Non small cell lung cancer medical therapy metastatic cancer: Difference between revisions

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Latest revision as of 23:28, 23 February 2018

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2] Maria Fernanda Villarreal, M.D. [3]

Overview

Therapies for non-small cell lung cancer stage IV include radiation therapy (for palliation) and palliative chemotherapy. The treatment of metastatic non-small cell lung cancer depends on the site and extension of the disease. If specific mutations are diagnosed, targeted treatment should be administered.

Local or Regional Recurrence

The algorithm below shows the approach for a local or regional recurrence of a non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.^[1]

What is the site of the recurrence?

Bronchial obstruction

Mediastinal lymph node

Superior vena cava obstruction

Severe hemoptysis

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

The algorithm bellow shows the approach for systemic metastasis of a non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.^[1]

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

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.^[1]

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.^[1]

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
Erlotinib

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 algorithm for the treatment of metastatic squamous cell carcinoma are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.^[1]

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

0-1

2

3-4

Cisplatin based 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

Continue treatment(cetuximab or gemcitabine)
OR
Switch mantainance (erlotinib or docetaxel)
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.^[1]

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 algorithm for the treatment of multiple non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.^[1]

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 treatments:

Preferred option: Parenchymal sparing resection
Radiation therapy
Ablation therapy

Click here for the treatment of systemic metastasis

Go to the appropriate algorithm according to the characteristics of the disease: local or regional recurrence or metastasis

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

[NCCN-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 ^1.5 ^1.6 http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

