Lung cancer is one of the most prevalent malignancies worldwide and it represents the leading cause of cancer-related deaths, accounting for the highest mortality rates among both men and women. In Italy, lung cancer is the second most frequent malignancy among men and the third among women. The high incidence of lung cancer, along with the mortality statistics associated with this disease, underscore the critical role of primary prevention, especially in the battle against smoking, which represents the most relevant risk factor for lung cancer.

THE MULTIDISCIPLINARY TEAM

At the IEO, the management of patients with a diagnosis of lung cancer occurs within a multidisciplinary team, in which a group of different healthcare professionals work together, each of whom plays a key role.

• Thoracic Cancer Surgery
• Thoracic Oncology
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

Several risk factors contribute to the development of lung cancer, making it imperative to understand them and to implement comprehensive preventive measures to promote lung health on a global scale.

According to the data of the World Health Organization (WHO), tobacco smoking represents the largest threat to human health and the most critical risk factor for chronic pulmonary disease and lung cancer, with one billion smokers worldwide. Constant and prolonged tobacco exposure negatively affects the length of life and its quality: indeed, 20 cigarettes a day reduce the average lifespan of a young person who starts smoking at 25 by approximately 4.6 years. Moreover, approximately 50% of smokers die prematurely, resulting in an average loss of 14 years of life per smoker. The severity of physical damage due to exposure to tobacco smoking is proportional to the overall extent of exposure, including age at the beginning of smoking history, smoking years and number of smoked cigarettes per day. It takes approximately 10 years after smoking cessation to reduce the risk of lung cancer.

Whether through cigarettes, cigars, or pipes, over 5000 chemicals are released by tobacco products and at least 70 of these substances, spreading through lungs and other organs, are carcinogens that directly damage the DNA of lung cells, triggering malignant transformations over time. Notably, the risk for non-smokers is also significant when exposed to secondhand smoke.

Beyond smoking, occupational hazards also play a role. Indeed, exposure to substances such as asbestos, radon, certain chemicals and pollutants increase the likelihood of developing lung cancer. For instance, radon is a naturally occurring radioactive gas that forms from the decay of uranium in soil, rock, and water. It can seep into buildings, accumulating to potentially hazardous levels indoors. When radon is inhaled, its decay products release alpha particles that can damage the cells lining the lungs, leading to cell damage and DNA mutations and ultimately increasing the risk of lung cancer.

Furthermore, environmental factors like air pollution, particularly from the combustion of petroleum compounds, can exacerbate the risk of lung cancer. When petroleum products such as gasoline, diesel, and coal are burned for energy or transportation purposes, they release a variety of pollutants into the air, including particulate matter, volatile organic compounds (VOCs), nitrogen oxides (NOx), and polycyclic aromatic hydrocarbons (PAHs). These pollutants can be inhaled into the lungs, where they can cause inflammation, oxidative stress and DNA damage. Particulate matter, especially fine particles known as PM2.5, can penetrate deep into the lungs and even enter the bloodstream, leading to respiratory and cardiovascular damage. VOCs and PAHs are known carcinogens that can directly damage lung tissue and contribute to the development of lung cancer over time. NOx can react with other pollutants in the atmosphere to form ozone and other harmful compounds that exacerbate lung inflammation and damage. Exposure to air pollution from the combustion of petroleum compounds is associated with a higher risk of lung cancer, particularly in urban and industrial areas where pollution levels are elevated.

PREVENTION AND DIAGNOSIS

Primary Prevention 

Primary prevention for lung cancer involves measures aimed at reducing the risk of developing the disease in individuals who have not been diagnosed with lung cancer. The most significant primary prevention strategy for lung cancer is the avoidance of tobacco smoke, including smoking cessation and preventing exposure to secondhand smoke.

Other strategies include promoting a healthy lifestyle, including regular physical activity and a balanced diet. The latter typically includes a variety of foods from different groups, such as fruits, vegetables, whole grains, lean proteins and healthy fats. A balanced diet provides essential nutrients like vitamins, minerals, protein, carbohydrates, and fats, which are necessary for proper growth, development, and functioning of the body. Most importantly, a balanced diet supports a healthy immune system to protect against cellular damage and to reduce chronic inflammation.

