A pragmatic and successful approach to treating nonsmall-cell lung carcinoma

AORN Journal, Nov, 2004 by Paul D. Kiernan, Paula R. Graling, Vivian L. Hetrick, Betty E. Vaughan, Michael J. Sheridan, Johnny K. Lee

Lung cancer is the single leading cause of cancer deaths for men and women combined, (1) resulting in 31% of cancer deaths in men and 25% of cancer deaths in women. (2) Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases. (3) Were smoking to be reduced significantly, the incidence of lung cancer likely would decrease proportionately.

The survival rates for patients with stage II or IIIA disease (ie, 41% and 36%, respectively) treated at Inova Fairfax Hospital, Falls Church, Va, between 1981 and 1989 match the best results achieved by other health care facilities. (4,5)

This article details the methods of patient selection, preoperative and intraoperative care, and postoperative outcomes for patients treated for NSCLC from 1991 through 2003 at Inova Fairfax Hospital. Based on the knowledge that incomplete tumor resection precludes long-term survival where late-stage disease (ie, III, IV) was recognized, patients were treated selectively and progressively with preoperative neoadjuvant chemotherapy, radiation therapy, or a combination of both therapies to try to downstage the disease so that complete resection might be feasible. The outcomes from this data collection period are consistent with Inova's results from 1981 through 1989. (5,6) The results match or exceed the best results for treatment of late-stage (ie, III and IV) disease reported anywhere to date. (7,8)

STAGE OF TUMOR

The pioneering work of H. C. Nohl, MD, (9) and D. L. Paulson, MD, (10) provides near universal agreement on the importance of lung cancer staging, which is a method of estimating the extent of disease and thereby indirectly determining a patient's prognosis to help determine the best treatment plan. The international tumor, node, metastasis (TNM) staging system uses a "T" to describe the size, location, and pulmonary or extrapulmonary spread of the primary tumor. An "N" is used to describe whether the tumor involves or has progressed via metastasis to particular groups of lymph nodes. The "M" describes metastases to distant organ sites (eg, adrenal, bone, brain, liver) (Table 1). (11, 12) This staging system is accepted by the American Joint Committee on Cancer. (12,13)

Lung tumors then are grouped according to their stage (Table 2). Individuals without nodal spread lie, stage I) or with intrapleural, regional nodal spread of disease (ie, stage II) may undergo surgical resection, occasionally supplemented with adjuvant therapy leg, chemotherapy, radiation therapy), in the hope that all disease will be extirpated. Numerous articles attest to the success of surgical resection of NSCLC when the disease is diagnosed before it progresses to extrapleural, mediastinal lymphatic (ie, stage III), or distant metastatic (ie, stage IV) disease. (6,14-18) Until recently, however, the treatment of stage III and stage IV cancer has been considered only palliative--the end result of which is a foregone, dismal conclusion. (4-5)

The microscopically verified TNM staging system

   has proved to be the best method
   ... to determine treatment strategies
   and ultimate prognosis ... the
   involvement of intrapulmonary (N1)
   or mediastinal (N2,
   extrapulmonary) lymph
   nodes remains the most
   important predictor of
   outcome after resection of
   lung cancer)(9)

Figure 1 illustrates the anatomic location of various N1 (ie, intrapulmonary) and N2 (ie, extrapulmonary, mediastinal) nodes. (12) Figure 2 relates the microscopically proven pathological stage to the likely post-treatment prognosis, (12) thus, when microscopically proven pathological disease is described, the letter "P" is used (eg, PN1, PN2) to differentiate from preoperative, clinical estimate of stage, which uses the letter "C" instead (eg, CN1, CN2).

[FIGURE 1 & 2 OMITTED]

Preoperative clinical attempts to forecast the actual pathological burden (ie, stage) of disease rest on accuracy in an array of anatomic and physiological imaging modalities, including computed tomography (CT) and positron emission tomography (PET). One experienced surgeon admonishes that the clinical appearance of disease may be misleading, noting that in his experience

if all the patients a with N-2 disease that is detected by preoperative CT scanning were uniformly excluded from operation, 39% of PN0 or PN1 patients would have been excluded. (20)

The selective addition of PET scanning to routine use of CT is considered progress in the direction of less invasive and more efficacious diagnosis and therapy. Experience indicates that PET scanning seems to achieve a high negative predictive value in the evaluation of mediastinal (ie, N2) disease. (21-23) In other words, a negative result may be 93% to 95% accurate, so in this instance 93 to 95 out of 100 patients with a negative result will not have mediastinal disease. A PET scan also seems to be particularly helpful in evaluating patients in whom bulky nodes persist on CT after neoadjuvant therapy. A PET scan is significantly more costly than a CT scan, so clinicians at Inova Fairfax Hospital use PET scanning when