[1]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Non small cell lung cancer}}
+{{CMG}}; {{AE}} {{Alonso}} {{MV}}
-{{CMG}}; {{AE}} {{Alonso}}
+==Overview==
+Therapies for non-small cell lung cancer stage IV include [[radiation therapy]] (for palliation) and palliative [[chemotherapy]]. The treatment of [[metastatic]] non-small cell lung cancer depends on the site and extension of the disease.  If specific [[mutations]] are diagnosed, targeted treatment should be administered.
-==Overview==
+==Local or Regional Recurrence==
+The algorithm below shows the approach for a local or regional recurrence of a non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
-==Local or regional recurrence==
 {{familytree/start}}
 {{familytree | | | | | | | | | A01 | | | | | | | | | | A01=What is the site of the recurrence?}}
 {{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | |}}
-{{familytree | B01 | | B02 | | B03 | | B04 | | B05 | | | B01=[[Bronchus|Bronchial]] obstruction|B02=Mediastinal [[lymph node]]|B03=[[Superior vena cava]] obstruction|B04=Severe [[hemoptisis]]|B05=Resectable [[tumor]]}}
+{{familytree | B01 | | B02 | | B03 | | B04 | | B05 | | | B01=[[Bronchus|Bronchial]] obstruction|B02=Mediastinal [[lymph node]]|B03=[[Superior vena cava]] obstruction|B04=Severe [[hemoptysis]]|B05=Resectable [[tumor]]}}
 {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |}}
-{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C01=Surgical correction of the obstruction: laser therapy, stent or any other surgical procedure<br>OR<br>[[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]] (external-beam or brachytherapy)<br>OR<br>Photodynamic therapy|C02=Has the patient received [[radiation therapy]]?|C03=Chemotherapy + radiation therapy<br>OR<br>External-beam radiation therapy<br>OR<br>[[Superior vena cava]] stent collocation|C04=Surgery<br>OR<br>[[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]] (external-beam or brachytherapy)<br>OR<br>Laser therapy, photodynamic therapy or tumor [[embolization]]|C05=[[Tumor]] resection (preferred option)<br>OR<br>[[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]] ([[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]] or external-beam radiation therapy)}}
+{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C01=Surgical correction of the obstruction: laser therapy, stent or any other surgical procedure<br>OR<br>[[Non small cell lung cancer radiation therapy|Radiation therapy]] (external-beam or brachytherapy)<br>OR<br>Photodynamic therapy|C02=Has the patient received [[radiation therapy]]?|C03=[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|Chemotherapy + radiation therapy]]<br>OR<br>External-beam [[Non small cell lung cancer radiation therapy|radiation therapy]]<br>OR<br>[[Superior vena cava]] stent collocation|C04=Surgery<br>OR<br>[[Non small cell lung cancer radiation therapy|Radiation therapy]] (external-beam or brachytherapy)<br>OR<br>Laser therapy, photodynamic therapy or [[tumor]] [[embolization]]|C05=[[Tumor]] resection (preferred option)<br>OR<br>[[Non small cell lung cancer radiation therapy|Radiation therapy]] ([[Non small cell lung cancer radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]] or external-beam [[Non small cell lung cancer radiation therapy|radiation therapy]])}}
 {{familytree | |!| |,|-|^|-|.| |!| | | |!| | | |!| | | |}}
 {{familytree | |!| D01 | | D02 |!| | | |!| | | |!| | | D01=Yes|D02=No}}
 {{familytree | |!| |!| | | |!| |!| | | |!| | | |!| | | |}}
-{{familytree | |!| E01 | | E02 |!| | | |!| | | |!| | | | E01=Administer systemic therapy ([[Non small cell carcinoma of the lung medical therapy metastatic cancer|Click here for the treatment of metastatic cancer]])|E02=Administer [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]}}
+{{familytree | |!| E01 | | E02 |!| | | |!| | | |!| | | | E01=Administer systemic therapy ([[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]])|E02=Administer [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]}}
