Non small cell lung cancer medical therapy metastatic cancer

Non Small Cell Lung Cancer Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

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 radiation therapy or external-beam radiation therapy)

Yes

No

Administer systemic therapy (Click here for the treatment of metastatic disease)

Administer chemotherapy + radiation therapy

Are findings suggestive of disseminated disease present?

Yes

No

Click here for the treatment of metastatic disease

Observation OR Click here for the treatment of metastatic disease

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-beamradiation 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

Medical Therapy for Metastatic Non Small Cell Lung Cancer

The algorithms for the treatment of metastatic non small cell carcinoma of the lung are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

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

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

Squamous cell carcinoma

Is the patient a smoker or former smoker?

Yes

No

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

Perform specific EGFR and ALK mutation testing: Is there a mutation in any of those genes present?

Yes

No

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

Metastatic Adenocarcinoma, Large Cell Carcinoma and Not Specified Non-Small Cell Carcinoma

The algorithms for the treatment of metastatic adenocarcinoma, large cell carcinoma and not specified non small cell carcinoma of the lung are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

Positive Sensitizing EGFR Mutation

Was the mutation discovered before the initiation of first line therapy?

Yes

No

Initiate erlotinib or afatinib

Suspend or complete chemotherapy and initiate erlotinib or afatinib OR Add erlotinib or afatinib to chemotherapy regimen

Did the tumor progress or respond?

Tumor progression

Positive response or stable tumor

Symptomatic disease

Asymptomatic disease

Systemic metastasis

Brain metastasis

Continue treatment

Multiple metastasis

Single metastasis

Multiple metastasis

Single metastasis

Continue treatment, consider local therapy

Continue treatment, consider whole brain radiation therapy

Continue treatment, consider local therapy

Consider platinum based chemotherapy with or without Bevacizumab AND/OR Erlotin

If findings suggestive of progression of the disease are present, click here for the third line therapy

Positive ALK Mutation

Was the mutation discovered before the initiation of first line therapy?

Yes

No

Initiate crizotinib

Suspend or complete chemotherapy and initiate crizotinib

Did the tumor progress or respond?

Tumor progression

Positive response or stable tumor

Symptomatic disease

Asymptomatic disease

Systemic metastasis

Brain metastasis

Continue treatment or change to certinib according to the degree of disease

Multiple metastasis

Single metastasis

Multiple metastasis

Single metastasis

Continue treatment, consider local therapy

Continue treatment, consider whole brain radiation therapy

Continue treatment, consider local therapy

Initiate certinib OR Consider platinum based chemotherapy with or without Bevacizumab AND/OR Erlotinib

If findings suggestive of progression of the disease are present, click here for the third line therapy

Negative EGRF and ALK or Unknown Mutation

What is the performance status (PS) of the patient?

0-1

2

3-4

Doublet chemotherapy OR Bevacizumab + Chemotherapy OR Cetuximab/vinorelbine/cisplatin

Chemotherapy

Supportive care

What was the tumor response to the treatment?

Progression

Positive response or stable tumor

Administer 4-6 cycles and assess progression of the disease

PS 0-2

PS 3-4

Tumor progression

Positive response or stable tumor

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

Provide supportive care

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

Continuation maintenance (cetuximab or gemcitabine) OR Switch maintenance (erlotinib or decetaxel) OR Close observation

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

If findings suggestive of progression of the disease are present, click here for the third line therapy

Metastatic squamous cell carcinoma

The algorithms for the treatment of metastatic squamous cell carcinoma are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

What is the performance status (PS) of the patient?

0-1

2

3-4

Doublet chemotherapy OR Cetuximab/vinorelbine/cisplatin

Chemotherapy

Suportive care

What was the tumor response to the treatment?

Progression

Positive response or stable tumor

Administer 4-6 cycles and assess progression of the disease

PS 0-2

PS 3-4

Tumor progression

Positive response or stable tumor

Initiate docetaxel or erlotinib or gemcitabine

Provide suportive care

Initiate docetaxel or erlotinib or gemcitabine

Continuation mantainance (cetuximab or gemcitabine) OR Switch mantainance (erlotinib or decetaxel) OR Close observation

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

If findings suggestive of progression of the disease are present, click here for the third line therapy

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

Multiple lung cancers

The algorithms for the treatment of multiple non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

Is there suspicion of multiple lung cancers?

Yes

No

Perform the following tests: If not previously done, PET scan or CT scan Contrast chest CT Brain MRI

Administer treatment according to the TNM stage of the tumor

Is the disease is confined to the chest or is there systemic proliferation?

Disease confined to the chest

Systemic proliferation

Assess the mediastinal lymph nodes in order to determine the N stage of the tumor

Click here for the treatment of systemic metastasis

What is the N stage of the tumor?

N0-1

N2-3

Is the patient symptomatic?

Click here for the treatment of systemic metastasis

Yes

No

Is the lesion a solitary nodule or are there multiple nodules?

Solitary nodule

Multiple nodules

What is the risk of turning into a symptomatic disease?

High

Low

Is definitive local therapy possible?

Observation

No

Yes

Consider palliative chemotherapy with or without local radiation therapy

Administer one of the following tratments: Preferred option: Parenchymal sparing resection Radiation therapy Ablatipn therapy

Click here for the treatment of systemic metastasis

Click here for the follow-up recommendations and treatment of recurrence and metastasis