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Unsatisfactory outcomes with radiotherapy alone and the advent of very potent and possibly radiation enhancing drugs, especially platinum compounds and vinkaalkaloids, prompted the preclinical and clinical investigation of combinded radiochemotherapy protocols with second generation chemotherapeutic drugs as a definitive treatment in inoperable NSCLC. Not for all substances used unequivocal experimental...
Evidence shows that treating locally advanced non-small cell lung cancer (NSCLC) patients with concurrent radiation and second generation chemotherapy agents provides a survival benefit when compared to delivering the same therapy sequentially. However, survival results remain dismal and concurrent chemoradiation exhibits significant toxicity. As third generation chemotherapy agents have become available,...
Surgery is standard treatment approach in patients with early stage (I-II) nonsmall cell lung cancer. However, there are patients who do not undergo surgery due to existing comorbidities, advanced age or refusal. They have traditionally been treated with radiation therapy which provided median survival times of > 30 months and 5-year survival rates of > 30% in stage I disease.
Stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiation therapy (SBRT) utilizes advanced techniques of immobilization, image guidance, and unique field arrangements to deliver precise, oligofractionated radiotherapy to a variety of tumor types. SABR has been established as a technologically innovative therapy for early stage non-small cell lung cancer (NSCLC) and has emerged...
The role of post-operative radiotherapy (PORT) in treatment of non-small cell lung cancer (NSCLC) is unclear. Currently, the available evidence suggests that PORT is indicated for stage II and III (node-positive) NSCLC, but not for stage I NSCLC. However, it is still disputed in which cases patterns of failure necessitate further treatment following surgery, and if it is warranted, the question becomes...
The role of Photodynamic Therapy (PDT) in the current multi-disciplinary approach to thoracic oncology is analyzed and reviewed. The simplicity of drug, light and reaction resulting in excellent clinical response has brought PDT to a worldwide audience. This chapter reviews the scientific and clinical rationale for thoracic PDT including photosensitizers, light sources, photodynamic reaction, dosimetry...
Currently, the standard of care for stage I non-small cell lung cancer (NSCLC) is surgical resection. Although this treatment modality has been demonstrated to have 5 year survival rates approaching 80%, there need to be effective alternative treatments for patients who are medically inoperable. Radiofrequency ablation (RFA) has emerged as a minimally-invasive therapy to fill this void. This modality...
RTOG 73-01 established standard doses of radiation for the treatment of patients with stage III non-small-cell lung cancer at 60 Gy in 2 Gy per fraction. However, overall survival was still poor, and local failures were a continuing problem. Over the next 30 years, a number of single institution and multi institution studies have been performed, attempting to improve overall survival by reducing local...
Locally advanced nonsmall cell lung cancer is one of the major battlegrounds in clinical research in lung cancer due to opportunities for all the treatment options to be employed either alone or in various combinations in both curative and palliative setting. In curative setting, though, recent evidence reconfirms advantage of concurrent radiochemotherapy over other existing treatment options. It...
This review addresses recent evidence on the role of surgery in different clinical subsets of so called 'potentially resectable' stage III NSCLC. In some selected subsets of stage III patients, in particular those with T3-4N0-1, surgery plays a key role. Resection has to be decided on by a multidisciplinary team and carried out in a high volume institution by an experienced team. In all patients who...
The incidence of brain metastases following locoregional treatment for locally advanced non-small cell lung cancer (LA-NSCLC) is high. Brain metastases impair quality of life and are associated with a poor prognosis. The rationale behind prophylactic cranial irradiation (PCI) is to control or eradicate undetectable micrometastases before they become clinically significant without inducing severe adverse...
About two-thirds of patients with non-small cell lung cancer are diagnosed with incurable disease and are usually treated with a palliative intent. Palliative radiotherapy is defined as radiotherapy given with less than radical doses. Although a large variation in treatment schedules considering dose, fractionation, and overall treatment time are used, usually a dose 50 Gy is considered as palliative...
Intraoperative radiotherapy is a feasible technical modality to improve precision and dose-escalation in high-local risk lung cancer patients. Methodology is described regarding the use of high-energy electron beams or brachytherapy. Results of normal tissue tolerance in experimental animal models and in clinical experiences are analyzed in detail. Characteristics of clinical experiences using IORT...
Brachytherapy is the direct placement of a radioactive source inside or close to a tumor mass. The use of endobronchial brachytherapy for bronchogenic carcinoma is not new, being the initial use reported back in the early 1920s. Brachytherapy for lung cancer can be done either by implanting the source directly via the upper airway (endoluminal brachytherapy) or by placing the source interstitially...
About one-third of all patients with small cell lung cancer present with their disease confined to thorax. In the last two decades, combined radiation therapy and chemotherapy have been considered standard treatment option in this disease. This particularly became evident when radical thoracic radiation therapy was combined with concurrent platinum-etoposide chemotherapy. Prophylactic cranial irradiation...
Approximately two-thirds of all patients with small-cell lung cancer have the disease that spread beyond confines of the thorax, including as well patients whose disease has traditionally been described as "too large to be encompassed with a tolerable radiation port". For these patients, chemotherapy has been considered standard treatment option for many decades. However, patterns of failure...
Prophylactic cranial radiation (PCI) has been used in the management of small-cell lung cancer given the propensity of disease relapse in the brain. Several studies have shown that PCI reduces the rate of brain metastases and improves survival. However, the use of PCI in the management of small-cell lung cancer has been controversial due to conflicting evidence of efficacy and toxicities. For example,...
Western world is rapidly aging, yet the exact threshold age for differentiating elderly versus non-elderly is not widely adopted. Elderly are also underrepresented in clinical trials and level of evidence of preferred treatment in both non-small-cell and small-cell lung cancer is basically lacking. From the existing evidence, however, it seems that radiation therapy is safe and effective treatment...
Recurrence is still a dominating and bitter event after the treatment of lung cancer regardless of histology, stage, or initial treatment. All recurrences can be broadly divided into the local (e.g., lung parenchyma, bronchial stump, or chest wall), regional (e.g., mediastinal lymph nodes), and distant (e.g., brain, liver, or bones). Recurrent disease almost always present as fatal event and only...
Bone metastases occur in up to 40% of NSCLC patients. If associated with pathological fractures or metastatic spinal cord compression (MSCC), they are considered “complicated” lesions. Otherwise, they are considered “uncomplicated”. 1x8 Gy of radiation therapy (RT) can be considered the standard treatment of most uncomplicated painful bone metastases. Single-fraction RT requires re-RT more often than...
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