Additionally, minimizing exposure to environmental carcinogens and early detection and treatment of conditions like chronic obstructive pulmonary disease (COPD), associated with an increased risk of lung cancer, can also contribute to primary prevention efforts. Radon exposure is estimated to be responsible for a significant proportion of lung cancer cases worldwide, particularly among non-smokers, therefore  mitigating radon exposure through proper ventilation and testing in homes and workplaces is crucial. Moreover, efforts to reduce air pollution through emission controls, alternative energy sources, and transportation policies are essential to protect public health.

Secondary Prevention: Lung Cancer Screening

Screening for lung cancer in high-risk individuals, such as heavy smokers, has shown a reduction in tumor-specific mortality and a significant increase in early-stage diagnosis. The COSMOS (Continuous Observation of Smoking Subject) study was conducted at the IEO and it demonstrated that computer tomography (CT) at low dose radiation is effective in increasing the probability of diagnosis lung cancer at early stages in heavy smokers, therefore increasing the opportunities of curable treatments. Currently, in Italy, lung cancer screening is not included in public health programs. However, it is strongly recommended for smokers or ex-smokers who meet specific criteria: indeed, individuals who have smoked at least 15 cigarettes a day for over 25 years, or at least 10 cigarettes a day for over 30 years, or who quit smoking less than 10 years ago, should consider annual chest CT screening as the preferred option.

Diagnosis

Among invasive malignant lung tumors, the two most frequent histological subtypes are non-small cell lung cancer (NSCLC), accounting for 80-85% of cases, and small cell lung cancer (SCLC), accounting for 15-20% of cases. Non-small cell lung cancer includes squamous cell carcinomas and adenocarcinomas, whereas less common histotypes include large-cell neuroendocrine carcinoma (LCNEC), pleomorphic carcinomas, sarcomatoid carcinomas and other rare histological variants, such as carcinoids. The histological subtype offers prognostic information and is one of the several parameters that are useful in guiding the therapeutic strategy. 
Lung tumors are heterogeneous as they not only differ in histology but also express molecular alterations or biomarkers, that are crucial to determine the treatment algorithm. For this reason, a treatment that helps one patient may not help another one.

STAGING OF LUNG CANCER

Non-small cell lung cancer (NSCLC) is staged using the TNM (Tumor Nodes Metastases) system, which takes into account the size and extent of the tumor (T), whether nearby lymph nodes are involved (N) and whether the cancer has spread to distant sites (M). The TNM for lung cancer identifies four stages:

• Stage I: the cancer is localized into the lung and has not spread to nearby lymph nodes or distant sites. Treatment generally involves surgery to remove the tumor, sometimes followed by adjuvant treatments. 
• Stage II: the tumor size is larger and/or it has spread to nearby lymph nodes but remains confined to the lung. Treatment may involve surgery, often followed by adjuvant treatments. 
• Stage III: the cancer has spread to lymph nodes in the lung or chest area, and may also involve nearby structures such as the chest wall or diaphragm. Stage III NSCLC is further divided into subcategories based on the extent of lymph node involvement and whether the cancer is resectable (able to be surgically removed). Treatment may involve surgery, when the tumor is resectable, and peri-operative treatments or a combination of chemotherapy, radiation therapy and immunotherapy when the disease is not-resectable. Stage IV: the cancer has spread beyond the lung to distant sites in the body, such as the other lung, liver, bone, or brain. 
• Stage IV NSCLC is considered advanced or metastatic, and treatment focuses on controlling the disease and managing symptoms rather than aiming at a curative intent. Treatment typically involves systemic therapy such as chemotherapy, targeted therapy, immunotherapy, or a combination of these approaches.

Overall, the main differences between stages lie in the extent of the cancer's spread within the lung, the involvement of nearby lymph nodes and the presence of distant metastases, which in turn influence treatment options and prognosis.

Small cell lung cancer (SCLC) is also staged using the TNM system, similar to other types of lung cancer. However, SCLC is often classified into two broad categories: limited stage and extensive stage.

