Surgery

Of all treatment modalities, surgical resection of the affected lobe or lung leads to the greatest improvement in survival for patients with early-stage and locally ad-vancedNSCLC (clinical stage IA, IB, or IIA). The candidacy of the tumor for resection should only be determined by an experienced thoracic surgeon who routinely works with cancer patients. During surgery, peripheral lymph nodes may be removed if they are thought to be involved, and mediastinal nodes are often dissected for biopsy to determine their involvement. In patients with advanced disease NSCLC, surgery is not curative and as a general approach does not prolong survival. However, surgery for advanced disease is an important palliative treatment that can improve quality of life in some patients. In this respect, surgery is limited to local sites where the tumor is causing significant morbidity (e.g., spinal cord compression). Patients with small cell carcinomas are rarely treated with surgery because the results of a randomized trial published in 1969 showed that surgery did not result in any 5- or 10-year survivors, whereas radiation produced a 4% survival rate at 5 and 10 years.15 With improved imaging and surgical techniques as well as the use of effective adjuvant therapy, some clinicians believe that surgery does have a role in early-stage SCLC. However, this has yet to be proven in a clinical trial.

FIGURE 90-1. Clinical pathway for nonsmall cell lung cancer. aSee text for specific treatment recommendations. (Chemo, chemotherapy; NSCLC, nonsmall cell lung cancer; PORT, postoperative radiotherapy; TNM, tumor node metastasis.)

Radiotherapy

As mentioned earlier, radiotherapy is the treatment of choice for limited-stage SCLC. Optimal patient outcomes are achieved when radiation is administered concurrently with chemotherapy because of synergy between the two modalities. Limited and extensive stage SCLC patients who respond to therapy should also receive prophylactic cranial irradiation (PCI), which prevents brain metastasis and improves cure rates for limited stage disease. Patients with localized NSCLC are best treated with surgery; however, many of these patients are inoperable because of comorbidities (e.g., lung disease from smoking). In these situations, radiation therapy can be used with curative intent in place of surgery, and the success rate is approximately 50% that of surgery.16 Similar to SCLC, patients with late-stage NSCLC can receive radiation therapy to pal liate symptomatic metastases. Although radiation is less invasive than surgery, it can have marked toxicity on normal tissue and patients may experience esophagitis, pneu-monitis, cardiac abnormalities, myelopathies, and skin irritation. These adverse events can be decreased by using stereotactic radiation and/or hyperfractionated administra-tion.17

Postoperative radiotherapy (PORT) is thought to eliminate remnants of the resected tumor that might be deposited in nearby tissue. In clinical trials, PORT decreases local recurrence; however, a survival benefit has never been shown. A meta-analysis of investigations evaluating PORT suggested that it may actually be detrimental to patients with stage I or IINSCLC.18 The meta-analysis evaluated older studies that used outdated radiation techniques, and consequently, some argue that the meta-analysis does not apply to current practice. Nonetheless, no studies to date have demonstrated a survival advantage with the use of PORT. In cases where local recurrence is a significant risk, PORT still may be a viable option. In fact, current guidelines recommend that patients with positive surgical margins (i.e., cancerous cells are detected on the surface of the excised tissue) undergo re-resection or systemic chemotherapy or PORT.19 Outside of this recommendation, adjuvant radiotherapy without concurrent chemotherapy is not considered beneficial, especially in early-stage disease.

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