Chirurgie

Lung cancer: increasingly personalized treatments

Mathilde Regnault
08/24/2017
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The therapeutic decisions are made during multidisciplinary consultation meetings with pneumologist, oncologist, surgeon, radiotherapist, radiologist, nuclear physician and anatomopathologist.

The aim is to individualize the treatment, by taking account of recommendations according to regional, national and international references, of the possibility of taking part in a therapeutic trial protocol, and of the patient’s overall state of health and wishes.

 

Treatment of small cell lung cancer

Two thirds of small cell lung carcinoma are diagnosed at the metastatic stage.

Chemotherapy is the primary treatment for small cell cancer. Given rapid cell growth the existence of concealed metastases is likely, hence chemotherapy is used regardless of the stage. Treatment of small cell lung cancer is considered to be a relative therapeutic emergency.

Treatment of small cell cancer located in the chest is based on chemotherapy and radiotherapy. There are very few surgical indications in small cell cancers.

Treatment of metastatic small cell cancer is based on chemotherapy alone.

No targeted therapy is indicated to date in the treatment of small cell cancer, but certain specific signaling pathway inhibitors, such as DLL-3, are being studied. Immunotherapy is also assessed in small cell cancers.

 

Treatment of non-small cell lung carcinoma

Excision surgery - removal of the tumor - remains the only curative treatment for non-small cell lung cancer. Surgery is the primary treatment in stage I and II cancers, and has an important role for certain stage-III cancers, combined with chemotherapy and radiotherapy.

The traditional approach is posterolateral thoracotomy. The extent of the excision depends mainly on the size of the tumor, its location and the extent of the spread to the lymph nodes or neighboring organs. In fact, most patients today can be operated on first through minimally-invasive surgery (thoracoscopy, video-assisted surgery), with simpler postoperative recovery, and a faster return to normal.

Postoperative chemotherapy and/or postoperative radiotherapy may be discussed, depending on the analysis of the removed tissues.

In patients for whom surgery presents a high risk, stereotaxic radiotherapy can be used, involving radiation highly focused on the lung tumor; this is as effective as surgery in this context.

For inoperable stage-III tumors, the use of chemotherapy combined with radiotherapy is the current standard treatment.

For stage-IV tumors, associated with metastases, treatment is general and involves chemotherapy, immunotherapy and targeted therapies.

If the tumor presents a molecular oncogenic anomaly, treatment is based on targeted biotherapy against this anomaly. The molecular anomalies for which targeted treatments are now available are mutations of EGFR, MET and BRAF, and rearrangements of ALK and ROS1. Characterization of these anomalies is essential as soon as the diagnosis is made. Using new generation sequencing (NGS), it is now possible to identify other molecular anomalies, that can be targeted by medications as part of therapeutic trial protocols. The benefit of these precision therapeutic approaches is that treatment can be personalized.

If the tumor expresses target markers of immunotherapy, such as PD-L1, the treatment involves immunotherapy, which may be administered as soon as the diagnosis is made or following the first chemotherapy treatment. Immunotherapy produces prolonged responses, by stimulating the patient’s immune system, with toxicity levels lower than those of chemotherapy.

Chemotherapy remains the standard treatment for non-small cell lung cancers, and may be used in combination with targeted therapies and immunotherapy, as part of sequential treatment strategies, adapted to the histology of the tumor. Chemotherapy may also be combined with anti-angiogenic treatments, which destroy the blood vessels around the tumor, thus asphyxiating it.