• Limited Stage SCLC typically involves only one lung and nearby lymph nodes. Limited stage SCLC is potentially treatable with a combination of chemotherapy and radiation therapy. 
• Extensive Stage SCLC has spread beyond one lung to distant sites in the body, such as the other lung, liver, bone, or brain. It may involve multiple areas within the chest or distant metastases outside the chest. Extensive stage SCLC is generally treated with systemic chemotherapy and immunotherapy, as surgery or radiation therapy alone are typically not sufficient to control the disease at this stage.

These stages provide a general framework to understand the extent of lung cancer, but the specific treatment approach may vary depending on individual factors such as overall health, tumor size, and response to previous treatment.

SYMPTOMS

Lung cancer symptoms vary, depending on the type of lung cancer, its location within the lung and whether it has spread to other parts of the body. Common symptoms of lung cancer may include:

• Persistent cough, that doesn’t go away or worsens over time; 
• Chest pain, often exacerbated by deep breathing, coughing, or laughing; 
• Shortness of breath, especially with exertion; 
• Hemoptysis, or coughing up blood or rust-colored sputum, a concerning symptom that should be evaluated promptly; 
• Fatigue, or persistent tiredness or weakness that doesn’t improve with rest; 
• Sudden and unintended weight loss, even without changes in diet or activity level; 
• Loss of appetite or feeling full even after eating small amounts of food; 
• Hoarseness, when the tumor affects the nerves controlling the vocal cords; 
• Wheezing or noisy breathing, particularly if it’s new or persistent, may indicate a blockage in the airways caused by lung cancer; 
• Bone pain, particularly in the back, hips, or ribs.

These symptoms can also be caused by other medical conditions, and not every patient with lung cancer will experience all of these symptoms. However, when these symptoms are persistent or worsening, it’s essential to consult a healthcare professional for evaluation and appropriate management. Early detection and treatment can significantly improve outcomes for patients with lung cancer.

ADVANCED OR METASTATIC LUNG CANCER

Overall, metastatic spread in lung cancer is common and can involve multiple sites throughout the body. The presence of metastatic disease often indicates advanced-stage disease. The most frequent sites of metastatic lesions from lung cancer include:

• Regional lymph nodes: Metastasis to nearby lymph nodes within the chest (mediastinal and hilar lymph nodes); 
• Brain: These metastases can cause symptoms such as headaches, seizures, weakness, and changes in cognitive function; 
• Bones: particularly to the spine, ribs, pelvis, and long bones of the extremities. Bone metastases can cause bone pain, fractures, and spinal cord compression; 
• Liver: Liver metastases may cause symptoms such as abdominal pain, jaundice (yellowing of the skin and eyes), and abnormal liver function tests; 
• Adrenal glands: Adrenal metastases may not cause symptoms initially but can eventually lead to adrenal insufficiency and symptoms such as fatigue, weakness, and weight loss; 
• Lung: lung cancer can also metastasize to other areas of the lung, leading to the development of multiple lung nodules or satellite lesions; 
• Pleura: lung cancer can metastasize to the pleura, the thin membrane that lines the chest cavity and covers the lungs, leading to the development of pleural metastases or malignant pleural effusions; 
• Other distant organs: kidneys, pancreas, and gastrointestinal tract, although less frequently than to the sites mentioned above.

DIAGNOSTIC AND THERAPEUTIC PROCEDURES FOR LUNG CANCER AND FOR DISEASES OF THE RESPIRATORY SYSTEM

INTERVENTIONAL PNEUMOLOGY

Interventional Pneumology is a branch of pneumology that uses minimally invasive techniques for the diagnosis and treatment of patients suffering from respiratory diseases, including lung cancer. At the IEO, an outpatient clinic of interventional pulmonology offers state-of-art minimally invasive procedures for patients requiring a preliminary evaluation, before surgical procedures are performed. The IEO interventional pneumology program started in 2010, to provide a diagnostic and therapeutic service at the forefront of pulmonary medicine. The Division of Interventional Pneumology annually performs more than 700 operational bronchoscopy procedures for the diagnosis and treatment of lung cancer patients. The interventional pulmonologists work within the Thoracic Surgery Division and collaborate with many specialists (radiation oncologists, medical oncologists and other surgical specialties) for the diagnosis and treatment of lung cancers.

