on the principle of depicting the metabolism of an organ. After injecting a radiopharmaceutical (a combination of an organ-specific substance and a radioactive radiation source), the radiation emitted by the patient in the body is measured using a special examination device, a so-called gamma camera. Depending on the accumulation of the radioactive substance in the lungs, different clinical pictures can be diagnosed quickly and in early stages with a high level of sensitivity.

For the efficient treatment of potentially fatal acute pulmonary embolism, early detection of this clinical picture is essential. The influx of a venous blood clot from, for example, a deep vein in the leg, which usually forms as a result of long periods of immobilization or bed rest, can lead to blockage of downstream pulmonary arteries and hinder the ongoing gas exchange in the lungs. Lung scintigraphy is used to rule out pulmonary embolism as a valid alternative to other diagnostic procedures with higher radiation exposure. To do this, the patient first inhales a radioactively labeled gas mixture to demonstrate the ventilation of both lungs. The radiopharmaceutical is then administered venously to demonstrate pulmonary blood flow. A comparison of these two scintigraphic images enables the early detection of a deficiency in pulmonary blood flow compared to ventilation, which is considered diagnostically groundbreaking for pulmonary embolism.

Knowledge of the blood flow in the individual lungs and its quantitative representation is of enormous importance, especially before thoracic surgery / lung operations. With regard to this question, lung scintigraphy is also considered an effective and established procedure. Nuclear medicine procedures are of great importance with regard to pulmonological issues, and not just in emergency diagnostics.

Positron emission tomography (PET) has been an established and sensitive examination method for years to diagnose and stage malignant lung diseases. Here, the patient is injected with radioactively labeled biomolecules, such as glucose, which accumulate in the organism in accordance with the body's cell function. The radiopharmaceutical FDG (fluoro-18-deoxyglucose) has primarily become established in cancer diagnostics. Compared to healthy tissue, the sugar accumulates more in degenerate, i.e. malignant, cells of the lung tissue and thus helps to detect even small lesions. Settlements in lymph nodes and other organs can also be made visible in this way. The combination of this nuclear medicine examination method with computer tomographic cross-sectional imaging (CT) ensures an even better anatomical representation of the lungs and thus an excellent assessment of potentially malignant cells.