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General Practitioner in
Oncology Self-directed
Learning Program 2006
LUNG CANCER
MODULE
Lung Cancer Case Scenario 1
A 65-year-old man presents with a 6- week history of cough, progressive
SOB and a 20-pound weight loss. He has a 50-pack year smoking history
and his family doctor orders a chest x-ray and blood work.
The chest x-ray shows a left lower lobe mass. His physical is normal. He is
otherwise healthy, and takes no regular medication.
1. How would you further investigate this man, in order to get a
pathological diagnosis?
2. What tests are required to properly stage this patient?
His blood work, which consisted of a CBC, electrolytes, Urea, Creatinine,
Liver Function tests, are all normal. The CT scan of his chest and upper
abdomen shows a 3 cm mass in the left lower lobe and enlarged mediastinal
lymph nodes confined to the left hemithorax. The liver and adrenal glands
are normal on CT scan. His bronchoscopy with washings revealed small cell
carcinoma.
3. What stage of disease does this patient have?
4. Assuming his disease is confined to the chest, what stage is this man’s
small cell lung cancer?
5. How does staging for small cell lung cancer differ from non-small cell
lung cancer?
6. With respect to staging in small cell lung cancer, how would stage be
affected if the patient had contralateral supraclavicular nodes or a malignant
pleural effusion?
7. What is considered the present standard of care for limited stage disease?
8. What percentage of limited stage lung cancer is cured by treatment?
9. What prognostic factors predict for an improved outcome?
10. How and when is the radiation delivered?
11. What is the role of Prophylactic Cranial Irradiation and when is it
administered? What are some of the short and long term side effects of this
therapy?
12. Is there a role for surgery in limited stage disease?
This patient receives 6 cycles of etoposide and cisplatin chemotherapy and
has a complete response on chest x-ray and CT scan of the thorax and
abdomen.
13. Is this unusual?
14. Does he require any further therapy at this time?
15. How would you follow him in the clinic post-chemotherapy? Does he
require any ongoing investigations?
He is well for six months and then presents with headaches and a seizure. A
CT scan of his head show multiple brain metastases. On functional inquiry,
he has no other symptoms of concern. Restaging investigations including
chest x-ray and blood work are normal.
16. What treatment would you offer this patient at this time?
17. What are the most common sites of metastases in this cancer?
18. What are paraneoplastic syndromes? Which are most commonly seen in
small cell lung cancer and how are they managed?
He responds to dexamethasone and whole brain radiation but deteriorates 1
month later with progressive supraclavicular and mediastinal adenopathy as
well as 2-1cm liver metastases. His liver function is normal.
He wants to know what treatment options are available for him at this time,
and whether or not he should have a PET scan?
19. What would be considered appropriate second line therapy?
20. Is there a role for further radiation?
21. How would treatment recommendations be affected if this patient were
bed confined versus having an ECOG of 1?
22. What is the role of PET scanning in lung cancer?
23. How would your treatment recommendation differ is, at initial
presentation, this patient had extensive stage disease?
24. How would your recommendations be affected if this patient were a
diabetic with a creatinine of 140?
25. What is the role of radiation in extensive stage disease?
26. How can most small cell lung cancers be prevented?
Latest Revision January 2006
Lung Cancer Case Scenario 2
A 55-year old woman presents with cough and exertional shortness of
breath. She has a 40-pack year smoking history but is otherwise healthy.
Chest x-ray reveals a right lower lobe mass. She is referred to a respirologist
for further investigation. She undergoes bronchoscopy and
mediastinoscopy. On bronchoscopy a mass at the right lower lobe bronchus
is seen. Pathology reveals a moderately well differentiated adenocarcinoma.
Mediastinoscopy does not reveal any abnormal lymph nodes on pathological
assessment from biopsy of station 2, 4 and 7. CT of the thorax shows a 3.5
cm mass but fails to identify any abnormal lymph nodes. Staging workup
including a CT head, CT abdomen and bone scan is normal.
1. What staging tests are required to properly stage this patient?
2. What stage of disease does this patient present with?
3. Does she require any assessment of her pulmonary function at this time?
If so, what test would you use to assess her pulmonary function?
She has T2 N0 M0, Stage 1B disease. Her PFTs were done in her
community hospital, and the patient informs you that the result was
‘normal’.
4. Is this patient a surgical candidate?
5. If so, what surgical options are considered?
6. What are the post-operative mortality rates following lobectomy and
pneumonectomy?