 {{familytree | |`|-|^|-|-|-|^|-|+|-|-|-|^|-|-|-|'| | | |}}
 {{familytree | | | | | | | | | F01 | | | | | | | | | | | F01=Are findings suggestive of disseminated disease present?}}
@@ Line 22: / Line 26: @@
 {{familytree | | | | | | G01 | | | | G02 | | | | | G01=Yes|G02=No}}
 {{familytree | | | | | | |!| | | | | |!| | | | | |}}
-{{familytree | | | | | | H01 | | | | H02 | | | | | H01=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]|H02=Observation<br>OR<br>[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
+{{familytree | | | | | | H01 | | | | H02 | | | | | H01=[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]|H02=Observation<br>OR<br>[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
 {{familytree/end}}
 <br>
-==Systemic metastasis==
+==Systemic Metastasis==
+The algorithm bellow shows the approach for systemic metastasis of a non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
 {{familytree/start}}
 {{familytree | | | | | | | | | A01 | | | | | | | | | | A01=What are the characteristics of the [[metastasis]]?}}
@@ Line 32: / Line 38: @@
 {{familytree | B01 | | B02 | | B03 | | B04 | | B05 | | | B01=Diffuse [[brain]] metastasis|B02=[[Bone]] metastasis|B03=Localized symptoms||B04=Solitary [[metastasis]]|B05=Multiple [[metastasis]]}}
 {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |}}
-{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C01=External-beam [[Non small cell carcinoma of the lung radiation therapy#Palliative Radiation Therapy Regimens|radiation therapy]] (palliative)|C02=External-beam [[Non small cell carcinoma of the lung radiation therapy#Palliative Radiation Therapy Regimens|radiation therapy]] (palliative) + limb stabilization (prevention of pathological fractures)<br>Denosumab or biophosphonate therapy should be considered|C03=External-beam[[Non small cell carcinoma of the lung radiation therapy#Palliative Radiation Therapy Regimens|radiation therapy]](palliative)|C04=[[Non small cell carcinoma of the lung medical therapy stage IV|Click here for the treatment of stage IV M1b (solitary site metastasis]])|C05=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
+{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C01=External-beam [[Non small cell lung cancer radiation therapy#Palliative Radiation Therapy Regimens|radiation therapy]] (palliative)|C02=External-beam [[Non small cell lung cancer radiation therapy#Palliative Radiation Therapy Regimens|radiation therapy]] (palliative) + limb stabilization (prevention of pathological fractures)<br>Denosumab or biophosphonate therapy should be considered|C03=External-beam[[Non small cell lung cancer radiation therapy#Palliative Radiation Therapy Regimens|radiation therapy]](palliative)|C04=[[Non small cell lung cancer medical therapy stage IV|Click here for the treatment of stage IV M1b (solitary site metastasis]])|C05=[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
 {{familytree | |`|-|-|-|+|-|-|-|'| | | | | | |}}
-{{familytree | | | | | D01 | | | | | | | | | | D01=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
+{{familytree | | | | | D01 | | | | | | | | | | D01=[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
 {{familytree/end}}
@@ Line 47: / Line 53: @@
 * [[Adenocarcinoma]]<br>
 * [[Large cell carcinoma of the lung]]<br>
-* Not specified non-small cell lung cancer</div>|B02=[[Squamous cell carcinoma of the lung|Squamous cell carcinoma]]}}
+* Not specified non-small cell lung cancer</div>|B02=Squamous cell carcinoma}}
 {{familytree | | | | | |!| | | | | | | | | |!| | | }}
 {{familytree | | | | | |!| | | | | | | | | C02 | | | C02=Is the patient a smoker or former smoker?}}
@@ Line 53: / Line 59: @@
 {{familytree | | | | | |!| | | | | | | Y01 | | Y02 | | | | | Y01=Yes|Y02=No}}
 {{familytree | | | | | |!| | | | | | | |!| | | |!| | | }}
