What are the treatment options for a patient with hilar lung cancer?

From the Guidelines

For patients with hilar lung cancer, endosonography, specifically the combination of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic (oesophageal) ultrasound with fine needle aspiration (EUS-FNA), is recommended as the initial staging procedure over surgical staging, according to the European Respiratory Journal guidelines 1.

Treatment Options

The treatment of hilar lung cancer is multifaceted and depends on various factors including the stage of the cancer, the patient's overall health, and specific characteristics of the tumor.

• For early-stage disease, surgical resection is often considered the best option for a potential cure, with techniques such as lobectomy or pneumonectomy being employed.
• When surgery is not feasible due to the patient's health status or tumor location, definitive radiation therapy may be considered, with stereotactic body radiation therapy (SBRT) being an option for early-stage disease and conventional fractionated radiation for more advanced cases.
• Locally advanced hilar lung cancer may require a multimodal approach, including concurrent chemoradiation, with platinum-based regimens like cisplatin/etoposide or carboplatin/paclitaxel being commonly used.
• For patients with metastatic disease, systemic therapy is the mainstay of treatment, which can include targeted therapies for specific mutations (such as erlotinib for EGFR mutations or alectinib for ALK rearrangements), immunotherapy (like pembrolizumab or nivolumab), or traditional chemotherapy combinations.

Diagnostic Approach

Given the hilar location of the tumor, which is near critical structures such as major blood vessels and airways, a thorough diagnostic workup is essential.

• Pulmonary function testing is crucial before any surgical intervention to ensure that the patient will have adequate lung function post-operatively.
• The use of endosonography for staging, as recommended by the European Society of Gastrointestinal Endoscopy (ESGE) guideline in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) 1, highlights the importance of minimally invasive diagnostic techniques in the management of lung cancer.
• A multidisciplinary tumor board evaluation is vital for developing an optimal treatment plan that balances the potential for cure or control of the disease with considerations for the patient's quality of life.

Quality of Life Considerations

In the treatment of hilar lung cancer, it is essential to consider the potential impact of different therapeutic approaches on the patient's quality of life.

• This includes not only the immediate effects of treatment but also long-term outcomes and the potential for complications or side effects.
• The choice between surgical resection, radiation therapy, chemotherapy, or a combination of these should be made with careful consideration of how each option may affect the patient's functional status, symptoms, and overall well-being, as guided by the most recent and highest quality evidence available 1.

From the FDA Drug Label

In small cell lung cancer, the Etoposide Injection, USP dose in combination with other approved chemotherapeutic drugs ranges from 35 mg/m 2/day for 4 days to 50 mg/m 2/day for 5 days. The treatment options for a patient with hilar lung cancer may include etoposide as part of a combination chemotherapy regimen, with dosing ranges from 35 mg/m 2/day for 4 days to 50 mg/m 2/day for 5 days, as seen in small cell lung cancer treatment 2.

• Key considerations for etoposide administration include:
  • Dose modification for patients with renal impairment
  • Monitoring for myelosuppression and other adverse effects
  • Handling and preparation precautions to minimize exposure risk 2.

From the Research

Treatment Options for Hilar Lung Cancer

• The treatment options for hilar lung cancer depend on the type and stage of the tumor identified 3.
• For stages I through IIIA non-small cell carcinoma, surgical resection is preferred 3.
• Advanced non-small cell carcinoma is treated with a multimodality approach that may include radiotherapy, chemotherapy, and palliative care 3.
• Chemotherapy (combined with radiotherapy for limited disease) is the mainstay of treatment for small cell carcinoma 3.

Staging of Lung Cancer

• Thorough clinical staging of patients with lung cancer is important, because therapeutic options and management are to a considerable degree dependent on stage at presentation 4.
• Radiologic imaging is an essential component of clinical staging, including chest radiography in some cases, computed tomography, MRI, and PET 4.
• Multiplanar imaging modalities allow assessment of features that are important for surgical, oncologic, and radiation therapy planning, including size of the primary tumor, location and relationship to normal anatomic structures in the thorax, and existence of nodal and/or metastatic disease 4.

Role of PET-CT in Assessing Mediastinal and Hilar Lymph Node Status

• Positron emission tomography combined with computed tomography (PET-CT) is important in the assessment and workup of lung cancer staging 5.
• However, inconsistencies between clinical image results obtained and pathologic findings of surgical specimens are still very common, particularly in patients with clinical early stage lung cancer 5.
• The cut-off point of mediastinal LN SUV(max) was 1.6 calculated by receiver operating characteristic (ROC) curve, with a sensitivity of 40% and specificity of 88.7% 5.

Concurrent Pemetrexed and Radiation Therapy

• Pemetrexed can be administered safely at full systemic doses with either cisplatin or carboplatin concomitantly with radical doses of thoracic radiation therapy 6.
• The results from phase II trials suggest that this regimen has promising activity with an acceptable toxicity profile 6.
• However, the phase III PROCLAIM trial found that pemetrexed-cisplatin combined with thoracic radiation therapy followed by consolidation pemetrexed was not superior to standard chemoradiotherapy for stage III unresectable nonsquamous non-small-cell lung cancer 7.