Non small cell lung cancer medical therapy stage IV: Difference between revisions
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{{Non small cell lung cancer}} | {{Non small cell lung cancer}} | ||
{{CMG}}; {{AE}} {{Alonso}} | {{CMG}}; {{AE}} {{Alonso}} {{MV}} | ||
==Overview== | ==Overview== | ||
Therapies for non-small cell lung cancer stage IV include [[cytotoxic]] combination [[chemotherapy]] (first line), combination chemotherapy with bevacizumab or cetuximab, EGFR [[tyrosine kinase inhibitors]], EML4-ALK inhibitors in patients with EML-ALK translocations, and immune checkpoint inhibition with nivolumab for selected patients with squamous or non-squamous metastatic. Maintenance therapy following first-line chemotherapy, include endobronchial laser therapy or [[brachytherapy]] (for obstructing lesions) and external-beam radiation therapy (primarily for palliation of local symptomatic tumor growth). Local therapies (ambulatory catheter drainage, [[pleurodesis]] or mediastinal window) plus therapy for [[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non-Small Cell Lung Cancer|systemic metastasis]] is the preferred combination for patients with stage IV M1a non-small cell lung cancer. Patients with solitary site [[metastasis]] (stage IV M1b) should be treated according to the site of [[metastasis]]. | |||
==Medical Therapy for Stage IV Non-Small Cell Lung Cancer== | ==Medical Therapy for Stage IV Non-Small Cell Lung Cancer== | ||
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{{familytree | | | |!| | | | | | | |!| | | |}} | {{familytree | | | |!| | | | | | | |!| | | |}} | ||
{{familytree | | | C01 | | | | | | C02 | | | C01=<div style="float: left; text-align: left;">Perform the following tests:<br> | {{familytree | | | C01 | | | | | | C02 | | | C01=<div style="float: left; text-align: left;">Perform the following tests:<br> | ||
* Perform [[thoracentesis]] and/or [[ | * Perform [[thoracentesis]] and/or [[pericardiocentesis]]<br> | ||
* Perform a [[thoracoscopy]] if [[thoracocentesis]] is inconclusive | * Perform a [[thoracoscopy]] if [[thoracocentesis]] is inconclusive | ||
</div>|C02=<div style="float: left; text-align: left;">Perform the following tests:<br> | </div>|C02=<div style="float: left; text-align: left;">Perform the following tests:<br> | ||
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* Mediastinal window<br> | * Mediastinal window<br> | ||
PLUS<br> | PLUS<br> | ||
Therapy for metastatic disease ([[Non small cell lung cancer metastatic cancer|click here for the treatment of metastatic cancer]]) | Therapy for metastatic disease ([[Non small cell lung cancer medical therapy metastatic cancer|click here for the treatment of metastatic cancer]]) | ||
</div>|F02=<div style="float: left; text-align: left;">Treat according to tumor stage:<br> | </div>|F02=<div style="float: left; text-align: left;">Treat according to tumor stage:<br> | ||
* [[Non small cell | * [[Non small cell lung cancer medical therapy#Stage I|I]]<br> | ||
* [[Non small cell | * [[Non small cell lung cancer medical therapy#Stage II|II]]<br> | ||
* [[Non small cell | * [[Non small cell lung cancer medical therapy#Stage III|III]]<br> | ||
</div>|F03=Perform a [[needle aspiration biopsy]] for metastasis confirmation|F04=<div style="float: left; text-align: left;">Surgical resection + adjuvant radiation therapy<br>Radiation therapy alone:<br> | </div>|F03=Perform a [[needle aspiration biopsy]] for metastasis confirmation|F04=<div style="float: left; text-align: left;">Surgical resection + adjuvant radiation therapy<br>Radiation therapy alone:<br> | ||
* [[Non small cell | * [[Non small cell lung cancer radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]] + [[Non small cell lung cancer radiation therapy#Palliative Radiation Therapy Regimens|Whole brain radiation therapy]]<br>OR<br> | ||
* [[Non small cell | * [[Non small cell lung cancer radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]]<br> | ||
PLUS<br> | PLUS<br> | ||
Pathologic evaluation of surgical piece and [[lymph nodes]]</div>}} | Pathologic evaluation of surgical piece and [[lymph nodes]]</div>}} | ||
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* [[Non small cell lung cancer radiation therapy|Radiation therapy]]<br> | * [[Non small cell lung cancer radiation therapy|Radiation therapy]]<br> | ||
OR<br> | OR<br> | ||
