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LUNG CANCER
Lung cancer is having a malignant tumor in the lungs especially in the cells lining air passages.
Primary tumor-related signs and symptoms are cough, dyspnea, hemoptysis, and chest discomfort.
Signs and symptoms due to intrathoracic spread may involve the nerves (hoarseness, dyspnea, muscle wasting of upper limb, Horner's syndrome), chest wall and pleura (chest pain, dyspnea) and vascular structures (facial swelling, dilated neck veins, cardiac tamponade) & viscera (dsyphagia).
The signs and symptoms due to metastatic spread are bone pain with or without pleuritic pain, neurologic symptoms, limb weakness, unsteady gait, cervical lymphadenopathy, and skin nodules.

Radiotherapy

Radiotherapy for Non-Small Cell Lung Cancer (NSCLC)
  • Used as an adjunct for patients with resectable lesions, as initial primary local treatment for medically unfit patients and with unresectable disease, as definitive therapy for locally advanced NSCLC, treatment recurrences and metastases, and as a palliative modality for patients with advanced diseases
  • Preoperative RT is recommended for patients with resectable superior sulcus tumors and may be considered inpatients with stage IIIA with minimal LN involvement and candidates for lobectomy
  • Postoperative RT may be considered in patients with mediastinal involvement, multiple positive LN, extracapsular extension of LN, bulky LN, or with positive surgical margins
  • Can be given to patients with stage IV NSCLC with extensive metastasis as a palliative care

Radical Radiotherapy/External Beam Radiation Therapy (EBRT)

  • Recommended for patients with stage I and II who are not fit for or do not consent to surgery
  • Should be offered, in combination with chemotherapy, to patients with stage IIIA or IIIB NSCLC of good performance status (PS), in whom the tumor can be safely encompassed

Stereotactic Ablative Radiotherapy (SABR/BBRT)

  • Recommended for patients with stage I and IIA who are not fit for or do not consent to surgery
  • May also be considered for patients at high risk for complications following lobectomy (eg ≥75 years old, poor lung function)

Definitive Chemoradiation 

  • Recommended for patients with stage II-III NSCLC with unresectable disease
  • Superior to radiation alone or sequential chemotherapy followed by radiation in patients with locally advanced NSCLC but may be considered in frail patients intolerant to concurrent therapy
  • Preoperative concurrent chemoradiation is recommended for operable superior sulcus lesions and may be considered in operable stage IIIA lesions
    • May also be given postoperatively or in trimodality therapy
  • Consolidation Durvalumab after chemoradiotherapy is recommended for patients with stage III disease
  • Recommended dose: 60-70 Gy in 2 Gy fractions

Interstitial Radiotherapy or Laser Therapy

  • Recommended for patients with recurrent NSCLC associated with endobronchial lesions

Palliative Radiotherapy

  • Shorter courses of RT (single-fraction stereotactic RT: 12-16 Gy) are preferred for patients with poor PS and/or shorter life expectancy 
  • Fractionated, higher dose is recommended for patients with thoracic symptoms and good performance status but do not meet the requirements for radical radiotherapy for palliation of symptoms
  • Higher dose or longer courses are recommended (eg ≥30 Gy in 10 fractions) modestly improves patient survival and symptoms
Radiotherapy for Small Cell Lung Cancer (SCLC)
  • Since SCLC is radiosensitive, radiotherapy is a vital part of treatment
    • Recommended for post-lobectomy LD SCLC patients with clinical stage I-IIA with pathologic N2 involvement
      • May also be considered in patients with pathologic N1
    • Important for palliation of symptoms in extensive disease small cell lung cancer (ED SCLC) patients with brain, epidural and bone metastasis
  • Radiotherapy, once started, should proceed without interruption
  • Advise patient to stop smoking prior to radiotherapy

Stereotactic Ablative Radiotherapy (SABR/SBRT)

  • Recommended for LD SCLC patients with stage I-IIA who are not fit for or do not consent to surgery

Thoracic Irradiation

  • May be given to limited disease small cell lung cancer (LD SCLC) patients simultaneously with 1st or 2nd chemotherapy cycle
    • May also be given after completing chemotherapy if good response within the thorax is achieved
  • After completion of chemotherapy, radiotherapy may be offered to ED SCLC patients provided a complete response on the distant sites and at least partial response within the thorax are achieved
    • Recommended dose range: 30 Gy in 10 fractions/day to 60 Gy in 30 fractions/day

Prophylactic Cranial Irradiation (PCI)

  • Aims to eradicate microscopic brain metastasis and increase overall survival
    • Increases the overall survival while decreasing the incidence of brain metastasis in patients with LD SCLC who responded to initial treatment
    • Decreases the incidence of brain metastasis in patients with ED SCLC who responded to systemic therapy 
  • Considered in patients with LD or ED SCLC (pathologic stage IIB-III) of PS 0-2 in whom a complete or partial response to primary treatment is achieved
  • Should be incorporated within 3-5 weeks of the last cycle of chemotherapy
  • Recommended after adjuvant systemic therapy in patients who had complete resection
  • Not recommended for patients with poor PS or impaired neurocognitive functioning
  • Recommended dose: 25 Gy in 10 fractions/day; dose reduced for patients with ED SCLC
    • Memantine may be administered during and post-radiotherapy to decrease neurocognitive impairment
  • Hippocampal-sparing PCI using intensity-modulated RT may be considered

Whole Brain Radiation Therapy (WBRT)

  • Recommended for patients with brain metastasis 
  • Repeat WBRT may be considered in some patients who developed brain metastases post-PCI
  • Recommended dose: 30 Gy in 10 fractions/day
  • Hippocampal-sparing WBRT using intensity-modulated RT plus Memantine is preferred for patients with better prognosis due to lesser cognitive function failure compared to conventional WBRT plus Memantine

Palliative Radiotherapy

  • For extracranial metastases, common radiation dose-fractionation regimens (eg 30 Gy in 10 fractions, 20 Gy in 5 fractions, 8 Gy in 1 fraction) may be considered
  • Conformal techniques and/or higher dose intensity approaches may also be considered in select patients
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