EBUS-TBNA (TRANS-BRONCHIAL ULTRASOUND)

EBUS (Endo-bronchial Ultrasound) is a minimally invasive bronchoscopy technology that allows the respiratory specialist to visualize the central structures of the mediastinum and peripheral lung parenchyma, otherwise not accessible with traditional bronchoscopy, using an ultrasound probe.

EBUS is used in many suspected or confirmed cases of lung cancer for the evaluation of lung nodules and/or enlarged mediastinal lymph nodes and for the diagnosis of benign pulmonary and mediastinal diseases such as thymomas, tuberculosis and sarcoidosis. In Thoracic Oncology, EBUS is a useful tool for mediastinal staging, to further guide treatment decision-making.

The procedure does not require general anesthesia and is performed under sedation by the anesthesiologist, to ensure safety alongside avoiding patient discomfort during the procedure.

EBUS significantly increases the diagnostic accuracy of transbronchial biopsies under fluoroscopic guidance and transbronchial needle aspiration.

At the IEO, EBUS-TBNA bronchoscopies are performed in collaboration with a pathologist in the endoscopy room, who can provide immediate evaluation of the sample material (ROSE: Rapid on-site cytologic Evaluation). EBUS-TBNA is also an excellent method to obtain new tissue biopsies in cancer patients, to improve the disease histological and molecular characterization.

RIGID BRONCHOSCOPY

Rigid bronchoscopy is performed under general anesthesia, to obtain the clearance of major airways, such as the trachea and main bronchi, that may have been obstructed by intra-luminal lung cancer, thereby restoring their patency. Lesions are typically mechanically removed or treated with laser therapy. For patients with intra-luminal lesions resistant to complete recanalization or experiencing trachea-bronchial tree distortion due to extrinsic compression, endo-bronchial stents may be strategically placed for palliative purposes.

PLEURAL MEDICAL INSPECTION

Pleuroscopy plays a pivotal role in thoracic oncology by providing minimally invasive access to the pleural cavity for diagnostic and therapeutic interventions. Through a small incision, a thin, flexible tube with a camera attached (pleuroscope) is inserted, enabling visualization of the pleura and associated structures. This procedure aids in obtaining biopsies of pleural lesions, staging of lung cancer, and assessing pleural effusions. Additionally, pleuroscopy allows for the instillation of medications directly into the pleural space and the drainage of fluid or air, contributing to improved patient outcomes and management of thoracic malignancies.

CHEST COMPUTED TOMOGRAPHY (TC)

Chest computer tomography (CT) is crucial in lung cancer diagnosis, as it offers detailed images of the lungs and surrounding structures. It can be used to detect tumors, determining their size, location and spread, to further guide treatment decisions, disease monitoring and response to therapy. 

The CT scan of the brain and the abdomen completes staging, to determine the presence of suspected distant metastases.

POSITRON EMISSION TOMOGRAPHY (PET)

Positron emission tomography (PET) with 18-fluorodeoxyglucose (18-FDG) is pivotal in lung cancer diagnosis and monitoring treatment response as it provides functional imaging by detecting metabolic activity. PET scans can distinguish between benign and malignant lesions, identify distant metastases and aid in staging lung cancer, guiding treatment decisions for optimal patient management.

FINE-NEEDLE ASPIRATION/TRANS-THORACIC BIOPSY

CT-guided fine needle aspiration biopsy and transthoracic biopsy are particularly useful when the lesion is accessible from the outside of the chest wall.

