MEDICAL BLOGS:TREATMENT OF NON SMALL CELL LUNG CANCER (Part 4)

1) SURGERY 

If your doctor thinks the lung cancer can be treated with surgery, pulmonary function tests will be done beforehand to see if you would still have enough healthy lung tissue left after surgery.

·      Other tests will check the function of your heart and other organs to be sure you’re healthy enough for surgery.

·      SURGERY to remove the cancer (often along with other treatments) may be AN OPTION ONLY FOR EARLY STAGE LUNG CANCER ( NSCLC)

·      If surgery can be done, it provides the best chance to cure NSCLC.

·      Lung cancer surgery is a complex operation that can have serious consequences, so it should be done by a Thoracic surgeon or Onco-surgeon, who has a lot of experience operating on lung cancers.

·      The cancer has already spread to the lymph nodes between the lungs. This is often done just before surgery with mediastinoscopy.

Types of lung surgery

Different operations can be used to treat (and possibly cure) NSCLC:
If one can imagine a large airway with a tumour, as similar to the sleeve of a shirt with a stain a couple of inches above the wrist, the sleeve resection would be like cutting across the sleeve above and below the stain and then sewing the cuff back onto the shortened sleeve. 
   *With any of these operations, nearby lymph nodes are also removed to look for possible spread of the cancer.
Increasingly, doctors now treat early-stage lung cancers in the outer parts of the lung with a procedure called video-assisted thoracic surgery (VATS), which requires smaller incisions than a thoracotomy.
Radiation therapy uses high-energy rays (such as x-rays) or particles to kill cancer cells.
There are 2 main types of radiation therapy:
    *Brachytherapy (internal radiation therapy)
External beam radiation therapy (EBRT) focuses radiation from outside the body on the cancer. This is the type of radiation therapy most often used to treat NSCLC or its spread to other organs.
In people with NSCLC, brachytherapy is sometimes used to shrink tumors in the airway to relieve symptoms.
Before surgery to shrink tumour size.
Concurrent therapy along with radiation for cancer that cannot be removed by surgery. As main therapy for advanced stages of cancer.
*Carboplatin
*Paclitaxel (Taxol)
*Albumin-bound paclitaxel (nab-paclitaxel, Abraxane)
*Docetaxel (Taxotere)
*Gemcitabine (Gemzar)
*Vinorelbine (Navelbine)
*Irinotecan (Camptosar)
*Etoposide (VP-16)
*Vinblastine
*Pemetrexed (Alimta)
Targeted drugs work differently from standard chemotherapy. At this time, they are most often used for advanced lung cancers, either along with chemo or by themselves. Drugs that target tumor blood vessel growth (angiogenesis) For tumors to grow, they need to form new blood vessels to keep them nourished. This process is called angiogenesis. Some targeted drugs, called angiogenesis inhibitors, block this new blood vessel growth:
This drug is often used with chemo for a time. 
Then if the cancer responds, the chemo may be stopped and the bevacizumab given by itself until the cancer starts growing again.
Ramucirumab (Cyramza) can also be used to treat advanced NSCLC. VEGF has to bind to cell proteins called receptors to act. This drug is a monoclonal antibody that targets a VEGF receptor. This helps stop the formation of new blood vessels. This drug is most often given after another treatment stops working. It is often combined with chemo.
Drugs that target cells with EGFR changes
Epidermal growth factor receptor (EGFR) is a protein on the surface of cells.
Erlotinib (Tarceva) 
Afatinib (Gilotrif)
Gefitinib (Iressa) 
These drugs can be used alone (without chemo) as the first treatment for advanced NSCLCs that have certain mutations in the EGFR gene.
EGFR inhibitors used for squamous cell NSCLC
Necitumumab (Portrazza) is a monoclonal antibody (a man-made version of an immune system protein) that targets EGFR. It can be used along with chemotherapy as the first treatment in people with advanced squamous cell NSCLC. This drug is given as an infusion into a vein (IV).
About 5% of NSCLCs have a rearrangement in a gene called ALK.
Ceritinib (Zykadia)
Alectinib (Alecensa)
These drugs can often shrink tumors in people whose lung cancers have the ALK gene change.

·      Pneumonectomy: This surgery removes an entire lung. This might be needed if the tumor is close to the center of the chest.

·      Lobectomy: The lungs are made up of 5 lobes (3 on the right and 2 on the left). In this surgery, the entire lobe containing the tumor(s) is removed. This is often the preferred type of operation for NSCLC if it can be done.

·      Segmentectomy or wedge resection: In these surgeries, only part of a lobe is removed. This approach might be used, for example, if a person doesn’t have enough lung function to withstand removing the whole lobe. 

·      Sleeve resection: This operation may be used to treat some cancers in large airways in the lungs. 

 *A surgeon may be able to do this operation instead of a pneumonectomy to preserve more lung function.

These operations require general anesthesia (where you are in a deep sleep) and are usually done through a surgical incision between the ribs in the side of the chest (called a thoracotomy).

The type of operation your doctor recommends depends on the size and location of the tumor and on how well your lungs are functioning.

Doctors often prefer to do a more extensive operation (for example, a lobectomy instead of a segmentectomy) if a person’s lungs are healthy enough, as it may provide a better chance to cure the cancer.

When you wake up from surgery, you will have a tube (or tubes) coming out of your chest and attached to a special canister to allow excess fluid and air to drain out. The tube(s) will be removed once the fluid drainage and air leak subside. Generally, you will need to spend 5 to 7 days in the hospital after the surgery.

