Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Neurotoxicity Related to Radiotherapy and Chemotherapy for Nonsmall Cell and Small Cell Lung Cancer

Summary of Key Points Radiation-induced brachial plexopathy (RIBP) occurs with treatment of apical tumors and is frequently complicated by tumor-related brachial plexopathy (TRBP). Stereotactic ablative radiotherapy (SABR) of apical tumors, which employs a higher dose per fraction, can cause RIBP as well. RIBP symptoms include upper extremity paresthesias, motor weakness, muscle atrophy, and neuropathic pain. The peak incidence is 1–2 years, and the onset is often…

Acute and Late Toxicities of Thoracic Radiotherapy: Pulmonary, Esophagus, and Heart

Summary of Key Points The acute and late toxicity of radiotherapy (RT) for lung cancer usually involves the lungs, esophagus, and heart. Lung Post-RT, there are multiple biochemical and molecular events involving type II pneumocytes, surfactant protein transudation into alveolar spaces, with subsequent inflammation with associated capillary obstruction, and then much later tissue fibrosis. The risk for clinical lung injury has been associated with various dosimetric…

Palliative Radiotherapy for Lung Cancer

Summary of Key Points Palliative radiotherapy is an effective and well tolerated treatment for palliation of thoracic and other symptoms in patients with lung cancer (both nonsmall cell lung cancer and small cell lung cancer). There is ample high-quality evidence from many randomized trials that short courses (one or two fractions only) of thoracic radiation provide high rates of symptomatic relief. There is ongoing controversy about…

Radiotherapy in the Management of Small Cell Lung Cancer: Thoracic Radiotherapy, Prophylactic Cranial Irradiation

Summary of Key Points In patients with clinically nonmetastatic small cell lung cancer (SCLC), positron emission tomography–computed tomography (PET–CT) as well as brain imaging is suggested to classify tumor stage. To classify stage, it is recommended to use the Veterans Administration system (limited disease [LD] vs. extensive disease [ED]) as well as the International Union for International Cancer Control TNM Classification of Malignant Tumors seventh edition…

Radiotherapy for Locally Advanced Nonsmall Cell Lung Cancer Including Combined Modality

Summary of Key Points Concerning radiotherapy, higher physical or biologic dose (altered fractionation) is associated with better local control and, in some trials, with better survival. Current evidence favors a schedule of 60 Gy to 66 Gy in 6 weeks to 7 weeks, with no benefit for doses beyond that. Concurrent chemoradiation therapy is the optimal treatment strategy with curative intent for fit patients not candidates…

Ablation Options for Localized Nonsmall Cell Lung Cancer

Summary of Key Points Since the initial identification of radiofrequency ablation (RFA) as the prototypical thermal ablation technique, it has been joined by microwave ablation, cryoablation, and, more recently, irreversible electroporation as potential options for tumor ablation. Factors that influence size of the ablation zone can be divided into probe and tissue characteristics. Probe characteristics can vary by the number of probes used, the use of…

Stage I Nonsmall Cell Lung Cancer and Oligometastatic Disease

Summary of Key Points Stereotactic ablative radiotherapy (SABR) is recommended in treatment guidelines as the nonoperative therapy of choice for early-stage nonsmall cell lung cancer (NSCLC). SABR can be adequately performed using either traditional linear accelerators equipped with suitable image-guidance technology or linear accelerators specifically adapted for SABR and using dedicated delivery systems. Clinical assessment, staging of disease, and multidisciplinary discussion should be based on published…

Patient Selection for Radiotherapy

Summary of Key Points Patient selection is crucial to ensure treatment selection and optimal outcome. The performance status, described by, for example, the Karnofsky or the Eastern Cooperative Oncology Group (ECOG) score, is the most important prognostic parameter. The benefit of concurrent chemotherapy and radiotherapy has only been demonstrated in patients with an ECOG score of 0–1. Patients with a bad performance status (ECOG 3 or…

Radiobiology of Lung Cancer

Summary of Key Points The hallmarks of radiobiology are the “4 Rs”: r epair, r eassortment, r eoxygenation, r epopulation. Radiation exerts its biologic effects by causing damage to DNA. The linear–quadratic model provides a convenient method to compare different radiation dose and fractionation schedules. Radiobiologic principles have underpinned the rationale for many early clinical trials in lung cancer testing including the use of alternative fractionation…

Technical Requirements for Lung Cancer Radiotherapy

Summary of Key Points Radiotherapy plays a central role in the treatment of lung cancer for patients in both the palliative and curative settings. Major advances in the technologic aspects of both radiotherapy and medical imaging have dramatically increased the accuracy and precision of treatment, resulting in less toxic and more curative treatment. In the developed world, the minimum standard for curative intent radiotherapy is linear…

