When Lung Cancer Spreads to Your Lymph Nodes: What to Expect

The first lymph nodes that lung cancer cells usually spread to are ones closest to the lungs, but cancer can also travel to nodes farther away. "Knowing exactly which lymph nodes are affected helps doctors figure out the stage of the cancer and decide on the best treatment," says Tingting Tan, MD, PhD, a medical oncologist and hematologist at City of Hope in Newport Beach, California.

Doctors assign lung cancer a stage based on the size of the tumor, whether cancer cells are in the lymph nodes, how many nodes contain cancer, and whether the cancer has spread to distant sites like the bones, brain, or adrenal glands, says Dr. Anderson.

Non-Small Cell Lung Cancer (NSCLC) Staging

• Stage 0 Cancer cells are only in the layers of the lung and it hasn't spread to any other parts of the lung or to lymph nodes.
• Stage 1 The cancer is larger. It has invaded other parts of the lung, but it has not spread to lymph nodes.
• Stage 2 The tumor is larger than stage 1 and it may have spread to nearby lymph nodes.
• Stage 3 Cancer is in the lymph nodes, possibly including nodes in the mediastinum (the area between the lungs).
• Stage 4 The cancer has spread to distant lymph nodes and organs.

Small Cell Lung Cancer (SCLC) Staging

• Limited stage: The cancer is on one side of the chest. It may be in lymph nodes on the same side of the chest as the tumor.
• Extensive stage: Cancer has spread through one lung, to the other lung, or to other parts of the body.

Lymph Node Classifications

• Peribronchial lymph nodes are near the air passages — bronchi — of the lungs.
• Hilar lymph nodes are in the hilum — the area where the airways, blood vessels, and nerves enter the lungs.
• Pulmonary lymph nodes are in the lung.
• Mediastinal lymph nodes are in the mediastinum — the space between the lungs.
• Subcarinal lymph nodes are in the area where the windpipe splits into the right and left lung airways.
• Supraclavicular nodes are above the collarbone.

TNM Staging

• T: How large is the tumor and has it grown into nearby structures or organs?
• N: Has the cancer spread to lymph nodes, and if so, which ones?
• M: Has the cancer metastasized, or spread to distant organs like the brain, bones, or adrenal glands?

• N0: There is no cancer in the lymph nodes.
• N1: There is cancer in the pulmonary or hilar lymph nodes on the same side of the body as the cancer.
• N2: There is cancer in the mediastinal lymph nodes on the same side of the body as the cancer, or in the subcarinal nodes.
• N3: There is cancer in the mediastinal, hilar, or supraclavicular nodes on the opposite side of the body as the cancer.

• A constant cough
• Coughing up blood
• Shortness of breath
• A hoarse voice
• Appetite loss
• Unexplained weight loss
• Repeated lung infections
• Tiredness and weakness

• Computed Tomography (CT) Scan A CT scan takes multiple X-ray images from different angles, and then a computer combines the pictures to create a very detailed cross-sectional picture of the suspected area. This test can show enlargement that might be cancer in a lymph node.
• Positron Emission Tomography (PET) Scan A PET scan uses radioactive sugar to find areas of cancer in lymph nodes or distant sites. Cancer cells take in more sugar than healthy tissue, which makes them "light" up on the scan.

The only way to confirm the diagnosis is with a biopsy. "This might involve removing a lymph node surgically or using a needle to collect tissue samples," says Dr. Tan. The doctor can guide the needle with a camera placed in the airway, which is called an endobronchial ultrasound (EBUS). A lab then tests the biopsy samples for cancer.

Once cancer has spread to the lymph nodes, a more systemic (body-wide) treatment may be needed. "The [treatment] plan depends on how much the cancer has spread and what the patient prefers," says Tan.

Treatment options include one or more of these therapies:

• Surgery Depending on the extent of the cancer, surgery could involve removing part of a lobe, an entire lobe, or a whole lung.

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   The surgeon will take out the tumor, some surrounding tissue, and any lymph nodes that are suspected or known to contain cancer.

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• Chemotherapy This treatment uses powerful medicines to kill cancer cells all over the body. It's often part of the treatment for lung cancer that has spread to lymph nodes, sometimes in combination with surgery or radiation therapy. Chemotherapy for lung cancer is typically delivered into a vein.

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• Radiation Therapy It uses high-energy X-rays to damage the DNA inside cancer cells and stop the cells from dividing. Radiation therapy is often part of the treatment when lung cancer has spread to the lymph nodes, sometimes along with chemotherapy or immunotherapy. The radiation is delivered externally from a machine, or internally from pellets or other radioactive objects placed inside the body near the tumor.

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• Targeted Therapy These medicines block proteins or other substances that help lung cancer grow. Targeted therapy is a treatment for lung cancers with certain gene mutations, such as KRAS, EGFR, or ALK.

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• Immunotherapy This treatment helps the immune system more effectively fight the cancer. Immune checkpoint inhibitors are a type of immunotherapy used to treat lung cancer. These drugs act on cellular “switches” that turn on or off cancer-fighting immune cells to launch an attack.

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Once cancer escapes the lung and gets into the lymph nodes, it can affect the prognosis. The outlook depends on how far the cancer has spread and how well it responds to treatment.

"While lung cancer with lymph node involvement is more advanced than cancer confined to the lung, individualized treatment approaches can help patients achieve meaningful disease control and maintain quality of life," says Tan.

• Lung cancer can spread from the lungs to nearby lymph nodes, or to nodes in the neck or belly.
• Cancer in the lymph nodes affects staging and treatment.
• Treatment options for lung cancer in the lymph nodes include surgery, radiation therapy, chemotherapy, immunotherapy, and targeted therapy.
• The prognosis depends on how far the cancer has spread, and whether it's in distant organs.