Neoplasms of the Lung

Lung cancer is largely a disease of modern man and was considered quite rare before 1900.
Leading cause of cancer-related death in North America and Europe, killing more than three
times as many men as prostate cancer and nearly twice as many women as breast cancer.
Tobacco consumption is the primary cause of lung cancer.
While tobacco smoking remains the primary cause of lung cancer worldwide, more than 60% of
new lung cancers occur in never smokers (smoked <100 cigarettes per lifetime).
Moreover, 1 in 5 women and 1 in 12 men diagnosed with lung cancer have never smoked.
Epidemiology
Lung cancer is the most common cause of cancer death among American men and women.
Lung cancer is rare below age 40, with rates increasing until age 80, after which the rate tapers
off.
The projected lifetime probability of developing lung cancer is estimated to be approximately
8% among males and approximately 6% among females.

Risk Factors
Cigarette smokers have a tenfold or greater increase in risk.
A deep sequencing study suggested that one genetic mutation is induced for every 15 cigarettes
smoked.
The size of the risk reduction increases with the length of time the person has quit smoking.
Cigarette smoking increases the risk of all the major lung cancer cell types.
Environmental tobacco smoke (ETS) or secondhand smoke is also an established cause of lung
cancer.
With a 20–30% increase in lung cancer observed among never smokers married for many years
to smokers.

Other risk factors including occupational exposures to asbestos, arsenic, bischloromethyl ether,
hexavalent chromium, mustard gas, nickel, and polycyclic aromatic hydrocarbons.
The risk of lung cancer appears higher among individuals with low fruit and vegetable intake
during adulthood.
Ionizing radiation is also an established lung carcinogen.
Prior lung diseases such as chronic bronchitis, emphysema, and tuberculosis have been linked to
increased risks of lung cancer as well.

Smoking Cessation
Stopping tobacco use before middle age avoids more than 90% of the lung cancer risk
attributable to tobacco.
Smoking cessation can even be beneficial in individuals with an established diagnosis of lung
cancer, as it is associated with improved survival, fewer side effects from therapy, and an overall
improvement in quality of life.
Physicians need to understand the essential elements of smoking cessation therapy.
The individual must want to stop smoking and must be willing to work hard to achieve the goal
of smoking abstinence.
Inherited Predisposition to Lung Cancer
First-degree relatives of lung cancer probands have a two- to threefold excess risk of lung cancer
and other cancers, many of which are not smoking-related.
Individuals with inherited mutations in RB (patients with retinoblastoma living to adulthood) and
p53 genes may develop lung cancer.

Pathology
Lung cancer is used for tumors arising from the respiratory epithelium (bronchi, bronchioles, and
alveoli).
World Health Organization classification, epithelial lung cancers consist of four major cell types:
small cell lung cancer (SCLC) and the so-called non-small cell lung cancer (NSCLC) histologies
including adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.
These four histologies account for approximately 90% of all epithelial lung cancers.
The remainder include undifferentiated carcinomas, carcinoids, bronchial gland tumors
(including adenoid cystic carcinomas and mucoepidermoid tumors), and rarer tumor types.
Tumors may occur as single or mixed-type histology.

The histologies associated with heavy tobacco use are squamous and small cell carcinomas.
Squamous carcinoma was the most commonly diagnosed form of NSCLC.
Adenocarcinoma has replaced squamous cell carcinoma as the most.
In lifetime never smokers adenocarcinoma tends to predominate.
Among women and young adults (<60 years), adenocarcinoma tends also to be the most
common form of lung cancer.

Small cell carcinoma is a poorly differentiated neuroendocrine tumor that tends to occur as a
central mass with endobronchial growth and is strongly associated with smoking.
There is often widespread cellular necrosis.
May produce specific peptide hormones such as adrenocorticotrophic hormone (ACTH),
arginine vasopressin (AVP), atrial natriuretic factor (ANF), and gastrin-releasing peptide (GRP).

Squamous cell carcinomas tend to occur centrally and are classically associated with a history of
smoking.