-{{familytree | | | | | Z01 | | | | | | Z02 | | |!| | | | | Z01=Perform specific [[EGFR]] and ALK [[mutation]] testing: What is the specific [[mutation]]?|Z02=Perform specific [[EGFR]] and ALK [[mutation]] testing: Is there a mutation in any of those genes present?}}
+{{familytree | | | | | Z01 | | | | | | Z02 | | |!| | | | | Z01=Perform specific [[EGFR]] and ALK [[mutation]] testing: What is the specific [[mutation]]?|Z02=Perform specific [[EGFR]] and ALK [[mutation]] testing: Is there a [[mutation]] in any of those genes present?}}
 {{familytree | | | | | |!| | | | | |,|-|^|-|.| |!| | | |}}
 {{familytree | | | | | |!| | | | | W01 | | W02 |!| | | | W01=Yes|W02=No}}
 {{familytree | | | | | |`|-|-|v|-|-|'| | | |`|v|'| | | |}}
 {{familytree | | | | |,|-|-|-|+|-|-|-|.| | | |!|}}
-{{familytree | | | | D01 | | D02 | | D03 | | D04 | | | | D01=Sensitizing [[EGFR]] mutation|D02=ALK mutation|D03=Negative [[EGFR]] and ALK|D04=[[Non small cell carcinoma of the lung medical therapy#Metastatic squamous cell carcinoma|Click here for the squamous cell carcinoma specific treatment]]}}
+{{familytree | | | | D01 | | D02 | | D03 | | D04 | | | | D01=Sensitizing [[EGFR]] mutation|D02=ALK mutation|D03=Negative [[EGFR]] and ALK|D04=[[Non small cell lung cancer medical therapy metastatic cancer#Metastatic Squamous Cell Carcinoma|Click here for the squamous cell carcinoma specific treatment]]}}
 {{familytree | | | | |!| | | |!| | | |!| | | | |}}
-{{familytree | | | | E01 | | E02 | | E03 | | | E01=[[Non small cell carcinoma of the lung medical therapy#Positive sensitizing EGFR mutation|Click here for the sensitizing EGFR mutation specific treatment]]|E02=[[Non small cell carcinoma of the lung medical therapy#Positive ALK mutation|Click here for the specific therapy for the ALK mutation specific treatment]]|E03=[[Non small cell carcinoma of the lung medical therapy#Negative EGRF and ALK or unknown mutation|Click here for the treatment of negative sensitizing EGFR and ALK mutation metastatic disease]]}}
+{{familytree | | | | E01 | | E02 | | E03 | | | E01=[[Non small cell lung cancer medical therapy metastatic cancer#Positive Sensitizing EGFR Mutation|Click here for the sensitizing EGFR mutation specific treatment]]|E02=[[Non small cell lung cancer medical therapy metastatic cancer#Positive ALK Mutation|Click here for the specific therapy for the ALK mutation specific treatment]]|E03=[[Non small cell lung cancer medical therapy metastatic cancer#Negative EGRF and ALK or Unknown Mutation|Click here for the treatment of negative sensitizing EGFR and ALK mutation metastatic disease]]}}
 {{familytree/end}}
 <br>
-==Metastatic adenocarcinoma, large cell carcinoma and not specified non-small cell carcinoma==
+==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.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
-===Positive sensitizing EGFR mutation===
+===Positive Sensitizing EGFR Mutation===
 {{familytree/start}}
 {{familytree | | | | | | | | | | | | | | | E01 | | | | | | | | |E01=Was the mutation discovered before the initiation of first line therapy?}}
@@ Line 75: / Line 81: @@
 {{familytree | | | | | | | | | | | | G01 | | | | G02 | | |G01=Initiate erlotinib or afatinib|G02=Suspend or complete [[chemotherapy]] and initiate erlotinib or afatinib<br>'''OR'''<br> Add erlotinib or afatinib to chemotherapy regimen|}}
 {{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |}}
-{{familytree | | | | | | | | | | | | | | | H01 | | | | | | | | |H01=Did the tumor progress or respond?|}}
+{{familytree | | | | | | | | | | | | | | | H01 | | | | | | | | |H01=Did the [[tumor]] progress or respond?|}}
 {{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | }}
-{{familytree | | | | | | | | | | | | I01 | | | | I02 | | | |I01=Tumor progression|I02=Positive response or stable tumor}}
+{{familytree | | | | | | | | | | | | I01 | | | | I02 | | | |I01=[[Tumor]] progression|I02=Positive response or stable [[tumor]]}}
 {{familytree | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | |}}
 {{familytree | | | | | | | | J01 | | | | | | J02 | | | | | |J01=Symptomatic disease|J02=Asymptomatic disease}}