7. In what stage(s) of disease for NSCL lung cancer is surgery offered with
curative intent?
8. What treatment option(s) is/are available to patients if medically they are
not considered surgical candidates?
9. Is this/are these option(s) potentially curative?
10. Is there any role for chemotherapy in stage 1 and 2 disease? If so, what
chemotherapy is effective?
11. For patients who receive adjuvant chemotherapy in this setting, what
treatment options are available to them if/when they develop recurrent
disease?
Latest Revision January 2006
Lung Cancer Case Scenario 3
A 60-year-old man with a 50 pack-year smoking history presents to his
family doctor worsening cough, increased sputum production and lethargy.
He is diagnosed with ‘pneumonia’. When his symptoms don’t improve after
a course of antibiotics, a CXR is ordered which shows a mass in the left
lung, and a ‘bulky’ mediastinum. His staging investigations consisted of a
CT head, CT Thorax and Abdomen, Bone Scan, PFTs and blood work. His
blood work (CBC, chemistry, LFTs, Ca, Alb, ALK PHOS) is normal. CT
scan of the thorax shows a 4cm tumor in the left upper lobe.
Mediastinoscopy reveals bilateral paratracheal nodes to be positive.
Pathology from bronchoscopy is of an adenocarcinoma.
1. What are the roles of bronchoscopy and mediastinoscopy in making a
tissue diagnosis?
2. What stage of disease does this patient have?
3. What treatment options should be discussed?
4. What are the expected response rates and overall survival rates?
This patient is treated with combined modality chemotherapy in the form of
cisplatin and etoposide chemotherapy with radiation.
5. What are the expected toxicities?
6. When is the radiation administered, and does the timing of radiation
impact on response? Survival?
7. How would your chemotherapy recommendation be affected if this
patient were diabetic with a creatinine of 130?
8. Would your treatment recommendation alter if this patient had an ECOG
of 2 and/or he had lost more than 10% of his body weight in the last 3
months?
9. If/when a patient develops recurrent disease, is it usually local or distant?
10. What are the roles of chemotherapy and radiation in the setting of
recurrent disease?
11. How are chemotherapy options affected if this patient develops recurrent
disease after having completed adjuvant therapy more than 6 months
ago?
12. How would a solitary brain metastasis be treated if the patient did not
have recurrence elsewhere in the body?
13. What if there were multiple brain metastases?
14. If this patient were found to have asymptomatic bone metastases at the
time of presentation, how would this have affected his treatment options?
Latest Revision January 2006
Small Cell Lung Cancer Suggested Reading List
Useful Web Sites
-for practice guideline summaries from Cancer Care Ontario:
www.cancercare.on.ca/index_practiceGuidelines.htm
-to review the National Cancer Institute’s Physician Data Query on this
disease site: www.cancer.gov
-to view the American Society of Clinical Oncology website, visit
www.asco.org
-to view guidelines/special articles from the American Society of Clinical
Oncology visit: www.jco.org/misc/specialarticles.shtml
-to view guidelines from the National Comprehensive Cancer Network, visit
www.nccn.org
1. Roth BJ et al. Randomized Study of Cyclophosphamide, Doxorubicin,
and vincristine Versus Etoposide and Cisplatin versus Alternation of
these Two Regimens in Extensive small-cell Lung Cancer: A Phase III
Trial of the Southeastern Cancer Study Group. J Clin Oncol, Vol. 10, No.
2 (February), 1992: pp. 282-291.
2. Warde P, Pyane D. Does Thoracic Irradiation Improve survival and
Local Control in Limited-Stage Small-Cell Carcinoma of the Lung? A
Meta-Analysis. J Clin Oncol 10: 890-895.
3. Murray N et al. Importance of Timing for Thoracic Irradiation in the
combined Modality Treatment of Limited Stage Small-Cell Lung Cancer.
J Clin Oncol 11:336-344.
4. Bonomi P. Review of Selected Randomized Trials in Small Cell Lung
Cancer. Seminars in Oncology, Vol 25, No. 4 Suppl 9 (August) 1998:7078.
5. Hellenic co-operative Oncology Group study. Randomized comparison
of Etoposide-Cisplatin vs. etoposide-carboplatin and irradiation in smallcell lung cancer. Annals of Oncology 5: 601-607, 1994.
6. Gazdar AF. The Molecular and Cellular Basis of Human Lung Cancer.
Anticancer Research 13: 261-268 (1994).
