Non small cell lung cancer medical therapy stage III: Difference between revisions
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==Medical Therapy for Stage III Non-Small Cell Lung Cancer== | ==Medical Therapy for Stage III Non-Small Cell Lung Cancer== | ||
The algorithms for the treatment of stage III 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> | |||
====Stage IIIA: T3, N1==== | ====Stage IIIA: T3, N1==== | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | {{familytree | | | | | | | Z01 | | | | | | | | | Z01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Perform a pretreatment evaluation'''<br> | ||
* If not done, perform [[pulmonary function tests]]<br> | * If not done, perform [[pulmonary function tests]]<br> | ||
* Perform [[bronchoscopy]] (if possible intraoperative)<br> | * Perform [[bronchoscopy]] (if possible intraoperative)<br> | ||
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* Perform a [[Brain tumor MRI|brain MRI]]<br> | * Perform a [[Brain tumor MRI|brain MRI]]<br> | ||
* Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or [[spine]]</div>}} | * Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or [[spine]]</div>}} | ||
{{familytree | {{familytree | | | | | | | |!| | | | | | | | | | | |}} | ||
{{familytree | {{familytree | | | | | | | A01 | | | | | | | | A01=Where is the tumor located?}} | ||
{{familytree | {{familytree | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | |}} | ||
{{familytree | {{familytree | E03 | | | | | | | | | | | E04 | | | | | | | | | | | | | E03=Superior suculus tumor|E04=<div style="float: left; text-align: left; width: 14em; padding:1em;">Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]</div>}} | ||
{{familytree | {{familytree | |!| | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | | | | |}} | ||
{{familytree | {{familytree | F01 | | | | | F02 | | | | | | | | | F03 | | | | | | | | | | | | | F01=T3 (Invasion to adjacent structures), N0|F02=<div style="float: left; text-align: left; width: 14em; padding:1em;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left; width: 14em; padding:1em;">Neoadjuvant [[Chemotherapy]] <br>OR<br>[[Chemotherapy]] + [[radiation therapy]]</div>}} | ||
{{familytree | {{familytree | |!| | | | | | |!| | | | | | | | | | |!| | | | | | | |}} | ||
{{familytree | {{familytree | G01 | | | | | G03 | | | | | | | | | G04 | | | | | | G01=Neoadjuvant chemotherapy|G02=T4|G03=<div style="float: left; text-align: left; width: 10em; padding:1em;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G04=<div style="float: left; text-align: left; width: 10em; padding:1em;">Perform surgery + pathological determination of residual tumor</div>}} | ||
{{familytree | {{familytree | |!| | | |,|-|-|^|-|-|.| | | | | | | |!| | | | | | | | | |}} | ||
{{familytree | {{familytree | H01 | | H03 | | | | H04 | | | | | | H05 | | | | | | | | H01=Surgery + adjuvant [[chemotherapy]]|H03=Negative (R0)|H04=<div style="float: left; text-align: left; width: 10em; padding:1em;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}} | ||
{{familytree | {{familytree | | | | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| | | | | |}} | ||
{{familytree | {{familytree | | | | | I04 | | I05 | | I06 | | I07 | | I08 | | | | I03=No|I04=Adjuvant [[chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}} | ||
{{familytree | {{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | |}} | ||
{{familytree | {{familytree | | | | | | | | | J03 | | J04 | | J05 | | J06 | | | | | | J01=Initiate neoadjuvant [[chemotherapy]] + [[radiation therapy]]|J02=Initiate definitive [[chemotherapy]] + [[radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[chemotherapy]]<br>OR<br>[[Chemotherapy]] + [[radiation therapy]], followed or not by [[chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[chemotherapy]]<br>OR<br>[[Chemotherapy]] + [[radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}} | ||
{{familytree/end}} | {{familytree/end}} | ||
<br> | <br> | ||
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====IIIA: T4, N0-1==== | ====IIIA: T4, N0-1==== | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | | | | | | A01 | {{familytree | | | | | | | | | | | | | | A01 | | | | | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Perform a pretreatment evaluation'''<br> | ||
