Chapter 085. Neoplasms of the Lung (Part 15) Bulky NSCLC Stage IIIA and Dry IIIB (IIIB Without a Pleural Effusion) The presence of pathologically involved N2 nodes should be confirmed histologically because enlarged nodes detected by CT will be negative for cancer in ~30% of patients. Chemotherapy plus radiation therapy is the treatment of choice for patients with bulky stage IIIA or IIIB disease without pleural effusion (referred to as "dry IIIB"). Randomized studies demonstrate an improvement in median and long-term survival with chemotherapy followed by radiation therapy, compared with radiation therapy alone. Subsequent randomized trials have shown that administering chemotherapy and radiation therapy concurrently results in improved survival compared to sequential chemotherapy and radiation therapy, albeit with more side effects, such as fatigue, esophagitis, and neutropenia. Frequently, an additional two to three cycles of chemotherapy are also given. However, it is not clear whether these additional cycles should be administered before or after the chemoradiation, what the optimal drugs are, or whether doses should be attenuated during the radiation but given more frequently. (Lower doses of drugs may "sensitize" the tumor to radiation therapy but may not by themselves remove other microscopic disease.) Disseminated Non-Small Cell Lung Cancer Symptomatic Management of Metastatic Disease Patients who present with or progress to metastatic NSCLC have a poor prognosis, as do patients with pleural effusions. Untreated, the median survival of both of these patient groups is roughly 4–6 months. They are often treated in the same way. Standard medical management, the judicious use of pain medications, the appropriate use of radiotherapy, and outpatient chemotherapy form the cornerstone of this management. Palliative Radiation Therapy Patients whose primary tumor is causing urgent severe symptoms such as bronchial obstruction with pneumonitis, hemoptysis, upper airway or superior vena cava obstruction, brain or spinal cord compression, or painful bony metastases should have radiotherapy to the primary tumor to relieve these symptoms. Usually, radiation therapy is given as a course of 30–40 Gy over 2–4 weeks for palliative purposes. Radiation therapy provides relief of intrathoracic symptoms: hemoptysis, 84%; superior vena cava syndrome, 80%; dyspnea, 60%; cough, 60%; atelectasis, 23%; and vocal cord paralysis, 6%. Cardiac tamponade (treated with pericardiocentesis and radiation therapy to the heart), painful bony metastases (with relief in 66%), brain or spinal cord compression, and brachial plexus involvement may also be palliated with radiotherapy. Brain metastases are often isolated sites of relapse in patients with adenocarcinoma of the lung otherwise controlled by surgery or radiotherapy. These are usually treated with radiation therapy and, in highly selected cases, with surgical resection. Usually, in addition to radiotherapy for brain metastases and cord compression, dexamethasone (25–100 mg/d in four divided doses) is also given and then rapidly tapered to the lowest dosage that relieves symptoms. Because of the high frequency of brain metastases, the use of prophylactic cranial irradiation (PCI, given to the whole brain before metastatic disease becomes manifest) has been considered. However, PCI is of no proven value. Screening asymptomatic patients with head CT scans to find such lesions before such metastases become clinically evident is also not proven beneficial. Pleural effusions are common and are usually treated with thoracentesis. If they recur and are symptomatic, a pleurex catheter or chest tube drainage followed by pleurodesis with a sclerosing agent such as intrapleural talc, bleomycin, or tetracycline can be used. These sclerosing agents may be administered through the chest tube, or, in the case of talc, via thorascopic insufflation. In the former case, the chest cavity is completely drained. Xylocaine 1% is instilled (15 mL), followed by 50 mL normal saline. Then the sclerosing agent is dissolved in 100 mL normal saline, and this solution is injected through the chest tube. The chest tube is clamped for 4 h if tolerated, and the patient is rotated onto different sides to distribute the sclerosing agent. The chest tube is removed 24–48 h later, after drainage has become slight (usually <100 mL/24 h). While sclerosing agents have been widely used, an indwelling pleurex catheter is equivalent to chest tube drainage and better tolerated by patients. In this situation, the pleurex catheter is tunneled under the skin and can remain in place for weeks. The patient periodically drains the catheter into a specially designed bag, as needed. Symptomatic endobronchial lesions that recur after surgery or radiotherapy or develop in patients with severely compromised pulmonary function are difficult to treat with conventional therapy. Neodymium-YAG (yttrium-aluminum-garnet) laser therapy administered through a flexible fiberoptic bronchoscope (usually under general anesthesia) can provide palliation in 80–90% of such patients even when the tumor has relapsed after radiotherapy. Local radiotherapy delivered by brachytherapy, photodynamic therapy using a photosensitizing agent, and endobronchial stents are other measures that can relieve airway obstruction from recurrent tumor. . Chapter 085. Neoplasms of the Lung (Part 15) Bulky NSCLC Stage IIIA and Dry IIIB (IIIB Without a Pleural Effusion) The presence of pathologically involved N2. months. They are often treated in the same way. Standard medical management, the judicious use of pain medications, the appropriate use of radiotherapy, and outpatient chemotherapy form the cornerstone. metastases are often isolated sites of relapse in patients with adenocarcinoma of the lung otherwise controlled by surgery or radiotherapy. These are usually treated with radiation therapy and,