GRACE :: Lung Cancer

Introduction to Malignant Pleural Effusions

GRACE Cancer Video Library - Lung



Interventional pulmonologist Dr. Jed Gorden reviews malignant pleural effusions (MPEs) are a common complication of lung cancer and some other cancers.

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What is the Role of Memantine for Neuroprotection During Whole Brain Irradiation?

GRACE Cancer Video Library - Lung

GCVL_LU-CA03_ Memantine_Whole_Brain_Radiation_Therapy


What is the role for the neuroprotective agent memantine in patients receiving whole brain radiation therapy for brain metastases? Dr. Vivek Mehta reviews current practices to minimize risk of cognitive problems.

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Palliative Radiation for Bone Metastases

GRACE Cancer Video Library - Lung



Radiation therapy can be very helpful in treating painful bone metastases or those at risk for causing a fracture due to compromise of bone strength. Dr. Vivek Mehta reviews the basics of this approach.

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The Many Faces of Stage III NSCLC: Why We Have Such Trouble Nailing Down an Optimal Treatment for Locally Advanced Disease

There are many open questions in managing lung cancer, but one of our historical areas that has been especially challenging has been locally advanced/stage III NSCLC, which we most commonly treat with at least two different forms of therapy, such as chemotherapy followed by surgery, chemo and radiation followed by surgery, or (most commonly) chemotherapy and radiation without surgery. Why is it such a controversial area?

A key issue is the heterogeneity of both the cancer and patients who are part of this population, about 1/3 of all NSCLC patients, who are initially diagnosed with stage III disease.  A patient can have locally advanced NSCLC with just microscopic involvement of their cancer in a single mediastinal (mid-chest) lymph node that isn’t enlarged on scans, while others can have many bulky, enlarged nodes on both sides of the mid-chest, or lymph node involvement above the collarbone in the lower neck, or a large tumor that may be growing into important chest structures like the trachea, heart, or aorta.  Stage III NSCLC can be caused by an advanced tumor, extensive regional lymph node involvement, or a combination of these. 

Not surprisingly, patients with very minimal disease burden have a much better prognosis than patients with larger and/or more extensive tumor burden.  Patients with a single non-enlarged mediastinal lymph node involved with cancer can be cured with surgery +/- chemotherapy about 1/3 of the time, but the prognosis is much less favorable in patients with several lymph nodes involved or those with abnormally enlarged lymph nodes.  Yet when we do studies of stage III NSCLC, we pool many different patients and cancers that start with a very different prognosis.

We also know that some cancers are far more sensitive to our treatments than others. Unfortunately, we only learn how sensitive or resistant a patient’s cancer is by looking in hindsight. In 2015, we aren’t yet able to predict which cancers will be far more or less responsive to chemotherapy and/or radiation.

Another critical variable is the underlying health of the patient.  Some are very fit, have a good reserve of lung function, and can tolerate rigorous treatment very well. On the other end of the spectrum, we also have many patients who have compromised lung function from chronic smoking, emphysema, and other issues, who may be frail from other medical conditions, and are not likely to tolerate very aggressive treatments without developing debilitating side effects or even possibly die from the treatment. In most trials of multimodality treatment of stage III NSCLC, about 5% of patients die from “treatment-related mortality”, meaning that they died from the treatment rather than the disease.

This leaves us with the difficult situation of a cancer that may require a lot of intensive treatment to cure the cancer, often just at the upper limit of what a patient can tolerate, while other cancers may require more intensive treatment than it’s possible to safely deliver to that patient without the treatment causing more harm than benefit as the treatment becomes increasingly intensive. 

Stage III therapeutic window


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Liquid Biopsies: Faster Results, Easier on Patients

ASCO 2015 Highlights 13


Liquid biopsies (also called serum testing) is a practice already approved in Europe for EGFR lung cancer patients. Drawing blood to test for acquired resistance is easier and quicker than needle biopsies. How long until it is standard practice in the US?

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