* If not done, perform [[pulmonary function tests]]<br> | * If not done, perform [[pulmonary function tests]]<br> | ||
* Perform [[bronchoscopy]] (if possible intraoperative)<br> | * Perform [[bronchoscopy]] (if possible intraoperative)<br> | ||
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* Perform a [[Brain tumor MRI|brain MRI]]<br> | * Perform a [[Brain tumor MRI|brain MRI]]<br> | ||
* Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or [[spine]]</div>}} | * Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or [[spine]]</div>}} | ||
{{familytree | | | | | | | | | | | | | | |! | {{familytree | | | | | | | | | | | | | | |!| | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | B01 | {{familytree | | | | | | | | | | | | | | B01 | | | | B01=Is the tumor resectable?}} | ||
{{familytree | | | | | | | | | | |,|-|-|-|^|-|-|-|. | {{familytree | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | |}} | ||
{{familytree | | | | | | | | | | C01 | | | | | | C02 | {{familytree | | | | | | | | | | C01 | | | | | | C02 | | C01=Yes|C02=No}} | ||
{{familytree | | | | | | | | | | |!| | | | | | | |! | {{familytree | | | | | | | | | | |!| | | | | | | |!| | | |}} | ||
{{familytree | | | | | | | | | | D01 | | | | | | D02 | {{familytree | | | | | | | | | | D01 | | | | | | D02 | D01=Where is the tumor located?|D02=Definitive chemotherapy}} | ||
{{familytree | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|. | {{familytree | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | |}} | ||
{{familytree | | | E01 | | | | | | | | | | | | | E02 | {{familytree | | | E01 | | | | | | | | | | | | | E02 | | | E01=Superior suculus|E02=Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br [[Mediastinum]]}} | ||
{{familytree | | | |!| | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|.|}} | {{familytree | | | |!| | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|.|}} | ||
{{familytree | | | F01 | | | | | | | F02 | | | | | | | | | F03 | {{familytree | | | F01 | | | | | | | F02 | | | | | | | | | F03 | |F01=Initiate neoadjuvant [[chemotherapy]] + [[radiation therapy]]|F02=<div style="float: left; text-align: left; width: 14em; padding:1em;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left; width: 14em; padding:1em;">Neoadjuvant [[Chemotherapy]] <br>OR<br>[[Chemotherapy]] + [[radiation therapy]]</div>}} | ||
{{familytree | | | |!| | | | | | | | |!| | | | | | | | | | |! | {{familytree | | | |!| | | | | | | | |!| | | | | | | | | | |!| | |}} | ||
{{familytree | | | G01 | | | | | | | G02 | | | | | | | | | G03 | {{familytree | | | G01 | | | | | | | G02 | | | | | | | | | G03 | | | G01=Perform a surgical evaluation: Is the [[tumor]] resectable?|G02=<div style="float: left; text-align: left; width: 10em; padding:1em;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G03=<div style="float: left; text-align: left; width: 10em; padding:1em;">Perform surgery + pathological determination of residual tumor</div>}} | ||
{{familytree | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | | | |! | {{familytree | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | | | |!| |}} | ||
{{familytree | H01 | | H02 | | H03 | | | | H04 | | | | | | H05 | {{familytree | H01 | | H02 | | H03 | | | | H04 | | | | | | H05 | | | | | H01=Yes|H02=No|H03=Negative (R0)|H04=<div style="float: left; text-align: left; width: 10em; padding:1em;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}} | ||
{{familytree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|. | {{familytree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| |}} | ||
{{familytree | I01 | | I02 | | I04 | | I05 | | I06 | | I07 | | I08 | {{familytree | I01 | | I02 | | I04 | | I05 | | I06 | | I07 | | I08 | | I01=[[Tumor]] extraction + adjuvant [[chemotherapy]]|I02=Definitive [[chemotherapy]] + [[radiation therapy]]|I04=Adjuvant [[chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}} | ||
{{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |! | {{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}} | ||