Adenocarcinomas often occur in more peripheral lung locations and may be associated with a
history of smoking.
However, adenocarcinomas are the most common type of lung cancer occurring in never
smokers.
Histologically, the tissue may contain the presence of glands, papillary structure,
bronchioloalveolar pattern, cellular mucin, or solid pattern if poorly differentiated.
Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma that grows along the
alveoli without invasion and can present radiographically as a single mass, as a diffuse
multinodular lesion, as a fluffy infiltrate, and on screening CT scans as a "ground-glass" opacity
(GGO).

Large cell carcinomas tend to occur peripherally and are defined as poorly differentiated
carcinomas of the lung composed of larger malignant cells without evidence of squamous,
glandular differentiation, or features of small cell carcinoma by light microscopy.
Historically, for treatment and prognostication purposes, the major distinction has been between
SCLC and NSCLC, as these tumors have quite different natural histories and therapeutic
approaches.

SCLC is typically widely disseminated at diagnosis.

Even if localized, it is rarely curable by surgery.
By contrast, NSCLC can be potentially cured by resection in up to 30% of cases.
Small cell cancers tend to respond more favorably to traditional cytotoxic chemotherapy agents.
Intrinsic drug resistance is the norm for both SCLC and NSCLC.

Immunohistochemistry
The diagnosis of lung cancer most often rests on the morphologic or cytologic features correlated
with clinical and radiographic findings.
Immunohistochemistry may be used to verify neuroendocrine differentiation within a tumor,
with markers such as neuron-specific enolase (NSE), CD56 or neural cell adhesion molecule
(NCAM), synaptophysin, chromogranin, and Leu7.
Immunohistochemistry is also helpful in differentiating primary from metastatic
adenocarcinomas.
Thyroid transcription factor 1 (TTF-1), identified in tumors of thyroid and pulmonary origin, is
positive in more than 70% of pulmonary adenocarcinomas and is a reliable indicator of primary
lung cancer, provided a thyroid primary has been excluded.

Cytokeratins 7 and 20 used in combination can help narrow the differential diagnosis;
nonsquamous NSCLC, SCLC, and mesothelioma may stain positive for CK7 and negative for
CK20, while squamous cell lung cancer will be both CK7 and CK20 negative.

Molecular Pathogenesis
The exact cell of origin for lung cancers is not known.
Whether one cell of origin leads to all histologic forms of lung cancer is unclear.
However, at least for lung adenocarcinoma, type II epithelial cells (or alveolar epithelial cells)
have the capacity to give rise to tumors.
For SCLC, cells of neuroendocrine origin have been implicated as precursors.
The stem cell concept may explain the failure of standard medical therapies to eradicate lung
cancers, even when there is a clinical complete response.
Disease recurs because therapies do not eliminate the stem cell component, which may be more
resistant to chemotherapy.
 Early Detection and Screening
The clinical outcome for lung cancer is related to the stage at diagnosis.
Accordingly, it is presumed that early detection of occult tumors will lead to improved survival.
Early detection is a process that involves screening tests, surveillance, diagnosis, and early
treatment.
By contrast, screening is defined as a systematic testing of asymptomatic individuals for
preclinical disease.

In order for a screening program to be successful, the burden of disease within the population
must be high, effective treatment must be available that can reduce mortality rate, and the test
must be accessible, cost-effective, and both sensitive and specific.
No impact on lung cancer–specific mortality rate using screening chest radiographs with or
without sputum cytology in high-risk patients (age >50 years or history of smoking).
 Clinical Manifestations
More than half of all patients diagnosed with lung cancer present with advanced disease at the
time of diagnosis.
The majority of patients present with signs, symptoms, or laboratory abnormalities that can be
attributed to the primary lesion, local tumor growth, invasion or obstruction of adjacent
structures, growth at distant metastatic sites, or a paraneoplastic syndrome.
The prototypical lung cancer patient is a current or former smoker of either sex, usually in the
seventh decade of life.
A history of chronic cough with or without hemoptysis in a current or former smoker with COPD
aged 40 years or older should prompt a thorough investigation for lung cancer even in the face of
a normal chest x-ray.
A persistent pneumonia without constitutional symptoms and unresponsive to repeated courses
of antibiotics also should prompt an evaluation for the underlying cause.