7. Urschel JD. Surgical Treatment of Peripheral Small Cell Lung Cancer.
Chest Surgery Clinics of North America, Vol 7, No 1, Feb 1997: 95-103.
8. Feld R., Evans WK, coy P, et al. Canadian Multicentre randomized trial
comparing sequential and alternating administration of two non-crossresistant chemotherapy combinations in patients with limited small-cell
carcinoma of the Lung. Journal of Clinical Oncology 1987; 5(9): 1401-9.
9. Souhami RL et al. Five-day oral Etoposide treatment for advanced smallcell lung cancer: randomized comparison with intravenous
chemotherapy (see comments). Journal of the National Cancer Institute
1997; 89(8): 577-80.
10. Johnson DH et al. A randomized trial to compare intravenous and oral
Etoposide in combination with Cisplatin for the treatment of small cell
lung cancer. Cancer 1991; 67(1 Suppl): 245-9.
11. von Pawel J et al. Topotecan versus Cyclophosphamide, doxorubicin,
and vincristine for the treatment of recurrent small-cell lung cancer.
Journal of clinical Oncology 1999; 17(2): 658-67.
Latest revision November 2006
Non-Small Cell Lung Cancer Suggested Reading List
Useful Web Sites
-For practice guideline summaries from Cancer Care Ontario:
www.cancercare.on.ca/index_practiceGuidelines.htm
-To review the National Cancer Institute’s Physician Data Query on this
disease site: www.cancer.gov
-To view the American Society of Clinical Oncology website, visit
www.asco.org
-To view guidelines/special articles from the American Society of Clinical
Oncology visit: www.jco.org/misc/specialarticles.shtml
-To view practice guidelines from the National Comprehensive Cancer
Network, visit www.nccn.org
-to view and use an online assessment tool for decision making in adjuvant
therapy, visit www.adjuvantonline.com
12. Non-small Cell Lung Cancer Collaborative Group. Chemotherapy in
non-small cell lung cancer: a meta-analysis using updated data on
individual patients from 52 randomized clinical trials. BMJ, 1995; 311:
pp. 899-909.
13. Keller SM et al. A Randomized Trial of Postoperative Adjuvant Therapy
in Patients with completely resected Stage II or IIIA Non-Small Cell
Lung cancer. NEJM 2000; 343:1217-1222.
14. Comella P et al. Randomized Trial Comparing Cisplatin, Gemcitabine,
and Vinorelbine with either Cisplatin and Gemcitabine, or Cisplatin and
Vinorelbine in Advanced Non-Small Cell Lung Cancer: Interim Analysis
of a Phase III Trial of the Southern Italy cooperative Oncology Group.
JCO 18: 1451-1457, 2000.
15. Shepherd FA et al. Prospective randomized Trial of Docetaxel versus
Best Supportive Care in Patients with Non-Small Cell Lung cancer
Previously Treated with platinum Based Chemotherapy. JCO 18: 20952103; 2000.
16. The Elderly Lung Cancer Vinorelbine Italian Study Group. Effects of
Vinorelbine on Quality of Life and survival of Elderly Patients With
Advanced Non-Small Cell Lung Cancer. J Natl Cancer Inst 1999; 91:6672.
17. Kelly, K., Crowley J, Bunn PA Jr., et al. Randomized phase III trial of
Paclitaxel plus Carboplatin versus Vinorelbine plus Cisplatin in the
treatment of patients with Advanced Non-Small-Cell Lung Cancer: a
Southwest Oncology Group trial. J Clin Oncol 2001; 19:3210-8.
18. Schiller JH et al. Comparison of four chemotherapy regimens for
Advanced Non-Small-Cell Lung Cancer. N Eng J Med 2002; 346:92-98.
19. Fossella, F. et al. Randomized Phase III Trial of Docetaxel versus
Vinorelbine or Ifosfamide in patients with advanced Non-Small Cell
Lung Cancer Previously treated with Platinum-containing chemotherapy.
JCO 18: 2354-2362, 2000.
20. Marino P et al. Randomized Trials of Radiotherapy Alone versus
combined chemotherapy and Radiotherapy in Stages IIIa and IIIb
Nonsmall Cell Lung Cancer, A meta-analysis. Cancer 1995; 76: 593-601.
21. Pritchard RS et al. Chemotherapy plus Radiotherapy compared with
radiotherapy Alone in the treatment of Locally Advanced, Unresectable
Non-Small Cell Lung Cancer, a meta-analysis. Ann Intern Med. 1996;
125: 723-729.
