Treatment

Summary of Treatment Approach to Patients with Lung Cancer Harrison’s Principle of Internal Medicine 17th Edition p558

Non-small cell lung cancer NSCLC Stages I and II Surgery Treatment of choice pulmonary resection 5 year survival rate N0: 60-80%; N1: 50% Lobectomy superior too wedge resection reducing local recurrence Pneumonectomy: multiple lobes, very central tumors, patients with excellent pulmonary reserves Wedge resection and segmentectomy (VATS): poor pulmonary reserve and small peripheral lesions

Non-small cell lung cancer NSCLC Stages I and II Radiotherapy with curative intent Refuse surgery or not candidates for surgery Extent of disease and volume of chest for irradiation Distant metastases, malignant pleural effusion, cardiac involvement Long term survival: 20% Potentially curative, increase quality and length of life by controlling primary tumor and preventing symptoms related to recurrence Treatment for curative intent: 60-64 Gy Palliative thoracic radiation 30-45 Gy

Non-small cell lung cancer NSCLC Stages I and II Adjuvant Chemotherapy for NSCLC Stages IB and II Improvement of 5% at 5 years with cispaltin-based adjuvant therapy No role for stage IB disease Adjuvant Radiotherapy for NSCLC Stages I-II Does not improve survival, may actually be detrimental to survival in N0 and N1 disease

Non-small cell lung cancer NSCLC with T3, N0 disease (Stage IIB) With peripheral chest wal invasion: resection of involved ribs and underlying lung Repaired with chest wall musculature or Marlex mesh and methymethacrylate 5 year survival rate: 35-50% Adjuvant chemotherapy recommended

Non-small cell lung cancer NSCLC Stage III Local therapy (surgery or radiation therapy) + systemic chemotherapy Non-small cell lung cancer NSCLC Stage IIIA Nonbulky IIIA Adjuvant chemotherapy

Non-small cell lung cancer NSCLC Stage IIIA Bulky IIIA No evidence suggests that patients with bulky multilevel ipsilateral mediastinal lymph nodes (N2) have improved survival with surgery and either pre-or postoperative chemotherapy compared to treatment with chemotherapy plus radiotherapy. Treatment-related mortality greater in the surgery arm Surgery only conducted with clearing of mediastinal lymph nodes by neoadjuvant chemotherapy T4,N0 pr T4, N1 (Stage IIIB): preoperative chemotherapy

Non-small cell lung cancer NSCLC Stage IIIA Bulky NSCLC Stage IIIA and Dry IIIB (IIIB without a Pleural Effusion) Chemotherapy + radiation therapy: treatment of choice Improvement in median and long-term survival Concurrently > sequential

Disseminated NSCLC Palliative Radiation Therapy To relieve urgent severe symptoms such as bronchial obstruction with pneumonitis, hemoptysis, upper airway or SVC obstruction, brain or spinal cord compression, or painful bony mets Brain mets, spinal cord compression, symptomatic masses and bone lesions

Disseminated NSCLC Chemotherapy Palliates symptoms , improves quality of life, improves survival in newly diagnosed patients with stage IV NSCLC Cost-effective palliation for stage IV NSCLC For previously untreated, good-performance status patients: chemotherapy consisting of two drugs (“doublets”): Cisplatin/ carboplatin Taxane (paclitaxel/ docetaxel), gemcitabine or a vinca alkaloid

Disseminated NSCLC VEGF Targeted Therapy Bevacizumab Improves response rate, progression-free survival and overall survival of patients with advanced disease when combined with chemotherapy SE: bleeding, hypertension and proteinuria

Disseminated NSCLC EGFR Targeted Therapy Erlotinib 2nd or 3rd line therapy for NSCLC For patients whose tumors respond to EGFR TKI therapy

Small Cell Lung Cancer Chemotherapy Etoposide + Cisplatin/ carboplatin Most widely used given every 3 weeks outpatient basis for 4-6 cycles

Small Cell Lung Cancer Limited-Stage Disease Combined-Modality Chemoradiotherapy More effective than sequential chemoradiation More esophagitis and hematologic toxicity Palliative Radiation Therapy Cranial radiation decreases the signs and symptoms of brain metastases Surgery Not routinely recommended High cure rates if postoperative chemotherapy is used

Lung Cancer Prevention Encourage smoking cessation Chemoprevention No benefit has yet been shown Vitamin E and β-carotene Actually increased the risk of lung cancer in heavy smokers