Non-Small Cell Lung Cancer

• Understanding the disease
• Treatment options
• Side effects of treatment

Stephen Shamp, MD MSEE

David Bloom, MD PhD

Matthew Culbert, MD

Understanding Lung Cancer

Types of Lung Cancer

• Non-small cell carcinoma (NSCC) (87%)
• Adenocarcinoma (38%)
• Squamous cell (20%)
• Large cell (5%)
• Small cell carcinoma (13%)

Three lobes on the right and two on the left

(RUL)

(RML)

(RLL)

(LUL)

(LLL)

Importance of the Lymph Nodes

Spread to the Nodes on the side (hilar or N1 or Stage II ) is not as serious as if nodes in the middle or higher up are involved (N2 or mediastinal nodes or Stage III)

www.nccn.org

Treatment of Lung Cancer

• Stage I and II – surgery (if possible) and sometime Post-Operative chemotherapy or radiation. Radiation often used if inoperable
• Stage III – usually chemo plus radiation, sometime followed by surgery or immunotherapy
• Stage IV – systemic therapy or radiation, depending on the site of spread

When is Radiation Used?

Depending on the stage of the non-small cell lung cancer (NSCLC) and other factors, radiation therapy might be used:

• As the main treatment (sometimes along with chemotherapy), especially if the lung tumor can’t be removed because of its size or location, if a person isn’t healthy enough for surgery, or if a person doesn’t want surgery.
• After surgery (alone or along with chemotherapy) to try to kill any small areas of cancer that surgery might have missed.
• Before surgery (usually along with chemotherapy) to try to shrink a lung tumor to make it easier to operate on.
• To treat cancer spread to other areas such as the brain or bone.
• To relieve (palliate) symptoms of advanced NSCLC such as pain, bleeding, trouble swallowing, cough, or problems caused by spread to other organs such as the brain.

CT simulation (planning session)

• We will build a cradle to hold you in the same position with each treatment.
• Temporary or permanent marks will be made
• CT images are obtained and then imported into the treatment planning computer
• 4D-CT and/or abdominal compression can be used to allow for tumor to be target while you breathe

RapidArc IMRT Stage III NSCLC

SBRT Stage I NSCLC

Logistics of 60Gy/30fx CRT treatment:

• Usually 30 daily treatments, starting the same day as chemotherapy (if recommended)
• Treatment days are Monday-Friday 5 days per week, 6 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

Logistics of SBRT treatment:

• Usually 3-5 treatments
• Treatment days are Monday-Friday, 3 days per week
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

• Lasers and/or imaging is used to precisely deliver the daily radiation treatment.
• Expect to be on the treatment table less than 15 minutes.
• You will not feel any immediate effects.

Short Term Side Effects of Lung Radiation (usually start showing up after the second week or radiation)

• Esophagus – sore throat or trouble swallowing
• Trachea or lungs – cough or shortness of breath
• Chest wall – tenderness
• Skin – sunburn
• Fatigue�
• Your radiation oncologist will meet with you every week to help you manage side effects
• Most side effects will subside over time after completing treatment
• You may have other side effects related to chemotherapy as well

Long Term Side Effects of Lung Radiation, can show up weeks or months after completing radiation

• Esophagus – sometimes there can be prolonged irritation or stricture
• Lungs – there can be scar tissue (fibrosis) that can cause more shortness of breath or a delayed reaction (radiation pneumonitis) with fever, cough and shortness of breath
• Rare but serious complications can occur, including but not limited to secondary malignancy, cardiac toxicity, hemoptysis, brachial plexopathy, pulmonary fibrosis

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Images during radiation show tumor shrinking

Cancer on first day of radiation

Cancer halfway through

Image guided IMRT will monitor the response of the cancer as treatment proceeds.

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CT images built into the Vital Beam Linear Accelerator

cancer

Radiation low dose

Radiation high dose

Cancer Gone

Radiation inflammation

PET done at least one month after chemo- radiation

PET Scan showing near complete remission of the cancer in the right lung at 2.5 months

No longer ‘hot’

CT = large left upper lobe tumor invading the mediastinum

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CT Scan 3 years later = only scar tissue remains after chemo-radiation