Video-assisted thoracic surgery (VATS)

·      During this operation, a thin, rigid tube with a tiny video camera on the end is placed through a small cut in the side of the chest to help the surgeon see inside the chest on a TV monitor.

·      One or two other small cuts are created in the skin, and long instruments are passed through these cuts to do the same operation that would be done using an open approach (thoracotomy).

·      One of the incisions is enlarged if a lobectomy or pneumonectomy is done to allow the specimen to be removed.

·      Because only small incisions are needed, there is usually less pain after the surgery and a shorter hospital stay – typically 4 to 5 days.

·      Most experts recommend that only early-stage tumors near the outside of the lung be treated this way.

·      The cure rate after this surgery seems to be the same as with surgery done with a larger incision.

·      But it’s important that the surgeon doing this procedure is experienced, because it requires a great deal of technical

RECOVERY AFTER LUNG SURGERY

Surgery for lung cancer is a major operation. Recovering from lung cancer surgery typically takes weeks to months.

·      If the surgery is done through a thoracotomy (a long incision in the chest), activity might be limited for at least a month or two.

·      People who have VATS instead of thoracotomy tend to have less pain after surgery and to recover more quickly.

·      If the lungs are in good condition (other than the presence of the cancer) usually return to normal activities occurs after some time if a lobe or even an entire lung has been removed.

·      If one also has another lung disease such as emphysema or chronic bronchitis (which are common among long-time smokers), you might become short of breath with certain levels of activity after surgery.

2) RADIO FREQUENCY ABLATION (RFA) for NSCLC

This treatment might be an option for some people some small lung tumors that are near the outer edge of the lungs, especially if they can’t tolerate surgery.

·      RFA uses high-energy radio waves to heat the tumor. A thin, needle-like probe is put through the skin and moved in until the tip is in the tumor. Placement of the probe is guided by CT scans. Once the tip is in place, an electric current is passed through the probe, which heats the tumor and destroys the cancer cells.

·      RFA is usually done as an outpatient procedure, using local anesthesia (numbing medicine) where the probe is inserted. You may be given medicine to help you relax as well.

Radiation Therapy

·      *As main treatment approach along with chemotherapy if Surgery not possible (due to location or size of tumour or patient not fit)

·      After surgery ( alone or with chemo) to kill any remaining cancer cells

·      Before surgery ( along with chemo) to shrink tumour size.

·      To treat a single area of cancer spread, such as a tumour in the brain or an adrenal gland.

·      To relieve (palliate) symptoms of advanced NSCLC such as pain, bleeding, trouble swallowing, cough, or problems caused by spread to other organs such as the brain.

Types of radiation therapy

    *External beam radiation therapy

External beam radiation therapy

Brachytherapy (internal radiation therapy)

CHEMOTHERAPY for NSCLC:

Adjuvant chemotherapy After surgery ( sometimes along with radiation) to kill any cancer cells left behind. 

Drugs used to treat NSCLC

The chemo drugs most often used for NSCLC include:

*Cisplatin

·      Most often, treatment for NSCLC uses a combination of 2 chemo drugs.

·      Studies have shown that adding a third chemo drug doesn’t add much benefit and is likely to cause more side effects.

·      Single-drug chemo is sometimes used for people who might not tolerate combination chemotherapy well, such as those in poor overall health or who are elderly.

·      If a combination is used, it often includes cisplatin or carboplatin plus one other drug.

·      Sometimes gemcitabine with vinorelbine or paclitaxel, may be used.

·      For people with advanced lung cancers who meet certain criteria, targeted therapy a drug such as bevacizumab (Avastin), ramucirumab (Cyramza), or necitumumab (Portrazza) may be added to treatment as well.

·      Doctors give chemo in cycles, with a period of treatment (usually 1 to 3 days) followed by a rest period to allow the body time to recover.

·      Some chemo drugs, though, are given every day.

·      Chemo cycles generally last about 3 to 4 weeks.

·      For advanced cancers, the initial chemo combination is often given for 4 to 6 cycles.

·      If the initial chemo treatment for advanced lung cancer is no longer working, the doctor may recommend second-line treatment with a single chemo drug such as docetaxel or pemetrexed, or with a targeted therapy or immunotherapy drug.

Targeted therapy drugs for NSCLC:

Bevacizumab (Avastin) is used to treat advanced NSCLC. It is a monoclonal antibody (a man-made version of a specific immune system protein) that targets vascular endothelial growth factor (VEGF), a protein that helps new blood vessels to form.

It normally helps the cells grow and divide.

Drugs called EGFR inhibitors can block the signal from EGFR that tells the cells to grow. Some of these drugs can be used to treat NSCLC.

EGFR inhibitors used in NSCLC with EGFR gene mutations

These are more common in women and people who haven’t smoked.

Erlotinib can also be used for advanced NSCLC without these mutations if chemo isn’t working. All of these medicines are taken as pills.

EGFR inhibitors that also target cells with the T790M mutation

Drugs that target cells with ALK gene changes

This change is most often seen in non-smokers (or light smokers) who have the adenocarcinoma subtype of NSCLC.

Crizotinib (Xalkori) 

Although they can help after chemo has stopped working, they are often used instead of chemo in people whose cancers have the ALKgene rearrangement.

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Author- 

   

Dr. Ganjoo 

Head-Yoddhas Medical Expert Panel