Lung Cancer Overview

Contents 

Overview
Screening Recommendations
Staging of NSCLC
Staging of SCLC
Patient Assessment
Follow-Up After Therapy
Signs & Symptoms
Diagnosis
Surgery For NSCLC
Chemotherapy/Targeted Therapy For NSCLC
Radiotherapy For NSCLC
Surgery For SCLC
Chemotherapy For SCLC
Radiotherapy For SCLC
Palliative Care for Lung Cancer
Dosage Guidelines for NSCLC
Dosage Guidelines for SCLC
Guideline References

OVERVIEW
  • Lung cancer is having a malignant tumor in the lungs especially in the cells lining air passages. Primary tumor-related signs and symptoms are cough, dyspnea, hemoptysis, and chest discomfort.
  • Signs and symptoms due to intrathoracic spread may involve the nerves (hoarseness, dyspnea, muscle wasting of upper limb, Horner's syndrome), chest
    wall and pleura (chest pain, dyspnea) and vascular structures (facial swelling, dilated neck veins, cardiac tamponade) & viscera (dysphagia).
    The signs and symptoms due to metastatic spread are bone pain with or without pleuritic pain, neurologic symptoms, limb weakness, unsteady gait, cervical lymphadenopathy, and skin nodules.

Refer to Symptoms for more information.

Below is an overview of disease management of Lung Cancer:

LungCancer1

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LungCancer2

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LungCancer3

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Screening Recommendations

  • Developed by the American Association for Thoracic Surgery
  • Low-dose computed tomography (LDCT) annual screening should be done in the following patients:
    • Age 55-79 yrs w/ smoking history of ≥30 pack-yrs
    • Patients diagnosed w/ & treated for bronchogenic carcinoma, & have completed 4 yrs of radiographic surveillance w/ no evidence of recurrence
    • Age ≥50 yrs w/ smoking history of ≥20 pack-yrs & w/ additional risk factors (ie COPD, environmental or occupational exposure, history of cancer or radiation therapy, or positive family history)
    • Patients w/ ≤4 mm solid nodule on LDCT screening
    • Patients w/ <5 mm ground-glass nodule on LDCT screening
  • Repeat LDCT after 3 mths is advised in the following:
    • Presence of >6-8 mm solid nodule on LDCT screening
    • Presence of >8 mm solid nodule on LDCT screening that has low probability of cancer as shown on PET/CT scan
    • Presence of >10 mm ground-glass nodule on LDCT screening
  • Repeat LDCT after 6 mths is advised in the following:
    • Presence of >4-6 mm solid nodule on LDCT screening
    • Presence of >6-8 mm solid nodule on LDCT screening that has maintained its size; then annually if size remained stable
    • Presence of 5-10 mm ground-glass nodule on LDCT screening; then annually if size remained stable
    • Presence of >10 mm ground-glass nodule on LDCT screening that has maintained its size
    • Biopsy or surgery may also be done
  • Bronchoscopy should be done in patients w/ solid endobronchial nodule on LDCT screening
  • Surgery is recommended in the following patients:
    • Presence of >8 mm solid nodule on LDCT screening that has high probability of cancer as shown on PET/CT scan
    • Presence of >6-8 mm solid nodule on LDCT screening that increased in size
    • Presence of 5-10 mm ground-glass nodule on LDCT screening that increased in size or w/ suspicious malignant features

