1. Treatment

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

3. 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

4. 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: Gy
Palliative thoracic radiation Gy

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

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

15. 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

16. 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