Nonsmall cell lung cancer

Introduction

Surgical removal of non-small cell bronchogenic carcinoma continues to offer best possibility of a cure. Consequently, each patient should be considered where possible for surgical treatment, although advanced stage and significant co-morbidity will preclude this option in many patients. The aim of surgical treatment is cure; in patients where this is not possible suitable alternative treatments should be considered.

Before embarking on surgery all cases should undergo careful and detailed pre-operative assessment to establish:

♦ Histological proof of disease

♦ Staging of disease

♦ Fitness for surgery

Histological/cytological proof of non-small cell lung cancer

Pre-operative proof of malignancy is possible in the majority of patients suffering from lung cancer. Main methods of diagnosis continue to be:

♦ Sputum cytology

♦ Bronchoscopy with biopsy

♦ Bronchial brushings

These methods have a high yield of positive diagnosis, particularly in more centrally placed bronchogenic tumours. In more peripherally situated tumours percutaneous fine-needle aspiration for cytology or trucut-needle biopsy performed under fluoroscopic screening or guided by CT are preferred.

In a few patients pre-operative proof of malignancy may not be possible and surgery may be offered on radiological evidence (a mass lesion that has grown on sequential imaging).

Staging of disease

♦ Bronchoscopy

— relationship to chest wall, fissures, mediastinal structures, diaphragm

— lymph nodes >1 cm suggestive of tumour

♦ Mediastinoscopy

♦ Thoracoscopy

♦ Mediastinotomy

♦ Pleural aspiration, pleural biopsy

♦ Nodes may be enlarged due to reactive change

♦ CT liver and adrenals for metastases

♦ Bone scan and brain scan—only if symptoms

Fitness for surgery

In patients undergoing surgery for non-small cell lung cancer, pre-operative assessment is vital. Age alone should not be considered a contraindication to lung resection. Patient's performance status can be a useful indicator of ability to withstand major lung resection. Weight loss is an indicator of poor prognosis in lung cancer.

Table 16.1 TNM staging of lung cancer

T1 Tumour 3 cm or less in diameter, surrounded by lung or visceral pleura, distal to the main bronchus T2 Tumour >3 cm diameter; or involving main bronchus 2 cm or more distal to carina; or invading visceral pleura; or associated with atelectasis which extends to the hilum but does not involve the whole lung

T3 Tumour invading chest wall, diaphragm, mediastinal pleura, or pericardium; or tumour in main bronchus <2 cm distal to carina; or atelectasis of the whole lung T4 Tumour invading mediastinum, heart, great vessels, trachea, oesophagus, vertebra, or carina; or intralobar tumour nodules; or malignant pleural effusion NO No regional node metastases N1 Ipsilateral peribronchial or hilar node involvement N2 Ipsilateral mediastinal or subcarinal nodes

N3 Contra-lateral mediastinal nodes; scalene; or supraclavicular nodes Stage grouping

IIIb T4 any N MO; or any N3 MO

IV Any Ml

Pulmonary function tests are essential—as well as demonstrating adequate respiratory reserve they are useful in post-operative management. Other investigations include haematological and biochemical screening to exclude significant co-morbidity and electrocardiogram, with or without an exercise test.

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