Two parts to staging are: (1) determination of location (anatomic staging) and (2) assessment of pt's ability to withstand antitumor treatment (physiologic staging) (Table 69-1). Non-small-cell tumors are staged by the TNM/International Staging System (ISS). The T (tumor), N (regional node involvement), and M (presence or absence of distant metastasis) factors are taken together to define different stage groups. Small-cell tumors are staged by two-stage system: limited stage disease—confined to one hemithorax and regional lymph nodes; extensive disease—involvement beyond this. General staging procedures include careful ear, nose, and throat examination; chest x-ray (CXR); chest and abdominal CT scanning; and positron emission tomography scan. CT scans may suggest mediastinal lymph node involvement and pleural extension in non-small-cell lung cancer, but a definitive evaluation of mediastinal spread requires histologic examination. Routine radionuclide scans are not obtained in asymptomatic pts. If a mass lesion is on CXR and no obvious contraindications to curative surgical approach are noted, the mediastinum should be investigated. Major contraindications to curative surgery include extrathoracic metastases, superior vena cava syndrome, vocal cord and phrenic nerve paralysis, malignant pleural effusions, metastases to contralateral lung, and histologic diagnosis of small-cell cancer.
Treatment: Lung Cancer - Surgery in pts with localized disease and non-small-cell cancer; however, majority initially thought to have curative resection ultimately succumb to metastatic disease (Table 69-2). Adjuvant chemotherapy (cisplatin, four cycles at 100 mg/m2 plus a second active agent [etoposide, vinblastine, vinorelbine, vindesine, a taxane]) in pts with total resection of stage IIA and IIB diseases may modestly extend survival.
- Solitary pulmonary nodule: factors suggesting resection include cigarette smoking, age ≥35 years, relatively large (>2 cm) lesion, lack of calcification, chest symptoms, and growth of lesion compared with old CXR. See Fig. 69-1.
- For unresectable stage II non-small-cell lung cancer, combined thoracic radiation therapy and cisplatin-based chemotherapy reduces mortality by about 25% at 1 year.
- For unresectable non-small-cell cancer, metastatic disease, or refusal of surgery, consider for radiation therapy; addition of cisplatin/taxane-based chemotherapy may reduce death risk by 13% at 2 years and improve quality of life. Pemetrexed has activity in pts with progressive disease.
- Small-cell cancer: combination chemotherapy is standard mode of therapy; response after 6-12 weeks predicts median- and long-term survival.
- Addition of radiation therapy to chemotherapy in limited-stage small-cell lung cancer can increase 5-year survival from about 11% to 20%.
- Prophylactic cranial irradiation improves survival of limited-stage small-cell lung cancer by another 5%.
- Laser obliteration of tumor through bronchoscopy in presence of bronchial obstruction.
- Radiation therapy for brain metastases, spinal cord compression, symptomatic masses, bone lesions.
- Encourage cessation of smoking.
- Pts with adenocarcinoma carcinoma (3% of all pts with lung cancer): 7% of these have activating mutations in the EGF receptor. These pts often respond to gefitinib or erlotinib, EGF receptor inhibitors. About 5% of these have activating rearrangements of the alk gene and may respond to crizotinib.
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