Summary of Treatment Approach to Patients with Lung Cancer
| Non-Small-Cell Lung Cancer |
| Stages IA, IB, IIA, IIB, and some IIIA: |
| Surgical resection for stages IA, IB, IIA, and IIB |
| Surgical resection with complete-mediastinal lymph node dissection and consideration of neoadjuvant CRx for stage IIIA disease with “minimal N2 involvement” (discovered at thoracotomy or mediastinoscopy) |
| Consider postoperative RT for pts found to have N2 disease |
| Stage IB: discussion of risk/benefits of adjuvant CRx; not routinely given |
| Stage II: Adjuvant CRx |
| Curative potential RT for “nonoperable” pts |
| Stage IIIA with selected types of stage T3 tumors: |
| Tumors with chest wall invasion (T3): en bloc resection of tumor with involved chest wall and consideration of postoperative RT |
| Superior sulcus (Pancoast's) (T3) tumors: preoperative RT (30-45 Gy) and CRx followed by en bloc resection of involved lung and chest wall with postoperative RT |
| Proximal airway involvement (<2 cm from carina) without mediastinal nodes: sleeve resection if possible preserving distal normal lung or pneumonectomy |
| Stages IIIA “advanced, bulky, clinically evident N2 disease” (discovered preoperatively) and IIIB disease that can be included in a tolerable RT port: |
| Curative potential concurrent RT + CRx if performance status and general medical condition are reasonable; otherwise, sequential CRx followed by RT, or RT alone |
| Stage IIIB disease with carinal invasion (T4) but without N2 involvement: |
| Consider pneumonectomy with tracheal sleeve resection with direct reanastomosis to contralateral mainstem bronchus |
| Stage IV and more advanced IIIB disease: |
| RT to symptomatic local sites |
| CRx for ambulatory pts; consider CRx and bevacizumab for selected pts |
| Chest tube drainage of large malignant pleural effusions |
| Consider resection of primary tumor and metastasis for isolated brain or adrenal metastases |
| Small-Cell Lung Cancer |
| Limited stage (good performance status): combination CRx + concurrent chest RT |
| Extensive stage (good performance status): combination CRx |
| Complete tumor responders (all stages): consider prophylactic cranial RT |
| Poor-performance-status pts (all stages): |
| Modified-dose combination CRx |
| Palliative RT |
| Bronchioloalveolar or Adenocarcinoma with EGF Receptor Mutations or ALK rearrangements |
| Gefitinib or erlotinib, inhibitors of EGF receptor kinase activity |
| Crizotinib, an alk inhibitor, or ceritinib |
| All Pts |
| RT for brain metastases, spinal cord compression, weight-bearing lytic bony lesions, symptomatic local lesions (nerve paralyses, obstructed airway, hemoptysis, intrathoracic large venous obstruction, in non-small-cell lung cancer and in small-cell cancer not responding to CRx) |
| Appropriate diagnosis and treatment of other medical problems and supportive care during CRx |
| Encouragement to stop smoking |
| Entrance into clinical trial, if eligible |
Abbreviations: CRx, chemotherapy; EGF, epidermal growth factor; RT, radiotherapy.