Surgical Management of Patients Considered Marginally Resectable

Summary of Key Points Up to 25% of patients with stage I nonsmall cell lung cancer are considered medically inoperable or high risk for surgery. Therapies such as stereotactic body radiation therapy or ablation offer a less invasive alternative to surgery for marginally resectable patients. Guidelines have been developed to determine fitness for lung cancer surgery (see text). Guidelines to determine optimal therapy (e.g., surgery vs.…

Multiple Nodules: Management of Synchronous and Metachronous Lung Cancers

Summary of Key Points Multiple primary lung cancers (MPLCs) are increasing in incidence as imaging accuracies improve and resections are better tolerated. Differentiating MPLCs from intrathoracic metastatic disease is challenging and based primarily on clinical judgment. Molecular analysis for tumor clonality has the potential to increase accuracy of differentiation between MPLCs and intrathoracic metastatic disease. Complete resection is the treatment of choice for MPLCs, but preservation…

Extended Resections for Lung Cancer: Bronchovascular Sleeve Resections

Summary of Key Points Bronchovascular sleeve resection is an essential technique for general thoracic surgeons to preserve as much as possible the patient’s lung function and quality of life after pulmonary resection. Previous reports suggested that the incidence rates of bronchopleural fistula and surgical mortality after sleeve lobectomy and sleeve pneumonectomy were 3% and 2.5%, and 5.5% and 20.9%, respectively. In the tissue-healing process of the…

Extended Resections for Lung Cancer: Chest Wall and Pancoast Tumors

Summary of Key Points Chest Wall: Invasion of parietal pleura and chest wall indicates T3; involvement of vertebral body indicates T4 chest wall tumor. Extensive resection required. Long-term survival possible postresection if: No distant metastases No mediastinal lymph node involvement Complete (R0) resection. Systematic lymph node dissection should be performed as part of resection. Choice of prosthesis for chest wall reconstruction determined by size and location…

Extent of Surgical Resection for Stage I and II Lung Cancer

Summary of Key Points With the realization that many more lung cancers are being detected, which may not only be indolent but also smaller than 2 cm, thoracic surgeons are considering sublobar resections in their practice. There are conflicting data from meta-analyses and large databases regarding the efficacy of segmentectomy or wedge resection compared with lobectomy. Despite promising data from propensity-matched trials of lobectomy compared with…

Robotic Surgery: Techniques and Results for Resection of Lung Cancer

Summary of Key Points Robotic surgery can be used for completely portal (no utility incision) or robotic-assisted (uses utility incision) techniques. Appropriate patient and port positioning are critical for a successful performance of robotic lobectomy. Perioperative morbidity and mortality for robotic lobectomy are comparable to that for video-assisted thoracoscopic surgical (VATS) lobectomy. Robotic lobectomy may have advantages in terms of surgeon ergonomics, mediastinal lymph node dissection,…

Results of Video-Assisted Techniques for Resection of Lung Cancer

Summary of Key Points Many meta-analyses, outcomes and matched cohort studies demonstrate equal long-term outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy. Matched comparisons generally demonstrate equal long-term survival for VATS versus open lobectomy for lung cancer, suggesting that the improved survival seen in unmatched studies is due to confounding factors. Many meta-analyses, outcomes, and matched cohort studies demonstrate similar operative mortality for VATS and…

Preoperative Functional Evaluation of the Surgical Candidate

Summary of Key Points Predicted postoperative forced expiratory volume in 1 second (ppoFEV 1 ) has been shown to be inaccurate in predicting actual postoperative FEV 1 in patients with chronic obstructive pulmonary disease (COPD). It should not be used alone to select patients for surgery. FEV 1 and carbon monoxide lung diffusion capacity (DLCO) and their derivate ppoFEV 1 and predicted postoperative DLCO (ppoDLCO) should…

The Eighth Edition of the Tumor, Node, and Metastasis Classification of Lung Cancer

Summary of Key Points Size counts: From less than or equal to 1-cm to less than or equal to 5-cm tumor size, every centimeter has prognostic impact and separates into different T categories, and tumors greater than 5 cm but less than 7 cm are now T3; and those greater than 7 cm are now T4. Distance to carina does not count: Tumors with endobronchial location…

Preoperative and Intraoperative Invasive Staging of the Mediastinum

Summary of Key Points Staging of the mediastinum is a key component in the evaluation of patients with lung cancer and includes both preoperative and intraoperative components. The International Association for the Study of Lung Cancer lymph node map provides standard definitions of each nodal station and allows precise, uniform nomenclature when staging mediastinal and pulmonary lymph nodes. The importance of lymph node assessment in the…