SandboxAlonso

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

Surgical correction of the obstruction: laser therapy, stent or any other surgical procedure OR Radiation therapy (external-beam or brachytherapy) OR Photodynamic therapy

Has the patient received radiation therapy?

Chemotherapy + radiation therapy OR External-beam radiation therapy OR Superior vena cava stent collocation

Surgery OR Radiation therapy (external-beam or brachytherapy) OR Laser therapy, photodynamic therapy or tumor embolization

Tumor resection (preferred option) OR Radiation therapy (stereotactic ablative radiotherapy or external-beam radiation therapy)

Yes

No

Administer systemic therapy

Administer chemotherapy + radiation therapy

Are findings suggestive of disseminated disease present?

Yes

No

Click here for the treatment of metastatic disease

Observation OR systemic therapy

Systemic metastasis

What are the characteristics of the metastasis?

Diffuse brain metastasis

Bone metastasis

Localized symptoms

Solitary metastasis

Multiple metastasis

External-beam radiation therapy (palliative)

External-beam radiation therapy (palliative) + limb stabilization (prevention of pathological fractures) Denosumab or biophosphonate therapy should be considered

External-beam radiation therapy (palliative)

Click here for the treatment of stage IV M1b (solitary site metastasis)

Click here for the treatment of metastatic disease

Click here for the treatment of metastatic disease

Third line therapy

The algorithm below shows the third line therapy for metastatic disease according to the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

What is the performance status of the patient?

PS 0-2

PS 3-4

If not previously used, administer any of the following: Docetaxel Erlotinib Gemcitabine Pemetrexed

Administer erlotinib or provide suportive care

What is the performance status of the patients after the treatment?

PS 0-2 (stable tumor)

PS 3-4 (tumor progression)

Provide supportive care or try experimental treatments

Provide supportive care

Chemotherapy followed by radiotherapy

The list bellow show the options for chemotherapy followed by radiation therapy based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

• Cisplatin 100 mg/m² on days 1 and 29 + vinblastin 5 mg/m² per week on days 1, 8, 15, 22 and 29, then followed by radiation therapy.
• Paclitaxel 200 mg/m² administered for 3 hours in the first day + carboplatin AUC 6 administered in 1 hour and then every 21 days to a total of 2 cycles followed by thoracic radiation therapy.

Chemotherapy plus radiotherapy, followed by chemotherapy

The list bellow show the options for concomitant chemotherapy plus radiation therapy followed by chemotherapy based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

• Cisplatin 50 mg/m² on days 1, 8, 29 and 36 + etoposide 50 mg/m² through day 1 to 5 and then 29 to 33 + thoracic radiation therapy, then followed by cisplatin 50 mg/m² + etoposide 50 mg/m² to a total of 2 cycles.
• Paclitaxel 45 to 50 mg/m² once a week + carboplatin AUC 2 + thoracic radiation therapy, then followed by Paclitaxel 200 mg/m² + carboplatin AUC 6 to a total of 2 cycles.

Palliative Radiation Therapy Regimens

Listed bellow are the recommended palliative radiation therapy regimens for patients with non-small cell lung cancer according to the 2014 NCCN Non-Small Cell Lung Cancer guidelines

• Obstructive disease: Administer fractions of 3 Gy over a period of 2 to 3 weeks to a total dose of 30 to 45 Gy.
• Bone metastases associated with soft tissue mass: Administer fractions of 4 to 3 Gy over a period of 1 to 2 weeks to a total dose of 20 to 30 Gy.
• Bone metastases not associated with soft tissue mass: Administer fractions of 8 to 3 Gy over a period of 1 to 14 days to a total dose of 8 to 30 Gy.
• Patients with poor performance status and symptomatic chest disease: Administer fractions of 8.5 Gy over a period of 7 to 14 days to a total dose of 17 Gy.
• Metastatic disease in patients who have a poor performance status: Administer fractions of 8 to 4 Gy over a period of 1 to 7 days to a total dose of 8 to 20 Gy.
• Whole brain radiation therapy regimens for metastases to the brain are the following Adapted from the 2014 NCCN Central Nervous System Cancers guidelines:

• 10 fractions of 3 Gy each to a total of 30 Gy.
• 15 fractions of 2.5 Gy each to a total of 37.5 Gy.
• 5 fractions of 4 Gy each to a total of 20 Gy. Good option for patients with poor performance status.

References

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