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Staging of NSCLC

  • Clinical staging is established initially from history, physical exam, pathologic findings, chest, upper abdomen, & adrenal CT scan, CBC w/ platelet count, & chemistry profile of the patient
    • Pathologic mediastinal lymph node evaluation may be done through mediastinoscopy, mediastinotomy, EBUS, EUS, EBUS-FNA, EUS-FNA, or CT-guided biopsy
    • Supraclavicular lymph node metastasis in NSCLC may be staged using CT, PET-CT scan, or neck ultrasound FNA
    • FDG PET-CT scanning is recommended for detection of distant metastases in NSCLC
Revised Tumor, Nodes & Metastases (TNM) System (7th Edition)
  • Proposed by the International Association for the Study of Lung Cancer (IASLC) & adopted by the American Joint Committee on Cancer (AJCC) & Union Internationale Contre le Cancer
  • Determines if the patient would benefit from surgical resection & may predict patient’s survival
  • Currently recommended to classify both NSCLC & SCLC
Tumor Evaluation
  • Evaluates the degree of spread of the primary tumor
    • Tx
      • Tumor size cannot be assessed or tumor proven by presence of malignant cells in sputum or bronchial washings but not visualized by imaging techniques or bronchoscopy
    •  T0
      • No evidence of primary tumor
    • Tis      
      • Carcinoma in situ
    • T1
      • Tumor size ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, involves the lobar bronchus
    • T1a
      • Tumor size ≤2 cm in greatest dimension
    • T1b
      • Tumor >2 cm but ≤3 cm in greatest dimension
    • T2
      • Tumor size >3 cm but ≤7 cm or tumor w/ any of the following features:
      • Involves main bronchus
      • ≥2 cm distal to the carina
      • Invades the visceral pleura
      • Associated w/ partial atelectasis or obstructive pneumonitis not involving the entire lung
    • T2a
      • Tumor >3 cm but ≤5 cm in greatest dimension
    • T2b
      • Tumor >5 cm but ≤7 cm in greatest dimension
    • T3
      • Tumor of >7 cm or tumor directly involving any of the following: parietal pleural chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium, phrenic nerve, or tumor in the main bronchus <2 cm distal to the carina, w/ no carinal involvement, or associated w/ atelectasis or obstructive pneumonitis of the whole lung or separate tumor nodules in the same lobe
    • T4
      • Tumor of any size w/ invasion of these relevant structures: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body or main carina, or separate tumor nodules in a different ipsilateral lobe
Regional Lymph Node (LN) Evaluation
  • Evaluation of extent of nodal involvement
    • Mediastinal lymph node involvement usually makes surgical resection inappropriate
      • Nx
        • Regional LN cannot be assessed
      • N0
        • No regional LN metastasis
      • N1
        • Metastases in ipsilateral peribronchial &/or ipsilateral hilar & intrapulmonary LN
      • N2
        • Metastases in ipsilateral mediastinal &/or subcarinal LN
      • N3
        • Metastases in contralateral madiastinal LN &/or contralateral hilar LN, or ipsilateral or contralateral scalene LN, or supraclavicular LN
Evaluation of Distant Metastasis
  • M0
    • No distant metastasis
  • M1
    • Distant metastasis present
  • M1a
    • Separate tumor nodule/s in a contralateral lobe tumor w/ pleural nodules, or presence of malignant pleural or pericardial effusion
  • M1b
    • Distant metastasis
Staging
  • Occult carcinoma
    • TX N0 M0
  • Stage 0
    • Tis N0 M0
  • Stage IA
    • T1a N0 M0; T1b N0 M0
  • Stage IB
    • T2a N0 M0
  • Stage IIA
    • T1a N1 M0; T1b N1 M0
    • T2b N0 M0; T2a N1 M0
  • Stage IIB
    • T2b N1 M0
    • T3 N0 M0
  • Stage IIIA
    • T1a N2 M0; T1b N2 M0
    • T2a N2 M0; T2b N2 M0
    • T3 N1 M0; T3 N2 M0
    • T4 N0 M0; T4 N1 M0
  • Stage IIIB
    • T1a N3 M0; T1b N3 M0
    • T2a N3 M0; T2b N3 M0
    • T3 N3 M0
    • T4 N2 M0; T4 N3 M0
  • Stage IV
    • Any T Any N M1a; Any T Any N M1b

