Chapter 085. Neoplasms of the Lung (Part 14)

Superior Sulcus or Pancoast Tumors Non-small cell carcinomas of the superior pulmonary sulcus producing Pancoasts syndrome appear to behave differently than lung cancers at other sites and are usually treated with combined radiotherapy and surgery. Patients with these carcinomas should have the usual preoperative staging procedures, including mediastinoscopy and CT and PET scans, to determine tumor extent and a neurologic examination (and sometimes nerve conduction studies) to document involvement or impingement of nerves in the region. If mediastinoscopy is negative, curative approaches may be used in treating Pancoasts syndrome despite its apparent locally invasive nature. ...
Nội dung trích xuất từ tài liệu:
Chapter 085. Neoplasms of the Lung (Part 14) Chapter 085. Neoplasms of the Lung (Part 14) Superior Sulcus or Pancoast Tumors Non-small cell carcinomas of the superior pulmonary sulcus producingPancoasts syndrome appear to behave differently than lung cancers at other sitesand are usually treated with combined radiotherapy and surgery. Patients withthese carcinomas should have the usual preoperative staging procedures, includingmediastinoscopy and CT and PET scans, to determine tumor extent and aneurologic examination (and sometimes nerve conduction studies) to documentinvolvement or impingement of nerves in the region. If mediastinoscopy isnegative, curative approaches may be used in treating Pancoasts syndrome despiteits apparent locally invasive nature. The best results reported thus employedconcurrent preoperative irradiation [30 Gy in 10 treatments] and cisplatin andetoposide, followed by an en bloc resection of the tumor and involved chest wall3–6 weeks later; 65% of thoracotomy specimens showed either a completeresponse or minimal residual microscopic disease on pathologic evaluation. The 2-year survival rate was 55% for all eligible patients and 70% for patients who had acomplete resection. NSCLC with T3, N0 Disease (Stage IIB) The subset of T3, N0 disease (which does not present as Pancoast tumor)was initially considered stage III disease. However, it has a different naturalhistory and treatment strategy than stage III N2 disease and is now considered asstage IIB. Patients with peripheral chest wall invasion should have resection of theinvolved ribs and underlying lung. Chest wall defects are then repaired with chestwall musculature or Marlex mesh and methylmethacrylate. Five-year survivalrates as high as 35–50% have been found, and adjuvant chemotherapy is usuallyrecommended. NSCLC Stage III Treatment of locally advanced NSCLC is one of the most controversialissues in the management of lung cancer. Treatment options include a localtherapy (surgery or radiation therapy) combined with systemic chemotherapy tocontrol micrometastases. Interpretation of the results of clinical trials involvingpatients with locally advanced disease has been clouded by a number of issues,including changing diagnostic techniques, different staging systems, andheterogeneous patient populations with tumors that range from nonbulky stageIIIA (clinical N1 nodes with N2 nodes discovered only at the time of surgery,despite a negative mediastinoscopy) to bulky N2 nodes (enlarged adenopathyclearly visible on chest x-rays or multiple nodal level involvement) to clearlyinoperable stage IIIB disease. Thus, a team approach involving pulmonarymedicine, thoracic surgery, and medical and radiation oncology is essential for themanagement of these patients. NSCLC Stage IIIA Nonbulky IIIASurgery for N2 disease is a controversial area in themanagement of lung cancer. Patients with N2 disease can be divided intominimal disease (involvement of only one node with microscopic foci, usuallydiscovered at thoracotomy or mediastinoscopy) and the more common advancedbulky disease, clinically obvious on CT scans and discovered preoperatively.Patients who have an incidental finding of N2 disease at the time of resectionshould receive adjuvant chemotherapy. Bulky IIIA No evidence suggests that patients with bulky, multilevel ipsilateralmediastinal nodes (N2) have improved survival with surgery and either pre- orpostoperative chemotherapy compared to treatment with chemotherapy plusradiation therapy. This important issue was addressed in the multicenterrandomized Intergroup 0139 Trial involving patients with pathologically stagedN2 disease who received 45 Gy of induction radiation therapy plus two cycles ofcisplatin and etoposide to debulk tumors. The patients were then randomlyassigned to surgical resection of any residual tumor or to boost radiation therapyplus an additional two cycles of chemotherapy. Although a significantimprovement in progression-free survival was observed at 5 years for thosepatients randomized to surgical resection (22% vs. 11%; p = .017), the differencein 5-year overall survival while favoring surgery (22% vs. 11%; p = .10) was notsignificant. This is important since treatment-related mortality was greater in thesurgery arm (8% vs. 2%), with the majority of deaths occurring in patientsundergoing pneumonectomy. Patients who had persistent N2 disease followingneoadjuvant chemotherapy did particularly poorly, leading some oncologists toconclude that surgery for bulky IIIA disease should only be conducted in patientswho have clearing of their mediastinal nodes following neoadjuvant therapy. Themain role of neoadjuvant chemotherapy is to control micrometast ...