@@ Line 85: / Line 91: @@
 {{familytree | | L01 | | L02 | | L03 | | L04 |!| | | | |L01=Multiple [[metastasis]]|L02=Single [[metastasis]]|L03=Multiple [[metastasis]]|L04=Single [[metastasis]]}}
 {{familytree | | |!| | | |!| | | |!| | | |!| |!| | | | |}}
-{{familytree | | M01 | | M02 | | M03 | | M04 |!| | | | |M01=Continue treatment, consider local therapy|M02=Continue treatment, consider whole brain radiation therapy|M03=Continue treatment, consider local therapy|M04=Consider platinum doublet <br>with or without<br> [[Bevacizumab]] <br>AND/OR<br> Erlotin}}
+{{familytree | | M01 | | M02 | | M03 | | M04 |!| | | | |M01=Continue treatment, consider local therapy|M02=Continue treatment, consider [[Non small cell lung cancer radiation therapy#Palliative Radiation Therapy Regimens|whole brain radiation therapy]]|M03=Continue treatment, consider local therapy|M04=Consider [[Non small cell lung cancer chemotherapy#Cisplatin Based Therapy|platinum based chemotherapy]] <br>with or without<br> [[Bevacizumab]] <br>AND/OR<br> Erlotinib}}
 {{familytree | | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|'| | | |}}
-{{familytree | | | | | | | | | | N01 | | | | | | | | N01=If findings suggestive of progression of the disease are present, click here for the third line therapy}}
+{{familytree | | | | | | | | | | N01 | | | | | | | | N01=If findings suggestive of progression of the disease are present, [[Non small cell lung cancer medical therapy metastatic cancer#Third Line Therapy|click here for the third line therapy]]}}
 {{familytree/end}}
 <br>
-===Positive ALK mutation===
+===Positive ALK Mutation===
 {{familytree/start}}
 {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | |A01=Was the [[mutation]] discovered before the initiation of first line therapy?}}
@@ Line 99: / Line 106: @@
 {{familytree | | | | | | | | | | | | G03 | | | | G04 | | | | |G03=Initiate crizotinib|G04=Suspend or complete [[chemotherapy]] and initiate crizotinib|G05=Progression|G06=Positive response or stable tumor}}
 {{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | |}}
-{{familytree | | | | | | | | | | | | | | | H01 | | | | | | | | |H01=Did the tumor progress or respond?}}
+{{familytree | | | | | | | | | | | | | | | H01 | | | | | | | | |H01=Did the [[tumor]] progress or respond?}}
 {{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | |}}
-{{familytree | | | | | | | | | | | | I01 | | | | I02 | | | | | | | |I01=Tumor progression|I02=Positive response or stable tumor}}
+{{familytree | | | | | | | | | | | | I01 | | | | I02 | | | | | | | |I01=[[Tumor]] progression|I02=Positive response or stable [[tumor]]}}
 {{familytree | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | |}}
 {{familytree | | | | | | | | J01 | | | | | | J02 | | | | | | | | | |J01=Symptomatic disease|J02=Asymptomatic disease}}
 {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | |!| | | | | | | | | | | |}}
-{{familytree | | | | K01 | | | | | | K02 | | K03 | | | | | | | | |K01=Systemic metastasis|K02=Brain metastasis|K03=Continue treatment or change to certinib according to the degree of disease}}
+{{familytree | | | | K01 | | | | | | K02 | | K03 | | | | | | | | |K01=Systemic [[metastasis]]|K02=Brain [[metastasis]]|K03=Continue treatment or change to certinib according to the degree of disease}}
 {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| |!| | | | | | | | | | | |}}
 {{familytree | | L01 | | L02 | | L03 | | L04 |!| | | | | | | | |L01=Multiple [[metastasis]]|L02=Single [[metastasis]]|L03=Multiple [[metastasis]]|L04=Single [[metastasis]]}}
 {{familytree | | |!| | | |!| | | |!| | | |!| |!| | | | | | | | |}}
-{{familytree | | M01 | | M02 | | M03 | | M04 |!| | | | | | | | |M01=Continue treatment, consider local therapy|M02=Continue treatment, consider whole brain radiation therapy|M03=Continue treatment, consider local therapy|M04=Initiate certinib <BR>OR<BR> Consider platinum doublet <br>with or without<br> [[Bevacizumab]] <br>AND/OR<br> Erlotinib}}
