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:
| 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.[1]
- 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.[1]
- 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.
Radiation therapy regimens
Usual Dosages for Definitive Radiation Therapy
Administer fractions of 2 Gy over a period of 6 to 7.5 weeks to a total dose of 60 to 74 Gy.
Neoadjuvant Radiation Therapy Regimen
Administer fractions of 1.8 to 2 Gy over a period of 5 weeks to a total dose of 45 to 50 Gy.
Adjuvant Radiation Therapy Regimens
- Negative surgical piece margins: Administer fractions of 1.8 to 2 Gy over a period of 5 to 6 weeks to a total dose of 40 to 54 Gy.
- Positive surgical piece margins: Administer fractions of 1.8 to 2 Gy over a period of 6 weeks to a total dose of 54 to 60 Gy.
- Extracapsular nodal extension: Administer fractions of 1.8 to 2 Gy over a period of 6 weeks to a total dose of 60 to 70 Gy.
- Residual tumor: Administer fractions of 2 Gy over a period of 6 to 7 weeks to a total dose of 54 to 60 Gy.
Stereotactic Ablative Radiotherapy Usual Dosage
- Peripheral small tumors: 25 to 34 Gy not fractioned.
- Peripheral tumors and chest wall tumors larger than 1 cm: 45 to 60 Gy administered in 3 fractions.
- Central or peripheral tumors smaller than 5 cm: 48 to 60 Gy administered in 4 fractions.
- Central or peripheral tumors principally chest wall tumors smaller that 1 cm: 50 to 55 Gy administered in 5 fractions.
- Central tumors: 60 to 70 Gy administered in 8 to 10 fractions.
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[1]
- 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[2]:
- 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.