While post-operative chemotherapy has emerged as the standard treatment for patients with stage II and resected IIIA NSCLCC, and some patients with stage IB disease, trials conducted over the past few years are providing information about the option of treating with initial chemotherapy before surgery. A couple of trials were presented at ASCO this year that did not demonstrate a significant survival benefit of pre-operative chemo compared with no treatment.

The AVAiL trial in first-line advanced NSCLC, based in Europe, was designed to confirm the role of avastin with chemo using a different regimen of cisplatin and gemcitabine with a placebo or Avastin at 7.5 or 15 mg/mg every three weeks (the European trial was placebo-controlled, unlike the US-based Avastin trial with carbo/taxol). I described it in a prior post that described a glimpse of the results that were reported in a press release a few months ago, but we received more information at ASCO.

A member recently asked me whether treatment in the second-line or later setting for advanced lung cancer would potentially improve survival at a cost of quality of life, or whether patients can benefit not only in terms of how long they live but also how they live during that time. Since advanced lung cancer, both NSCLC and SCLC, aren't generally able to be approached with curative intent, it's important for the treatment not to be worse than the disease. Ideally, patients will even feel better with treatment, rather than have to choose between quality of life (QoL) and quantity of life.

We'll cover the general management principles for the more typical situation of patients with multiple brain metastases from lung cancer soon, but today we’ll cover the special situation of the patient who has a brain metastasis identified as the ONLY area of metastatic disease (generally referring to NSCLC, since SCLC has such a high tendency to spread distantly early in its history). Recall that metastatic, or stage IV, lung cancer, is treated with a palliative approach, due to the inability to achieve prolonged survival except in very rare cases.

While brain metastases are common, some patients seem to be at higher risk than others. As previously noted, SCLC has a very high risk of spread to the brain. For NSCLC subtypes, several studies have shown that patients with non-squamous lung cancers have a greater tendency to develop brain metastases than those with squamous cancers, which tend toward more local spread.

In most of the history of lung cancer management, we have been "lumpers" rather than "splitters", tossing together many different kinds of lung cancer together and presuming that they all respond similarly and should be treated similarly.

Historically, the main task of pathologists in lung cancer has been to divide them into small cell lung cancer and non-small cell lung cancer.

Between 7 and 15% of patients with lung cancer develop a malignant pleural effusion (MPE), a fluid collection outside of the lung in the chest cavity. Very often, if it develops, it recurs frequently. This is typically associated with shortness of breath, also know as dyspnea, so we want to try to manage these recurrent pleural effusions to minimize pulmonary symptoms (although some lung cancer patients have several reasons for shortness of breath and cough and still have symptoms even with effective management of an effusion. We’ll review several ways to manage this problem.

Pleural effusions related to lung cancer are quite common, so it's time that I discussed this issue. First, a pleural effusion is fluid outside of the lung, and it tends to follow gravity and pool at the bottom (base) of the lung, primarily along the back. Here's how it appears on a chest x-ray, filling up the bottom of the left side of the chest. The right side, in contrast, is mostly black, which is the way lungs should appear on a chest-x-ray (but not in real life, we hope).

I've discussed the general management of metastatic lung cancer, both SCLC and NSCLC, but there are also several common complications that sometimes require particular management. Bone metastases, for instance, may be treated by the same "whole body" approach with chemotherapy that treats other areas of tumor involvement, but may also benefit from additional approaches.