Adenocarcinoma of the lung medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [2]

Medical Therapy

Stage I

Shown below is the algorithm on the treatment of the stage I non-small cell lung cancer based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

In the tumor central o peripheral?

Peripheral

Central

Is the tumor T1 or T2a?

T1ab, N0

T2a, N0

T1ab-2a, N0

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan

Does the pathological evaluation showed positive disease in the mediastinal lymph nodes?

Does the pathological evaluation showed positive disease in the mediastinal lymph nodes?

Yes

No

Yes

No

Click here for the stage III treatment

Is the tumor operable?

Click here for the stage III treatment

Is the tumor operable?

Yes

No

Yes

No

Surgical resection + lymph node dissection

stereotactic ablative radiation therapy

Surgical resection + lymph node dissection

Does the patient presents metastasis to ipsilateral peribronchial and/or hiliar nodesand intrapulmonar nodes (N1)?

Yes

No

chemotherapy + radiation therapy

stereotactic ablative radiation therapy Adjuvant chemotherapy should be added for high-risk stages

Stage II

Stage IIA Shown below is the algorithm on the treatment of the stage IIA non-small cell lung cancer based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

T1a-b, 2a, N1 T2b, N0 T3 Tumor larger than 7 cm (not invasive)

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan

Does the pathological evaluation showed positive disease in the mediastinal lymph nodes?

Yes

No

Click here for the stage III treatment

Is the tumor operable?

Yes

No

Surgical resection + lymph node dissection

Does the patient presents metastasis to ipsilateral peribronchial and/or hiliar nodes and intrapulmonar nodes (N1)?

If lymph node extension is detected initiate neoadjuvantchemotherapy + radiation therapy

Yes

No

chemotherapy + radiation therapy

radiation therapy with stereotactic ablative radiotherapy Adjuvant Chemotherapy should be added for high-risk stages

Stage IIB Shown below is the algorithm on the treatment of the stage IIB non-small cell lung cancer based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan Perform a brain MRI Perform a spine MRI with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or spine

What is the location of the tumor?

Superior suculus tumor

Proximal airway OR Chest wall OR Mediastinum

T3 (Invasion to adjacent structures), N0

Preferred option: Surgery + pathological determination of microscopic residual tumor

Neoadjuvant chemotherapy OR chemotherapy + radiation therapy

Neoadjuvant chemotherapy

Are margins from the surgical piece positive or negative for residual tumor?

Perform surgery + pathological determination of residual tumor

Surgery + adjuvant chemotherapy

Negative (R0)

Positive: Is the residual tumor microscopic (R1) or macroscopic (R2)

Are margins from the surgical piece positive or negative for residual tumor?

Adjuvant chemotherapy

Microscopic (R1)

Macroscopic (R2)

Negative (R0)

Positive (R1-2)

Tumor resection + adjuvant chemotherapy OR chemotherapy + radiation therapy, followed or not by chemotherapy

Tumor resection + adjuvant chemotherapy OR chemotherapy + radiation therapy

Observation

Tumor resection

References

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