+{{familytree | | M01 | | M02 | | M03 | | M04 |!| | | | | | | | |M01=Continue treatment, consider local therapy|M02=Continue treatment, consider [[Non small cell lung cancer radiation therapy#Palliative Radiation Therapy Regimens|whole brain radiation therapy]]|M03=Continue treatment, consider local therapy|M04=Initiate certinib <BR>OR<BR> Consider [[Non small cell lung cancer chemotherapy#Cisplatin Based Therapy|platinum based chemotherapy]] <br>with or without<br> [[Bevacizumab]] <br>AND/OR<br> Erlotinib}}
 {{familytree | | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|'| | | |}}
-{{familytree | | | | | | | | | | N01 | | | | | | | | N01=If findings suggestive of progression of the disease are present, click here for the third line therapy}}
+{{familytree | | | | | | | | | | N01 | | | | | | | | N01=If findings suggestive of progression of the disease are present, [[Non small cell lung cancer medical therapy metastatic cancer#Third Line Therapy|click here for the third line therapy]]}}
 {{familytree/end}}
 <br>
-===Negative EGRF and ALK or unknown mutation===
+===Negative EGRF and ALK or Unknown Mutation===
 {{familytree/start}}
-{{familytree | | | | | | | | | C02 | | | | | | | |C02=Which is the mutation present?|C02=What is the performance status (PS) of the patient?}}
+{{familytree | | | | | | | | | C02 | | | | | | | |C02=Which is the [[mutation]] present?|C02=What is the performance status (PS) of the patient?}}
 {{familytree | | | | | |,|-|-|-|+|-|-|-|.| | | | | |}}
 {{familytree | | | | | D03 | | D04 | | D05 | | | | |D03=0-1|D04=2|D05=3-4}}
 {{familytree | | | | | |!| | | |!| | | |!| | | | | |}}
-{{familytree | | | | | E03 | | E04 | | E05 | | | | | | |E03=Doublet [[chemotherapy]]<BR> OR <BR> [[Bevacizumab]] + Chemotherapy <BR> OR <BR> [[Cetuximab]]/[[vinorelbine]]/[[cisplatin]]|E04=[[Chemotherapy]]|E05=Supportive care}}
+{{familytree | | | | | E03 | | E04 | | E05 | | | | | | |E03=Doublet [[chemotherapy]]<BR> OR <BR> [[Bevacizumab]] + [[Non small cell lung cancer chemotherapy|Chemotherapy]] <BR> OR <BR> [[Cetuximab]]/[[vinorelbine]]/[[cisplatin]]|E04=[[Chemotherapy]]|E05=Supportive care}}
 {{familytree | | | | | |`|-|v|-|'| | | | | | | | | | |}}
-{{familytree | | | | | | | F05 | | | | | | |F05=What was the tumor response to the treatment?}}
+{{familytree | | | | | | | F05 | | | | | | |F05=What was the [[tumor]] response to the treatment?}}
 {{familytree | | | | |,|-|-|^|-|-|-|-|.| |}}
-{{familytree | | | | G05 | | | | | | G06 | | | |G05=Progression|G06=Positive response or stable tumor}}
+{{familytree | | | | G05 | | | | | | G06 | | | |G05=Progression|G06=Positive response or stable [[tumor]]}}
 {{familytree | | | | |!| | | | | | | |!| | | | | |}}
 {{familytree | | | | |!| | | | | | | Z01 | | | | | | |Z01=Administer 4-6 cycles and assess progression of the disease}}
 {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
-{{familytree | | H03 | | H04 | | H05 | | | H06 | | | |H03=PS 0-2|H04=PS 3-4|H05=Tumor progression|H06=Positive response or stable tumor}}
+{{familytree | | H03 | | H04 | | H05 | | | H06 | | | |H03=PS 0-2|H04=PS 3-4|H05=[[Tumor]] progression|H06=Positive response or stable [[tumor]]}}
 {{familytree | | |!| | | |!| | | |!| | | | |!| | | | | |}}
 {{familytree | | I05 | | I06 | | I07 | | | I08 | | | | | |I05=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]|I06=Provide supportive care|I07=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]|I08=Continuation maintenance ([[cetuximab]] or [[gemcitabine]]) <br>OR<br> Switch maintenance (erlotinib or [[decetaxel]]) <br>OR<br> Close observation}}
@@ Line 135: / Line 143: @@
 {{familytree | | |!| | | | | | | |!| | | | K01 | | | | | |K01=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]}}
 {{familytree | | |`|-|-|-|-|-|-|-|+|-|-|-|-|'| | | | |}}
-{{familytree | | | | | | | | | | L01 | | | | | | | | | L01=If findings suggestive of progression of the disease are present, click here for the third line therapy}}
