Adenocarcinoma of the lung medical therapy

Adenocarcinoma of the Lung Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Adenocarcinoma of the Lung from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
Staging
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X Ray
Echocardiography and Ultrasound
CT
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Intervention
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Adenocarcinoma of the lung medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Adenocarcinoma of the lung medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Adenocarcinoma of the lung medical therapy
CDC on Adenocarcinoma of the lung medical therapy
Adenocarcinoma of the lung medical therapy in the news
Blogs on Adenocarcinoma of the lung medical therapy
Directions to Hospitals Treating Adenocarcinoma of the lung
Risk calculators and risk factors for Adenocarcinoma of the lung medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [2]

Medical Therapy

Stage I

Shown below is the algorithm on the treatment of the stage I non-small cell lung cancer based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

In the tumor central o peripheral?

Peripheral

Central

Is the tumor T1 or T2a?

T1ab, N0

T2a, N0

T1ab-2a, N0

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan

Does the pathological evaluation showed positive disease in the mediastinal lymph nodes?

Does the pathological evaluation showed positive disease in the mediastinal lymph nodes?

Yes

No

Yes

No

Click here for the stage III treatment

Is the tumor operable?

Click here for the stage III treatment

Is the tumor operable?

Yes

No

Yes

No

Surgical resection + lymph node dissection

stereotactic ablative radiation therapy

Surgical resection + lymph node dissection

Does the patient presents metastasis to ipsilateral peribronchial and/or hiliar nodesand intrapulmonar nodes (N1)?

Yes

No

chemotherapy + radiation therapy

stereotactic ablative radiation therapy Adjuvant chemotherapy should be added for high-risk stages

Stage II

Stage IIA

• Shown below is the algorithm on the treatment of the stage IIA non-small cell lung cancer based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

T1a-b, 2a, N1 T2b, N0 T3 Tumor larger than 7 cm (not invasive)

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan

Does the pathological evaluation showed positive disease in the mediastinal lymph nodes?

Yes

No

Click here for the stage III treatment

Is the tumor operable?

Yes

No

Surgical resection + lymph node dissection

Does the patient presents metastasis to ipsilateral peribronchial and/or hiliar nodes and intrapulmonar nodes (N1)?

If lymph node extension is detected initiate neoadjuvantchemotherapy + radiation therapy

Yes

No

chemotherapy + radiation therapy

radiation therapy with stereotactic ablative radiotherapy Adjuvant Chemotherapy should be added for high-risk stages

Stage IIB

• Shown below is the algorithm on the treatment of the stage IIB non-small cell lung cancer based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan Perform a brain MRI Perform a spine MRI with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or spine

What is the location of the tumor?

Superior suculus tumor

Proximal airway OR Chest wall OR Mediastinum

T3 (Invasion to adjacent structures), N0

Preferred option: Surgery + pathological determination of microscopic residual tumor

Neoadjuvant chemotherapy OR chemotherapy + radiation therapy

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

Stage III

• 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.

Stage IIIA: T3, N1

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan Perform a brain MRI Perform a spine MRI with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or spine

Where is the tumor located?

Superior suculus tumor

Proximal airway OR Chest wall OR Mediastinum

T3 (Invasion to adjacent structures), N0

Preferred option: Surgery + pathological determination of microscopic residual tumor

Neoadjuvant Chemotherapy OR chemotherapy + radiation therapy

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 If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan Perform a brain MRI Perform a spine MRI with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or spine

Is the tumor resectable?

Yes

No

Where is the tumor located?

Definitive chemotherapy

Superior suculus

Proximal airway OR Chest wall OR Mediastinum

Initiate neoadjuvant chemotherapy + radiation therapy

Preferred option: Surgery + pathological determination of microscopic residual tumor

Neoadjuvant chemotherapy OR chemotherapy + radiation therapy

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 If not done, order PET scan or CT scan Confirmation tests of lymph node infiltration stage: Thoracoscopy and mediastinoscopy Mediastinotomy Biopsy of the supraclavicular lymph nodes Needle aspiration biopsy Endoscopic ultrasound-guided biopsy Endobronchial ultrasound-guided biopsy Perform a brain MRI

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 cancer

Definitive chemotherapy + radiation therapy

Click here for the treatment of metastatic cancer

Definitive chemotherapy + radiation therapy

Yes

No

Definitive chemotherapy + radiation therapy

Click here for the stage IIIA treatment

References

Template:WikiDoc Sources