DIAGNOSIS OF NON-SMALL CELL LUNG CANCER

The diagnostic process for a pulmonary nodule typically involves several steps to determine the nature of the nodule and whether it is benign or malignant. According to national and international guidelines, the diagnostic workflow commonly includes:

1. Clinical evaluation: a detailed medical history and a complete physical examination allow to assess the patient's overall health and identify any risk factors for lung cancer, such as smoking history or exposure to environmental toxins.
2. Multidisciplinary discussion: the collaboration between multiple healthcare professionals ensures an accurate diagnosis and the appropriate management plan for each patient.
3. Imaging studies: computed tomography (CT) scans are often performed to detect and evaluate pulmonary nodules. CT scans provide detailed images of the lungs and can help determine the size, location, and characteristics of the nodule.
4. Further imaging: if the initial imaging studies reveal a suspicious nodule, additional imaging tests such as positron emission tomography (PET) scans may be performed to assess the metabolic activity of the nodule and its potential for malignancy.
5. Cardio-pulmonary function tests: also known as pulmonary function tests (PFTs), assess how well the lungs and heart are functioning together to provide oxygen to the body and remove carbon dioxide.
6. Biopsy: if the imaging studies suggest that the nodule may be cancerous, a biopsy may be performed to obtain a tissue sample for further analysis. Biopsy techniques may include bronchoscopy (using a thin, flexible tube inserted into the airways) or needle biopsy (using a needle inserted through the chest wall) or surgical biopsy (removing a tissue sample during surgery under general anesthesia through a minimally invasive video-assisted technique).
7. Pathological evaluation: the tissue sample obtained during the biopsy is examined by a pathologist under a microscope to determine whether the nodule is benign or malignant. This evaluation may also include molecular testing to identify specific genetic mutations associated with lung cancer.
8. Follow-up imaging: If the nodule is determined to be benign, regular follow-up imaging may be recommended to monitor for any changes in size or appearance. If the nodule is malignant, further tests may be performed to determine the stage of the cancer and develop an appropriate treatment plan.

Surgical biopsy for suspected lung cancer may be indicated in cases where less invasive procedures, such as bronchoscopy or needle biopsy, yield inconclusive results or provide inadequate tissue samples for analysis. Additionally, surgical biopsy may be considered when the suspected lung nodule is located in a challenging or inaccessible area, or if it is too small to be sampled safely using less invasive techniques. In such cases, an intraoperative pathology evaluation is performed to obtain histological diagnosis and, in case lung cancer is confirmed, surgery is performed. Ultimately, the decision to perform a surgical biopsy is based on various factors and is typically made by the multidisciplinary team.

TREATMENT STRATEGIES FOR EARLY NON-SMALL CELL LUNG CANCER

Surgical treatment options for early-stage non-small cell lung cancer (NSCLC), namely stage I-II NSCLC, typically involve the removal of the tumor and surrounding tissue through surgery. The main surgical approaches for early-stage NSCLC, either performed through video-assisted thoracoscopy (VATS) or thoracotomy, include:

• Lobectomy: it involves the removal of the entire lobe of the lung containing the tumor. A lobectomy is often recommended when the tumor is localized in one lobe, or two lobes (bi-lobectomy), and can be safely removed while preserving adequate lung function.
• Segmentectomy: in cases where the tumor is small and located in a specific segment of the lung. This procedure involves removing only the affected segment of the lung while preserving the rest of the lung tissue. Segmentectomy may be considered when preserving lung function is particularly important, such as in patients with limited lung reserve or compromised pulmonary function.
• Wedge resection: it can be considered for very small tumors or patients with limited lung function who may not tolerate more extensive surgery. This procedure involves removing only the tumor and a small margin of surrounding healthy tissue.
• Pneumonectomy: in rare cases where the tumor involves the entire lung or is located centrally and cannot be removed with a lobectomy or segmentectomy, a pneumonectomy may be necessary. This procedure involves removing the entire lung affected by cancer and can be associated with a higher risk of complications and reduced lung function compared to other surgical approaches. It is typically reserved for selected patients, when no other options are feasible.
• Sleeve resection, also known as bronchial sleeve resection or bronchoplasty: it is typically performed when the tumor or lesion is located near the main bronchus and involves a segment of the bronchial wall and requires the removal of a portion of a damaged segment of the main bronchus while preserving the continuity of the airway. This procedure preserves as much lung tissue and function as possible while effectively treating conditions such as lung cancer, bronchial stenosis (narrowing of the bronchus), or bronchiectasis (chronic dilation of the bronchial tubes). Benefits of sleeve resection include preservation of lung function, reduced risk of postoperative complications compared to more extensive lung resections, and improved quality of life.