Presenting Signs and Symptoms of Lung Cancer

Symptom and Signs Range of frequency
Cough 8–75%
Weight loss 0–68%
Dyspnea 3–60%
Chest pain 20–49%
Hemoptysis 6–35%
Bone pain 6–25%
Clubbing 0–20%
Fever 0–20%
Weakness 0–10%
SVCO 0–4%
Dysphagia 0–2%
Wheezing and stridor 0–2%

Clinical Findings Suggestive of Metastatic Disease

Symptoms Constitutional: weight loss >10 lb
elicited in Musculoskeletal: focal skeletal pain
history Neurologic: headaches, syncope, seizures, extremity weakness,
recent change in mental status
Signs found on Lymphadenopathy (>1 cm)
physical Hoarseness, superior vena cava syndrome
examination Bone tenderness
Hepatomegaly (>13 cm span)
Focal neurologic signs, papilledema
 Soft-tissue mass
Routine Hematocrit: <40% in men, <35% in women
laboratory tests Elevated alkaline phosphatase, GGT, SGOT, and calcium levels
Patients with central or endobronchial growth of the primary tumor may present with cough,
hemoptysis, wheeze, stridor, dyspnea, or postobstructive pneumonitis.
Peripheral growth of the primary tumor may cause pain from pleural or chest wall involvement,
dyspnea on a restrictive basis, and symptoms of a lung abscess resulting from tumor cavitation.
Regional spread of tumor in the thorax (by contiguous growth or by metastasis to regional lymph
nodes) may cause tracheal obstruction, esophageal compression with dysphagia, recurrent
laryngeal paralysis with hoarseness, phrenic nerve palsy with elevation of the hemidiaphragm
and dyspnea, and sympathetic nerve paralysis with Horner's syndrome (enophthalmos, ptosis,
miosis, and anhidrosis).

Malignant pleural effusions can cause pain or dyspnea.

Pancoast (or superior sulcus tumor) syndromes result from local extension of a tumor growing in
the apex of the lung with involvement of the eighth cervical and first and second thoracic nerves,
with shoulder pain that characteristically radiates in the ulnar distribution of the arm, often with
radiologic destruction of the first and second ribs.
Often Horner's syndrome and Pancoast syndrome coexist.
Other problems of regional spread include superior vena cava syndrome from vascular
obstruction; pericardial and cardiac extension with resultant tamponade, arrhythmia, or cardiac
failure; lymphatic obstruction with resultant pleural effusion; and lymphangitic spread through
the lungs with hypoxemia and dyspnea.

In addition, lung cancer can spread transbronchially, producing tumor growth along multiple
alveolar surfaces with impairment of gas exchange, respiratory insufficiency, dyspnea,
hypoxemia, and sputum production.
Constitutional symptoms may include anorexia, weight loss, weakness, fever, and night sweats.
Apart from the brevity of symptom duration, these parameters fail to clearly distinguish SCLC
from NSCLC or even from neoplasms metastatic to lungs.

Extrathoracic metastatic disease is found at autopsy in >50% of patients with squamous

carcinoma, 80% of patients with adenocarcinoma and large cell carcinoma, and >95% of
patients with SCLC.
Approximately one-third of patients present with symptoms as a result of distant metastases.
Lung cancer metastases may occur in virtually every organ system, and the site of metastatic
involvement largely determines other symptoms.
Patients with brain metastases may present with headache, nausea and vomiting, or neurologic
deficits.

Patients with bone metastases may present with pain, pathologic fractures, or cord compression.
Those with liver metastases may present with hepatomegaly, right upper quadrant pain, anorexia,
and weight loss. Liver dysfunction or biliary obstructions are rare.

Paraneoplastic syndromes are common in patients with lung cancer, especially those with SCLC,
and may be the presenting finding or the first sign of recurrence.
Often the paraneoplastic syndrome may be relieved with successful treatment of the tumor.
Systemic symptoms of anorexia, cachexia, weight loss (seen in 30% of patients), fever, and
suppressed immunity are paraneoplastic syndromes of unknown etiology or at least not well
defined.

