Lung Cancer: Treatment and Prognosis by Stage

Posted on Mar 5, 2025 in Medicine & Health

Treatment of Non-Small Cell Lung Cancer

Hidden In Situ (Tx/Tis)

  • Curability: 75%
  • Surgery
  • Radiation Therapy: External/Brachytherapy
  • Photodynamic Therapy

Stage I (T1-2 N0 M0)

  • Five-Year Survival: 50%
  • Surgery:
    • Lobectomy
    • Segmentectomy
    • Marginal Resection
    • Pneumonectomy
  • Five-Year Survival: Global (72%), T1 (83%), T2 (65%)
  • Radiotherapy
  • Photodynamic Therapy

Stage II (T1-2 N1/T3 N0/M0)

  • Five-Year Survival: 30%
  • Surgery:
    • Lobectomy
    • Lobectomy with Bronchoplasty
    • Pneumonectomy
  • Five-Year Survival: Global (49%), T1 (56%), T2 (48%)
  • Radiotherapy

Stage III

  • Radiation Characteristics: Intent radical (curative)
  • Dosage: 50-60 Gy
  • Continuous Pattern
  • Fraction: 1.8 to 2 Gy/day (5 days/week)
  • Results:
    • Local Control: 23-65%
    • Median Survival: 9-11 months
    • Five-Year Survival: 5%
  • Does not increase survival

Stage IIIA (T3 N1-2 M0)

  • Resectable: QT +/- RT followed by surgery.
  • Unresectable: QT simultaneously or followed by RT.

Most Active Cytostatics

Studies show a greater response with Ifosfamide with Vinblastine (27-40%), and 18-28% less effectiveness. Instead, Etoposide and Teniposide show about 10-15%. Other studies highlight Taxol and Taxotere with an effectiveness of 28% and a survival of 10-12 months.

Activity of Chemotherapy

  • 2-3 Cytostatic Combinations
  • Combinations with Cisplatin (100 mg/m2)
  • Maximum Response: 2-4 cycles
  • Objective Response (CR + PR): 20-40%
  • Objective Response Duration: 3-6 months
  • Prognostic Factors for Objective Response: PS 0-1, limited stage, <N° of metastases

Indication of Chemotherapy

  • Patients with good performance status (PS 0-2): Palliative intent. Always offered chemotherapy.
    • Standard Chemotherapy
    • Essay: Drug combinations and new/second line
  • Patients with poor general condition (PS > 2): Support without chemotherapy treatment.
    • Essay: Drug combinations and low toxicity

Prognostic Factors

  • Early Disease (Stages I, II, and III resectable): Tumor size, presence/absence of lymph node metastases, histological subtype.
  • Advanced Disease (Stages III and IV unresectable): Pretreatment stage, functional status, weight loss, sex, LDH, metastatic area.

Small Cell Lung Cancer (Microcytic)

Histological Impact

Oat cell comprises over 90%. This is followed by smaller percentages of mixed cells and small combined cells at 5% and 1%, respectively.

Symptoms

  • Primary Tumor: Cough, dyspnea, chest sounds, hemoptysis, chest pain, post-obstructive pneumonitis.
  • Regional Metastasis: Superior vena cava syndrome, dysphonia, dysphagia.
  • Distant Metastasis: Bone pain, CNS symptoms (headache, diplopia).

Clinical Features

Signs and Symptoms: Cough, dyspnea, wheezing, chest pain, obstructive pneumonitis, hemoptysis, dysphonia, dysphagia, superior vena cava syndrome, anorexia, metastasis.

Diagnosis

  • History and Complete Examination
  • General Analysis (liver function)
  • Chest X-ray
  • Bronchoscopy
  • Chest CT
  • Abdominal Ultrasound or CT
  • If clinical or laboratory suspicion: Bone scan/CT scan/Bone marrow biopsy
  • Staging: VALG Classification (Veterans Administration Lung Study Group):
    • Limited Disease: Tumor located in a hemithorax ± regional nodes.
    • Extensive Disease: Tumor that exceeds the above limits.
  • TNM Staging (same as Non-Small Cell Lung Cancer)

Prognostic Factors

  • Tumor-Dependent:
    • Stage of Disease: Limited is favorable.
    • In Limited Disease: Absence of mediastinal or supraclavicular nodes or pleural effusion is favorable.
    • In Disseminated Disease: Number of affected organs (only one is favorable).
    • Liver or Brain Involvement: Absence is favorable.
  • Patient-Dependent: General condition, sex (female is favorable).
  • Laboratory Findings: LDH, elevated alkaline phosphatase (unfavorable).

Treatment

  • 1950s: Surgery
  • 1960s: Radiotherapy
  • 1970s: Chemotherapy becomes the standard treatment

Treatment Summary

  • QTX is the main treatment (does not increase survival).
  • Combinations of 2-3 cytostatics.
  • No differences between schemes.
  • Alternating QT is accepted.
  • Duration of 4-6 cycles.
  • No maintenance QT.
  • Elderly patients: standard QT.
  • Chest RTX: In limited disease, simultaneous to the QT, and early.
  • ICP: Complete response in limited disease, upon completion of the QT.
  • Surgery may be considered in Stage I disease.

Monitoring

  • Patients Free of Disease: Chest X-ray every 3 months for 2 years, then annual chest X-ray.
  • Second Tumors: Survivors of more than two years have a 3.5 times greater risk. Cumulative incidence: 44% to 14%. Increased risk with thoracic RT.