Non small cell lung cancer medical therapy stage IV

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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] Maria Fernanda Villarreal, M.D. [3]

Overview

Therapies for non-small cell lung cancer stage IV include cytotoxic combination chemotherapy (first line), combination chemotherapy with bevacizumab or cetuximab, EGFR tyrosine kinase inhibitors, EML4-ALK inhibitors in patients with EML-ALK translocations, and immune checkpoint inhibition with nivolumab for selected patients with squamous or non-squamous metastatic. Maintenance therapy following first-line chemotherapy, include endobronchial laser therapy or brachytherapy (for obstructing lesions) and external-beam radiation therapy (primarily for palliation of local symptomatic tumor growth). Local therapies (ambulatory catheter drainage, pleurodesis or mediastinal window) plus therapy for systemic metastasis is the preferred combination for patients with stage IV M1a non-small cell lung cancer. Patients with solitary site metastasis (stage IV M1b) should be treated according to the site of metastasis.

Medical Therapy for Stage IV Non-Small Cell Lung Cancer

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

Is pleural or pericardial effusion present (suggestive of M1a) or are findings suggestive of systemic metastasis (M1b) present?

M1a

M1b: solitary site systemic metastasis

Perform the following tests: Perform thoracentesis and/or pericardiocentesis Perform a thoracoscopy if thoracocentesis is inconclusive

Perform the following tests: Brain MRI Bronchoscopy Mediastinal lymph node biopsy If not previously done, PET scan or CT scan

Is the liquid extracted positive for malignant cells?

Are findings suggestive of adrenal metastasis or brain metastasis?

Yes

No

Adrenal

Brain

Local therapy Ambulatory catheter drainage Pleurodesis Mediastinal window PLUS Therapy for metastatic disease (click here for the treatment of metastatic cancer)

Treat according to tumor stage: I II III

Perform a needle aspiration biopsy for metastasis confirmation

Surgical resection + adjuvant radiation therapy Radiation therapy alone: stereotactic ablative radiation therapy + Whole brain radiation therapy OR stereotactic ablative radiation therapy PLUS Pathologic evaluation of surgical piece and lymph nodes

If the lung disease is curable, administer local therapy for the adrenal lesion: Surgical adrenal resection OR Radiation therapy OR Administer therapy for metastatic disease in case of not curable lung lesions (click here for the treatment of metastatic cancer)

What is the TN stage of the lung tumor?

T1-2, No-1 T3, N0

T1-2, N2 T3, N1-2 N3, regardless of the T stage T4 regardless of the N stage

Surgical resection of lung tumor + adjuvant chemotherapy OR Neoadjuvant chemotherapy + surgical resection or stereotactic ablative radiation therapy OR Stereotactic ablative radiation therapy

Administer therapy for metastatic disease in case of not curable lung lesions (click here for the treatment of metastatic cancer)