SandboxAlonso

Stage IV

Is pleural or pericardial effusion present (suggestive of M1a) or are findings suggestive of systemic metastasis (M1b) present?

M1a

M1b

Perform the following tests: Perform thoracentesis and/or pericardiocenteis Perform a thoracoscopy if thoracocentesis is inconclusive

Perform the following tests: Brain MRI Bronchoscopy Mediastinal lymph node biopsy If not previously done, PET scan or CT scan

Is the liquid extracted positive for malignant cells?

Are findings suggestive of adrenal metastasis or brain metastasis?

Yes

No

Adrenal

Brain

Local therapy Ambulatory catheter drainage Pleurodesis Mediastinal window PLUS Therapy for metastatic disease (click here for the treatment of local and systemic metastasis and neoplastic recurrence)

Treat according to tumor stage: I II III

Perform a needle aspiration biopsy for metastasis confirmation

Surgical resection + adjuvant radiation therapy Radiation therapy alone: Sterotactic radio surgery + Whole brain radiation therapy OR Sterotactic radio surgery alone PLUS Pathologic evaluation of surgical piece and lymph nodes

If the lung disease is curable, administer local therapy for the adrenal lesion: Surgical adrenal resection OR Radiation therapy OR Administer therapy for metastatic disease in case of not curable lung lesions (click here for the treatment of local and systemic metastasis and neoplastic recurrence)

What is the TN stage of the lung tumor?

T1-2, No-1 T3, N0

T1-2, N2 T3, N1-2 N3, regardless of the T stage T4 regardless of the N stage

Surgical resection of lung tumor + adjuvant chemotherapy OR Neoadjuvant chemotherapy + surgical resection or stereotactic ablative radiation therapy OR Stereotactic ablative radiation therpay alone

Administer therapy for metastatic disease in case of not curable lung lesions (click here for the treatment of local and systemic metastasis and neoplastic recurrence)

Follow-up

Controls of history + physical exam and chest CT with or without contrast every 6-12 months (first 2 years), then annual controls

Is there evidence of local or regional recurrence OR systemic metastasis?

Local or regional recurrence

Systemic metastasis

Local or regional recurrence

What is the site of the recurrence?

Bronchial obstruction

Mediastinal lymph node

Superior vena cava obstruction

Severe hemoptisis

Resectable tumor

Metastatic disease

What the specific subtype according to the specific histological characteristics of the tumor?

Adenocarcinoma Large cell carcinoma Not specified non-small cell lung cancer

Squamous cell carcinoma

Perform specific EGFR and ALK mutation testing: What is the specific mutation?

Is the patient smoker or former smoker?

Sensitizing EGFR mutation

ALK mutation

Negative EGFR and ALK

Click here for the squamous cell carcinoma specific treatment

Click here for the sensitizing EGFR mutation specific treatment

Click here for the specific therapy for the ALK mutation specific treatment

Click here for the treatment of negative sensitizing EGFR and ALK mutation metastatic disease