Staging
Staging
Treatment by Stage
For early stage lung cancers, surgery or
radiation alone
For larger tumors (>4 cm) and N+,
chemotherapy should be added as well
For metastatic disease, chemotherapy and
palliative radiation is used
Surgery
Resection remains the preferred local tx
modality
For smokers, encourage quitting and waiting 4
weeks smoke-free before surgery
Surgery for Early Stage
Sleeve lobectomy is preferred
Sublobar resection: Segmentectomy is
preferred over wedge resection for pts with
poor pulm reserve, small nodules of AIS, >
50% ground glass appearance, or long
radiological doubling time
Goal of >2 cm margins, and should sample
N1/N2 LN stations if possible
VATS vs open thoracotomy
In centers with high volumes of VATS, there
are improved early outcomes:
• Reduced pain
• Shortened hospital stay
• Faster recovery
• Fewer complications
• Similar rates of tumor control
Radiation in Early Stage
Stereotactic Body Radiotherapy (SBRT)
delivers a high, tumor-ablative dose to the
target while minimizing normal tissue dose
In Stage I NSCLC, SBRT shows rates of local
tumor control (90-98%) and overall survival
30-80%) comparable to lobectomy
Stage III Controversies
Historically Stage IIIA/B have been considered
unresectable and definitive chemotherapy
and radiation (concurrently or sequentially) is
the tx of choice
Two randomized studies have failed to show
an OS benefit in adding surgical resection to
chemo and RT, but NCCN guidelines still
include it as an option to consider
Breaks from neoadjuvant tx for surgical
evaluation should be < 1 week
Resection of Stage IIIA (N2)
In addition to N1/N2 dissection, ipsilateral
mediastinal LN dissection should be done
Complete resxn (R0) = free margins, systemic
LN sampling or dissections, and the highest
mediastinal node taken should be negative
for tumor
Incomplete: positive margins, unremoved
positive LN’s, or positive pleural or
pericardial effusion (R1 if microscopic, R2 if
gross residual tumor)
Chemotherapy
Multiple randomized trials show the benefit of
chemotherapy in Stage II and III NSCLC
(maybe even Stage IB with tumor > 4cm)
Platinum-based doublet:
Cisplatin/etoposide
Cisplatin/vinblastine
Carboplatin/paclitaxel
Pemetrexed for nonsquamous histology,
gemcitabine for squamous
M1b, Solitary Site
• For solitary brain metastasis: resection +
WBI, or SBI + SRS, or SRS alone
• For adrenal metastasis: resection or RT
(SBRT) to metastasis
• Then tx the lung per it’s stage without the
metastasis
Advanced or Metastatic Disease
• EGFR and ALK testing for non-squamous
histologies
• Bevacizumab + chemotherapy in pts with
good performance status
• Erlotinib is first line therapy in pts with EGFR
mutation
• Crizotinib is first line therapy in pts who are
ALK positive
Targeted Therapies
Bevacizumab (Avastin) – VEGF
Erlotinib (Tarceva) – EGFR
Gefitinib (Iressa) – EGFR
Crizotinib – ALK
These targets are mainly applicable in
adenocarcinomas, with most SQCC lacking
EGFR mutation and ALK rearrangement
Cetuximab has shown activity in SQCC’s with
high EGFR expression (FLEX)
Future Targets for SQCC
In squamous cell NSCLC’s genomic profiling
shows potential targets in PI3K pathway,
FGFR1 amplifications and DDR2 mutations
ECLIPSE: Phase III trial of
carboplatin/gemcitabine =/- iniparib (a PARP
inhibitor) is underway
Phase III trial of carboplatin/paclitaxel +/ipilimumab (targets the inhibition of cytotoxic
T cells)
Follow Up
Physical exam and CT scan every 6 months
for 2 years
Exam and CT scan every year after that