Administer therapy for metastatic disease in case of not curable lung lesions ([[Non small cell lung cancer metastatic cancer|click here for the treatment of metastatic cancer]]) | Administer therapy for metastatic disease in case of not curable lung lesions ([[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|click here for the treatment of metastatic cancer]]) | ||
</div>|G02=What is the TN stage of the lung [[tumor]]?}} | </div>|G02=What is the TN stage of the lung [[tumor]]?}} | ||
{{familytree | | | | | | | | | | | |,|-|^|-|.| | |}} | {{familytree | | | | | | | | | | | |,|-|^|-|.| | |}} | ||
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{{familytree | | | | | | | | | | | I01 | | I02 | | | | I01=<div style="float: left; text-align: left;"> | {{familytree | | | | | | | | | | | I01 | | I02 | | | | I01=<div style="float: left; text-align: left;"> | ||
* Surgical resection of lung [[tumor]] + adjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]]<br>OR<br> | * Surgical resection of lung [[tumor]] + adjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]]<br>OR<br> | ||
* Neoadjuvant [[Non small cell | * Neoadjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]] + surgical resection or [[Non small cell lung cancer radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]]<br>OR<br> | ||
* [[Non small cell | * [[Non small cell lung cancer radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|Stereotactic ablative radiation therapy]]</div> | ||
|I02=<div style="float: left; text-align: left;">Administer therapy for metastatic disease in case of not curable lung lesions ([[Non small cell | |I02=<div style="float: left; text-align: left;">Administer therapy for metastatic disease in case of not curable lung lesions ([[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|click here for the treatment of metastatic cancer]])</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
[[Category:Up-To-Date]] | |||
[[Category:Oncology]] | |||
[[Category:Medicine]] | |||
[[Category: | |||
[[Category: | |||
[[Category:Pulmonology]] | [[Category:Pulmonology]] | ||
[[Category: | [[Category:Surgery]] | ||
Latest revision as of 23:31, 23 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2] Maria Fernanda Villarreal, M.D. [3]
Overview
Therapies for non-small cell lung cancer stage IV include cytotoxic combination chemotherapy (first line), combination chemotherapy with bevacizumab or cetuximab, EGFR tyrosine kinase inhibitors, EML4-ALK inhibitors in patients with EML-ALK translocations, and immune checkpoint inhibition with nivolumab for selected patients with squamous or non-squamous metastatic. Maintenance therapy following first-line chemotherapy, include endobronchial laser therapy or brachytherapy (for obstructing lesions) and external-beam radiation therapy (primarily for palliation of local symptomatic tumor growth). Local therapies (ambulatory catheter drainage, pleurodesis or mediastinal window) plus therapy for systemic metastasis is the preferred combination for patients with stage IV M1a non-small cell lung cancer. Patients with solitary site metastasis (stage IV M1b) should be treated according to the site of metastasis.
Medical Therapy for Stage IV Non-Small Cell Lung Cancer
The algorithms for the treatment of stage IV non small cell carcinoma of the lung are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.[1]
Is pleural or pericardial effusion present (suggestive of M1a) or are findings suggestive of systemic metastasis (M1b) present? | |||||||||||||||||||||||||||||||||||||||||||||
M1a | M1b: solitary site systemic metastasis | ||||||||||||||||||||||||||||||||||||||||||||
Perform the following tests:
| Perform the following tests:
| ||||||||||||||||||||||||||||||||||||||||||||
Is the liquid extracted positive for malignant cells? | Are findings suggestive of adrenal metastasis or brain metastasis? | ||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Adrenal | Brain | ||||||||||||||||||||||||||||||||||||||||||
Local therapy
PLUS | Perform a needle aspiration biopsy for metastasis confirmation | Surgical resection + adjuvant radiation therapy Radiation therapy alone:
PLUS | |||||||||||||||||||||||||||||||||||||||||||
If the lung disease is curable, administer local therapy for the adrenal lesion:
OR | What is the TN stage of the lung tumor? | ||||||||||||||||||||||||||||||||||||||||||||
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| Administer therapy for metastatic disease in case of not curable lung lesions (click here for the treatment of metastatic cancer) | ||||||||||||||||||||||||||||||||||||||||||||