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RFH Newsletter

Home / News and Features / Thoracic Malignancies

By Dr. Marzi Mehta,


1. Diagnostic evaluation of non-small lung cancer:

  • History and physical examination
  • ECOG scoring (performance index evaluation)
  • PET with contrast enhanced CT thorax (with special reference to thorax and upper abdomen to include adrenals)
  • Bronchoscopy: for central tumours along with bal and brushings
  • CT guided trucut biopsy for peripheral tumours or tumours not amenable to bronchoscopic biopsy
  • Ebus / mediastinoscopy: it is extremely vital to stage the mediastinum prior to surgery. The test needs to be done only for operable cases
  • Pulmonary function test with DLCO.

2. Treatment of non-small cell lung cancer:

a. Early localized:

  • Stage I NSCLC: treatment is surgery (lobectomy). This is to be done if the patient has enough respiratory reserve, i.e. expected post-operative FEV1 should be >0.8 or 40% and post-operative DLCO should be >0.8 or 40%.The Lobectomy is performed either through the conventional Thoracotomy or via VATS (Video Assisted Thoracoscopic Surgery).
  • Stage II NSCLC: surgery (conventional Thoracotomy or via VATS (Video Assisted Thoracoscopic Surgery) as for stage 1. no adjuvant therapy.

b. Locally Advanced Resectable: Stage IIIA: (T3 N1 Mx) : (T1-3 N2 Mx):

  • T3 N1: will be treated with neoadjuvant chemotherapy consisting of two cycles of chemotherapy followed by surgical resection. Adjuvant radiation in case of positive margins.
  • N2 Disease: Patients with good performance status, no contra-indication to surgery are to be treated with neoadjuvant chemotherapy for 2 cycles followed by surgery. If patient’s have low performance status or contra-indication to surgery, but have adequate pulmonary function tests then definitive chemo- radiotherapy can be done, otherwise palliative radiotherapy.


c. Locally Advanced Unresectable:

  • Patients with good performance status 0-2 and good pulmonary function tests should have combined modality therapy. The patients will receive concurrent chemotradiotherapy (both starting on day 1).
  • Patients’ poor performance status 3-4 and/or poor pulmonary function test should receive palliative radiotherapy.
  • Metastatic non-small cell lung cancer: treatment is palliative and prognosis poor. Newer targeted agents such as Gefitinib/ Afatinib for EGFR Positive, Crizotinib for ALK Positive and Nivolumab for anti-PD-1 monoclonal antibody may improve the overall survival in a select group of patients. Recurrent pleural effusion: May be subjected to a VATS Pleurodesis (Fig 4) or Pleurx catheter insertion.


1. Non Invasive Thymoma:
Surgical resection via Sternotomy or VATS Mediastinal mass resection (ENBLOC).

2. Invasive Thymoma: Stage 1:
Surgical resection as described above. Radiation therapy only if incompletely resected or poor surgical risk.

3. Stage II, III, IV:

  • Operable cases: en block resection neither through midline sternotomy or VATS with post-operative radiotherapy if positive margin.
  • Inoperable cases: like Stage III and IV will be treated with three cycles of neoadjuvant chemotherapy followed by radiation therapy and then surgical resection of residual disease if possible.

Esophageal Malignancy