lung%20cancer
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.

Principles of Therapy for Small Cell Lung Cancer (SCLC)

  • Adjuvant chemotherapy is advised in patients who underwent successful surgical resection
  • Lobectomy and mediastinal lymph node dissection or sampling is recommended for limited disease small cell lung cancer (LD SCLC) patients with clinical stage I-IIA (T1-2, N0, M0)
    • Patients without node involvement should be given systemic therapy
    • Adjuvant systemic therapy with or without sequential or concurrent mediastinal radiotherapy is recommended for patients with N1 node involvement
    • Adjuvant systemic therapy with sequential or concurrent mediastinal radiotherapy is recommended for patients with N2 node involvement
  • Surgery for patients with LD SCLC in excess of clinical stage T1-2, N0 is not recommended
    • For patients with PS 0-2, radiotherapy is recommended to be given concurrently with systemic therapy, but is to be given sequentially in patients with PS 3-4 due to SCLC
    • Systemic therapy with or without radiotherapy given concurrently or sequentially is recommended for patients with PS 3-4 due to SCLC
    • For SCLC patients with PS 3-4 due to comorbidities, treatment should be individualized
  • For asymptomatic extensive disease small cell lung cancer (ED SCLC) patients without localized symptomatic sites or brain metastases with PS 0-2 or PS 3-4 due to SCLC, combination systemic therapy with supportive therapy is recommended
    • For SCLC patients with PS 3-4 due to comorbidities, treatment should be individualized and supportive care should be provided
  • Systemic therapy with or without radiotherapy to symptomatic sites is recommended for ED SCLC patients with superior vena cava syndrome, lobar obstruction, or bone metastases
    • If at high risk for fracture secondary to osseous structural impairment, palliative EBRT with orthopedic stabilization should be considered
    • If spinal cord compression is present, radiotherapy prior to systemic therapy is preferred
  • Systemic therapy followed by whole brain radiotherapy after completed induction systemic therapy is recommended for asymptomatic ED SCLC patients with brain metastasis 
  • Symptomatic ED SCLC patients with brain metastasis may be given whole brain radiotherapy prior to initiation of systemic therapy unless immediate need for systemic therapy arises
  • Enrollment in a clinical trial should be considered in patients who are unresponsive to initial or adjuvant systemic therapy

Palliative Care for Lung Cancer

  • Identify all patients who may benefit from palliative care and specialist referral should be done immediately

Pain

  • Mild-moderate pain
    • Treat with Acetaminophen or nonsteroidal anti-inflammatory drug
    • May consider titrating short-acting opioid if pain control with NSAIDs/Acetaminophen is inadequate, may consider increasing the dose, or switching to combination therapies containing opioids
  • Severe pain
    • Treat with opioids
      • Meperidine is not used if pain medication will be given continuously; may cause dysphoria, agitation or seizure
      • May give medication for constipation prophylactically if opioid is used
    • Tricyclic antidepressants, anticonvulsants and neuropathic agents may be given to enhance the effect of pain medications
  • Bone pain secondary to cancer metastasis
    • Radiotherapy is recommended for pain relief
    • Bisphosphonates (eg Pamidronate, Zoledronic acid) are advised together with radiotherapy
      • Effectively relieve bone pain, treat hypercalcemia of malignancy and delay onset of bone disease progression
    • Denosumab, a receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor, demonstrated pain relief in patients with pain secondary to bone metastases

Cachexia/Anorexia

  • Appetite stimulants may help improve the quality of life of patients with months to days' life expectancy
  • Consider consultation with a nutritionist for appropriate calorie supplementation

Dyspnea, Cough and Compression Symptoms

  • Opioid and non-opioid antitussives (eg Morphine, Fentanyl, Oxycodone) may be given to the patient to reduce coughing
    • External beam radiotherapy is also an option
  • Symptom relief by administration of opioids may be considered for dyspneic patients
    • May consider adding benzodiazepines if dyspnea is associated with anxiety 
  • Excessive secretions can be managed using Scopolamine, Atropine, Hyoscyamine or Glycopyrrolate 
  • Radiotherapy and stents may be considered in patients if there are breathlessness and hemoptysis due to the endobronchial tumor
  • Relief of pleural effusion should be done primarily by thoracentesis
    • Recurrent pleural effusions should be managed with chest tube drainage, pleurodesis, or indwelling pleural catheter
  • Use of supplemental O2 and noninvasive mechanical ventilation may be considered

Superior Vena Cava (SVC) Obstruction

  • Chemotherapy is recommended for patients with symptomatic SVC obstruction secondary to SCLC
  • Stent insertion and/or radiotherapy are recommended for patients with symptomatic SVC obstruction secondary to NSCLC and SCLC who do not respond to chemotherapy

Osseous Structural Impairment

  • Orthopedic stabilization should be done prior to radiotherapy for patients at high risk for fracture due to osseous structural impairment
    • Preferred therapy for spinal cord compression and fractures compared to surgery

Brain Metastases

  • Corticosteroids may be given to relieve headache, seizures and sensorimotor deficits
  • Resection of isolated brain metastasis may be considered in NSCLC patients after complete tumor resection and with no metastasis found on other sites
    • Whole brain radiotherapy should follow removal of isolated single brain metastasis
  • Stereotactic radiotherapy may be considered in patients with single brain metastasis
    • Given alone, after surgical resection, or with whole brain radiotherapy

Depression

  • Should always be assessed and managed
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Oncology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
Natalia Reoutova, 21 Nov 2019

Final analysis of the POEMS (Prevention of Early Menopause) study finds that breast cancer (BC) patients treated with the gonadotrophin-releasing hormone agonist (GnRHa) goserelin, in addition to chemotherapy, are more likely to avoid premature menopause and to become pregnant without negatively impacting disease-related outcomes.

Jairia Dela Cruz, 04 Dec 2019
In breast cancer, especially hormone-negative tumours, an ultrasound-guided core biopsy (CNB) is useful for predicting pathologic complete response (pCR) to chemotherapy and may thus help to avoid surgery for some patients, a study has found.
Stephen Padilla, 05 Dec 2019
Circulating miR-155 may be potentially used as a diagnostic and therapeutic monitoring marker in breast cancer, suggests an Indonesian study presented at the 2019 Asia Congress of the European Society for Medical Oncology (ESMO Asia 2019).
Christina Lau, 14 Feb 2019
Progress in the treatment of rare cancers has been named Advance of the Year by the American Society of Clinical Oncology (ASCO).