The choice of the surgical approach depends on factors such as the size and location of the tumor, the patient's overall health and lung function, and the goals of the treatment. It is important for patients to discuss the potential risks and benefits of each surgical option with their healthcare team to determine the most appropriate treatment plan for their individual circumstances.

Lymphadenectomy, also known as lymph node dissection, is a surgical procedure performed during surgery to remove lymph nodes in the mediastinum (the area between the lungs) and assess whether cancer has spread to these lymph nodes. The role of lymphadenectomy in NSCLC surgery is multifaceted and includes accurate disease staging, prognostic evaluation and reducing the risk of locoregional recurrence while improving the chances of long-term disease control.

Patients undergoing lung cancer surgery with a curative intent must undergo pulmonary function tests prior to treatment as well as cardiac and anesthesia assessments in order to exclude from surgery those patients that could be at high risk of developing severe consequences after thoracic surgery.

The treatment of stage IIIA NSCLC requires a multidisciplinary approach with the collaboration of thoracic surgeons, medical oncologists, radiation oncologists and pneumologists:

• Chemoradiotherapy (CRT): concurrent CRT involves the administration of chemotherapy along with radiation therapy, typically delivered simultaneously over several weeks. Chemotherapy helps to sensitize the cancer cells to the effects of radiation, leading to improved tumor control. Chemoradiotherapy may be followed by consolidation immunotherapy in selected patients.
• Surgery followed by adjuvant therapy: For selected patients with resectable stage IIIA NSCLC, surgery may be performed, followed by adjuvant therapy to reduce the risk of disease recurrence. Adjuvant therapy may include chemotherapy, radiation therapy, targeted therapy, immunotherapy or a combination of them, depending on the extent of lymph node involvement, molecular biology and other risk factors. Patient’s selection is required.
• Neoadjuvant therapy followed by surgery: In some cases, neoadjuvant therapy (chemotherapy or chemoradiotherapy given before surgery) may be recommended to downstage the tumor and improve the chances of successful surgical resection. Neoadjuvant therapy may be followed by surgery to remove the remaining tumor and involved lymph nodes.

TREATMENT STRATEGIES FOR LOCALLY ADVANCED, NON-RESECTABLE NON-SMALL CELL LUNG CANCER

The treatment of locally-advanced non-resectable non-small cell lung cancer (NSCLC) typically involves a combination of chemotherapy, radiation therapy, and in some cases immunotherapy upon completion. The goal of treatment is to control the growth of the cancer, alleviate symptoms, and improve overall survival. Here are the main treatment modalities for locally-advanced non-resectable NSCLC:

• Chemoradiotherapy (CRT): Concurrent chemoradiotherapy is considered the standard approach and involves the administration of chemotherapy along with radiation therapy, typically delivered simultaneously over several weeks. Chemoradiotherapy may be followed by consolidation immunotherapy in some cases.
• Radiation therapy: External beam radiation therapy (EBRT) is commonly used to deliver high-dose radiation to the tumor and nearby lymph nodes. It may be given alone or in combination with chemotherapy. Stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) may also be considered for selected patients with limited metastatic disease or oligometastases.

THERAPY OF ADVANCED NON-SMALL CELL LUNG CANCER

Overall, the treatment landscape for NSCLC is characterized by personalized, multimodal, and innovative approaches aimed at maximizing therapeutic efficacy, minimizing treatment-related toxicities, and improving survival outcomes for patients across all stages of the disease. Rapid advancements in precision medicine and immunotherapy hold promise for further improving the prognosis and quality of life for individuals with NSCLC.

