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| __NOTOC__
| | {{Image|Noninferiority and equivalency randomized controlled trials.jpg|right|350px|Noninferiority and equivalency randomized controlled trials.}} |
| {{Adenocarcinoma of the lung}} | |
| {{CMG}}; {{AE}} {{SC}}
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| ==Overview==
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| ==Medical Therapy==
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| ===Stage I===
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| 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.<ref name=nccn>Non-small cell lung cancer. National Comprehensive Cancer Network 2015. http://www.nccn.org/professionals/default.aspx</ref>
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| {{familytree/start}}
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| {{familytree | | | | | | | | | | A01 | | |A01=In the [[tumor]] central o peripheral?}}
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| {{familytree | | | | | | |,|-|-|-|^|-|-|.| | | | |}}
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| {{familytree | | | | | | B01 | | | | | B02 | | | B01=Peripheral|B02=Central}}
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| {{familytree | | | | | | |!| | | | | | |!| | |}}
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| {{familytree | | | | | | C01 | | | | | |!| | | C01=Is the [[tumor]] T1 or T2a?}}
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| {{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |}}
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| {{familytree | | | D01 | | | | D02 | | D03 | | | D01=T1ab, N0|D02=T2a, N0|D03=T1ab-2a, N0}}
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| {{familytree | | | |!| | | | | |`|-|v|-|'| | | |}}
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| {{familytree | | | E01 | | | | | | E02 | | | | E01='''Perform a pretreatment evaluation'''<br>
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| * If not done, perform [[pulmonary function tests]]<br>
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| * Perform [[bronchoscopy]] (if possible intraoperative)<br>
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| * Perform a pathological [[lymph node evaluation]]<br>
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| * If not done, order [[PET]] scan or [[CT scan]]
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| |E02='''Perform a pretreatment evaluation'''<br>
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| * If not done, perform [[pulmonary function tests]]<br>
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| * Perform [[bronchoscopy]] (if possible intraoperative)<br>
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| * Perform a pathological [[lymph node]] evaluation<br>
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| * If not done, order [[PET]] scan or [[CT scan]]}}
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| {{familytree | | | |!| | | | | | | |!| | | | |}}
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| {{familytree | | | F01 | | | | | | F02 | | | | | F01=Does the pathological evaluation showed positive disease in the mediastinal [[lymph nodes]]?|F02=Does the pathological evaluation showed positive disease in the mediastinal [[lymph nodes]]?}}
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| {{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
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| {{familytree | G01 | | G02 | | G03 | | G04 | | G01=Yes|G02=No|G03=Yes|G04=No}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | |}}
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| {{familytree | H01 | | H02 | | H03 | | H04 | | | | H01=[[Non small cell carcinoma of the lung medical therapy stage III|Click here for the stage III treatment]]|H02=Is the [[tumor]] operable?|H03=[[Non small cell carcinoma of the lung medical therapy stage III|Click here for the stage III treatment]]|H04=Is the tumor operable?}}
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| {{familytree | | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
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| {{familytree | | | I01 | | I02 | | I03 | | I04 | | | I01=Yes|I02=No|I03=Yes|I04=No}}
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| {{familytree | | | |!| | | |!| | | |!| | | |!| | | |}}
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| {{familytree | | | J01 | | J02 | | J03 | | J04 | | | J01=Surgical resection + [[lymph node]] dissection|J02=[[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]]|J03=Surgical resection + [[lymph node]] dissection|J04=Does the patient presents metastasis to ipsilateral peribronchial and/or hiliar nodesand intrapulmonar nodes (N1)?}}
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| {{familytree | | | | | | | | | | | | | |,|-|^|-|.| | |}}
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| {{familytree | | | | | | | | | | | | | K01 | | K02 | | |K01=Yes|K02=No}}
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| {{familytree | | | | | | | | | | | | | |!| | | |!| | | |}}
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| {{familytree | | | | | | | | | | | | | L01 | | L02 | | | L01=[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|L02=[[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]]<br>Adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]] should be added for high-risk stages}}
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| {{familytree/end}}
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| ==Stage II==
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| '''Stage IIA'''
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| * 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.