Weight loss greater than 10% of total body weight is considered a bad prognostic sign.
Endocrine syndromes are seen in 12% of patients; hypercalcemia resulting from ectopic
production of parathyroid hormone (PTH), or more commonly, PTH-related peptide, is the most
common life-threatening metabolic complication of malignancy, primarily occurring with
squamous cell carcinomas of the lung.
Clinical symptoms include nausea, vomiting, abdominal pain, constipation, polyuria, thirst, and
altered mental status.

Hyponatremia may be caused by the syndrome of inappropriate secretion of antidiuretic hormone

(SIADH).
SIADH resolves within 1–4 weeks of initiating chemotherapy in the vast majority of cases.

Skeletal–connective tissue syndromes include clubbing in 30% of cases (usually NSCLCs) and
hypertrophic primary osteoarthropathy in 1–10% of cases (usually adenocarcinomas).
Patients may develop periostitis, causing pain, tenderness, and swelling over the affected bones
and a positive bone scan.
Diagnosing Lung Cancer
Tissue sampling is required to confirm a diagnosis in all patients with suspected lung cancer.
Tumor tissue may be obtained via minimally invasive techniques such as bronchial or
transbronchial biopsy during fiberoptic bronchoscopy, by fine-needle aspiration (FNA) or
percutaneous biopsy using image guidance, or via endobronchial ultrasound (EBUS)-guided
biopsy.
The diagnostic yield of any biopsy depends on several factors, including location (accessibility)
of the tumor, tumor size, tumor type, and technical aspects of the diagnostic procedure including
the experience level of the bronchoscopist and pathologist.

Diagnostic accuracy for SCLC versus NSCLC for most specimens is excellent, with lesser
accuracy for subtypes of NSCLC.
Bronchoscopic specimens include bronchial brush, bronchial wash, bronchioloalveolar lavage,
and transbronchial FNA.
Overall sensitivity for combined use of bronchoscopic methods is approximately 80%, and
together with tissue biopsy, the yield increases to 85–90%.

Sputum cytology is inexpensive and noninvasive but has a lower yield than other specimen types
due to poor preservation of the cells and more variability in acquiring a good-quality specimen.
The yield for sputum cytology is highest for larger and centrally located tumors such as
squamous cell carcinoma and small cell carcinoma histology.
The specificity for sputum cytology averages close to 100%, although sensitivity is generally less
than 70%.
Staging Lung Cancer
Lung cancer staging consists of two parts:
first, a determination of the location of the tumor and possible metastatic sites (anatomic
staging), and second, an assessment of a patient's ability to withstand various antitumor
treatments (physiologic staging).
All patients with lung cancer should have a complete history and physical examination, with
evaluation of all other medical problems, determination of performance status, and history of
weight loss.
Staging with regard to a patient's potential for surgical resection is principally applicable to
NSCLC.

Anatomic Staging of Patients with Lung Cancer

All patients with NSCLC should undergo initial radiographic imaging with CT scan, positron
emission tomography (PET), or preferably CT-PET. PET scanning attempts to identify sites of
malignancy based on glucose metabolism by measuring the uptake of fluorodeoxyglucose F18.
Confirmation with tissue biopsy is required.
For brain metastases, MRI is the most effective method.
In patients with NSCLC, the following are major contraindications to potential curative
resection:
Extrathoracic metastases; superior vena cava syndrome; vocal cord and, in most cases, phrenic
nerve paralysis; malignant pleural effusion; cardiac tamponade; tumor within 2 cm of the
carina; metastasis to the contralateral lung; metastases to supraclavicular lymph nodes;
contralateral mediastinal node metastases; and involvement of the main pulmonary artery.