+{{familytree | | | | | | | | | | L01 | | | | | | | | | L01=If findings suggestive of progression of the disease are present, [[Non small cell lung cancer medical therapy metastatic disease#Third Line Therapy|click here for the third line therapy]]}}
 {{familytree/end}}
 <br>
-==Metastatic squamous cell carcinoma==
+==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.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
+The algorithm for the treatment of metastatic squamous cell carcinoma are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
 {{familytree/start}}
@@ Line 147: / Line 155: @@
 {{familytree | | | | | D03 | | D04 | | D05 | | | | |D03=0-1|D04=2|D05=3-4}}
 {{familytree | | | | | |!| | | |!| | | |!| | | | | |}}
-{{familytree | | | | | E03 | | E04 | | E05 | | | | | | |E03=Doublet chemotherapy<BR> OR <BR> [[Cetuximab]]/[[vinorelbine]]/[[cisplatin]]|E04=Chemotherapy|E05=Suportive care}}
+{{familytree | | | | | E03 | | E04 | | E05 | | | | | | |E03=[[Non small cell lung cancer chemotherapy#Cisplatin Based Chemotherapy|Cisplatin based chemotherapy]]<BR> OR <BR> [[Cetuximab]]/[[vinorelbine]]/[[cisplatin]]|E04=[[Non small cell lung cancer chemotherapy|Chemotherapy]]|E05=Suportive care}}
 {{familytree | | | | | |`|-|v|-|'| | | | | | | | | | |}}
-{{familytree | | | | | | | F05 | | | | | | |F05=What was the tumor response to the treatment?}}
+{{familytree | | | | | | | F05 | | | | | | |F05=What was the [[tumor]] response to the treatment?}}
 {{familytree | | | | |,|-|-|^|-|-|-|-|.| |}}
-{{familytree | | | | G05 | | | | | | G06 | | | |G05=Progression|G06=Positive response or stable tumor}}
+{{familytree | | | | G05 | | | | | | G06 | | | |G05=Progression|G06=Positive response or stable [[tumor]]}}
 {{familytree | | | | |!| | | | | | | |!| | | | | |}}
 {{familytree | | | | |!| | | | | | | Z01 | | | | | | |Z01=Administer 4-6 cycles and assess progression of the disease}}
 {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
-{{familytree | | H03 | | H04 | | H05 | | | H06 | | | |H03=PS 0-2|H04=PS 3-4|H05=Tumor progression|H06=Positive response or stable tumor}}
+{{familytree | | H03 | | H04 | | H05 | | | H06 | | | |H03=PS 0-2|H04=PS 3-4|H05=[[Tumor]] progression|H06=Positive response or stable [[tumor]]}}
 {{familytree | | |!| | | |!| | | |!| | | | |!| | | | | |}}
-{{familytree | | I05 | | I06 | | I07 | | | I08 | | | | | |I05=Initiate [[docetaxel]] or  erlotinib or [[gemcitabine]]|I06=Provide suportive care|I07=Initiate [[docetaxel]] or erlotinib or [[gemcitabine]]|I08=Continuation mantainance ([[cetuximab]] or [[gemcitabine]]) <br>OR<br> Switch mantainance (erlotinib or [[decetaxel]]) <br>OR<br> Close observation}}
+{{familytree | | I05 | | I06 | | I07 | | | I08 | | | | | |I05=Initiate [[docetaxel]] or  erlotinib or [[gemcitabine]]|I06=Provide suportive care|I07=Initiate [[docetaxel]] or erlotinib or [[gemcitabine]]|I08=Continue treatment([[cetuximab]] or [[gemcitabine]]) <br>OR<br> Switch mantainance (erlotinib or [[docetaxel]]) <br>OR<br> Close observation}}
 {{familytree | | |!| | | | | | | |!| | | | |!| | | | | | | |}}
 {{familytree | | |!| | | | | | | |!| | | | K01 | | | | | |K01=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]}}
 {{familytree | | |`|-|-|-|-|-|-|-|+|-|-|-|-|'| | | | |}}
-{{familytree | | | | | | | | | | L01 | | | | | | | | | L01=If findings suggestive of progression of the disease are present, click here for the third line therapy}}
+{{familytree | | | | | | | | | | L01 | | | | | | | | | L01=If findings suggestive of progression of the disease are present, [[Non small cell lung cancer medical therapy metastatic cancer#Third Line Therapy|click here for the third line therapy]]}}
 {{familytree/end}}
 <br>
-==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.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
@@ Line 187: / Line 196: @@
 <br>
-==Multiple lung cancers==
+==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.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
