So localized disease is
mediastinal structures of the chest wall excessively
can be cured by resection. But that is only
about 15% of the patients and if a patient,
one of these lucky 1 in 6, 1 in 7 patients
has a resection, their 5 year survival is
about 70%. So not bad. However they have a
85% have inoperable disease and their 5 years
survival is very poor indeed. But having a
localized tumour is not the only thing a patient
requires before they can have curative surgery.
They need to be out of cope with a surgery
and that depends on their function and status.
So for example if you got a patient who is out
walking around looking after themselves has
a good functional status then surgery would
be a reasonable option.
However if you got somebody presenting with
resectable cancer who is unable to walk due
to very severe COPD etc. Then they are not
really going to be candidate for surgery.
Not only as a low functional status, but
we needed to think about what their lung function
is like. So the example about the patient
who was out walking about maybe they are walking
a 100 yards before they get breathless because of COPD.
However if you do a lung resection that ability
to walk a 100 yards is going to fall because
you have lost lung volume. So you need to
consider whether the lung resection itself may
make the patient unable to breathe adequately
for normal life and then there is general
comorbidities. Somebody who
has got extensive cardiac disease, renal disease,
and existing tumour elsewhere in the body
then surgery is a much less attractive option.
There are essentially two types of tumour
resection. One is a lobectomy and that's if the
cancer is confined to one lobe and the other
is the pneumonectomy. So if a tumour has crossed
the oblique fissure and therefore affecting
the upper and the lower lobe then the patient
will have to have the total whole lung removed.
The survival from lobectomy, the risk from
the lobectomy operation is less than from
a pneumonectomy. Actually the lung function
lost from lobectomy is a lot less than a lung
function lost from pneumonectomy. And these
considerations need to be taking for count
when identifying patients for surgery.There is a
another option which is what we called a wedge
resection where just the cancer and the tissue
near to the cancer is removed but is known that the
chance of recurrence after wedge resection is higher.
So wedge resection are kept in reserve for
patients who really cannot tolerate more
than that small amount of lung being removed.
If you have tumour which is extensive, the higher stages
but still resectable ones of hilar lymph nodes
for example then the patient is quite likely to
get chemotherapy or radiotherapy after the
operation as that seems to reduce the chance
If a patient has a localized tumour that can
be enclosed in one radiotherapy field but
cannot survive, he's not fit enough to have
surgery and radical radio therapy is another alternative
method of potentially curing that cancer.
But the cure rate from radical radiotherapy
is a lot lower than it is from resection.
So it's the second best option.
Now, unfortunately they said 80-85% of patients
presenting with lung cancer do not have curable
disease. The stage has gone to mediastinal
invasion, chest wall invasion, distal
metastases and therefore you cannot cure the
tumour by resection. There 5 years of
survival is less than 5%. We know that
chemotherapy is helpful and that
it delays the deterioration in the patient’s
condition on average by about 6 months extends
a life expectancy of about 6 months. But it
is not aimed to curing. It is a palliative
treatment. If the patient has specific
of these are very susceptible, very easily
treatable with radiotherapy. First so for
example, pain due to invasion of the chest
wall, pain due to metastases in the bone,
obstruction of the bronchus due to a large
tumour, haemoptysis, and brain metastases
are all situations where you'll consider giving
the patient what we call palliative radio
therapy. This is not aimed to cure the patients
but it is aimed to alleviate the problems
of that specific issue it's causing. Stopping
haemoptysis, reducing the pain, opening at
the bronchus so the patient so the patient's
breathing improves slowing down the growth
for brain metastases. In patient with brain
metastases, alot of
the problems that they have are due to the
edema around the growing tumour. So if you
give the patients steroids that reduces that edema.
It is actually quite striking, the improvement
in somebody’s neurological conditions that
could be given just by giving them high dose
corticosteroids. Quite often somebody would come
into the hospital with dense left hemiplegia, unable
to move the left hand side of the body because
of the large brain metastases in the right
side. But if you give them corticosteroids
what will happen is that the edema will shrink down
and the movement will come back. So that is
the useful therapy at least acutely.
Recently there have been developments in the
chemotherapy which are very exciting and potentially
very important for the future. So for example,
there are specific mutations that affect patients
with adenocarcinoma of the lung which affects
surface receptor called the EGFR and there are
now inhibitors of the EGFR function which
are used in these patients with that type
of mutation, have got a marked effects on tumour
growth quite often causing a large decrease
in the tumour growth at least temporarily.