Treatment

Early-Stage Disease - is defined as stages I and II. - In this group are T1 and T2 tumors (with or without local N1 nodal involvement) and T3 tumors (without N1 nodal involvement).

Current Standard Of Treatment

surgical resection accomplished by lobectomy or pneumonectomy, depending on the tumor location.

Appropriate surgical procedures for patients with early-stage disease

lobectomy sleeve lobectomy occasionally pneumonectomy with mediastinal lymph node dissection or sampling. Sleeve resection - is performed for tumors located at airway bifurcations when an adequate bronchial margin cannot be obtained by standard lobectomy. Pneumonectomy - is rarely performed - primary indications for pneumonectomy in early-stage disease include the presence of large central tumors involving the distal main stem bronchus and inability to completely resect involved N1 lymph nodes.

Carcinoma arising in the extreme apex of the chest - with associated arm and shoulder pain - atrophy of the muscles of the hand - and Horner syndrome was first described by Henry Pancoast in 1932.
Pancoast's tumor - Any tumor of the superior sulcus, including tumors without evidence of involvement of the neurovascular bundle.

 Pancoast's tumors have been difficult to treat, with high rates of local recurrence and poor 5year survival with radiation and/or surgical resection.

Surgical excision is performed via thoracotomy with en bloc resection of the chest wall, vascular structures, and anatomic lobectomy.

En bloc resection - is used for other locally advanced tumors (T3) with direct invasion of the adjacent chest wall, diaphragm, or pericardium. - If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous obstruction

Locoregional Advanced Disease

Surgical resection as sole therapy has a limited role in treatment of stage III disease. T3 N1 tumors can be treated with surgery alone, and a 5-year survival rate of approximately 25% is seen with such therapy. Patients with clinically evident N2 disease (i.e., bulky adenopathy on CT scan or mediastinoscopy, with lymph nodes often replaced by tumor) have a 5-year survival rate of 5 to 10% with surgery alone.

Two strategies for delivery are available

1. Sequential chemoradiation - involves full-dose systemic chemotherapy (i.e., cisplatin combined with a second agent) followed by standard radiotherapy (approximately 60 Gy). 2. Concurrent chemoradiation - An alternative approach, is to administer chemotherapy and radiotherapy at the same time.

The advantages of this approach are: - improved local control of the primary tumor and associated nodal disease - a lack of delay in administering radiotherapy. Disadvantage of this approach: - is the necessary reduction in chemotherapy dosage to diminish overlapping toxicities, which can potentially lead to undertreatment of systemic micrometastases.

Preoperative (Induction) Chemotherapy for NonSmall Cell Lung Cancer

The use of chemotherapy before possible surgical resection has a number of potential advantages: 1. The tumor's blood supply is still intact, which allows better chemotherapy delivery and avoids tumor cell hypoxia (in any residual microscopic tumor remaining postoperatively), which would increase radioresistance. 2. The primary tumor may be downstaged with enhanced resectability.

3. Patients are better able to tolerate chemotherapy before surgery and are more likely to complete the prescribed regimen than when chemotherapy is given after surgery. 4. Preoperative chemotherapy functions as an in vivo test of the primary tumor's sensitivity to chemotherapy. 5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy. 6. Systemic micrometastases are treated. 7. Patients who have progressive disease (nonresponders) are identified and spared a pulmonary resection.

Potential disadvantages include the following: 1. In theory the perioperative complication rate may increase (predominantly in patients requiring right pneumonectomy after induction chemotherapy). 2. While the patient is receiving chemotherapy, potentially curative resection is delayed; if the patient does not respond, this delay could result in tumor spread.

Surgery in Stage IV Disease

Chemotherapy - treatment of patients with stage IV disease. - However, on occasion, patients with a single site of metastasis are encountered, particularly patients with adenocarcinomas who have a solitary brain metastasis.

Small Cell Lung Carcinoma

Small cell lung carcinoma (SCLC) -accounts for approximately 20% of primary lung cancers and generally is not treated surgically. - These aggressive neoplasms have early, widespread metastases. - they can be difficult to distinguish from lymphoproliferative lesions and atypical carcinoid tumors.

Three groups of SCLC are recognized

1. pure small cell carcinoma (oat cell carcinoma) 2. small cell carcinoma with a large cell component 3. combined (mixed) tumors.

- the clinical stage of SCLC is defined broadly by the presence of either local "limited" or distant "disseminated" disease. limited SCLC - presenting with bulky locoregional disease but no evidence for distant metastatic disease - the primary tumor is large and associated with bulky mediastinal adenopathy, which may lead to obstruction of the superior vena cava.

disseminated - presents with metastatic disease throughout the patient's body. - Regardless of the stage of presentation, treatment is primarily chemotherapy and radiation. - Surgery is appropriate for the rare patient with an incidentally discovered peripheral nodule that is found to be SCLC. - If a stage I SCLC is identified after resection, postoperative chemotherapy usually is given.

Metastatic Lesions to the Lung

Features suggestive of metastatic disease are: - multiplicity - smooth, round borders on CT scan -temporal proximity to the original primary lesion One must always entertain the possibility that a single new lesion is a primary lung cancer.

The likelihood of a new primary lung cancer is highest in patients with a history of: - uterine carcinoma (74%) - bladder carcinoma (89%) - lung carcinoma (92%) - head and neck carcinoma (94%)
Resection of pulmonary metastases - is associated with modest survival benefits in a very select group of patients.

General Principles Governing Appropriate Selection of Patients for Pulmonary Metastasectomy

1. Primary tumor must already be controlled. 2. Patient must be able to tolerate general anesthesia, potential single-lung ventilation, and the planned pulmonary resection. 3. Metastases must be completely resectable based on computed tomographic imaging. 4. There is no evidence of extrapulmonary tumor burden. 5. Alternative superior therapy must not be available.