9th January 2024

Management

The treatment of lung cancer includes numerous modalities, from palliative care to immunotherapy and surgery. An important point of note is whether the lung cancer is a SCLC or NSCLC. Treatment is usually limited to a palliative approach in SCLC, whereas a curative approach may be taken in NSCLC.

Smoking cessation services should be offered to all patients. Stop-smoking services offer support and medical therapy, including Varenicline, Bupropion and nicotine-replacement therapy.

Patients are assigned a McMillan specialist cancer nurse at the lung cancer clinic. This nurse becomes the patient’s point of call for support, advice, and access to palliative care. The patient is treated with a multidisciplinary team (MDT) approach. Respiratory physicians, thoracic surgeons, radiologists, specialist nurses and the patient are involved in the decision-making process.

Some patients are found to have advanced disease and cannot be offered curative treatment, or they do not have the capacity to undergo the recommended treatment. Such patients can be managed with a purely palliative approach.

Pleural effusions can be managed with pleural aspirations or a pleural drain. Talc pleurodesis is used after drainage to prevent re-accumulation of the effusion. Palliative radiotherapy and/or endobronchial stents can be offered as required to minimise respiratory distress.

Brain metastases are treated with dexamethasone, and the dose is slowly weaned down to the lowest therapeutic dose in an attempt to reduce corticosteroid side effects.

Bone metastases are treated with radiotherapy and analgesia.

NSCLC

In NSCLC, where curative intent may be suitable, a lobectomy can be offered. This is commonly done via video-assisted thoracoscopic surgery (VATS), a minimally invasive technique similar to laparoscopic surgery in the abdomen. The benefits of VATS procedures over open surgery include reduced length of hospital stay, fewer post-operative complications and reduced time needing chest drains. More extensive surgery, including a pneumonectomy or bi-lobectomy, can be offered if clear margins are needed and cannot be confidently gained from a VATS procedure.

For patients in whom surgical intervention cannot be offered or it is declined, radical radiotherapy or chemotherapy can be offered. The survival benefits must be weighed up against the toxic side effects of the therapies. Patients with a good performance status should be offered adjuvant chemotherapy. Chemotherapy and immunotherapy regimens are selected based on particular mutations found in the NSCLC.

SCLC

SCLC is usually treated with chemo- and radiotherapy, but if at an early stage with no lymphatic or metastatic spread, surgery can be considered. Novel treatments can be offered to patients as part of clinical trials.

Asbestos-related lung disease

The mesothelium is a protective lining of various organs, and depending on the organ, it can be called the pleura, peritoneum, pericardium or tunica vaginalis. It can, therefore, lead to symptoms related to these different organ systems. Asbestos exposure can cause benign or malignant disease within the mesothelium – benign changes are often inconsequential, but mesothelioma is an incurable cancer.

Asbestosis is a form of basal lung fibrosis. It is caused by inhalation of asbestos fibres, and disease occurs many years after exposure. A chest X-ray may be entirely normal, so a high-resolution CT chest is necessary to visualise the lung parenchyma. Pulmonary function tests show a restrictive deficit, and these investigations, alongside a strong exposure history is usually enough to make a diagnosis. A lung or pleural biopsy is rarely needed.

Pleural effusions, plaques and thickening can occur as asbestos-related lung disease. The pleural effusions can resolve spontaneously, and plaques/thickening may be found with a chest X-ray. Pleural plaques are not known to cause any symptoms and do not lead to mesothelioma, so patients with these X-ray or CT findings can be reassured and discharged. Pleural thickening can lead to respiratory symptoms.

Mesothelioma is malignant change of the mesothelium (in this case, we are limiting the topic to the pleura). The exact mechanism is unknown but is suspected to be due to lymphatic spread of asbestos fibres to the pleura. The diagnosis of mesothelioma is made with a biopsy, often as a VATS procedure. If a pleural effusion is present, then this can also be drained.

Treatment of asbestos-related lung disease is largely based around symptomatic relief. For example, treatment of a pleural effusion would involve insertion of a chest drain until dry, and then using talc pleurodesis. Conservative measures such as smoking cessation services, vaccinations and supplemental oxygen can be offered.

Patients with mesothelioma are offered palliative chemo- and radiotherapy, as well as palliative surgical therapy. Only around 45% of patients survive mesothelioma 1 year after the diagnosis is made.

Since asbestos-related lung disease is related to occupational exposure, patients have a legal claim to compensation. Pleural plaques are an exception because they are not known to cause any symptoms.

References

• Guerrera Francesco, Anne Olland, Enrico Ruffini and Pierre-Emmanuel Falcoz. “Vats lobectomy vs. open lobectomy for early-stage lung cancer: An endless question—are we close to a definite answer?” Journal of Thoracic Disease 11, no. 12 (2019): 5616–5618.
• Lung cancer: diagnosis and management – NICE guideline [NG122] https://www.nice.org.uk/guidance/ng122/chapter/Treatment (accessed October 2022)
• UpToDate [Internet]. Uptodate.com. 2022 [cited 10 October 2022]. Available from:  https://www.uptodate.com/contents/overview-of-the-initial-treatment-and-prognosis-of-lung-cancer