+The algorithm for the treatment of multiple non small cell lung cancers are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.<ref name="NCCN">http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf</ref>
 {{familytree/start}}
@@ Line 205: / Line 214: @@
 {{familytree | | | | | E01 | | E02 | | | | E01=Disease confined to the [[chest]]|E02=Systemic proliferation}}
 {{familytree | | | | | |!| | | |!| | | |}}
-{{familytree | | | | | F01 | | F02 | | | F01=Assess the [[mediastinal]] [[lymph nodes]] in order to determine the N stage of the [[tumor]]|F02=Click here for the treatment of systemic metastasis}}
+{{familytree | | | | | F01 | | F02 | | | F01=Assess the [[mediastinal]] [[lymph nodes]] in order to determine the N stage of the [[tumor]]|F02=[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of systemic metastasis]]}}
 {{familytree | | | | | |!| | | | | |}}
 {{familytree | | | | | G01 | | | | | G01=What is the N stage of the [[tumor]]?}}
@@ Line 211: / Line 220: @@
 {{familytree | | | H01 | | H02 | | | H01=N0-1|H02=N2-3}}
 {{familytree | | | |!| | | |!| | | |}}
-{{familytree | | | I01 | | I02 | | | I01=Is the patient symptomatic?|I02=Click here for the treatment of systemic metastasis}}
+{{familytree | | | I01 | | I02 | | | I01=Is the patient symptomatic?|I02=[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of systemic metastasis]]}}
 {{familytree | |,|-|^|-|.| | | | | |}}
 {{familytree | J01 | | J02 | | | | | J01=Yes|J02=No}}
@@ Line 227: / Line 236: @@
 {{familytree | P01 | | P02 | | |!| | | | P01=No|P02=Yes}}
 {{familytree | |!| | | |!| | | |!| | | |}}
-{{familytree | Q01 | | Q02 | | |!| | | | Q01=Consider palliative chemotherapy with or without local radiation therapy|Q02=<div style="text-align: left; padding:1em;">Administer one of the following tratments:<br>
+{{familytree | Q01 | | Q02 | | |!| | | | Q01=Consider palliative chemotherapy with or without local [[Non small cell lung cancer radiation therapy|Radiation therapy]]|Q02=<div style="text-align: left; padding:1em;">Administer one of the following treatments:<br>
 * Preferred option: Parenchymal sparing resection<br>
-* Radiation therapy<br>
+* [[Non small cell lung cancer radiation therapy|Radiation therapy]]<br>
-* Ablatipn therapy</div>}}
+* Ablation therapy</div>}}
 {{familytree | |!| | | |`|-|v|-|'| | | |}}
-{{familytree | R01 | | | | R02 | | | | R01=Click here for the treatment of systemic metastasis|R02=Click here for the follow-up recommendations and treatment of recurrence and metastasis}}
+{{familytree | R01 | | | | R02 | | | | R01=[[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of systemic metastasis]]|R02=Go to the appropriate algorithm according to the characteristics of the disease: [[Non small cell lung cancer medical therapy metastatic cancer#local or regional recurrence|local or regional recurrence]] or [[Non small cell lung cancer medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|metastasis]]}}
 {{familytree/end}}
 <br>
@@ Line 238: / Line 247: @@
 ==References==
 {{reflist|2}}
 [[Category:Disease]]
@@ Line 246: / Line 252: @@
 [[Category:Pulmonology]]
 [[Category:Lung cancer]]
+ [[Category:Up-To-Date]]
 [[Category:Oncology]]
+[[Category:Medicine]]
-{{Tumors}}
+[[Category:Pulmonology]]
+[[Category:Surgery]]
+ [[Category:Up-To-Date]]
+[[Category:Oncology]]
+[[Category:Medicine]]
+[[Category:Pulmonology]]
+[[Category:Surgery]]

Non small cell lung cancer medical therapy metastatic cancer: Difference between revisions

Latest revision as of 23:28, 23 February 2018

Overview

Local or Regional Recurrence

Systemic Metastasis

Medical Therapy for Metastatic Non Small Cell Lung Cancer

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

Positive Sensitizing EGFR Mutation

Positive ALK Mutation

Negative EGRF and ALK or Unknown Mutation

Metastatic Squamous Cell Carcinoma

Third Line Therapy

Multiple Lung Cancers

References

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