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| {{familytree/start}}
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| {{familytree | | | B01 | | | B01=<div style="float: left; text-align: left;">
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| * T1a-b, 2a, N1<br>
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| * T2b, N0<br>
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| * T3 Tumor larger than 7 cm (not invasive)</div>}}
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| {{familytree | | | |!| | | | | | | | |}}
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| {{familytree | | | C01 | | | | | C01=<div style="float: left; text-align: left;">'''Perform a pretreatment evaluation'''<br>
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| * If not done, perform [[pulmonary function tests]]<br>
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| * Perform [[bronchoscopy]] (if possible intraoperative)<br>
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| * Perform a pathological [[lymph node]] evaluation<br>
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| * If not done, order [[PET]] scan or [[CT scan]]
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| </div>}}
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| {{familytree | | | |!| | | |}}
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| {{familytree | | | D01 | | | |D01=Does the pathological evaluation showed positive disease in the [[mediastinal]] [[lymph nodes]]?}}
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| {{familytree | |,|-|^|-|.| | | |}}
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| {{familytree | E01 | | E02 | | | E01=Yes|E02=No}}
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| {{familytree | |!| | | |!| | | | |}}
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| {{familytree | F01 | | F02 | | | F01=[[Non small cell carcinoma of the lung medical therapy stage III|Click here for the stage III treatment]]|F02=Is the [[tumor]] operable?}}
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| {{familytree | | |,|-|-|^|-|-|.| | |}}
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| {{familytree | | G01 | | | | G02 | | G01=Yes|G02=No}}
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| {{familytree | | |!| | | | | |!| | | |}}
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| {{familytree | | H01 | | | | H02 | | | | H01=Surgical resection + [[lymph node]] dissection|H02=Does the patient presents metastasis to ipsilateral [[Tracheobroncuial lymph nodes|peribronchial]] and/or [[Tracheobroncuial lymph nodes|hiliar nodes]] and intrapulmonar nodes (N1)?}}
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| {{familytree | | |!| | | |,|-|^|-|.| | | |}}
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| {{familytree | | I03 | | I01 | | I02 | | | | | I01=Yes|I02=No|I03=If lymph node extension is detected initiate neoadjuvant[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]}}
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| {{familytree | | | | | | |!| | | |!| | |}}
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| {{familytree | | | | | | J01 | | J02 | | J01=[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|J02=[[Non small cell carcinoma of the lung medical therapy radiation therapy|radiation therapy with stereotactic ablative radiotherapy]]<br>Adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]] should be added for high-risk stages}}
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| {{familytree/end}}
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| <br>
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| '''Stage IIB'''
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| * 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.
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| {{familytree/start}}
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| {{familytree | | | | | | | C02 | | | | | | | | | | C02=<div style="float: left; text-align: left; width: 12em;">'''Perform a pretreatment evaluation'''<br>
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| * If not done, perform [[pulmonary function tests]]<br>
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| * Perform [[bronchoscopy]] (if possible intraoperative)<br>
| |
| * Perform a pathological [[lymph node]] evaluation<br>
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| * If not done, order [[PET]] scan or [[CT scan]]<br>
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| * Perform a [[Brain tumor MRI|brain MRI]]<br>
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| * Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the [[subclavian vessels]] or [[spine]]</div>}}
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| {{familytree | | | | | | | |!| | | | | | | | | | | | |}}
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| {{familytree | | | | | | | D02 | | | | | | | | | | D02=What is the location of the [[tumor]]?}}
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| {{familytree | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | |}}
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| {{familytree | E03 | | | | | | | | | | | E04 | | | | E03=Superior suculus tumor|E04=<div style="float: left; text-align: left; width: 12em;">Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]</div>}}
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| {{familytree | |!| | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | | }}
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| {{familytree | F01 | | | | | F02 | | | | | | | | | F03 | | F01=T3 (Invasion to adjacent structures), N0|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]] <br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
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| {{familytree | |!| | | | | | |!| | | | | | | | | | |!| | | |}}
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| {{familytree | G01 | | | | | G03 | | | | | | | | | G04 | | G01=Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]|G02=T4|G03=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G04=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual tumor</div>}}
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| {{familytree | |!| | | |,|-|-|^|-|-|.| | | | | | | |!| | | | | | | | | |}}
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| {{familytree | H01 | | H03 | | | | H04 | | | | | | H05 | | | | | | | | H01=Surgery + adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
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| {{familytree | | | | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| | | | | |}}
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| {{familytree | | | | | I04 | | I05 | | I06 | | I07 | | I08 | | | | I03=No|I04=Adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
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| {{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | |}}
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| {{familytree | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherpay plus Radiation Therapy|Chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]<br>OR<br> [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Therapy, Followed by Chemotherapy|chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]<br>OR<br> [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
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| {{familytree/end}}
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| | |
| ==Stage III==
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| * 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.
