Elsevier

The Lancet

Volume 355, Issue 9202, 5 February 2000, Pages 479-485
The Lancet

Seminar
Lung cancer

https://doi.org/10.1016/S0140-6736(00)82038-3Get rights and content

Summary

Lung cancer remains a major worldwide health problem, accounting for more than a sixth of cancer deaths. The proportion of cancers that are adenocarcinomas is increasing in North America and to some degree in Europe, leading to a changing clinical picture characterised by early development of metastases. Newer diagnostic techniques have allowed for more accurate tumour staging and treatment planning. In patients with non-small-cell cancer, surgical resection offers substantial cure rates in early-stage cases. Combined chemotherapy plus radiation therapy has clearly improved the treatment results for patients with locally advanced cancers, and patients with metastatic disease are now candidates for newer chemotherapy regimens with more favourable results than in the past. Small-cell lung cancer is highly responsive to chemotherapy, and recent advances in radiation therapy have improved the prospects for long survival. New techniques for screening, and innovative approaches to both local and systemic treatment offer hope for substantial progress against this disease in the near future.

Section snippets

Clinical and pathological features

Features visible on light microscopy classify lung cancers into two major groups: small-cell and non-small-cell cancers. The latter include squamous-cell (epidermoid) carcinoma, adenocarcinoma, and large-cell carcinoma; bronchoalveolar carcinoma is generally subclassified under adenocarcinoma. This division is sufficient for most clinical needs.

The proportion of squamous-cell carcinomas has decreased from about 40% of lung cancers to 20–25% in North America in the past 15–20 years. In European

Clinical features

Patients may present for medical attention because of symptoms related to the primary tumour, mediastinal spread of tumour, distant metastatic spread, or paraneoplastic syndrome. Symptoms related to the primary tumour include cough, dyspnoea, haemoptysis, and postobstructive pneumonia. Chest pain suggests parietal pleural involvement or other extension beyond the lung. Superior sulcus tumours may produce shoulder pain, arm pain or brachial plexopathy, or Horner's syndrome.

Symptoms related to

Diagnosis

As with any cancer, accurate tissue diagnosis is essential, with the main differentiation being small-cell or non-small-cell carcinoma. In patients with unresectable tumours, thoracotomy for tissue diagnosis is almost never necessary. Sputum cytology may give a high yield for typically endobronchial tumours (eg, small-cell and squamous-cell carcinoma) but the yield is poor for adenocarcinomas. Overall, because of the changing histological patterns, the yield is probably less than 50%.

Staging of lung cancer

The main aim of staging is to identify candidates for surgical resection, since this approach offers the highest potential for cure lung cancer. Careful staging is also warranted to identify candidates for new aggressive multimodal treatments for locally advanced disease. The staging assessment covers three major issues: distant metastases; the state of the chest and mediastinum; and the condition of the patient.

In the assessment for metastatic spread, the history and physical examination are

Treatment of non-small-cell lung cancer

Stage I (T1N0, T2N0) cancers are treated whenever possible by surgical resection. 5-year survival is in the range of 40–67%, with the better results in patients with T1N0 staging.11, 12 Many presumed recurrences are second primary cancers. No role for adjuvant therapy has been established, although a trial comparing adjuvant chemotherapy with observation alone is underway for patients with T2N0 cancers. In this group chemoprevention trials are of great interest, in an effort to prevent the

Treatment of small-cell lung cancer

Chemotherapy is the mainstay of treatment for small-cell lung cancer, and adjuvant radiotherapy is commonly used in patients with limited disease. Surgical resection is reserved for patients with pathologically documented stage I or II disease, or as part of a combined-modality clinical trial. Active drugs include cisplatin, carboplatin, etoposide, cyclophosphamide, doxorubicin, vincristine, lomustine, and ifosfamide. Newer drugs of interest include altretamine, paclitaxel, docetaxel, topotecan

The future

Therapy for lung cancer has made progress in recent years. Chemotherapy is now firmly established as a useful therapeutic modality for both small-cell and advanced non-small-cell lung cancer (stages III and IV). Nevertheless, most patients will die of disease progression, and current treatments, in particular concomitant chemoradiotherapy for stage III disease, are very toxic. Therefore, the investigation of novel agents remains a high priority. Current interest is focused on agents that may

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