Lung cancer is a common disease that seriously endangers people’s lives and health, and the incidence and mortality rate of lung cancer is still increasing at home and abroad. Lung cancer accounts for 38.08% of malignant tumor deaths in men and 16% in women in urban areas, both ranking first. The clinical manifestations of lung cancer are complex and can be generally categorized into primary masses, intrathoracic spread, distant dissemination and extra-pulmonary manifestations of lung cancer.
The first symptoms and X-ray signs of central and peripheral lung cancer can be different, and their diagnosis should mainly strive for histopathological or cytological confirmation, which involves the choice of the most effective treatment. From a therapeutic point of view, there is a worldwide trend to classify the two types of lung cancer with different biological behavior into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). However, imaging and clinical manifestations are also very important.
Researchers at home and abroad have conducted in-depth research on early diagnosis, multidisciplinary treatment and prognosis of lung cancer, and have achieved considerable achievements. Some of the recent achievements are reported below.
I. Early diagnosis of lung cancer.
1.Regular checkup: chest X-ray and chest X-ray are still the most effective methods for early diagnosis of lung cancer. There are no accurate and sensitive tumor markers yet.
2.The research results of basic medicine have given a new turn to the early diagnosis of tumor, using the detection of oncogenes, oncogenes and microsatellite instability changes in peripheral blood and sputum to achieve real early diagnosis. ras gene family, berb-B group oncogenes; p53 oncogenes; microsatellite loci on chromosome 3, 6 and 9. Ahrendt in UK applied bronchoalveolar lavage fluid (BAL) to detect K-ras gene, mutated p53 gene and 15 sensitive microsatellite loci, and the results significantly improved the early diagnosis rate of lung cancer.
II. Multidisciplinary treatment of lung cancer.
Multidisciplinary treatment of lung cancer is defined as the rational and planned integrated application of existing treatments according to the patient’s organism condition, pathological type, invasion scope (pathology) and development trend of tumor, with a view to improving the cure rate and patient’s quality of life more substantially. The superiority of comprehensive treatment over monotherapy for lung cancer has been recognized by academic circles.
(A) Comprehensive treatment of small cell lung cancer
Chemotherapy and radiotherapy are still the main treatment methods for small cell lung cancer, and the recent efficacy of radiotherapy is good, with an efficiency rate of over 80%. 60% of patients can achieve complete remission after treatment, but the long-term outcome is poor. Recent cohorts have reported some improvement, but the variation is substantial. A major development in recent years has been the inclusion of surgical treatment.
1. Characteristics of treatment for small cell lung cancer (SCLC)
Small cell lung cancer accounts for 10-25% of lung cancers, with an average natural survival of only 3-6 months. the clinicobiological characteristics of SCLC are
1. High malignancy – treatment should be timely + strong.
2. Clinical staging is extremely important – conventional examination + bone marrow aspiration or biopsy, or ECT.
3, short doubling time (TD) 75.9 days, >90% have extranodal invasion + distant metastasis.
4.Highly sensitive to chemotherapy: CR30-40%, RR60-90%, systemic chemotherapy mainly, sufficient + strong dose, high dose chemotherapy + stem cell transplantation.
5, is a typical systemic disease-is typical of multidisciplinary treatment, but 25-50% of SCLC still have local recurrence after effective chemotherapy.
6, SCLC subtypes and prognosis are related: pure SCLC-chemotherapy sensitive; SCLC + large cell OR squamous carcinoma-chemotherapy insensitive; SCLC + adenocarcinoma-chemotherapy insensitive.
7, there is heterogeneity-more important for those who relapse: pure SCLC of which 35% relapsed after effective treatment and became NSCLC or mixed type with drug resistance.
8, SCLC with chemotherapy as the main multidisciplinary treatment, chemotherapy: adequate dose + strong + timely.
SCLC current chemotherapy features.
1, 2-3 drug combination chemotherapy.
2, concurrent application of chemotherapy drugs, better than sequential application.
3, dose is sufficient.
4, Intensive dose is better than standard dose.
5, cyclic alternating regimen is better than a single regimen (can make the drug resistance reduced).
6.Short interval, sequential.
Indications for chemotherapy.
1.Stage Ⅰ-can be operated first and then chemotherapy.
2.Stage II and IIIa-chemotherapy+surgery+chemotherapy and radiotherapy.
3, Surgery or radiotherapy must be followed by chemotherapy, including stage I
4.Stage IIIb, IV – chemotherapy is the mainstay, in principle
5.Recurrence or metastasis after treatment-chemotherapy again.
