Treatment of-lung-cancer

05/01/2023Tbilisi State Medical University 1

Treatment of lung cancer

Hari Prakash BharathiDepartment of Oncology

Tbilisi State Medical University


Types of lung cancer

• Small cell• Lung neuroendocrine tumors• Non small cell


Treatment of small cell lung carcinoma

• Depending on the stages of the cancer and other factors, treatment of SCLC are• Chemotherapy• Radiation therapy• Surgery• Supportive therapy• Palliative treatments can also be used to help with symptoms.


Supportive therapy

• Smoking caseation advice, counselling and pharmacotherapy• Use of 5A’s ask advice assess assist arrange• Syndromes inappropriate ADH

• Fluid restriction• Saline infusion • Antineoplastic therapy • Demeclocyline• Vasopressin receptor inhibitor

• Cushing syndrome treated priorly


Surgical treatment • NCCN guidelines for surgical treatment• Stage 1 (T1-2, N0) is eligible for surgical resection, excess stage 1 has no

benefits, after initial evaluation • Prior to surgery, all patients must undergo mediastinoscopy to rule out occult

nodal diseases• Patient who undergoes complete resection must undergo post operative

chemotherapy.• Patient with nodal mediastinal diseases must have chemotherapy and

mediastinal radiation therapy • PCI (prophylactic cranial irradiation) is recommended after chemotherapy but

is contraindicated in poor PS or impaired neurocognitive functions


Chemotherapy for SCLC

• Systemic therapy as primary or adjuvant therapy• Limited stages (max 4-6 cycles)• Cisplatin 60mg day 1 + etosopide 120mg days 1,2,3• Cisplatin 80mg day 1 + etosopide 100mg days 1,2,3• Carboplatin AUC 5-6 day 1 +etosopide 100mg days 1,2,3• During systemic therapy + RT, Cisplatin+ etosopide is recommended



• Extensive therapy (max 4-6 cycles)• Cisplatin 75mg day 1 + etosopide 100mg days 1,2,3• Cisplatin 80mg day 1 + etosopide 80mg days 1,2,3• Carboplatin AUC 5-6 day 1 +etosopide 100mg days 1,2,3• Cisplatin 25mg days 1,2,3 + etosopide 100mg days 1,2,3• Carboplatin AUC 5 day 1 + irinotecan 50 mg days 1,8, 15• Cisplatin 60 mg day1 +irinotecan 60 mg days 1, 8, 15• Cisplatin 30 mg + irinotecan 65 mg days 1,8,15



• During initial therapy+ RT, scans during therapy is not indicated, it is only allowed to scan for liver, chest or brain metastases after initial therapy.• During extensive therapy or initial therapy without RT, scans

are recommended for each 2-3 cycles.


Radiation therapy for SCLC• Depending on the stage of small cell lung cancer (SCLC) and

other factors, radiation therapy might be used in several situations:• In limited stage SCLC, radiation therapy can be given at the same time

as chemotherapy . Giving chemo and radiation together is called concurrent chemoradiation. The radiation may be started with the first or second cycle of chemo.

• Radiation can also be given after the chemo is finished. This is sometimes done for patients with extensive stage disease, or it can be used for people with limited stage disease who have trouble getting chemotherapy and radiation at the same time (as an alternative to chemoradiation).


Radiation therapy for SCLC

• SCLC often spreads to the brain. Radiation can be given to the brain to help lower the chances of problems from cancer spread there. This is called prophylactic cranial irradiation. This is most often used to treat people with limited stage SCLC, but it can also help some people with extensive stage SCLC.• Radiation can be used to shrink tumors to relieve (palliate) symptoms

of lung cancer such as pain, bleeding, trouble swallowing, cough, shortness of breath, and problems caused by spread to other organs such as the brain.


Radiation therapy for SCLC

• Dose and schedule:• For limited stages, 45 Gy in 3 to 5 weeks. (1.5 to 1.8 Gy daily)• There should be atleast 6 hours interval to allow repair of normal tissue

• Types of radiation used:• EBRT (external bean radiation therapy)• 3D CRT (3D conformal radiation therapy)• IMRT (intensity modulated radiation therapy)


Treatment for NSCLC

• Depending on the stage of the cancer and other factors treatment include:• Surgery• Radiofrequency ablation (RFA)• Radiation therapy• Chemotherapy• Targeted therapies• Immunotherapy

• Palliative treatments can also be used to help with symptoms.


Surgical treatment for NSCLC

• Different operations can be used to treat NSCLC:• Pneumonectomy• Lobectomy: 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. • Sleeve resection: This operation may be used to treat some cancers in large

airways in the lungs. And also where anatomical margins is not marked.