{{familytree | | | | | | | | | | | | | J03 | | J04 | | J05 | | J06 | {{familytree | | | | | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[chemotherapy]] + [[radiation therapy]]|J02=Initiate definitive [[chemotherapy]] + [[radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[chemotherapy]]<br>OR<br>[[Chemotherapy]] + [[radiation therapy]], followed or not by [[chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[chemotherapy]]<br>OR<br>[[Chemotherapy]] + [[radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}} | ||
{{familytree/end}} | {{familytree/end}} | ||
<br> | <br> | ||
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* Perform a [[Brain tumor MRI|brain MRI]]<br> | * Perform a [[Brain tumor MRI|brain MRI]]<br> | ||
</div>}} | </div>}} | ||
{{familytree | | | | | | | | | | | | | | |! | {{familytree | | | | | | | | | | | | | | |!| | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | A01 | | | | | | | | | A01=Is the [[tumor]] T1-3 or is it T4?}} | {{familytree | | | | | | | | | | | | | | A01 | | | | | | | | | A01=Is the [[tumor]] T1-3 or is it T4?}} | ||
{{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | |}} | {{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | |}} | ||
{{familytree | | | | | | | B01 | | | | | | | | | | | | B02 | {{familytree | | | | | | | B01 | | | | | | | | | | | | B02 | | B01=T1-3, N3|B02=T4}} | ||
{{familytree | | | | | | | |!| | | | | | | | | | | | | |! | {{familytree | | | | | | | |!| | | | | | | | | | | | | |!| | |}} | ||
{{familytree | | | | | | | C01 | | | | | | | | | | | | C02 | {{familytree | | | | | | | C01 | | | | | | | | | | | | C02 | | C01=Does the infiltration to [[lymph nodes]] meet the criteria for N3 or are there findings suggestive of [[metastatic disease]]?|C02=Is the infiltration to the [[mediastinal]] [[lymph nodes]] contralateral or are there findings suggestive of [[metastatic disease]]?}} | ||
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | |,|-|-|-|^|-|-|-|.| | | |}} | {{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | |,|-|-|-|^|-|-|-|.| | | |}} | ||
{{familytree | | | D01 | | | | | | D02 | | | | D03 | | | | | | D04 | | D01=Yes|D02=No|D03=Yes|D04=No}} | {{familytree | | | D01 | | | | | | D02 | | | | D03 | | | | | | D04 | | D01=Yes|D02=No|D03=Yes|D04=No}} | ||
{{familytree | |,|-|^|-|.| | | | | |!| | | |,|-|^|-|.| | | | | |!| | | |}} | {{familytree | |,|-|^|-|.| | | | | |!| | | |,|-|^|-|.| | | | | |!| | | |}} | ||
{{familytree | E01 | | E02 | | | | E03 | | E04 | | E05 | | | | E06 | | | | | E01=[[Metastatic disease]]|E02=Findings suggestive of N3|E03=See treatment|E04=[[Metastatic disease]]|E05=Positive contralateral [[mediastinal]] node infiltration|E06=Does the [[tumor]] infiltrated the ipsilateral [[mediastinal]] [[lymph nodes]]?}} | {{familytree | E01 | | E02 | | | | E03 | | E04 | | E05 | | | | E06 | | | | | E01=[[Metastatic disease]]|E02=Findings suggestive of N3|E03=See treatment|E04=[[Metastatic disease]]|E05=Positive contralateral [[mediastinal]] node infiltration|E06=Does the [[tumor]] infiltrated the ipsilateral [[mediastinal]] [[lymph nodes]]?}} | ||
{{familytree | |!| | | |!| | | | | | | | | |!| | | |!| | | |,|-|^|-|. | {{familytree | |!| | | |!| | | | | | | | | |!| | | |!| | | |,|-|^|-|.| | |}} | ||
{{familytree | F01 | | F02 | | | | | | | | F03 | | F04 | | F05 | | F06 | {{familytree | F01 | | F02 | | | | | | | | F03 | | F04 | | F05 | | F06 | | F01=[[Non small cell carcinoma of the lung medical therapy#Metastatic disease|Click here for the treatment of metastatic disease]]|F02=Definitive chemotherapy + radiation therapy|F03=[[Non small cell carcinoma of the lung medical therapy#Metastatic disease|Click here for the treatment of metastatic disease]]|F04=Definitive chemotherapy + radiation therapy|F05=Yes|F06=No}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | |! | {{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | |!| |}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | G01 | | G02 | {{familytree | | | | | | | | | | | | | | | | | | | | | | | G01 | | G02 | | G01=Definitive chemotherapy + radiation therapy|G02=[[Non small cell carcinoma of the lung medical therapy#Stage IIIA|Click here for the stage IIIA treatment]]}} | ||
{{familytree/end}} | {{familytree/end}} | ||
==References== | |||
{{reflist|2}} | |||
Revision as of 15:08, 24 June 2014
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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 Stage III Non-Small Cell Lung Cancer
