Non small cell lung cancer medical therapy metastatic cancer: Difference between revisions
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==Multiple lung cancers== | |||
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{{familytree | | | | | | | | | A01 | | | | A01=Is there suspicion of multiple lung cancers?}} | |||
{{familytree | | | | | | | |,|-|^|-|.| | |}} | |||
{{familytree | | | | | | | B01 | | B02 | | | B01=Yes|B02=No}} | |||
{{familytree | | | | | | | |!| | | |!| | | | |}} | |||
{{familytree | | | | | | | C01 | | C02 | | | | C01=<div style="text-align: left; padding:1em;">Perform the following tests:<br> | |||
* If not previously done, [[PET scan]] or [[CT scan]]<br> | |||
* Contrast chest [[CT]]<br> | |||
* [[Brain tumor MRI|Brain MRI]] | |||
</div>|C02=Administer treatment according to the TNM stage of the [[tumor]]}} | |||
{{familytree | | | | | | | |!| | | | | | | |}} | |||
{{familytree | | | | | | | D01 | | | | | D01=Is the disease is confined to the [[chest]] or is there systemic proliferation?}} | |||
{{familytree | | | | | |,|-|^|-|.| | | | |}} | |||
{{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 | | | | | |!| | | | | |}} | |||
{{familytree | | | | | G01 | | | | | G01=What is the N stage of the [[tumor]]?}} | |||
{{familytree | | | |,|-|^|-|.| | |}} | |||
{{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 | |,|-|^|-|.| | | | | |}} | |||
{{familytree | J01 | | J02 | | | | | J01=Yes|J02=No}} | |||
{{familytree | |!| | | |!| | | | | |}} | |||
{{familytree | |!| | | K01 | | | | | K01=Is the lesion a solitary nodule or are there multiple nodules?}} | |||
{{familytree | |!| |,|-|^|-|.| | |}} | |||
{{familytree | |!| L01 | | L02 | | L01=Solitary nodule|L02=Multiple nodules}} | |||
{{familytree | |!| |!| | | |!| | |}} | |||
{{familytree | |!| |!| | | M01 | | | M01=What is the risk of turning into a symptomatic disease?}} | |||
{{familytree | |!| |!| |,|-|^|-|.| |}} | |||
{{familytree | |!| |!| N01 | | N02 | |N01=High|N02=Low}} | |||
{{familytree | |`|-|+|-|'| | | |!| | |}} | |||
{{familytree | | | O01 | | | | O02 | | O01=Is definitive local therapy possible?|O02=Observation}} | |||
{{familytree | |,|-|^|-|.| | | |!| | | |}} | |||
{{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> | |||
* Preferred option: Parenchymal sparing resection<br> | |||
* Radiation therapy<br> | |||
* Ablatipn 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/end}} | |||
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Revision as of 14:28, 24 June 2014
Non Small Cell Lung Cancer Microchapters |
Differentiating Non Small Cell Lung Cancer from other Diseases |
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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]
Overview
Medical Therapy for Metastatic Non-Small Cell Lung Cancer
What the specific subtype according to the specific histological characteristics of the tumor? | |||||||||||||||||||||||||||||||||||||||
| Squamous cell carcinoma | ||||||||||||||||||||||||||||||||||||||
Perform specific EGFR and ALK mutation testing: What is the specific mutation? | Is the patient a 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 | |||||||||||||||||||||||||||||||||||||
Metastatic adenocarcinoma, large cell carcinoma and not specified non-small cell carcinoma
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]
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 doublet 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 doublet 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
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 | |||||||||||||||||||||||||||||||||||||||||||||||
Multiple lung cancers
Is there suspicion of multiple lung cancers? | |||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||
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:
| ||||||||||||||||||||||||||||||||
Click here for the treatment of systemic metastasis | Click here for the follow-up recommendations and treatment of recurrence and metastasis | ||||||||||||||||||||||||||||||||