Lung Cancer. Part 2
Now the management of lung cancer, other than small cell lung cancer – which is really split off in all instances as a separate entity – the management of the other types is primarily surgical if possible. That is the treatment of choice for stage I and II disease, is to be able to resect it. There are studies that have been done and continue to be done to look at the role of adjuvant radiation therapy and systemic therapy, particularly for stage II disease; which means involvement of bronchial or hyaloid nodes. I think that although they are suggestive it remains somewhat inconclusive as to the value of adjuvant treatments. If you look at surgical management, you have to say “All right, who gets an operation and who doesn’t?” That’s something in terms that you need to understand what are the complications of surgery in lung cancer. I think one of the greatest areas of progress in small cell lung cancer is realizing the factors that are on the slide. I don’t know that we can improve the numerator greatly surgically, but we decreased the denominator by realizing which patient shouldn’t be taken for a thoracotomy and I think spared a lot of unnecessary useless morbidity. If a patient has significant co-morbid medical disease they may not be a candidate for lumpectomy or pneumonectomy. Remember, most of these are related to smoking. Most people smoking have significant underlying heart and lung disease. Anybody with small cell histology should not undergo primary surgical resection. If you know in advance that it is small cell carcinoma, it’s is not a surgical disease. Clearly if there are extrathoracic metastases there is no point in removing the primary tumor in virtually any circumstance that I can think of. If you have a paralyzed vocal cord that’s usually due to the involvement with the left vagus nerve as it goes through the aortal pulmonary window. Pleural effusion, if it has a positive cytology for malignancy is also a manifestation of inoperability. And to varying extent spread to the carotid mediastinum are manifestations of inoperability as well.
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If you look at data with surgical management of lung cancer what you see is that the results are relatively dismal overall. These are the histologic types. These are stage I cases where patients had a tumor mass under 2 cm and no nodal involvement. These are bigger. If you look at all these data for patients with complete resections you can see that less than half of all patients who are surviving five years later despite resection. If you look at the small cell, as I said, it is clearly not a surgical disease. Data couldn’t get any worse than that. So that doesn’t work for small cell carcinoma of the lung. If you look as squamous and adenocarcinoma for stage I in acute patients you can see that somewhere between 15-30% of patients with stage II disease are going to be surviving, disease free, despite apparent surgical resection. Now of all patients who come in with lung cancer, you start with four patients. Two of the four are going to be inoperable before you go into the OR, or you never get to the OR because of either obvious metastases or co-morbid diseases. So you are going to take two of the four patients to surgery. One of those two that you take to surgery will be found to be inoperable when you open the chest. So you are only doing a resection in one out of four patients. So this is data that shows that 30% or 15 % five years. But these are patients that were taken to surgery and they only represent about a quarter of the group of patients that might have initially been diagnosed with the disease. So if there was ever a need for an effective systemic therapy for disease, certainly you have that in lung cancer. And I think that with improvement in chemotherapy of the disease there are at least some trials that have been done that suggest a small advantage for adjuvant systemic therapy. I think that the next incremental improvement in survival in this disease is going to come through the use of some form of systemic treatment.
If you look at more extensive lung cancer – again, we are still staying with non small cell cancer – disease that spreads to the mediastinum is known as stage III disease and these patients don’t have just a metastasis but they have an involvement with either ipsilateral or contralateral mediastinum. For patients with involved ipsilateral mediastinum, there has been a great deal of effort to try to shrink the disease down with preoperative chemotherapy and/or radiation therapy and then take patients to surgery and then either finish up with some radiation if it wasn’t given pre-op, or some additional chemotherapy. There have been many many single institutions and some cooperative group studies done looking at this. I think it’s still not clear what the long term benefit of this approach is with 3A disease. The data we have suggests that there will be some benefit. Clearly if you can shrink the disease you can do, technically, resections in these patients. You can do it. What’s less clear is whether the long term survival is going to be improved by using two or three different modalities empirically for these 3A patients. Usually in patients with 3D disease, that is disease spread to the opposite side of the mediastinum or to the carotid, these are considered non-respectable and therapy is usually palliative with either radiation therapy or chemotherapy.