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Stage IV

 
 
 
 
 
 
Is pleural or pericardial effusion present (suggestive of M1a) or are findings suggestive of systemic metastasis (M1b) present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
M1a
 
 
 
 
 
M1b
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform the following tests:
 
 
 
 
 
Perform the following tests:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 local and systemic metastasis and neoplastic recurrence)

 
Treat according to tumor stage:
 
Perform a needle aspiration biopsy for metastasis confirmation
 
Surgical resection + adjuvant radiation therapy
Radiation therapy alone:
  • Sterotactic radio surgery + Whole brain radiation therapy
    OR
  • Sterotactic radio surgery alone

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 local and systemic metastasis and neoplastic recurrence)

 
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 therpay alone
 
Administer therapy for metastatic disease in case of not curable lung lesions (click here for the treatment of local and systemic metastasis and neoplastic recurrence)
 
 
 

Follow-up

 
 
 
 
Controls of history + physical exam and chest CT with or without contrast every 6-12 months (first 2 years), then annual controls
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is there evidence of local or regional recurrence
OR
systemic metastasis?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Local or regional recurrence
 
Systemic metastasis
 
 

Local or regional recurrence

 
 
 
 
 
 
 
 
What is the site of the recurrence?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bronchial obstruction
 
Mediastinal lymph node
 
Superior vena cava obstruction
 
Severe hemoptisis
 
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 radiotherapy or external-beam radiation therapy)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer systemic therapy
 
Administer chemotherapy + radiation therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are findings suggestive of disseminated disease present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for the treatment of metastatic disease
 
 
 
Observation
OR
systemic therapy
 
 
 
 


Systemic metastasis

 
 
 
 
 
 
 
 
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-beam radiation 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
 
 
 
 
 
 
 
 
 

Metastatic disease

 
 
 
 
 
 
 
 
 
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