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Staging of SCLC

  • Full staging of SCLC should include history, physical exam, CT scan of the chest, liver, adrenal glands, MRI or CT scan of the head, CT of the chest, liver or adrenals, & a bone scan if PET scan is obtained
    • Bone marrow aspirate for biopsy is advised in patients w/ nucleated red blood cells on peripheral blood smear, neutropenia, thrombocytopenia & no evidence of other metastasis
    • Chest X-ray & PET scan may be optional part of initial evaluation
  • The updated TNM system by International Association for the Study of Lung Cancer (IASLC) may be used for staging SCLC
  • Staging should not delay the start of treatment for >1 wk because SCLC is a very aggressive disease
    • As compared w/ NSCLC, SCLC has faster doubling time, higher growth fraction, & earlier development of metastasis
Limited Disease (LD)
  • Confined to the primarily affected hemithorax, mediastinum or supraclavicular nodes
  • Equivalent to stages I to III of the TNM system except T3-4 w/ multiple lung nodules that do not fit or are too extensive in a tolerable radiation field
  • PFTs, bone imaging, & mediastinal staging via mediastinoscopy, mediastinotomy, endobronchial/esophageal UTZ-guided biopsy & video-assisted thoracoscopy may be performed prior to initial treatment
    • Mediastinal staging may not be performed if patient decides against surgical resection
Extensive Disease (ED)
  • Metastases found beyond the supraclavicular areas, in contralateral chest or at distant sites
  • Consistent w/ stage IV of the TNM system; includes T3-4 w/ multiple lung nodules that do not fit in a tolerable radiation field

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Patient Assessment

  • Identify comorbidities (ie heart, kidney, liver problems)
  • Assess performance status (PS)
    • Usually utilizes the grading system developed by the Eastern Cooperative Oncology Group (ECOG) to determine disease progression, effect of disease to the patient, prognosis & suitability of the treatment employed
    • Grade 0 - Fully active; no restriction
    • Grade 1 - W/ restrictions to strenuous activity but can do light work
    • Grade 2 - Capable of self-care but not other activity
    • Grade 3 - Performs limited self-care & stays in bed or chair for >50% of waking hrs
    • Grade 4 - Disabled; restricted to bed or chair
    • Grade 5 - Dead
  • Evaluate pulmonary function
    • Spirometry is recommended to patients being considered for lung surgery
    • May indicate increased risk of perioperative death & cardiopulmonary complication w/ standard lung surgery (ie FEV1 <40%, carbon monoxide diffusion capacity <40%, max O2 uptake <10 mL/kg/min, arterial O2 sat <90%)
  • Identify histologic subtype
    • Immunohistochemical staining is used to differentiate primary pulmonary adenocarcinoma from the following: squamous cell carcinoma, large cell carcinoma, metastatic carcinoma, and malignant mesothelioma
      • It is also used to determine if there is neuroendocrine differentiation
    • Squamous cell carcinomas are often TTF-1 negative & p63 positive, whereas adenocarcinomas are usually TTF-1 positive
    • Predictive biomarkers (eg EGFR, ALK) are molecules that is indicative of therapeutic efficacy; that is, there is an interaction between the biomolecule & therapy on patient outcome
Refer to Diagnosis for more information.

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Follow-Up After Therapy

  • Studies have shown 6.5 & 5-10% annual recurrence rate of NSCLC stage I & SCLC, respectively
  • Observation for complications of treatment is recommended for at least 3-6 mth
  • Follow up w/ history, physical exam & chest CT scan w/ or w/o contrast is advised every 6 mths for 2-3 yrs; then history, physical exam & chest CT scan w/o contrast annually thereafter
    • High-resolution CT scan is recommended 4 yrs after surgical resection of stages IA to IIIA NSCLC, followed by LDCT every yr starting in the 5th yr
    • Peak incidence of recurrence is between 2 & 3 yrs
  • Patients who smoke should be advised to quit
    • Please see Smoking Cessation Disease Management Chart for more details
  • Immunizations may also be given
    • Annual Influenza vaccination
    • Pneumococcal vaccination

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Lung Cancer Symptoms▶

Version: 02 Dec 2015

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