Benjamin Movsas, MD

In this interview we discuss how quality-of-life information from patients with lung cancer can be used to help guide treatment and inform outcomes.

This management guide for non–small-cell lung cancer (NSCLC) covers the symptoms, screening, diagnosis, staging, and treatment of adenocarcinoma, squamous cell carcinoma, and large-cell carcinoma of the lung.

This management guide covers the symptoms, screening, diagnosis, and treatment of small-cell lung cancer (SCLC), mesothelioma, and thymoma from a surgical, medical, and radiation oncology approach.

The treatment of inoperable stage III non–small-cell lung cancer (NSCLC) remains a challenge due to high rates of distant metastasis, local recurrence, and toxicity associated with definitive therapy.

Lung cancer has been the leading cause of cancer death among men in the United States for years, and since 1988, it has become the number-one cause of cancer death among women. An estimated 219,440 new cases of lung cancer are expected in 2009, and 159,390 deaths due to this disease are expected to occur, roughly 30% of all cancer deaths. This exceeds the combined number of deaths from the leading causes of cancer (breast, prostate, and colon cancers). It accounts for 6% of all deaths in the United States.

As discussed in chapter 3, there are two major subdivisions of lung cancer: small-cell lung cancer (SCLC), for which chemotherapy is the primary treatment, and non–small-cell lung cancer (NSCLC). SCLC is decreasing in frequency in the United States, with recent data showing it represents only 14% of lung cancers. This chapter provides information on the staging and prognosis, pathology and pathophysiology, treatment, and follow-up of long-term survivors of SCLC and concludes with brief discussions on mesothelioma and thymoma.

Radiation therapy (RT) is an important treatment modality for multiple thoracic malignancies. Incidental irradiation of the lungs, which are particularly susceptible to injury, is unavoidable and often dose-limiting. The most radiosensitive subunit of the lung is the alveolar/capillary complex, and RT-induced lung injury is often described as diffuse alveolar damage. Reactive oxygen species generated by RT are directly toxic to parenchymal cells and initiate a cascade of molecular events that alter the cytokine milieu of the microenvironment, creating a self-sustaining cycle of inflammation and chronic oxidative stress. Replacement of normal lung parenchyma by fibrosis is the culminating event. Depending on the dose and volume of lung irradiated, acute radiation pneumonitis may develop, characterized by dry cough and dyspnea. Fibrosis of the lung, which can also cause dyspnea, is the late complication. Imaging studies and pulmonary function tests can be used to quantify the extent of lung injury. While strict dose-volume constraints to minimize the risk of injury are difficult to impose, substantial data support some general guidelines. New modalities such as intensity-modulated radiation therapy and stereotactic body radiation therapy provide new treatment options but also pose new challenges in safely delivering thoracic RT.

Primary neuroendocrine neoplasms of the lung represent a clinical spectrum of tumors ranging from the relatively benign and slow-growing typical carcinoid to the highly aggressive small-cell lung carcinoma. The rarity of carcinoids has made the role of radiation therapy in their management controversial. This review considers the results of published studies to generate treatment recommendations and identify areas for future research. Surgery remains the standard of care for medically operable disease. Histology plays the most important role in determining the role of adjuvant radiation. Resected typical carcinoids likely do not require adjuvant therapy irrespective of nodal status. Resected atypical carcinoids and large-cell neuroendocrine carcinomas have a significant risk of local failure, for which adjuvant radiation likely improves local control. Definitive radiation is warranted in unresectable disease. Palliative radiation for symptomatic lesions has demonstrated efficacy for all histologies. Collaborative group trials are warranted.

As discussed in chapter 6, there are two major subdivisions of lung cancer:small-cell lung cancer (SCLC), for which chemotherapy is the primary treatment,and non-small-cell lung cancer (NSCLC). SCLC is decreasing in frequencyin the United States, with recent data showing it represents only 14%of lung cancers. This chapter provides information on the staging and prognosis,pathology and pathophysiology, treatment, and follow-up of longtermsurvivors of SCLC and concludes with brief discussions on mesotheliomaand thymoma.

The role of adjuvant therapy following complete resection of node-positive (stage II/IIIA) non-small-cell lung cancer remains controversial. Five-year survival rates in pathologic stage II disease range from 30% to 50% and in resected stage IIIA disease from 10% to 30%. The majority of recurrences following surgery are distant metastases.

The role of adjuvant therapy following complete resection of node-positive (stage II/IIIA) non-small-cell lung cancer remains controversial. Five-year survival rates in pathologic stage II disease range from 30% to 50% and in resected stage IIIA disease from 10% to 30%. The majority of recurrences following surgery are distant metastases. This two-part review, which will conclude in the January 2002 issue, analyzes the role of adjuvant therapy in this setting, using an evidence-based approach and focusing primarily on randomized trials and meta-analyses. The key variables in evaluating these studies are elucidated, ranging from the extent of mediastinal, systemic, and "molecular" staging to the quality of the adjuvant treatments administered. Some of the potential flaws inherent in meta-analyses are reviewed. To date, there is no convincing evidence that any therapy consistently improves survival in the adjuvant setting. Postoperative radiotherapy has been associated with a significant improvement in local control, particularly in patients with pathologic N2 disease. Chemotherapy should be offered to patients in appropriate clinical trials, and active phase III trials are reviewed. Future strategies include novel chemotherapy, methods to reduce toxicity, the emerging role of neoadjuvant therapy, and the promise of new biologic agents. [ONCOLOGY 15:1549-1558, 2001]

Using a series of 421 patients with localized prostate cancer who were treated with radiation, six predictive models were analyzed to determine which model correlates most closely to actual clinical outcome data in regard to biochemical freedom from failure. Multivariate analysis was performed using the following covariates: prostate specific antigen; Gleason score; stage; dose; PSA density; and perineural invasion. Initially, the Pisansky model appeared to be the most predictive.

Dr. Krasna provides a thoughtful review of thoracoscopy as an emerging technique for the staging of patients with lung and esophageal cancers. In lung cancer, thoracoscopy can be used as a complement to cervical mediastinoscopy in the evaluation of mediastinal and hilar lymph nodes. This is especially true in patients who have left-sided neoplasms with enlarged lymph nodes in the aortico-pulmonary window--a region typically inaccessible to cervical mediastinoscopy.