Lung Cancer.pdf

Treatment of Early-Stage Non–Small Cell Carcinoma of the Lung 115
KEY PRACTICE POINTS
• Patients with apparent clinical early-stage NSCLC (AJCC stages I and II) may
harbor asymptomatic distant metastases, and CT or MR imaging of the brain
and a bone scan are recommended for all patients with clinical stage IB or
more extensive disease. If full staging is not performed in a patient with
stage IA disease, the small risk of occult metastatic disease should be carefully
explained, and the patient should give informed consent to forego
screening.
• Anatomic surgical resection (lobectomy or greater) is considered the current
standard of care in patients with early-stage NSCLC who are medically fit to
undergo surgery.
• A full mediastinal lymph node dissection should be performed in patients
undergoing anatomic resection for clinical early-stage NSCLC to provide for
more accurate pathologic staging and assessment of prognosis.
• In patients with early-stage NSCLC who are unable to tolerate an anatomic
resection, wedge resection with negative surgical margins may be superior
to radiation therapy alone. However, newer modes of radiation therapy may
be shown to be of equivalent efficacy in the near future.
• One reason that so many patients with “early-stage” NSCLC eventually
succumb to the disease is probably related to measurement bias in staging
(i.e., understaging of patients). Newer staging modalities such as PET may
allow for more accurate staging and drift of the survival numbers for earlystage
NSCLC to a more favorable level. Clinicians should stay abreast of new
developments and further verification of these modalities as accurate staging
tools.
• As many patients with early-stage NSCLC will eventually succumb to the
disease (usually distant rather than local recurrence), assessment of the utility
of systemic chemotherapy in this patient population is crucial. Clinicians are
urged to enroll patients in randomized trials such as intergroup S9900 to
further evaluate the use of neoadjuvant chemotherapy in combination with
surgical resection.
Suggested Readings
Bush DA, Slater JD, Bonnet R, et al. Proton-beam radiotherapy for early-stage lung
cancer. Chest 1999;116:1313–1319.
Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection
for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac
Surg 1995;60:615–622.
Graham PH, Gebski VJ, Langlands AO. Radical radiotherapy for early nonsmall
cell lung cancer. Int J Radiat Oncol Biol Phys 1995;31:261–266.