Chapter 085. Neoplasms of the Lung (Part 17)

Chemotherapy The chemotherapy combination most widely used for SCLC is etoposide plus cisplatin or carboplatin, given every 3 weeks on an outpatient basis for four to six cycles. Increased dose intensity of chemotherapy adds toxicity without clear survival benefit. Appropriate supportive care (antiemetics, fluid support with cisplatin, monitoring of blood counts and blood chemistries, monitoring for signs of bleeding or infection, and, as required, use of hematopoietins) and adjustment of chemotherapy doses on the basis of nadir granulocyte counts are essential.The prognosis of patients who relapse is poor. Patients who relapse 3 months since the completion of their initial...
Nội dung trích xuất từ tài liệu:
Chapter 085. Neoplasms of the Lung (Part 17) Chapter 085. Neoplasms of the Lung (Part 17) Chemotherapy The chemotherapy combination most widely used for SCLC is etoposideplus cisplatin or carboplatin, given every 3 weeks on an outpatient basis for four tosix cycles. Increased dose intensity of chemotherapy adds toxicity without clearsurvival benefit. Appropriate supportive care (antiemetics, fluid support withcisplatin, monitoring of blood counts and blood chemistries, monitoring for signsof bleeding or infection, and, as required, use of hematopoietins) and adjustmentof chemotherapy doses on the basis of nadir granulocyte counts are essential. The prognosis of patients who relapse is poor. Patients who relapse >3months since the completion of their initial chemotherapy (so-calledchemosensitive disease) have a median survival of 4–5 months; patients who donot respond to initial chemotherapy or relapse within 3 months (chemorefractorydisease) have a median survival of only 2–3 months. Patients with chemosensitivedisease may be retreated with their initial regimen. Topotecan has modest activityas second-line therapy, or patients can be entered onto clinical trials testing newagents. Considerations for Therapy of SCLC Limited-Stage Disease Combined-Modality Chemoradiotherapy Radiation therapy to the thorax is associated with a small but significantimprovement in long-term survival for patients with limited-stage SCLC (5% at 3years). Chemotherapy given concurrently with thoracic radiation is more effectivethan sequential chemoradiation but is associated with significantly moreesophagitis and hematologic toxicity. In one randomized study, twice-dailyhyperfractionated radiation was compared with a once-daily schedule; both wereadministered concurrently with four cycles of cisplatin and etoposide. Survivalwas significantly higher with the twice-daily regimen (median survival 23 monthscompared with 19 months; 5-year survival 26% compared with 16%), but thetwice-daily regimen gave more grade 3 esophagitis and pulmonary toxicity.Patients should be carefully selected for concurrent chemoradiation therapy basedon good performance status and pulmonary reserve. PCI significantly decreases the development of brain metastases (whichoccur in about two-thirds of patients who do not receive PCI) and results in asmall survival benefit (~5%) in patients who have obtained a complete response toinduction chemotherapy. Deficits in cognitive ability following PCI areuncommon and often difficult to sort out from effects of chemotherapy or normalaging. Radiation Therapy for Palliation Palliative radiation therapy is an important component of the managementof SCLC patients. Cranial radiation often decreases the signs and symptoms ofbrain metastases. In the case of symptomatic, progressive lesions in the chest or atother critical sites, if radiotherapy has not yet been given to these areas, it may beadministered in full doses (e.g., 40 Gy to the chest tumor mass). Surgery Although surgical resection is not routinely recommended for SCLC,occasional patients meet the usual requirements for resectability (stage I or IIdisease with negative mediastinal nodes). Often this histologic diagnosis is madein some patients only on review of the resected surgical specimen. However, whensuch SCLC patients are discovered, they should receive standard SCLCchemotherapy. Retrospective series have reported high cure rates if postoperativechemotherapy is used, although it is unclear what the outcome would be withchemoradiation therapy alone, given the relatively low bulk disease of thesepatients. Lung Cancer Prevention Deterring children from taking up smoking and helping young adults stop islikely to be the most effective lung cancer prevention. Smoking cessationprograms are successful in 5–20% of volunteers; the poor efficacy is due to theaddictive nature of nicotine use, which is as strong as addiction to heroin. Chemoprevention is an experimental approach to reduce lung cancer risk;no benefit has yet been shown for chemoprevention. Two putativechemoprevention agents, vitamin E and β-carotene, actually increased the risk oflung cancer in heavy smokers. Benign Lung Neoplasms The benign neoplasms of the lung, representing they can present without symptoms as SPNs and are evaluated accordingly. In allcases, the extent of surgery must be determined at operation, and a conservativeprocedure with appropriate reconstructions is usually performed.