eMedicine Specialties > Emergency Medicine > Hematology & Oncology
Neoplasms, Lung: Treatment & Medication
Updated: Oct 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Prehospital Care
- No specific prehospital care is needed for patients with lung cancer.
- All prehospital personnel should inquire about the patient's resuscitation directives.
Emergency Department Care
All patients thought to have lung cancer should be encouraged to obtain follow-up care with their primary care physician. In almost all cases, document the possible diagnosis and discuss it with the patient. Definitive treatment of the underlying cancer is not the purview of the ED.
Treatment is based on symptoms, as follows:
- Upper airway obstruction
- Admit the patient to the intensive care unit.
- Prepare for intubation and/or cricothyrotomy.
- Obtain ears, nose, and throat and/or surgical consultation for fiberoptic laryngoscopy or intraoperative tracheostomy.
- Hemoptysis
- Administer supplemental oxygen and perform suctioning.
- If a threat of imminent demise exists, consider placing a double-lumen endotracheal tube.
- Position the patient with the bleeding hemithorax in a dependent location.
- Perform ABG and CBC (type and crossmatching) coagulation studies if the bleeding is more than trivial.
- A pulmonologist may have to perform fiberoptic bronchoscopy.
- Admit patients, except those with the most minor bleeding, to the intensive care unit.
- Pain control: See Special Concerns for workup and treatment of patients with CNS metastasis and cancer; infections in those with immunosuppression, Pancoast tumor, or Ogilvie intestinal pseudo-obstruction; or pain in those with severe cancer.
Consultations
- Consult an oncologist if cancer is present.
- Ear, nose, and throat; thoracic; general; orthopedic; vascular; and/or neurosurgical or neurological services may be required to address complications caused by spread of the disease.
Medication
Treatment differs according to the histologic type of cancer, the stage at presentation, and the patient’s functional status.
Chemotherapeutic agents
Because of a greater emphasis on outpatient therapies, patients taking chemotherapeutic agents frequently are seen in the ED.
Gemcitabine (Gemzar)
Cytidine analog, after intracellular metabolism to active nucleotide, inhibits ribonucleotide reductase and competes with deoxycytidine triphosphate for incorporation into DNA. Cell-cycle specific for S phase.
Adult
1000 mg/m2 IV given over 30 min on days 1, 8, 15 of a 28-d cycle or 1250 mg/m2 IV on days 1 and 8 of a 21-d cycle
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause myelosuppression (particularly thrombocytopenia); toxicities include flulike syndrome, LFT abnormality, maculopapular rash, pruritus, nausea, vomiting, dyspnea, hematuria, proteinuria, and hemolytic uremic syndrome; clearance reduced in women and elderly individuals
Cyclophosphamide (Cytoxan, Neosar)
Chemically related to nitrogen mustards; as an alkylating agent, the mechanism of action of active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.
Adult
40-50 mg/kg IV in divided doses over 2-5 d; other IV regimens include 10-15 mg/kg q7-10d or 3-5 mg/kg twice weekly; oral cyclophosphamide doses usually are 1-5 mg/kg
Pediatric
Administer as in adults
Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones; chloramphenicol may increase the half-life while decreasing metabolite concentrations; may increase the effect of anticoagulants; coadministration with high doses of phenobarbital may increase the rate of metabolism and leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia and neuromuscular blockade by inhibiting cholinesterase activity
Documented hypersensitivity; severely depressed bone marrow function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Regularly examine the hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; regularly examine the urine for RBCs, which may precede hemorrhagic cystitis; adverse effects include SIADH and pneumonitis
Doxorubicin (Adriamycin, Rubex)
Inhibits topoisomerase II and produces free radicals, which may cause destruction of DNA; combination of these two events can, in turn, inhibit growth of neoplastic cells.