Radiotherapy
1.Thoracic radiotherapy: chemotherapy first, then radiotherapy; timing arrangement – sequential, alternating and synchronous
2, brain prophylactic irradiation (PCI): SCLC with brain M accounted for 25-37%, survival of more than 2 years SCLC brain M reached 80%, Bunn reported 583 cases of SCLC without PCI, brain M accounted for 22%; 355 cases of SCLC with PCI, brain M accounted for 8%, but the survival rate of the two groups is similar.
Current preference: primary foci CR + PCI given after completion of multidisciplinary treatment.
Surgical treatment
1, 60s-70s-Tumors considered unsuitable for surgical treatment.
2.After 70’s-multidisciplinary treatment
3.Overall 5-year survival rate 24-52%
4.Stage I five-year survival rate 53.4%
5.Stage II five-year survival rate 31.4%
6.Stage III five-year survival rate 28.4%
7.Surgical treatment removes the remaining drug-resistant cells in the primary focus and the presence of NSCLC components, which is the necessary way for radical treatment.
Biological therapy (BRM)
1, BRM is feasible in disease-free stage, interferon
2.Survival rate is better in interferon group than control group
3.Interferon can also play a sensitizing role to chemoradiotherapy, and it is found that CR is more in the interferon group. Dose 1 million u-3 million u/time, T.I.w or B.I.w intramuscular injection
4. Generally in the early stage of tumor, small tumor, the use of interferon after CR, can prolong the disease-free survival.
Multidisciplinary treatment
1.With TNM stage-formulation of chemotherapy regimen-supplemented with surgery and radiotherapy, the number of chemotherapy > 4 cycles is preferred.
2.Ⅰ-Hand-chem + IFNα
3.II – hand – chemotherapy (international);
4.Chemical-hands-chemical (domestic)
5.Ⅲa-chem-hands+releasing-chem
6.IIIb-chemical-relaxation+chemical
7.IV-chemical-palliative radiotherapy + symptomatic, support
8.Treatment end without recurrence give IFNα for six months – one year.
(B) Comprehensive treatment of NSCLC
For the comprehensive treatment of NSCLC there have been many reports over the years, but there are not many successful experiences. For patients with T1 and T2 without lymph node metastasis, the 5-year survival rate after radical surgery can reach 65-83%. Shanghai Chest Hospital Mei-Lin Liao reported no significant difference between postoperative + chemotherapy or radiotherapy and postoperative without radiotherapy. The current focus is on how to improve the cure rate of stage II and III patients. Stage IIIa was previously treated with surgery + chemotherapy and/or radiotherapy. Stage IV is then dominated by chemotherapy and/or radiotherapy.
NSCLC accounts for 80% of lung cancer. The clinicobiological characteristics of NSCLC are.
1, lower malignancy, slow local progression, threat of micrometastasis, adenocarcinoma routinely small lesions with large metastases.
2, ploidy time (DT): sq-92 days, ad-168 days.
3.It is a both local and systemic disease.
4, poor sensitivity to chemotherapy: drug resistance; heterogeneity (especially in relapsed and refractory NSCLC)
Chemotherapy
90s: platinum-based drugs were produced, combination chemotherapy RR rose to 40%, survival rate improved.
Chemotherapy regimen
Combination chemotherapy is superior to best supportive care. Common combination regimens: MVP, NIP, MAP, IVP, EP, NP, TP, GP.
Stage IIIb, IV: no surgical indication, chemotherapy is the mainstay, except PD should be adhered to two cycles of the same regimen of chemotherapy after evaluation and observation for one month before confirming the efficacy
Adjuvant chemotherapy: surgery, chemotherapy after radiotherapy
Objective: To kill local residual and micro-metastases with whole blood vessels and lymphatic vessels. Adjuvant chemotherapy is advocated after surgery except for stage I. It is administered within 2-4 weeks after surgery, usually for 2-6 cycles, with the same chemotherapy regimen as before.
Induction chemotherapy (neoadjuvant chemotherapy).
Non-surgically resectable NSCLC (stage III), chemotherapy is given – to shrink the primary foci and eliminate micrometastases, which is beneficial to surgery and radiotherapy. 2-3 cycles are appropriate, along with supportive therapy.
1.Surgical treatment.
It is the main treatment for NSCLC, but only 20-30% can be suitable for surgery. Indications: stage I and II patients without obvious intrathoracic organ invasion and distant metastases, some stage III estimated possible total resection, or those with indications after induction chemotherapy.
2. The surgical approach is the key to influence the prognosis.
Surgical specifications: surgical movements should be gentle, do not squeeze, lobotomy is the main focus; open the mediastinum and remove the naked eye visible lymph nodes along the station.
Radiotherapy: it is another important local treatment for NSCLC, chemotherapy + radiotherapy can increase the efficacy.
Biologic therapy: applicable to the disease-free period after the end of -NSCLC treatment for 6 months-2 years.