Adenocarcinoma of the lung medical therapy metastatic cancer
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [2]
Local or Regional Recurrence
- The algorithm bellow 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 | |||||||||||||||||||||||||||||||||||||||
| 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? | |||||||||||||||||||||||||||||||||||||||||||||
| 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:
| 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.[2]
| 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 treatments:
| ||||||||||||||||||||||||||||||||
| 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 Lung cancer. National Comprehensive Cancer Network 2015. http://www.nccn.org/professionals/default.aspx
- ↑ http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf