The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and role of the surgeon in
The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative evaluation for extent of disease, androle of the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aimof the Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.
Following each guideline is a brief narrative highlighting and expandingon selected sections of the guideline document, with a few relevant references.The current staging system for the site and approximate 5-year survivaldata are also included.
The Society does not suggest that these guidelines replace good medicaljudgment. That always comes first. We do believe that the family physician,as well as the health maintenance organization director, will appreciatethe provision of these guidelines as a reference for better patient care.
Symptoms and Signs Early-stage disease
Evaluation of the Symptomatic Patient Diagnosis
Cytologic or histologic confirmation
Preoperative Evaluation for Extent of Disease Complete history and physical examination
Role of Surgeon in Management Preoperative
These guidelines are copyrighted by the Society of Surgical Oncology(SSO). All rights reserved. These guidelines may not be reproduced in anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
Lung cancer is the most common cause of cancer death for both men andwomen in North America. The age-adjusted incidence is 60 cases per 100,000people, but by age 70 in males incidence exceeds 500 cases per 100,000.
Cigarette smoking has been firmly implicated as the primary cause ofthis cancer. Other environmental pollutants that have been implicated includepassive smoking, radon exposure, and occupational exposure to polycyclicaromatic hydrocarbons, nickel, uranium, and asbestos. Most of these occupationalfactors act as cocarcinogens with smoking. There is a proven familial incidenceof this disease.
Despite the well-known etiologic factors, attempts at mass screeningof high-risk individuals using annual sputum cytology and chest x-ray havefailed to improve ultimate survival from lung cancer, although early casescan be detected by such screening.
Lung cancer is divided into two major pathologic types: non-small-celllung cancer and small-cell lung cancer. With non-small-cell lung cancer,the TNM staging system (Table 1) hasbeen used to determine treatment modalities and ultimate survival. Withsmall-cell lung cancer, the distinction between limited (disease limitedto the thorax) and extensive (metastatic) disease determines treatmentand prognosis. Subdividing small-cell lung cancer into more specific TNMcategories, as are used for non-small-cell lung cancer, can further defineprognosis but has little impact on treatment decisions.
The survival rates at each stage are outlined in Table1. The overall survival of patients who develop lung cancer is lessthan 15%. However, up to 80% of patients with very early-stage lung cancer(T1, N0) can be cured by surgical resection. In stage II disease, the rateof 5 year-survival drops to 40% and in stage IIIa, it is only 10% to 40%.Only the occasional patient with stage IIIb and IV (solitary metastases)disease can be cured by surgical resection.
Most stage I disease presents as an asymptomatic nodule or mass on routinechest x-ray. Once the tumor has spread locally within the lung or intothe mediastinum, symptoms develop due to intrabronchial irritation or obstructionor compression of intrathoracic structures.
The goal of diagnosis and clinical staging is to determine the besttreatment approach for the patient.
Non-Small-Cell Lung Cancer
Early-stage lung cancer (stages I, II, and selected IIIA) is best treatedby surgical excision, whenever possible. Once mediastinal lymph nodes areinvolved, however, the role of surgical resection is more questionable.
Multimodality approaches including preoperative chemotherapy are beinginvestigated. In more advanced local disease (stages IIIA and IIIB), radiotherapy,now frequently combined with chemotherapy, is the treatment of choice.Once metastatic disease develops (stage IV), chemotherapy is the best option,except for the occasional patient with a solitary site of metastasis, whowould be treated surgically.
The aim of surgery is a complete resection together with complete mediastinallymph node staging performed by sampling or mediastinal lymphadenectomy.The role of palliative resections in the treatment of lung cancer, withoutcurative intent, is extremely questionable.
The role of postoperative adjuvant therapy has yet to be conclusivelydetermined. Randomized trials have demonstrated that postoperative radiotherapyfollowing surgical resection of N1 or N2 disease will improve local controlwithout any significant impact on ultimate survival. Most postoperativeadjuvant chemotherapy trials have failed to demonstrate an improvementin survival regardless of the pathologic stage. In locally advanced lungcancer (N2 disease), there has been an apparent improvement in survivalwith the use of chemotherapy or chemoradiotherapy prior to surgical resection.
Small-Cell Lung Cancer
Small-cell lung cancer is treated primarily with chemotherapy plus radiotherapy.Occasionally surgery is used for "very limited" (stage I andII) disease. The role of surgery in small-cell lung cancer is usually limitedto small peripheral tumors, which are often not diagnosed until the timeof surgery. Surgical resection following by adjuvant chemotherapy yieldsup to a 50% 5-year survival in patients with stage I small-cell lung cancer.
Palliative maneuvers used in lung cancer are aimed at relieving airwayobstruction, controlling life-threatening complications, and relievingdyspnea. These may include: bronchoscopic removal of endobronchial tumor,endobronchial brachytherapy, and endoscopic insertion of stents; palliativere- sections to relieve otherwise uncontrollable situations (eg, massivehemoptysis or unrelenting lung abscesses); and relief of symptomatic pleuraleffusions by thoracentesis, thoracostomy drainage and sclerosis, shuntprocedures, or, rarely, decortication.
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