• Sublobar resection or segmentectomy should achieve resection of >2cm or >size of tumor. It is preferred in patients with:• Poor pulmonary reserve• Nodule < 2 cm

• VATS (video assisted thoracic surgery)



• Stage 1 or 2 is recommended for the surgery• Minimum 3 N2 node must be sampled


Radiofrequency ablation for nsclc

• 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


Radiation therapy for NSCLC

• There are 2 main types of radiation therapy:• External beam radiation therapy• Brachytherapy (internal radiation therapy)


Radiation therapy for NSCLC

• In early stages (stage 1, 2a) SABR is recommended• Locally advanced NSCLC (stage2-3) sequential chemotherapy

+ radiation therapy• Advanced metastatic NSCLC, definitive local radiation

therapy to isolated and limited metastatic sites.


Chemotherapy regimens with RT

• Cisplatin + vinorelbine• Cisplatin + etoposide• Cisplatin + gemcitabine• Cisplatin + docetaxal• Cisplatin + Pemetrexed


Chemotherapy for NSCLC

• First line therapy • Maintenance therapy • Subsequent therapy


Chemotherapy for NSCLC

• First line therapy• Cisplatin + pemetrexed • Cisplatin + gemcitabine• Response assessed after 2 cycles, then 2-4 cycles with CT of known sites

• Maintenance therapy • Use of one of the first line drug for 4-6 cycles in there is no progression of disease• Use different drug if there is progression

• Subsequent therapy• Response assessment with CT of know sites for 6-12 weeks


Chemotherapy for NSCLC (adenocarcinoma)


Chemotherapy for NSCLC (squamous cell carcinoma)


Targeted therapy for NSCLC

• 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:

• Bevacizumab (Avastin) is used to treat advanced NSCLC. It is a monoclonal that targets vascular endothelial growth factor (VEGF), a protein that helps new blood vessels to form. This drug is often used with chemo for a time.

• 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.


Target therapy for NSCLC• Side effects• High blood pressure• Tiredness• Bleeding• Low white blood cell counts• Headaches• Mouth sores• Loss of appetite• Diarrhea


Targeted therapy for NSCLC

• Drugs that target cells with EGFR changes

• EGFR inhibitors used in NSCLC with EGFR gene mutations• Erlotinib (Tarceva)• Afatinib (Gilotrif)• Gefitinib (Iressa)

• EGFR inhibitors used for squamous cell NSCLC• Necitumumab (Portrazza) is a monoclonal

antibody

• Side effects• Common side effects of all EGFR

inhibitors include:• Skin problems• Diarrhea• Mouth sores• Loss of appetite


Targeted therapy for NSCLC• Drugs that target cells with ALK

gene changes• Crizotinib (Xalkori)• Ceritinib (Zykadia)• Alectinib (Alecensa)

• These drugs can often shrink tumors in people whose lung cancers have the ALK gene change.

• These drugs also seem to be useful in treating people whose cancers have changes in the ROS1 gene.

• Side effects• Common side effects of ALK

inhibitors include:• Nausea and vomiting• Diarrhea• Constipation• Fatigue• Changes in vision


Immunotherapy for NSCLC

• Nivolumab (Opdivo) and pembrolizumab (Keytruda) target PD-1, a protein on immune system cells called T cells that normally helps keep these cells from attacking other cells in the body. By blocking PD-1, these drugs boost the immune response against cancer cells. This can shrink some tumors or slow their growth.

• Atezolizumab (Tecentriq) targets PD-L1, a protein related to PD-1 that is found on some tumor cells and immune cells. Blocking this protein can also help boost the immune response against cancer cells.

• Pembrolizumab can also be used as the first treatment


Immunotherapy for NSCLC

• Side effects• Fatigue• cough• nausea• itching• skin rash

• loss of appetite,• constipation, • joint pain,• diarrhea.


Treatment for Lung neuroendocrine tumors

• Surgery (only for stage 1, 2, 3a)• chemotherapy


Chemotherapy for LNT

• Capecitabine + temozolomide• Everolimus• Cisplatin/etoposide• Temozolomide• Sunitinib• Consider octreotide or lanreotide, if octreotide scan is positive

for carcinoid


Side effects of chemotherapy• The side effects of chemo depend on the type and dose of drugs given and how

long they are taken. Some common side effects include:• Hair loss• Mouth sores• Loss of appetite• Nausea and vomiting• Diarrhea or constipation• Easy bruising or bleeding (from having too few blood platelets)• Fatigue (from having too few red blood cells)

• These side effects usually go away after treatment is finished.


Thank you

Treatment of-lung-cancer

Health & Medicine

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