Summary of Treatment Approach to Pts 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; CRx plus immune checkpoint inhibition for selected pts | |||
| 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 or CRx plus immune checkpoint inhibition 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 with or without immune checkpoint inhibition | |||
| 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 | |||
| Ceritinib or brigatinib, alk inhibitors | |||
| 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 | |||