Non small cell lung cancer management

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

Overview

The optimal management approach of non-small cell lung cancer will depend on a series of characteristics, that include: pre-treatment evaluation, location, and adequate staging. Common treatment options for management of non-small cell lung cancer, include: surgery, neoadjuvant chemotherapy, adjuvant chemotherapy, and radiation therapy.

Management Approach

• The table below summarizes the different standard treatment options according to the TNM criteria for non-small cell lung cancer

Standard Treatment Options Adapted from Non-Small Cell Lung Cancer Treatment (PDQ® 2016)
Stage (TNM criteria)	Standard Treatment Options
Stages IA and IB	Surgery Radiation therapy IB, if the tumor is >4cm, surgery and chemotherapy
Stages IIA and IIB	Surgery Neoadjuvant chemotherapy Adjuvant chemotherapy Radiation therapy
Stage IIIA	Resected or resectable disease Surgery Neoadjuvant therapy Adjuvant therapy Unresectable disease Radiation therapy Chemoradiation therapy Superior sulcus tumors Radiation therapy alone Radiation therapy and surgery Concurrent chemotherapy with radiation therapy and surgery Surgery alone (for selected patients) Tumors that invade the chest wall Surgery Surgery and radiation therapy Radiation therapy alone Chemotherapy combined with radiation therapy and/or surgery
Stage IIIB	Sequential or concurrent chemotherapy and radiation therapy Chemotherapy followed by surgery (for selected patients) Radiation therapy alone
Stage IV	Cytotoxic combination chemotherapy (first line) Combination chemotherapy with bevacizumab or cetuximab EGFR tyrosine kinase inhibitors (first line) EML4-ALK inhibitors in patients with EML-ALK translocations Immune checkpoint inhibition with nivolumab for selected patients with squamous or nonsquamous metastatic Maintenance therapy following first-line chemotherapy Endobronchial laser therapy and/or brachytherapy (for obstructing lesions) External-beam radiation therapy (primarily for palliation of local symptomatic tumor growth)
Recurrent	Radiation therapy (for palliation) Chemotherapy or kinase inhibitors alone EGFR inhibitors in patients with/without EGFR mutations EML4-ALK inhibitors in patients with EML-ALK translocations Surgical resection of isolated cerebral metastasis (for highly selected patients) Laser therapy or interstitial radiation therapy (for endobronchial lesions) Stereotactic radiation surgery (for highly selected patients)