The best predictor of metastatic disease remains a careful history and physical examination.
If signs, symptoms, or findings from physical examination suggest the presence of malignancy,
then sequential imaging starting with the most appropriate study should be performed.
If the findings from the clinical evaluation are negative, then imaging studies beyond CT-PET
are unnecessary and the search for metastatic disease is complete.
There are limited data on the use of CT-PET in the staging of patients with SCLC.
Current staging recommendations include a CT scan of the chest and abdomen (because of the
high frequency of hepatic and adrenal involvement), MRI of the brain (positive in 10% of
asymptomatic patients), and radionuclide (bone) scan if symptoms or signs suggest disease
involvement in these areas.
Bone marrow biopsies and aspirations are rarely performed given the low incidence of isolated
bone marrow metastases.
Confirmation of metastatic disease, ipsilateral or contralateral lung nodules, or metastases
beyond the mediastinum may be achieved by the same modalities recommended above for
patients with NSCLC.
If a patient has signs or symptoms of spinal cord compression (pain, weakness, paralysis, urinary
retention), a spinal CT or MRI scan and examination of the cerebrospinal fluid cytology should
be performed.
 The Staging System for Non-Small Cell Lung Cancer
The TNM International Staging System provides useful prognostic information and is used to
stage all patients with NSCLC.
Staging system within the T classification; T1 tumors are divided into tumors 2 cm in size, as
these patients were found to have a better prognosis compared to tumors >2 cm but 3 cm.
T2 tumors are divided into those that are >3 cm but 5 cm and those that are >5 cm but 7 cm.
T3 tumors are >7 cm.
T4 tumors include those that have additional nodules in the same lobe or tumors that have a
malignant pleural effusion.
M1a, malignant pleural or pericardial effusion, pleural nodules or nodules in the contralateral
lung, or M1b distant metastasis (e.g., bone, liver, adrenal, or brain metastasis).
Sixth and Seventh Edition TNM Staging Systems for Non-Small Cell Lung Cancer
  Sixth Edition Seventh Edition
Tumor (T) 
T1
Tumor 3 cm diameter without invasion Tumor 2 cm diameter, surrounded by lung or
more proximal than lobar bronchus visceral pleura, without invasion more proximal than
lobar bronchus
T1a  
Tumor 2 cm in diameter
T1b  
Tumor >2 cm but 3 cm in diameter
T2 Tumor >3 cm diameter OR tumor of any size
with any of the following: Tumor >3 cm but 7 cm with any of the
following:
   Visceral pleural invasion

   Atelectasis of less than entire lung    Involves main bronchus, 2 cm distal to carina

   Proximal extent at least 2 cm from carina    Invades visceral pleura

   Associated with atelectasis or obstructive

pneumonitis extending to hilar region but not
involving the entire lung
T2a  
Tumor >3 cm but 5 cm in diameter
T2b  
Tumor >5 cm but 7 cm in diameter
T3 Tumor of any size that invades any of the Tumor >7 cm or directly invades any of the
following: chest wall, diaphragm, mediastinal following: chest wall (including superior sulcus
pleura, parietal pericardium tumors), phrenic nerve, mediastinal pleura, parietal
pericardium
Tumor <2 cm distal to carina
Tumor <2 cm distal to carina but without
involvement of carina

Tumor with associated atelectasis or obstructive

pneumonitis of entire lung

Separate tumor nodule(s) in same lobe

T4 Tumor of any size that invades any of the Tumor of any size that invades any of the following:
following: mediastinum, heart or great mediastinum, heart or great vessels, trachea,
vessels, trachea, esophagus, vertebral body, recurrent laryngeal nerve, esophagus, vertebral
carina body, carina
 Tumor with malignant pleural or pericardial Separate tumor nodule(s) in a different ipsilateral
effusion lobe

Separate tumor nodules in same lobe

Nodes (N) 
N0 No regional lymph node metastasis No regional lymph node metastasis
N1 Metastasis in ipsilateral peribronchial and/or Metastasis in ipsilateral peribronchial and/or hilar
hilar lymph node(s) lymph node(s) and intrapulmonary node(s), including
involvement by direct extensions
N2 Metastasis in ipsilateral mediastinal and/or Metastasis in ipsilateral mediastinal and/or
subcarinal lymph node(s) subcarinal lymph node(s)
N3 Metastasis in contralateral mediastinal, Metastasis in contralateral mediastinal, hilar,
contralateral hilar, ipsilateral or contralateral ipsilateral or contralateral scalene or supraclavicular
scalene or supraclavicular lymph node(s) lymph node(s)
Metastasis (M) 
M0 No distant metastasis No distant metastasis
M1 Distant metastasis (includes tumor nodules in Distant metastasis
different lobe from primary)
M1a   Separate tumor nodules in a contralateral lobe

