Lung Cancer.pdf

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Surgical Treatment of Locally Advanced Non–Small Cell <strong>Lung</strong> <strong>Cancer</strong> 135 diation therapy because it is associated with an increased risk of wound healing problems (especially at bronchial margins) after surgery and because the dose that can be delivered before surgery is lower than the dose that can be delivered after (45 Gy vs 66 Gy). If the final pathologic margins after surgery are involved, postoperative radiation therapy is delivered to reduce the risk of local-regional recurrence. Patients with T4N0–1 Pancoast tumors are treated in a phase II study evaluating surgical resection followed by postoperative chemoradiation. After surgery, radiation therapy is delivered over 5 to 6 weeks. Patients receive 2 fractions per day, to a total dose of 60 Gy in patients with negative margins or 64.8 Gy in patients with positive margins, plus concurrent chemotherapy (cisplatin 50 mg/m 2 on days 1 and 8 and etoposide given by mouth 30 to 60 minutes prior to each administration of radiation therapy on days 1 through 5 and 8 through 12, with this chemotherapy cycle repeated starting on day 29). Prophylactic cranial irradiation (25 Gy in 10 fractions of 2.5 Gy) is given on completion of chest irradiation because of the high risk of brain recurrences. Three additional cycles of chemotherapy are delivered after prophylactic cranial irradiation. This aggressive approach has resulted in long-term survival in a fraction of patients in whom negative pathologic margins can be obtained (Gandhi et al, 1999). Because of the complexity of this operation, careful coordination between the medical oncologists, surgical oncologists, and radiation oncologists is required. These rare tumors should be treated at an experienced referral center to ensure the maximum chance for overall success. Operative Strategy Surgery for T4N0–1 non-Pancoast tumors is usually performed after induction chemotherapy. In some cases, the preoperative chemotherapy has significantly downstaged the tumor (Figure 7–2). Nevertheless, the original extent of the tumor must be kept in mind to avoid leaving behind tissue that may still contain microscopic deposits of viable tumor. To help ensure complete resection, scans showing the original extent of the tumor are displayed in the operating room during surgery. The main T4 tumors approached surgically are tumors that invade the carina, vertebral body, or atrium. Resection of the vertebral body will be discussed in the discussion of Pancoast tumors. Invasion of the carina is rare and should be approached surgically only if all the mediastinal nodes are negative on cervical mediastinoscopy. All carinal resections should focus on minimizing the tension on airway anastomoses by developing a pretracheal plane without interrupting the lateral blood supply of the trachea. The hilum can also be mobilized with an inferior hilar release of the pericardium on either side, and a suprahyoid laryngeal release can be performed if necessary. After surgery, all patients are put in cervical flexion, with a stitch secured from the chin to the ante-
136 S.G. Swisher A B Figure 7–2. Downstaging of a T4N0 tumor involving the carina with preoperative chemotherapy. Images are from before (A) and after (B) 3 courses of paclitaxel and carboplatin. Right upper lobe sleeve resection with preservation of the right middle and lower lobe was subsequently performed. The patient was alive without evidence of disease 3 years after surgery.
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Lung Cancer Frank V. Fossella, MD R
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Frank V. Fossella, MD Department of
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vi Foreword possible. Since the res
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x Contents Chapter 7 Surgical Treat
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xii Contributors Joe B. Putnam, Jr.
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2 J.B. Putnam, Jr., F.V. Fossella,
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26 F.V. Fossella common sites of lu
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28 F.V. Fossella history and physic
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30 F.V. Fossella Computed Tomograph
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32 F.V. Fossella Pulmonary Function
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34 F.V. Fossella The use of flexibl
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36 R.F. Munden and J.J. Erasmus hav
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38 R.F. Munden and J.J. Erasmus che
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40 R.F. Munden and J.J. Erasmus tha
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42 R.F. Munden and J.J. Erasmus (Gu
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44 R.F. Munden and J.J. Erasmus A B
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46 R.F. Munden and J.J. Erasmus in
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48 R.F. Munden and J.J. Erasmus Pat
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50 R.F. Munden and J.J. Erasmus D C
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52 R.F. Munden and J.J. Erasmus A B
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54 R.F. Munden and J.J. Erasmus Bol
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56 R.F. Munden and J.J. Erasmus Swe
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58 P. Tamboli and J.Y. Ro Chapter O
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60 P. Tamboli and J.Y. Ro Figure 4-
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62 P. Tamboli and J.Y. Ro Postopera
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64 P. Tamboli and J.Y. Ro Table 4-1
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66 P. Tamboli and J.Y. Ro Atypical
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68 P. Tamboli and J.Y. Ro Diffuse I
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70 P. Tamboli and J.Y. Ro noma. Cig
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72 P. Tamboli and J.Y. Ro Figure 4-
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74 P. Tamboli and J.Y. Ro alone. BA
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76 P. Tamboli and J.Y. Ro Other Mal
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78 P. Tamboli and J.Y. Ro Electron
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80 P. Tamboli and J.Y. Ro Niho S, Y
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82 Y. De Jesus and G.L. Walsh Chapt
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Page 103 and 104: Figure 5-2. Patient “pathway to r
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Page 113 and 114: 100 Y. De Jesus and G.L. Walsh Jenn