Molecular and PD-L1 testing plays a central role in the personalized management of NSCLC (see Thoracic Oncology, Treatment of Lung Cancer). Indeed, it allows a more specific treatment selection, predicting treatment response, monitoring treatment resistance, and providing valuable prognostic information. Incorporating molecular testing into routine clinical practice enhances treatment decision-making, improves patient outcomes, and contributes to the advancement of precision medicine in NSCLC care.

ROLE OF RADIOTHERAPY IN NON-SMALL CELL LUNG CANCER

Overall, the decision to include radiotherapy as part of the treatment plan in NSCLC depends on factors such as tumor size, location, histology, disease stage, patient comorbidities and treatment goals.

• Definitive (curative) radiotherapy: for patients who are not candidates for surgery due to comorbidities, poor lung function, or patient preference, definitive radiotherapy may be used as the primary treatment. High-dose radiation therapy is delivered to the tumor and surrounding tissues with the goal of eradicating cancer cells while preserving normal lung function. Definitive radiotherapy may be delivered alone or in combination with chemotherapy (concurrent chemoradiotherapy) for enhanced tumor control.
• Adjuvant radiotherapy: in selected cases where surgery has been performed but there is a high risk of local recurrence, adjuvant radiotherapy may be recommended to reduce the risk of recurrence and improve long-term disease control. Adjuvant radiotherapy is typically delivered to the surgical bed and regional lymph nodes to target any residual cancer cells that may remain after surgery.
• Palliative radiotherapy: in cases where the tumor is causing symptoms such as pain, dyspnea (difficulty breathing), or hemoptysis (coughing up blood), palliative radiotherapy may be used to alleviate symptoms and improve quality of life. Radiotherapy can be used to treat symptomatic bone metastases and brain metastases.

THERAPY OF SMALL CELL LUNG CANCER

SCLC is often aggressive and tends to spread quickly to other organs, therefore treatment is usually aimed at controlling the disease and alleviating symptoms. The choice of treatment for SCLC depends on factors such as the stage of the disease, tumor size and location, overall health and functional status of the patient, and treatment goals.

For patients with limited-stage small cell lung cancer (SCLC), which is confined to one side of the chest and can be encompassed within a tolerable radiation field, the treatment typically involves a combination of chemotherapy and thoracic radiation therapy. The goal of treatment is to achieve local control of the disease, prevent distant metastasis, and improve overall survival.

• Chemotherapy, most commonly platinum-based chemotherapy (such as cisplatin or carboplatin) in combination with etoposide. Chemotherapy is usually administered intravenously in cycles over a period of several weeks, with rest periods in between to allow the body to recover from treatment-related side effects.
• Thoracic radiation therapy: Concurrent thoracic radiation therapy is typically administered along with chemotherapy for patients with limited-stage SCLC. Radiation therapy is delivered to the primary tumor in the lung as well as any involved lymph nodes in the chest. The goal of radiation therapy is to shrink the tumor, prevent local recurrence, and improve overall disease control. Radiation therapy may be given using external beam radiation therapy (EBRT) or intensity-modulated radiation therapy (IMRT), depending on the size and location of the tumor.

Prophylactic cranial irradiation is a type of radiation therapy that may be recommended for patients with limited-stage SCLC who have had a good response to initial treatment. PCI involves delivering low-dose radiation to the brain to reduce the risk of developing brain metastases, which are common in SCLC. PCI has been shown to improve overall survival and reduce the incidence of brain metastases in patients with limited-stage SCLC.

For patients with extensive-stage small cell lung cancer, which has spread beyond one side of the chest to distant sites in the body, the treatment typically involves systemic chemotherapy in combination with immunotherapy along with supportive care to manage symptoms and improve quality of life. Unlike limited-stage SCLC, the treatment approach for extensive-stage SCLC is focused on controlling the spread of the disease and alleviating symptoms.

LOCO-REGIONAL TREATMENT AND OTHER TREATMENTS FOR LUNG CANCER METASTASES

Beyond palliative radiotherapy, surgical approaches can be considered for the treatment of contralateral lung, bones and other metastatic sites, provided that these indications are discussed within a multidisciplinary team.

Furthermore, systemic treatments for extensive bone lesions are available and can be discussed with the medical team, when indicated.