22. Rapp E et al. Chemotherapy can prolong survival in patients with
Advanced Non-Small Cell Lung Cancer-Report of a Canadian
Multicentre Randomized Trial. J Clin Oncol 6:633-641.
23. Rosell R et al. A Randomized Trial Comparing Preoperative
Chemotherapy plus Surgery with Surgery alone in Patients with NonSmall-Cell Lung Cancer. NEJM 1994; 330:153-8.
24. Roth JA et al. A Randomized Trail comparing Perioperative
Chemotherapy and Surgery with Surgery Alone in Resectable Stage IIIA
Non-Small Cell Lung Cancer. J Natl Cancer Inst 86:673-680, 1994.
25. Gazdar AF. The Molecular and Cellular Basis of Human Lung Cancer.
Anticancer Research 13; 261-268 (1994).
26. Albain KS et al. Concurrent Cisplatin, Etoposide, and Chest
Radiotherapy in Pathologic Stage IIIB Non-Small-Cell Lung Cancer: A
Southwest Oncology Group Phase II Study, SWOG 9019. J Clin Oncol
20: 3454-3460.
27. Gandara DR, Chansky K, Albain KS et al. Consolidation Docetaxel after
concurrent Chemoradiotherapy in stage IIIB Non-Small-Cell Lung
Cancer: Phase II Southwest Oncology Group Study S9504. J Clin Onc,
2003; 21:2004-10.
28. Kosmidis P et al. Paclitaxel Plus Carboplatin Versus Gemcitabine Plus
Paclitaxel in Advanced Non-Small Cell Lung Cancer: A Phase III
Randomized Trial. J Clin Oncol 20:3578-3585.
29. Gridelli C et al. Chemotherapy for Elderly Patients with Advanced NoSmall Cell Lung Cancer: The Multicentre Italian Lung Cancer in the
Elderly Study (MILES) Phase III Randomized Trial. J Natl Cancer Inst
2003; 95:362-72.
30. Roszkowski K et al. A Multicentre, randomized, phase III study of
docetaxel plus best supportive care versus best supportive care in
chemotherapy-naïve patients with metastatic or non-resectable localized
non-small cell lung cancer (NSCLC). Lung Cancer 27 (2000) 145-157.
31. Beorgoulias V et al. Platinum-based and non-platinum-based
chemotherapy in advanced non-small-cell lung cancer: a randomized
multicentre trail. The Lancet 2001:357:1478-84.
32. Fukouoka, M. et al. Multi-Institutional Randomized Phase II Trial of
Gefitinib for Previously Treated Patients with Advanced Non-Small Cell
Lung Cancer. J Clin Oncol 21(12): 2237-2246, June 15, 2003.
33. Fossella, F. et al. Randomized, Multinational, Phase III Study of
Docetaxel Plus Platinum Combinations Versus Vinorelbine Plus
Cisplatin for Advanced Non-Small Cell Lung Cancer: The TAX 326
Study Group. J Clin Oncol 21(16): 3106-3024, August 15, 2003.
34. Alberola, V. et al. Cisplatin Plus Gemcitabine Versus a Cisplatin-Based
Triplet Versus Nonplatinum Sequential Doublets in Advanced NonSmall–Cell Lung Cancer: A Spanish Lung Cancer Group Phase III
Randomized Trial. J Clin Oncol 21(17): 3207-3213, September 1, 2003.
35. Non-small Cell Lung Cancer Collaborative Group. Chemotherapy in
non-small cell lung cancer: a meta-analysis using updated data on
individual patients from 52 randomized clinical trials. BMJ 311 (7010):
899-909,1995.
36. Winton TL et al. Vinorelbine plus Cisplatin vs. Observation in Resected
Non-Small-Cell Lung Cancer. N Eng J Med 2005; 352:2589-97.
37. Arriagada R. et al. Cisplatin-based adjuvant chemotherapy in patients
with completely resected non-small-cell lung cancer. N Engl J Med 350
(4): 351-60, 2004
38. Hotta K et al. Role of adjuvant chemotherapy I patients with resected
non-small-cell lung cancer: reappraisal with a meta-analysis of
randomized controlled trails. J Clin Oncol 22 (19): 3860-7, 2004.
39. Goodman GE et al. The Beta-Carotene and Retinol Efficacy Trial:
incidence of lung cancer and cardiovascular disease mortality during 6year follow-up after stopping beta-carotene and retinol supplements. J
Natl Cancer Inst 96 (23): 1743-50, 2004.