Page 115 and 116: 102 W.R. Smythe nation for these su
Page 117 and 118: 104 W.R. Smythe patient reports of
Page 119 and 120: 106 W.R. Smythe bar or limited lung
Page 121 and 122: 108 W.R. Smythe hospitals for 149 p
Page 123 and 124: 110 W.R. Smythe Figure 6-1. Postsur
Page 125 and 126: 112 W.R. Smythe nant neoplasms has
Page 127 and 128: 114 W.R. Smythe Future Directions F
Page 129 and 130: 116 W.R. Smythe Henschke CI, McCaul
Page 131 and 132: 7 SURGICAL TREATMENT OF LOCALLY ADV
Page 133 and 134: 120 S.G. Swisher Treatment Options
Page 135 and 136: 122 S.G. Swisher Initial Assessment
Page 137 and 138: 124 S.G. Swisher Figure 7-1. Region
Page 139 and 140: 126 S.G. Swisher Table 7-2. (contin
Page 141 and 142: 128 S.G. Swisher upper paratracheal
Page 143 and 144: 130 S.G. Swisher is performed only
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Page 147: 134 S.G. Swisher Pancoast tumors th
Page 151 and 152: 138 S.G. Swisher a combination of t
Page 153 and 154: 140 S.G. Swisher Dartevelle PG, Cha
Page 155 and 156: 8 NONSURGICAL TREATMENT OF EARLY-ST
Page 157 and 158: 144 R. Komaki morbid conditions pre
Page 159 and 160: 146 R. Komaki and 26 patients had c
Page 161 and 162: 148 R. Komaki Around 1998, by using
Page 163 and 164: 150 R. Komaki Table 8-5. Survival a
Page 165 and 166: 152 R. Komaki A total of 610 patien
Page 167 and 168: 154 R. Komaki tially obstructed air
Page 169 and 170: 156 R. Komaki report of Radiation T
Page 171 and 172: 9 TREATMENT OF PATIENTS WITH ADVANC
Page 173 and 174: 160 R. Zinner chemotherapy, in pati
Page 175 and 176: Table 9-1. Chemotherapy in Older Pa
Page 177 and 178: 164 R. Zinner results of additional
Page 179 and 180: Table 9-3. Third-Generation-Agent M
Page 181 and 182: Table 9-4. Third-Generation Agents
Page 183 and 184: Table 9-5. Third-Generation Platinu
Page 185 and 186: Table 9-6. Comparisons between Diff
Page 187 and 188: 174 R. Zinner may play an important
Page 189 and 190: Table 9-8. Third-Generation Cisplat
Page 191 and 192: 178 R. Zinner wards higher survival
Page 193 and 194: 180 R. Zinner KEY PRACTICE POINTS
Page 195 and 196: 182 R. Zinner DeVore RF, Fehrenbach
Page 197 and 198: 184 R. Zinner Perng RP, Chen YM, Mi
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10 TREATMENT OF LIMITED-STAGE SMALL
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188 R. Komaki Age is not a signific
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190 R. Komaki lished between 1979 a
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Table 10-1. Complete Response Rates
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194 R. Komaki twice daily to a tota
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196 R. Komaki Intergroup study 0096
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198 R. Komaki Figure 10-1. Survival
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200 R. Komaki cisplatin with concur
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202 R. Komaki KEY PRACTICE POINTS
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204 R. Komaki tients (Pts) with lim
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206 R. Komaki Wagner H, Kim K, John
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208 G.R. Blumenschein, Jr. recurs a
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210 G.R. Blumenschein, Jr. syndrome
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212 G.R. Blumenschein, Jr. toxicity
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214 G.R. Blumenschein, Jr. the year
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216 G.R. Blumenschein, Jr. is chara
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218 G.R. Blumenschein, Jr. new cyto
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12 PALLIATIVE CARE IN PATIENTS WITH
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222 J.B. Putnam, Jr. therapy. Patie
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224 J.B. Putnam, Jr. tion—includi
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226 J.B. Putnam, Jr. rates were 47%
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228 J.B. Putnam, Jr. Dyspnea The ma
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230 J.B. Putnam, Jr. Small-bore cat
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232 J.B. Putnam, Jr. A B Figure 12-
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234 J.B. Putnam, Jr. C D Figure 12-
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236 J.B. Putnam, Jr. B Figure 12-3.
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238 J.B. Putnam, Jr. KEY PRACTICE P
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240 J.B. Putnam, Jr. Rendina EA, De
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242 A.A. Vaporciyan, J.F. Kelly, an
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14 PREVENTION AND EARLY DETECTION O
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258 E.S. Kim and F.R. Khuri A secon
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260 E.S. Kim and F.R. Khuri Smoking
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262 E.S. Kim and F.R. Khuri Reversa
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264 E.S. Kim and F.R. Khuri yet to
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266 E.S. Kim and F.R. Khuri nation
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268 E.S. Kim and F.R. Khuri Methodo
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270 E.S. Kim and F.R. Khuri have be
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272 E.S. Kim and F.R. Khuri the tre
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274 E.S. Kim and F.R. Khuri changes
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276 E.S. Kim and F.R. Khuri KEY PRA
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278 E.S. Kim and F.R. Khuri Hong WK
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15 MOLECULAR EVENTS IN LUNG CANCER
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282 W.N. Hittelman, J.M. Kurie, and
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300 Index Anterior spinal column re
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302 Index Cardiac murmurs, 104 Card
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304 Index Diagnosis. See also under
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306 Index Growth. See Tumor growth
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308 Index Magnetic resonance (MR) i
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310 Index p16 gene, 285 p19 arf gen
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312 Index Pulmonary resection (cont
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314 Index Squamous metaplasia, 263-
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316 Index Vitamin A, 262 Vocal cord
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