Lung Cancer. Part 4
In terms of the management, we have developed increasingly better drug and radiotherapy combinations for dealing with this. Patients who have disease which is limited in presentation, clinically limited to the ipsilateral hemithorax. That is we don’t have clinical evidence of spread even though it’s thought to be there microscopically, about half of these patients will be able to go into complete remission and the overall remission duration for these patients is somewhere on the order of 15 to 20 months. If you look at a survival curve for small cell lung cancer, if you look at those with overt metastases, results are extremely poor. On the other hand, if you look at patients who have disease which is limited – as I said, clinically – to the ipsilateral hemithorax, somewhere around 20% of these patients seem to go into remission that may be durable and some of these patients may be cured of the disease. What is being looked at for these patients is; can we do anything to get the tail on the curve up a little bit. Can we do something to increase the fraction of patients with complete remission rates. Can we do something to keep these patients in remission instead of having this fall-off. Intensive therapy with stem-cell support is being looked at. There is pilot data from Elias and Ferguson that looks pretty good, but it needs to be reproduced in a larger group setting. Also it is important to understand the theory for this as considerable morbidity and even mortality, the use of intensive drugs and radiation in middle-aged or older adults who often have significant underlying pulmonary disease that has led to a lot of respiratory complications, their central nervous system, complications from prophylactic brain radiation and drug therapy. So there’s no free lunch. It’s difficult therapy and there are significant long range morbidities from the treatment but the good news is that at least a proportion of patients with limited disease are able to achieve a disease-free survival from this naturally pretty aggressive condition.
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I think you can’t leave the subject of lung cancer when talking to internists without talking about the pulmonary nodule. This is sort of a common internal medicine management problem. These are some of the things I think that should be tried in dealing with this. First of all what you want to know if there is a pulmonary nodule is; is the lesion new? And if the lesion is not new, has it changed in size? So the first thing you want to do is obtain old films. I think that today management strategies for medicine, the less people have chest x-rays on a routine basis and that may hamper making that sort of assessment. But where old films are available I think management always starts with getting the old film. If you can get some archival film from ten years ago that shows the same lesion I think you are going to have almost certainly no problem. The next step is if there is a nodule and it appears to be new, or we don’t have an old film, we need to know; is it solitary or multiple? The decision analysis will be different if you have multiple lesions. Remember, chest x-ray is a lot less sensitive than a CT in terms of showing the lung parenchyma. So what looks like a solitary lesion on a chest x-ray could turn out to be multiple lesions on a CT-scan. Once we have characterized what we have, you are going to undergo some type of pre-biopsy or pre-surgical evaluation to look at extrapulmonary sources that need to be ruled out. It doesn’t have to be exhaustive. A good history and physical and maybe a minimal amount of laboratory testing is probably useful in this setting. If the studies are negative or you don’t demonstrate conclusively that this is a metastatic presentation of some other lesion, then it is necessary to go after this thing and clarify what it is. Many of these lesions have proved to be benign lesions and even if it does prove to be an adenocarcinoma presenting as a lung lesion, the prognosis of this is relatively favorable, quite favorable indeed compared to other forms of carcinoma of the lung that are resected. No meat no treat is a good rule to follow. Don’t make assumptions based on the x-ray getting a pathologic diagnosis.