40. Kris, MG et al. Efficacy of gefitinib, an inhibitor of epidermal growth
factor receptor Tyrosine Kinase, in symptomatic patients with Nonsmall
Cell lung cancer: a randomized trial. JAMA 2003, 290 (16): 2149-58.
41. Shepherd, FA et al. Erlotinib in Previously Treated Non-Small-Cell
Lung Cancer. N Eng J Med 2005; 353(2): 123-132.
31. Tsao MS et al. Erlotinib in Lung Cancer-Molecular and Clinical
Predictors of Outcome. N Eng J Med 2005; 353:133-44.
32. Douillard , JY et al. Adjuvant vinorelbine plus cisplatin versus
observation in patients with completely resected stage 1B-IIIA non-smallcell lung cancer (Adjuvant Navelbine International Trialist Association
(ANITA)): a randomised controlled trial. Lancet Oncol 2006; 7: 719-27.
Latest revision November 2006
Radiation and Lung Cancer Suggested Reading List
Useful Web Sites
-for practice guideline summaries from Cancer Care Ontario:
www.cancercare.on.ca/index_practiceGuidelines.htm
-to review the National Cancer Institute’s Physician Data Query on this
disease site: www.cancer.gov
-to view the American Society of Clinical Oncology website, visit
www.asco.org
-to view guidelines/special articles from the American Society of Clinical
Oncology visit: www.jco.org/misc/specialarticles.shtml
-To view practice guidelines from the National Comprehensive Cancer
Network, visit www.nccn.org
Articles Dealing with Thoracic Irradiation
42. Furuse K et al. Phase III Study of concurrent Versus Sequential Thoracic
Radiotherapy in combination with Mitomycin, Vindesine, and Cisplatin
in Unresectable Stage III Non-Small Cell Lung Cancer. J Clin Oncol 17:
2692-2699, 1999.
43. Sause WT et al. Radiation therapy Oncology Group (RTOG) 88-08 and
eastern Cooperative Oncology Group (ECOG) 4588: Preliminary results
of a Phase III Trial in Regionally Advanced, Unresectable Non-Small
Cell Lung cancer. J Natl Cancer Inst 87: 198-205, 1995.
44. Talton BM et al. Curative radiotherapy in Non-Small Cell Carcinoma of
the Lung. Int. J. Radiation Oncology biol. Phys., vol. 19, pp. 15-21.
45. PORT Meta-analysis Trialists Group. Postoperative radiotherapy in nonsmall cell lung cancer: systematic review and meta-analysis of individual
patient data from nine randomized controlled trials. The Lancet, 1998,
352: 257-263.
46. Chakravarthy A et al. The Role of Radiation, with or without
Chemotherapy in the Management of NSCLC, Oncology Suppl 5 Oct
1999; p. 93-100.
47. Dillman RO. Et al. Improved survival in stage III non-small-cell lung
cancer: seven-year follow-up of cancer and leukemia group B (CALGB)
8433 trial (see comments). J Natl Cancer Inst 1996; 88(17): 1210-1215.
48. Anonymous. Chemotherapy in non-small cell lung cancer: a metaanalysis using updated data on individual patients from 52 randomized
clinical trial. Non-small Cell Lung Cancer Collaborative Group (see
comments). British Medical Journal 1995; 311(7010): 899-909.
49. Curran WJ et al. Phase III comparison of Sequential vs. Concurrent
Chemoradiation for patients with Unresected Stage III Non-Small Cell
Lung Cancer (NSCLC): Initial Report of Radiation Therapy Oncology
Group (RTOG) 9410. ASCO Online 2000, #1891.
50. Pignon, JP et al. A meta-analysis of thoracic radiotherapy for small-cell
lung cancer. N Eng J Med 327(23): 1618-24, 1992.
51. Warde P, Payne, D. Does thoracic irradiation improve survival and local
control in limited-stage small-cell carcinoma of the lung? A metaanalysis. J Clin Oncol 10(6): 890-5. 1992.
Articles Dealing with Prophylactic Cranial Irradiation
1. Auperin A et al. Prophylactic Cranial Irradiation for Patients with SmallCell Lung Cancer in Complete Remission. NEJM 1999; 341:476-84.
2. Gregor A et al. Prophylactic Cranial Irradiation is Indicated Following
complete Response to Induction Therapy in Small Cell Lung Cancer:
Results of a Multicentre Randomized Trail. Eur J Cancer, Vol. 33, No.
11, pp. 1752-1758, 1997.
Latest revision November 2006