Derived and updated by consensus of members of the Providence Thoracic Oncology Work Group with the aid of evidence-based American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN) national guidelines and National Guidelines Clearing House.
General Principles:
All lung cancer patients are reviewed in a multidisciplinary lung cancer conference with subsequent recommendations communicated to the referring physician.
All eligible patients should be offered participation in clinical trials.
All patients being considered for resection with mediastinal nodes >1 cm or radiographically suspicious on CT scan and/or PET, must undergo pathologic staging of the mediastinum prior to resection of the primary tumor.
Patients with small, positive N2 nodes should be entered into clinical trials or undergo preoperative chemo and/or radiotherapy prior to resection or if unresectable or inoperable should be treated with chemoradiotherapy with curative intent if comorbidities allow.
Patients with multiple or bulky, biopsy-proven mediastinal adenopathy are generally considered unresectable even if N2 and should be treated with chemoradiotherapy with curative intent if comorbidities allow.
All patients with centrally located tumors or T3 tumors must undergo pathologic staging of the mediastinum prior to resection, regardless of the presence or absence of suspicious nodes in the mediastinum on CT scan and/or PET.
Clinical, functional, quality of life and satisfaction outcomes should be documented in all patients.
Smoking cessation should be discussed with all actively smoking patients, regardless of disease stage.
Evaluation:
All suspected lung cancer patients should have a CT scan of the chest through the liver and adrenals with contrast (unless contraindicated) and laboratory tests including a blood count, chemistries, liver function tests and serum calcium.
Evaluation of patients with other than clinical T1N0 lesions should include biopsy prior to resection when feasible. Biopsy can be accomplished by CT-guided FNA for accessible lesions, by bronchoscopy for central lesions or if the patient has hemoptysis or obstructive airway symptoms, or by EUS-guided biopsy of accessible nodes or mediastinoscopy.
Patients with abnormal alkaline phosphatase, serum calcium or bony pain should undergo bone scanning.
Patients with neurologic symptoms and those with small cell lung cancer or adenocarcinoma should undergo MRI of the brain unless contraindicated and brain MRI should be considered in patients with large tumors or involved lymph nodes or other evidence of metastatic disease outside the chest.
Patients being considered for surgery should undergo complete pulmonary physiologic evaluation, cardiac risk assessment and PET evaluation prior to surgery.
Lobectomy is superior to lesser resection and should be used unless contraindicated or unless within the context of a clinical trial.
All resected patients should consult with a medical oncologist to discuss adjuvant therapy and for patients with other than stage IA disease, consultation may be considered preoperatively to assess clinical trial eligibility.
Non-small Cell Lung Cancer:
T1N0M0:
Consider clinical trial participation.
Resection after negative mediastinal node dissection.
Refer for postoperative chemoprevention studies, if available.
Definitive radiation therapy, if medically inoperable.
T2N0M0; T1N1M0; T2N1M0:
Consider clinical trial participation.
Consider neoadjuvant chemotherapy for bulky lesions after mediastinal staging if patient is eligible for neoadjuvant clinical trials.
Resection after negative mediastinal node dissection.
Discuss participation in adjuvant or neoadjuvant chemotherapy trials before resection if possible.
Refer for discussion of adjuvant chemotherapy trials within 3 weeks of surgery.
Consider radiotherapy for positive margins.
T3N0M0:
Consider clinical trial participation.
Consider induction therapy if questionably resectable due to location, chest wall involvement or PFTs.
Resection if after prior negative mediastinal node surgical evaluation or if following induction therapy.
Refer for radiation for positive margins.
Consider primary chemo/RT for extensive chest wall involvement.
Refer for discussion of adjuvant chemotherapy, on or off clinical trial, within 3 weeks of surgery.
T3N1M0, T1-3N2M0:
Consider clinical trial participation.
Staging of the mediastinum requires biopsy.
ECOG performance status less than or equal to 2:
Non-bulky N2 nodes (resectable) – Refer for induction therapy on a clinical trial if available. If ineligible or refuses, consider therapy off protocol. Patients with positive N2 nodes after resection should be considered for adjuvant radiation therapy for local control.
All patients (N2 or otherwise) should be considered for adjuvant chemotherapy.
Bulky N2 nodes (unresectable) – consider investigational protocols or combined modality definitive therapy with chemoradiotherapy off study if ineligible or refuses.
ECOG performance status greater than 2:
Radiotherapy or palliative care (interventional airway techniques).
Clinical trials if available.
Biological therapy if available.
T4N0-3,M0(exceptmalignant effusion):T1-3N3M0: ECOG performance status less than or equal to 2:
Consider for clinical trials.
Combined modality chemoradiotherapy, if ineligible or refuses.
ECOG performance status greater than 2:
Radiotherapy or palliative care as above.
Clinical trials if available.
Biological therapy if available.
T1-2N0-1M1with solitarymetastasis: ECOG performance status less than or equal to 2:
Thorough metastatic work-up.
Consider metastasectomy followed by resection of the primary lesion.
Consider use of radiosurgery for isolated brain metastasis.
Consider adjuvant or neoadjuvant chemotherapy or radiation depending upon pathologic findings.
T4withmalignant effusionN0-3, M0: ECOG performance status less than or equal to 2:
Chemotherapy (clinical trial or standard chemotherapy).
Biological therapy if available.
Management of malignant effusion if symptomatically indicated (with indwelling home-care chest tube or pleurodesis)
ECOG performance status greater than 2:
Palliative care including radiotherapy to appropriate symptomatic lesions.
Pleurodesis or indwelling, home-care chest tube drainage for symptomatic effusion.
Clinical trials if available.
Biological therapy if available.
T 1-4N0-3M1(exceptT1-2N0M1with solitarymetastasis): ECOG performance status less than or equal to 2:
Consider clinical trial participation.
Chemotherapy (clinical trial or standard).
Radiotherapy to appropriate symptomatic metastases.
Supportive care.
Biological therapy if available.
ECOG performance status greater than 2:
Consider clinical trial participation.
Palliative care.
Supportive care.
Biological therapy if available.
Synchronousprimaries: ECOG performance status less than or equal to 2:
Thorough metastatic work-up.
Treat for the highest stage lesion.
Post-Operative Follow Up:
Discussion of the risks and possible benefits of surveillance imaging (for local tumor recurrence or development of second primary cancer) should be held with the patient.
Ongoing efforts of smoking cessation and tobacco abstinence should be emphasized.
Small Cell Lung Cancer:
Limited stage (confined to one hemithorax) Resected Solitary Pulmonary Nodule:
Refer for adjuvant chemotherapy.
Consider PCI and clinical trial.
No effusion, minimal weight loss, ECOG performance status less than 2:
Consider clinical trial participation.
Combined modality concurrent chemoradiotherapy.
Consider prophylactic cranial irradiation (PCI) or clinical trials for complete responders.
Malignant effusion or ECOG performance status greater than 2:
Chemotherapy.
Consider addition of radiotherapy during or after chemotherapy depending on response.
Consider PCI in patients with response to therapy.
Extensive stage ECOG performance status less than or equal to 2:
Consider clinical trial participation.
Standard chemotherapy if ineligible or refuses.
PCI after completion of chemotherapy for patients responding to chemotherapy.
Consider radiation for symptomatic metastases unresponsive to chemotherapy or to the primary for complete response in metastatic sites.
ECOG performance status greater than 2:
Consider clinical trial participation.
Palliative care.
Chemotherapy.
PCI after completion of chemotherapy for patients responding to chemotherapy.