Adult
40-75 mg/m2 IV, depending on whether drug is used alone or in combination
Pediatric
Administer as in adults
May decrease phenytoin and digoxin plasma levels; phenobarbital may decrease plasma levels; cyclosporine may induce coma or seizures; mercaptopurine increases toxicity; cyclophosphamide increases cardiac toxicity
Documented hypersensitivity; severe heart failure; cardiomyopathy; impaired cardiac function; preexisting myelosuppression
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Irreversible cardiac toxicity and myelosuppression may occur; extravasation may result in severe local tissue necrosis; reduce dose in patients with impaired hepatic function; adverse effects include pancytopenia, ECG changes, nausea, and vomiting
Vincristine (Oncovin)
Mechanism of action is uncertain; may involve a decrease in reticuloendothelial cell function or an increase in platelet production. However, neither of these mechanisms fully explains the effect in thrombotic thrombocytopenic purpura and hemolytic uremic syndrome.
Adult
1.4 mg/m2 IV qwk
Pediatric
<10 kg: 0.05 mg/kg IV qwk
>10 kg: 2 mg/m2 IV qwk
Acute pulmonary reaction may occur when taken with mitomycin-C
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with severe cardiopulmonary or hepatic impairment and patients with preexisting neuromuscular disease; adverse effects include leukopenia, peripheral neuropathy, constipation, and abdominal pain
Etoposide (Toposar)
Inhibits topoisomerase II and causes DNA strand breakage, causing cell proliferation to arrest in the late S or early G2 portion of cell cycle; do not administer IT.
Adult
Ranges from 35 mg/m2/d for 4 d to 50 mg/m2/d for 5 d IV; PO route is twice the IV dose rounded to the nearest 50 mg
Pediatric
Administer as in adults
May prolong the effects of warfarin and increase the clearance of methotrexate; cyclosporine and etoposide have additive effects in the cytotoxicity of tumor cells
Documented hypersensitivity; IT administration may cause death
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Bleeding, severe myelosuppression, alopecia, and nausea may occur
Cisplatin (Platinol)
Inhibits DNA synthesis and, thus, cell proliferation by causing DNA cross-linking and denaturation of the double helix.
Adult
120 mg/m2 IV
Pediatric
Administer as in adults
Increases toxicity of bleomycin and ethacrynic acid
Documented hypersensitivity; preexisting renal insufficiency; myelosuppression; hearing impairment
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Ensure adequate hydration before and 24 h after cisplatin administration to reduce risk of nephrotoxicity; myelosuppression, ototoxicity, neurotoxicity, nausea, and vomiting may occur
Antineoplastic Agent, Alkylating Agent
Carboplatin
Analog of cisplatin. This is a heavy metal coordination complex that exerts its cytotoxic effect by platination of DNA, a mechanism analogous to alkylation, leading to interstrand and intrastrand DNA crosslinks and inhibition of DNA replication. Binds to protein and other compounds containing SH group. Cytotoxicity can occur at any stage of the cell cycle, but cell is most vulnerable to action of these drugs in G1 and S phase.
Has same efficacy as cisplatin but with better toxicity profile. Main advantages over cisplatin include less nephrotoxicity and ototoxicity not requiring extensive prehydration, less likely to induce nausea and vomiting, but more likely to induce myelotoxicity.
Dose is based on the following formula: total dose (mg) = (target AUC) x (GFR+25) where AUC (area under plasma concentration-time curve) is expressed in mg/mL/min and GFR (glomerular filtration rate) is expressed in mL/min.
Adult
Can be dosed on basis of body surface area, but current formulas take into account patient's renal function; one such formula is Calvert formula
Pediatric
Not established
Nephrotoxicity increases with aminoglycosides and other nephrotoxic drugs
Documented hypersensitivity; bone marrow suppression
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor bone marrow function
More on Neoplasms, Lung |
| Overview: Neoplasms, Lung |
| Differential Diagnoses & Workup: Neoplasms, Lung |
 Treatment & Medication: Neoplasms, Lung |
| Follow-up: Neoplasms, Lung |
| Multimedia: Neoplasms, Lung |
| References |
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Further Reading
Keywords
lung neoplasm, bronchogenic carcinoma, lung cancer, lung malignancy, adenocarcinoma, squamous cell carcinoma, SCC, oat cell carcinoma, large cell carcinoma, smoking, tobacco, passive smoke, secondhand smoke, SCLC, NSCLC
