Treatment of Lung Neoplasms
Treatment of Lung Neoplasms
Treatment of Lung Neoplasms
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).
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
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.
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.
- 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.
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.