Tumor with pleural nodules or malignant pleural or

pericardial effusion
M1   Distant metastasis
b
The Staging System for Small Cell Lung Cancer
Small cell lung cancer has a distinct two-stage system.
Patients with limited-stage disease (LD) have cancer that is confined to the ipsilateral hemithorax
and can be encompassed within a tolerable radiation port.
Thus, contralateral supraclavicular nodes, recurrent laryngeal nerve involvement, and superior
vena caval obstruction can all be part of limited-stage disease.
Patients with extensive-stage disease (ED) have overt metastatic disease by imaging or
physical examination.
Cardiac tamponade, malignant pleural effusion, and bilateral pulmonary parenchymal
involvement generally qualify disease as extensive-stage.
Sixty to 70% of patients are diagnosed with extensive disease at presentation.

Physiologic Staging
Patients with an FEV1 (forced expiratory volume in 1 s) of greater than 2 L or greater than 80%
of predicted can tolerate a pneumonectomy, and those with an FEV1 greater than 1.5 L have
adequate reserve for a lobectomy.
In patients with borderline lung function but a resectable tumor, cardiopulmonary exercise
testing could be performed as part of the physiologic evaluation.

Patients deemed unable to tolerate lobectomy or pneumonectomy from a pulmonary functional

standpoint may be candidates for more limited resections.
A myocardial infarction within the past 3 months is a contraindication to thoracic surgery
because 20% of patients will die of reinfarction.
An infarction in the past 6 months is a relative contraindication.
Other major contraindications include uncontrolled arrhythmias, an FEV1 of less than 1 L, CO2
retention (resting PCO2 >45 mmHg), DLCO <40%, and severe pulmonary hypertension.

Treatment of Non-Small Cell Lung Cancer

Management of Occult and Stage 0 Carcinomas
Surgical resection following bronchoscopic localization improves survival compared to no
treatment.
Close follow-up of these patients is indicated because of the high incidence of second primary
lung cancers (5% per patient per year).

Solitary Pulmonary Nodule and "Ground-Glass" Opacities

Defined as an x-ray density completely surrounded by normal aerated lung with circumscribed
margins, of any shape, usually 1–6 cm at greatest diameter.

The approach to a patient with a solitary pulmonary nodule is based on an estimate of the
probability of cancer, determined according to the patient's smoking history, age, and
characteristics on imaging.

Clinical characteristics (age, cigarette smoking status, and prior cancer diagnosis) and three
radiologic characteristics (nodule diameter, spiculation, and upper lobe location) were
independent predictors of malignancy.
At present, only two radiographic criteria are thought to predict the benign nature of a solitary
pulmonary nodule: lack of growth over a period >2 years and certain characteristic patterns of
calcification.
Calcification alone, however, does not exclude malignancy; a dense central nidus, multiple
punctate foci, and "bull's-eye" (granuloma) and "popcorn ball" (hamartoma) calcifications are
highly suggestive of a benign lesion.

Large lesion, lack of or asymmetric calcification, chest symptoms, associated atelectasis,

pneumonitis, or growth of the lesion or a positive PET scan are suggestive of a malignant
process and warrant further attempts to establish a histologic diagnosis.

Assessment of Risk of Cancer in Patients with Solitary Pulmonary Nodules

  Risk
Variable Low Intermediate High
Diameter (cm) <1.5 1.5–2.2 Greater or equal 2.3
Age (years) <45 45–60 >60
Smoking status Never smoker Current smoker (<20 Current smoker
cigarettes/d) (>20 cigarettes/d)
 Smoking cessation Quite qual or greater Quit <7 years ago Never quit
status than 7 years ago or
quit
Characteristics of Smooth Scalloped Corona radiata or
nodule margins spiculated

Management of Stages I and II NSCLC

Surgical Resection for Stages I and II NSCLC is the treatment of choice for patients who are
able to tolerate the procedure.

