Choices:
1) surgery
2) chemotherapy
3) radiation as appropriate, depending on tumor type and stage

Eligibility of treatment may be affected by:
1) poor cardiopulmonary reserve
2) malnutrition
3) frailty/ poor physical performance status
4) co-morbidities inc. cytopenias
5) psychiatric or cognitive illness

* all may lead to a decision for palliative over curative treatment or for no treatment at all, even though cure might technically be possible.


Surgery
• performed only on patient who will have adequate pulm. reserve once a lobe or lung is resected
• pneumonectomy- can be tolerated by patients with FEV1 > 2 L
• FEV1 < 2 L – undergo a quantitative radionuclide perfusion scan to determine the proportion of function the patient can expect to lose from resection.

Chemotherapy
• multiple chemo regimens exist- no one regimen is proven superior
• choice of regimen- depends on local practice, contraindications and toxicities
• for disease that recurs after treatment, treatment options vary by location and include:
• repeat chemo for local recurrence
• radiation therapy for metastases
• brachytherapy* for endobronchial disease (disease of the lining of bronchi) when additional external radiation can’t be tolerated
*a type of radiation therapy, also called internal radiation therapy. Allows physician to use a higher total dose of radiation to treat smaller areas and in shorter time than is possible with external radiation therapy

Radiation treatment
• Carries risk of radiation pneumonitis (inflammation of lung tissue)- when large areas of lung are exposed to high doses of radiation over time.
• can occur up to 3 mo after treatment.
• Clinical presentation: Cough, dyspnoea, low-grade fever, pleuritic chest pain, pleural friction rub.
• Chest x-rays- may be nonspecific
• CTs may show nonspecific infiltration without discrete mass.
• Treated with 60 mg for 2 to 4 wk followed by a gradual decrease of dosage.

End-of-life care
• should be anticipated since many patients with lung CA die
• common symptoms- breathlessness, pain, anxiety, nausea, anorexia
• can be treated with:
• parenteral morphine,
• oral, transdermal / parenteral opioids
• antiemetics

SMALL CELL LUNG CARCINOMA (SCLC)
• typically initially responsive to treatment, but responses are usually short-lived.
• Surgery generally plays no role in treatment of SCLC- but it may be curative in the rare patient who has a small focal tumor without spread (e.g. a solitary pulmonary nodule).

Limited-stage disease- 30%, confined to one hemithorax and regional lymph nodes inc mediastinal, contralateral hilar, and ipsilateral supraclavicular nodes- whther tumor can be encompassed within a tolerable radiation therapy port
- etoposide + a platinum compound (either cisplatin/ carboplatin) in 4-6 cycles  Thought to be most effective
- Other commonly used drugs: vinca alkaloids (vinblastine, vincristine
, vinorelbine), alkylating drugs (cyclophosphamide, ifosfamide), doxorubicin, taxanes (docetaxel, paclitaxel), and gemcitabine
• Cranial radiation- to prevent brain metastases since micrometastases are common in SCLC and chemotherapy doesn’t cross BBB

Extensive-stage disease-70%exceeding those boundaries
• treatment - the same as with limited-stage disease but without concurrent radiation
• Replacing etoposide with topoisomerase inhibitors (irinotecan/topotecan) may improve survival.
• Radiation is often used as palliative treatment for metastases to bone or brain.
**In general, recurrent SCLC carries a poor prognosis- but patients who maintain good performance status should be offered a clinical trial.


NON-SMALL CELL LUNG CARCINOMA (NSCLC)
• Treatment depends on the stage.

Stage I and II disease
• surgical resection with lobectomy (removal of a lobe) / pneumonectomy (removal of entire lung) combined with mediastinal lymph node sampling or complete dissection.
• Patients with poor pulm reserve- lesser resections, inc segmentectomy and wedge resection (removal of a small wedge-shaped piece of lung that contains the lung cancer and a margin of healthy tissue around the cancer) - likely to be done when lung function would be decreased too much by lobectomy
• Surgery - curative in about 55-75% of patients with stage I ;35-55% of patients with stage II
• Adjuvant chemotherapy- probably helpful in early-stage disease (stages Ib and II).
• An ↑ in 5-yr overall survival (69% vs 54%) and disease-free survival (61% vs 49%) occurs with cisplatin + vinorelbine. Because the improvement is small, the decision for adjuvant chemotherapy should be made on an individual basis.
• role of neoadjuvant chemotherapy (treatment given prior to surgery to ↓ the tumor size eg chemotherapy/radiation therapy) in early-stage NSCLC = under investigation.

Stage III disease
Stage IIIA tumors- with occult mediastinal nodal metastases discovered during surgery - resection results in 20 to 25% 5-yr survival.
• Radiation therapy with/without concurrent chemo = standard for unresectable clinically staged IIIA disease- survival is poor (median survival, 10 to 14 mo). Recent trials suggest slightly better results with preoperative chemo +radiation followed by surgery and subsequent chemotherapy remains an area of investigation.
Stage IIIB tumors- with contralateral mediastinal nodal disease, supraclavicular nodal disease/ malignant pleural effusions – radiation/chemo/both.
• addition of radiation-sensitizing chemotherapeutic drugs, eg cisplatin, paclitaxel, vincristine, and cyclophosphamide↑ survival slightly.
• Patients with locally advanced tumors invading the heart, great vessels, mediastinum, or spine usually receive radiation.
• T4N0M0 tumors,surgical resection with either neoadjuvant or adjuvant chemoradiation
• 5-yr survival rate for treated stage IIIB patients is 5%.

Stage IV disease • goal = palliation of symptoms.
• Chemo and radiation may be used to reduce tumor burden, treat symptoms, and improve quality of life.
• median survival is only 9 mo; < 25% of patients survive 1 yr.