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Kufe DW, Pollock RE, Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker; 2003.

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Holland-Frei Cancer Medicine. 6th edition.

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Performance status

, MD, , MD, , MD, PhD, , MD, and , MD.

In both NSCLC and SCLC, the patient's functional status or performance status (PS) is a key determinant of not only the patient's ability to undergo therapy, but also the patient's prognosis. PS is a general measure of a patient's physiologic status, taking into account the cancer and its associated effects along with other concurrent medical problems, such as cardiac or pulmonary disease. The PS is measured by two scales, the Zubrod and the Karnofsky (Table 92-10).

Table 92-10. Performance Status Scales.

Table 92-10

Performance Status Scales.

Patients who are fully ambulatory and either asymptomatic (PS 0) or mildly symptomatic but fully ambulatory (PS 1) usually tolerate therapy well. Patients who are symptomatic and in bed less than 50% of the day (PS 2) do not tolerate therapy as well and are at higher risk for complications due to chemoradiotherapy and usually are not surgical candidates. Patients who are symptomatic and in bed more than 50% of the day but not bedridden (PS 3) and those patients who are bedridden (PS 4) usually are not candidates for therapy. Introduction of measures to correct medical problems, such as infection, anemia, electrolytes, malnutrition, and cardiac dysfunction, may improve the PS to permit therapy.

In a study of more than 5,000 patients entered into the VALG protocols between 1968 and 1978, 77 prognostic factors were analyzed (see Table 92-10).302 The most important prognostic factors were performance status at the time of diagnosis. In addition, extent of disease, weight loss greater than 10% in the previous 6 months, and the presence of any systemic symptoms were identified as key prognostic factors.

General Guidelines for Lung Cancer Management

General management guidelines used at our institution for the management of patients with lung cancer are shown in Figures 92-9, 92-10, 92-11, and 92-12. Patients who present with a new lung lesion and no evidence of metastatic disease by history, physical examination, or chest radiography should undergo CT scanning of the chest, including the liver and adrenal glands. Sputum cytology can provide a diagnosis in about 10% of patients; it is more sensitive in patients with central lesions. A diagnosis can also be obtained by fiber optic bronchoscopy (FOB) or fine-needle aspiration (FNA) as discussed previously. In some circumstances, when a clinical stage I malignancy is suspected, invasive diagnostic studies can be waived, and the patient can undergo resection for diagnosis and treatment. If a resection beyond a lobectomy is required or if the patient is a high surgical risk, it is best to attempt to diagnose the lesion preoperatively. If the patient requires a pneumonectomy, a cancer diagnosis should be made before proceeding with the resection.

Figure 92-9. Adapted from the M.

Figure 92-9

Adapted from the M.D. Anderson Cancer Center lung cancer guidelines. General guidelines for non-small-cell lung cancer, part 1. CBC = complete blood count; CT = computed tomography; CXR = chest radiography; ECG = electrocardiogram; hx = history; LDH = (more...)

Figure 92-10. Adapted from the MD Anderson Cancer Center lung cancer guidelines.

Figure 92-10

Adapted from the MD Anderson Cancer Center lung cancer guidelines. General guidelines for non-small-cell lung cancer, part 2. CBC = complete blood count; CT = computed tomography; CXR = chest radiography; ECG = electrocardiogram; hx = history; LDH = lactate (more...)

Figure 92-11. Adapted from the MD Anderson Cancer Center lung cancer guidelines.

Figure 92-11

Adapted from the MD Anderson Cancer Center lung cancer guidelines. General guidelines for small-cell lung cancer, part 1. CBC = complete blood count; CT = computed tomography; CXR = chest radiography; ECG = electrocardiogram; FNA = fine-needle aspiration; (more...)

Figure 92-12. Adapted from the MD Anderson Cancer Center lung cancer guidelines.

Figure 92-12

Adapted from the MD Anderson Cancer Center lung cancer guidelines. General guidelines for small-cell lung cancer, part 2. BUN = blood ureanitrogen; CBC = complete blood count; CT = computed tomography; CXR = chest radiography; ECG = electrocardiogram; (more...)