Pneumonectomy is reserved for patients with very central tumors and should only be performed
in patients with excellent pulmonary reserve.
The 5-year survival rates are 60–80% for patients with stage I NSCLC and 40–50% for patients
with stage II NSCLC.
Patients should have a complete mediastinal node dissection.

Radiation Therapy in Stages I and II NSCLC

No role for adjuvant radiation therapy in patients following resection of stage I or II NSCLC.
Patients with stage I or II disease who refuse or are not candidates for pulmonary resection
should be considered for radiation therapy with curative intent.
5-year survival rates of 13–39% in patients with stage I or II NSCLC treated with radical
radiotherapy.

Chemotherapy in Stages I and II NSCLC

Chemotherapy should start 6 to 8 weeks after surgery, if the patient has recovered, and should be
administered for four cycles.
All patients should be treated with a cisplatin-based regimen.
Carboplatin is a reasonable consideration in patients who are unlikely to tolerate cisplatin for
reasons such as reduced renal function, presence of neuropathy, or hearing impairment.

All patients with resected NSCLC are at high risk of recurrence or developing a second primary
lung cancer.
Thus, it is reasonable to follow these patients with regular imaging.
CT scans of the chest with contrast every 6 months for the first 2 years after surgery, followed by
yearly CT scans of the chest without contrast thereafter.

Management of Stage III NSCLC

Surgery followed by adjuvant chemotherapy is the treatment of choice for patients with stage
IIIA disease due to hilar nodal involvement (T3N1).
Surgery for N2 disease is more controversial.
Surgery alone in stage IIIA disease (N2 disease) is associated with a 14–30% 5-year survival.
The best survival rate is seen in cases with minimal N2 disease and complete resection.
Chemotherapy plus radiation therapy is the treatment of choice for patients with N3 nodal
involvement or bulky stage IIIA disease.

Superior Sulcus or Pancoast Tumors

Neoadjuvant chemotherapy or combined chemotherapy and radiation therapy is typically
reserved for those patients with N0 or N1 involvement.
For patients with Pancoast tumors that have metastatic disease at the time of presentation,
radiation therapy with or without chemotherapy may be offered for palliation of symptoms.

Treatment of Metastatic Non-Small Cell Lung Cancer

These patients have a median survival of 4–5 months and a 1-year survival of 10% when
managed with best supportive care alone
Standard medical management, the judicious use of pain medications, and the appropriate use of
radiotherapy and chemotherapy form the cornerstone of management.

Chemotherapy palliates symptoms, improves the quality of life, and improves survival in patients
with stage IV NSCLC, particularly in patients with good performance status.

First-Line Chemotherapy for Metastatic or Recurrent Non-Small Cell Lung Cancer

Cisplatin-based regimens; 20–30% response rate and an 8- to 10-month median.
ECOG PS 0–1.

Longer duration of chemotherapy has been associated with increased toxicities and impaired
quality of life.
Therefore, prolonged therapy (beyond four to six cycles) with platinum-based regimens is not
recommended in patients with advanced NSCLC.
Nonsquamous NSCLC had an improved survival when treated with cisplatin while patients with
squamous carcinoma had an improved survival when treated with cisplatin and gemcitabine.

Treatment of Small Cell Lung Cancer

Treatment of Limited Disease Small Cell Lung Cancer
Surgery
Surgical resection is not routinely recommended for patients because even those patients with
LD-SCLC still have occult micrometastases.
Chemotherapy
Chemotherapy significantly prolongs survival in patients with SCLC.
Combination chemotherapy with a platinum agent (cisplatin or carboplatin) and etoposide for
four to six cycles is the mainstay of treatment.
Radiation Therapy

Benign Lung Neoplasm

Benign tumors account for about 5% of all lung cancers.
About half are hamartomas; the lungs are the site of about 90% of all hamartomas.
The other half are bronchial adenomas.

Hamartomas
They are more common in men than in women and have a peak incidence in the 60s.
Solitary nodules.
They have a pathognomonic "popcorn" pattern of calcification in some cases.

Miesso(MD)