The algorithms for the treatment of stage III non small cell carcinoma of the lung are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.[1]
Stage IIIA: T3, N1
Perform a pretreatment evaluation
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Where is the tumor located? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Superior suculus tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
T3 (Invasion to adjacent structures), N0 | Preferred option: Surgery + pathological determination of microscopic residual tumor | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Neoadjuvant chemotherapy | Are margins from the surgical piece positive or negative for residual tumor? | Perform surgery + pathological determination of residual tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Surgery + adjuvant chemotherapy | Negative (R0) | Positive: Is the residual tumor microscopic (R1) or macroscopic (R2) | Are margins from the surgical piece positive or negative for residual tumor? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adjuvant chemotherapy | Microscopic (R1) | Macroscopic (R2) | Negative (R0) | Positive (R1-2) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tumor resection + adjuvant chemotherapy OR Chemotherapy + radiation therapy, followed or not by chemotherapy | Tumor resection + adjuvant chemotherapy OR Chemotherapy + radiation therapy | Observation | Tumor resection | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
IIIA: T4, N0-1
Perform a pretreatment evaluation
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is the tumor resectable? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Where is the tumor located? | Definitive chemotherapy | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Superior suculus | Proximal airway OR Chest wall OR<br Mediastinum | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Initiate neoadjuvant chemotherapy + radiation therapy | Preferred option: Surgery + pathological determination of microscopic residual tumor | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Perform a surgical evaluation: Is the tumor resectable? | Are margins from the surgical piece positive or negative for residual tumor? | Perform surgery + pathological determination of residual tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Negative (R0) | Positive: Is the residual tumor microscopic (R1) or macroscopic (R2) | Are margins from the surgical piece positive or negative for residual tumor? | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Tumor extraction + adjuvant chemotherapy | Definitive chemotherapy + radiation therapy | Adjuvant chemotherapy | Microscopic (R1) | Macroscopic (R2) | Negative (R0) | Positive (R1-2) | |||||||||||||||||||||||||||||||||||||||||||||||||||
Tumor resection + adjuvant chemotherapy OR Chemotherapy + radiation therapy, followed or not by chemotherapy | Tumor resection + adjuvant chemotherapy OR Chemotherapy + radiation therapy | Observation | Tumor resection | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stage IIIB
Perform a pretreatment evaluation
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Is the tumor T1-3 or is it T4? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
T1-3, N3 | T4 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Does the infiltration to lymph nodes meet the criteria for N3 or are there findings suggestive of metastatic disease? | Is the infiltration to the mediastinal lymph nodes contralateral or are there findings suggestive of metastatic disease? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Metastatic disease | Findings suggestive of N3 | See treatment | Metastatic disease | Positive contralateral mediastinal node infiltration | Does the tumor infiltrated the ipsilateral mediastinal lymph nodes? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Click here for the treatment of metastatic disease | Definitive chemotherapy + radiation therapy | Click here for the treatment of metastatic disease | Definitive chemotherapy + radiation therapy | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Definitive chemotherapy + radiation therapy | Click here for the stage IIIA treatment | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||