Asymptomatic patients who have no abnormal results on physical examination and who are potential surgical candidates with clinical stage I, stage II, or stage IIIA (N0 or N1) disease can proceed to resection. Patients with chest CT scan evidence of metastatic disease, particularly N2 or N3 disease, should undergo invasive studies, which may include cervical mediastinoscopy. In some instances, FNA can be performed. For patients with potentially resectable stage III disease, the status of the mediastinal lymph nodes is the most important factor in determining therapy. If the lymph nodes are radiographically enlarged (>1 cm in cross-sectional diameter), histologic or cytologic evaluation is necessary prior to proceeding to thoracotomy. Evidence of improved outcome using neoadjuvant chemotherapy in this population has allowed some of these patients to come to resection. Randomized trials and institutional series have sought several different treatment strategies for potentially resectable stage IIIA (N2) disease: preoperative chemotherapy and/or radiation therapy, or chemotherapy and radiation therapy with no surgery. These studies will be discussed in more detail later in this chapter. If N3 (stage IIIB) disease is discovered, nonoperative management is appropriate.

If a diagnosis of SCLC is made, a thorough search for metastatic disease should be undertaken followed by appropriate treatment in the form of chemotherapy or chemoradiotherapy. Only in rare circumstances, 5% of cases, can a patient with SCLC be considered for surgical intervention because of very early-stage disease, that is, disease confined only to the lung without evidence of N or M disease.

If the history and physical examination are suggestive of metastatic disease, other noninvasive staging studies directed to the area of concern should be performed. In addition to a chest CT scan, these studies may include a PET scan, a CT scan of the brain, bone scan, and a CT scan of the abdomen if the CT scan of the chest did not include the liver and adrenal glands. The bone scan remains the most sensitive imaging study to detect skeletal metastases. However, there can be an apparent 50% false-positive rate.303 Bone scan will detect metastases in only 3% to 4% of asymptomatic patients, most of whom will have other foci of metastases.304 Bone scanning in asymptomatic patients should generally be reserved for those patients with locally advanced (T3, T4, or N2) or stage IV disease. These scans can be helpful in determining unsuspected sites of metastases. Should such areas be identified, they should be confirmed radiologically and, if need be, by histologic or cytologic confirmation.

Upper abdominal CT scans do not need to be routinely performed for patients with clinical stage I or stage II disease. Extrathoracic metastases are unusual under such circumstances. In patients with potentially resectable disease, one series showed that 12% of the patients had unsuspected hepatic involvement.304 In the same series, unsuspected adrenal metastases were identified in 8% of patients. In another consecutive series of 172 patients who underwent adrenal CT scanning, 12% had metastatic disease; more than one-half of those patients had no other identifiable site of disease, and all were confirmed cytologically by FNA biopsy.305 Approximately 10% of all lung cancer patients have central nervous system metastases at the time of diagnosis.306 CNS metastases are most commonly seen in patients with SCLC. Occult brain metastases will be present in approximately 3% to 6% of patients with NSCLC.304,307 CT scanning of the brain identified a 13% incidence of metastases in patients being evaluated for resection, although only 21% of these were unsuspected by virtue of an unremarkable neurologic examination.304 Because of this low incidence of occult brain metastases, particularly in patients with early clinical stages of disease, routine brain CT scanning is not performed.

In patients with locally advanced (T3, T4, or N2) or stage IV disease, a CT scan of the brain and a bone scan are essential. These should be performed, even if extensive disease elsewhere has been confirmed. The discovery of brain metastases will alter the type of therapy. Brain MRI is probably more sensitive than CT for identifying and diagnosing asymptomatic metastatic disease to the brain, but its role in routine staging remains to be defined.

By agreement with the publisher, this book is accessible by the search feature, but cannot be browsed.

Copyright © 2003, BC Decker Inc.
Bookshelf ID: NBK13476

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