Chapter 085. Neoplasms of the Lung (Part 10)

Staging of Small Cell Lung Cancer Pretreatment staging for patients with SCLC includes the initial general lung cancer evaluation with chest and abdominal CT scans (because of the high frequency of hepatic and adrenal involvement) as well as fiberoptic bronchoscopy with washings and biopsies to determine the tumor extent before therapy; brain CT scan (10% of patients have metastases); and radionuclide scans (bone) if symptoms or other findings suggest disease involvement in these areas. Bone marrow biopsies and aspirations are rarely performed given the low incidence of isolated bone marrow metastases. Chest and abdominal CT scans are very useful...
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Chapter 085. Neoplasms of the Lung (Part 10) Chapter 085. Neoplasms of the Lung (Part 10) Staging of Small Cell Lung Cancer Pretreatment staging for patients with SCLC includes the initial generallung cancer evaluation with chest and abdominal CT scans (because of the highfrequency of hepatic and adrenal involvement) as well as fiberoptic bronchoscopywith washings and biopsies to determine the tumor extent before therapy; brain CTscan (10% of patients have metastases); and radionuclide scans (bone) ifsymptoms or other findings suggest disease involvement in these areas. Bonemarrow biopsies and aspirations are rarely performed given the low incidence ofisolated bone marrow metastases. Chest and abdominal CT scans are very usefulto evaluate and follow tumor response to therapy, and chest CT scans are helpfulin planning chest radiotherapy ports. If signs or symptoms of spinal cord compression or leptomeningitis developat any time in lung cancer patients with disease of any histologic type, a spinal CTscan or MRI scan and examination of the cerebrospinal fluid cytology areperformed. If malignant cells are detected, radiotherapy to the site of compressionand intrathecal chemotherapy (usually with methotrexate) are given. In addition, abrain CT or MRI scan is performed to search for brain metastases, which often areassociated with spinal cord or leptomeningeal metastases. Resectability and Operability In patients with NSCLC, the following are major contraindications tocurative surgery or radiotherapy alone: extrathoracic metastases; superior venacava syndrome; vocal cord and, in most cases, phrenic nerve paralysis; malignantpleural effusion; cardiac tamponade; tumor within 2 cm of the carina (not curableby surgery but potentially curable by radiotherapy); metastasis to the contralaterallung; bilateral endobronchial tumor (potentially curable by radiotherapy);metastasis to the supraclavicular lymph nodes; contralateral mediastinal nodemetastases (potentially curable by radiotherapy); and involvement of the mainpulmonary artery. Pleural effusions are generally considered malignant regardlessof whether they are cytology positive, particularly if they are exudative, bloody,and have no other probable etiology. Most patients with SCLC have unresectabledisease; however, if clinical findings suggest the potential for resection (mostcommon with peripheral lesions), that option should be considered. Physiologic Staging Patients with lung cancer often have cardiopulmonary and other problemsrelated to chronic obstructive pulmonary disease as well as other medicalproblems. To improve their preoperative condition, correctable problems (e.g.,anemia, electrolyte and fluid disorders, infections, and arrhythmias) should beaddressed, smoking stopped, and appropriate chest physical therapy instituted.Since it is not always possible to predict whether a lobectomy or pneumonectomywill be required until the time of operation, a conservative approach is to restrictresectional surgery to patients who could potentially tolerate a pneumonectomy. Inaddition to nonambulatory performance status, a myocardial infarction within thepast 3 months is a contraindication to thoracic surgery because 20% of patientswill die of reinfarction. An infarction in the past 6 months is a relativecontraindication. Other major contraindications include uncontrolled majorarrhythmias, an FEV1 (forced expiratory volume in 1 s) 45 mmHg), DLCO 80% predicted usually permits apneumonectomy. In patients with borderline lung function but a resectable tumor,cardiopulmonary exercise testing could be performed as part of the physiologicevaluation. This test allows an estimate of the maximal oxygen consumption(ṼO2max). A ṼO2max Lung Cancer: Treatment The overall treatment approach to patients with lung cancer is shown inTable 85-4. Patients should be encouraged to stop smoking, particularly if theywill be undergoing surgery or radiation therapy. Those who do fare better thanthose who continue to smoke. Table 85-4 Summary of Treatment Approach to Patients with LungCancer Non-Small Cell Lung Cancer Stages IA, IB, IIA, IIB, and some IIIA: Surgical resection for stages IA, IB, IIA, and IIB Surgical resection with complete-mediastinal lymph node dissection andconsideration of neoadjuvant CRx for stage IIIA disease with minimal N2involvement (discovered at thoracotomy or mediastinoscopy) Consider postoperative RT for patients found to have N2 disease Stage IB: discussion of risk/benefits of adjuvant CRx; not routinely given Stage II: Adjuvant CRx Curative potential RT for nonoperable patients Stage IIIA with selected types of stage T3 tumors: ...