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| | |
| '''Stage IIIA: T3, N1'''
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| {{familytree/start}}
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| {{familytree | | | | | | | Z01 | | | | | | | | | Z01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Perform a pretreatment evaluation'''<br>
| |
| * If not done, perform [[pulmonary function tests]]<br>
| |
| * Perform [[bronchoscopy]] (if possible intraoperative)<br>
| |
| * Perform a pathological [[lymph node]] evaluation<br>
| |
| * If not done, order [[PET]] scan or [[CT scan]]<br>
| |
| * Perform a [[Brain tumor MRI|brain MRI]]<br>
| |
| * Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or [[spine]]</div>}}
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| {{familytree | | | | | | | |!| | | | | | | | | | | |}}
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| {{familytree | | | | | | | A01 | | | | | | | | A01=Where is the tumor located?}}
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| {{familytree | |,|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | |}}
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| {{familytree | E03 | | | | | | | | | | | E04 | | | | | | E03=<div style="float: left; text-align: left;">Superior suculus tumor</div>|E04=<div style="float: left; text-align: left;">Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]</div>}}
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| {{familytree | |!| | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | |}}
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| {{familytree | F01 | | | | | F02 | | | | | | | | | F03 | | F01=<div style="float: left; text-align: left;">T3 (Invasion to adjacent structures), N0</div>|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]] <br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
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| {{familytree | |!| | | | | | |!| | | | | | | | | | |!| | | |}}
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| {{familytree | G01 | | | | | G03 | | | | | | | | | G04 | | | G01=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]</div>|G02=T4|G03=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G04=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual tumor</div>}}
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| {{familytree | |!| | | |,|-|-|^|-|-|.| | | | | | | |!| | | |}}
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| {{familytree | H01 | | H03 | | | | H04 | | | | | | H05 | | | H01=<div style="float: left; text-align: left;">Surgery + adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]</div>|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
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| {{familytree | | | | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
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| {{familytree | | | | | I04 | | I05 | | I06 | | I07 | | I08 | | I03=No|I04=Adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
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| {{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}}
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| {{familytree | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy, followed by chemotherapy|Chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
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| {{familytree/end}}
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| <br>
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| | |
| '''IIIA: T4, N0-1'''
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| {{familytree/start}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | | A01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Perform a pretreatment evaluation'''<br>
| |
| * If not done, perform [[pulmonary function tests]]<br>
| |
| * Perform [[bronchoscopy]] (if possible intraoperative)<br>
| |
| * Perform a pathological [[lymph node]] evaluation<br>
| |
| * If not done, order [[PET]] scan or [[CT scan]]<br>
| |
| * Perform a [[Brain tumor MRI|brain MRI]]<br>
| |
| * Perform a spine [[MRI]] with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or [[spine]]</div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | | | | | | | B01 | | | | B01=Is the tumor resectable?}}
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| {{familytree | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | |}}
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| {{familytree | | | | | | | | | | C01 | | | | | | C02 | | C01=Yes|C02=No}}
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| {{familytree | | | | | | | | | | |!| | | | | | | |!| | | |}}
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| {{familytree | | | | | | | | | | D01 | | | | | | D02 | D01=Where is the [[tumor]] located?|D02=Definitive [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]]}}
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| {{familytree | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | |}}
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| {{familytree | | | E01 | | | | | | | | | | | | | E02 | | | E01=Superior suculus|E02=Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]}}
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| {{familytree | | | |!| | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|.|}}
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| {{familytree | | | F01 | | | | | | | F02 | | | | | | | | | F03 | |F01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]] <br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
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| {{familytree | | | |!| | | | | | | | |!| | | | | | | | | | |!| | |}}
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| {{familytree | | | G01 | | | | | | | G02 | | | | | | | | | G03 | | | G01=Perform a surgical evaluation: Is the [[tumor]] resectable?|G02=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G03=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual [[tumor]]</div>}}
| |
| {{familytree | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | | | |!| |}}
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| {{familytree | H01 | | H02 | | H03 | | | | H04 | | | | | | H05 | | | | | H01=Yes|H02=No|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
| |
| {{familytree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| |}}
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| {{familytree | I01 | | I02 | | I04 | | I05 | | I06 | | I07 | | I08 | | I01=[[Tumor]] extraction + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]|I02=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|I04=Adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
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| {{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}}
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| {{familytree | | | | | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy, followed by chemotherapy|Chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
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| {{familytree/end}}
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| <br>
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| | |
| '''Stage IIIB'''
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| | |
| {{familytree/start}}
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| {{familytree | | | | | | | | | | | | Z01 | | | | | | | | | Z01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Perform a pretreatment evaluation'''<br>
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| * If not done, order [[PET]] scan or [[CT scan]]<br>
| |
| * Confirmation tests of [[lymph node]] infiltration stage:<br>
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| :* [[Thoracoscopy]] and [[mediastinoscopy]]<br>
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| :* Mediastinotomy<br>
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| :* [[Biopsy]] of the [[supraclavicular lymph nodes]]<br>
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| :* [[Needle aspiration biopsy]]<br>
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| :* Endoscopic ultrasound-guided biopsy<br>
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| :* Endobronchial ultrasound-guided biopsy<br>
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| * Perform a [[Brain tumor MRI|brain MRI]]<br>
| |
| </div>}}
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| {{familytree | | | | | | | | | | | | |!| | | | | | |}}
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| {{familytree | | | | | | | | | | | | A01 | | | | | | | | | A01=Is the [[tumor]] T1-3 or is it T4?}}
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| {{familytree | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | |}}
| |
| {{familytree | | | | | B01 | | | | | | | | | | | | B02 | | B01=T1-3, N3|B02=T4}}
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| {{familytree | | | | | |!| | | | | | | | | | | | | |!| | |}}
| |
| {{familytree | | | | | C01 | | | | | | | | | | | | C02 | | C01=Does the infiltration to [[lymph nodes]] meet the criteria for N3 or are there findings suggestive of [[metastatic disease]]?|C02=Is the infiltration to the [[mediastinal]] [[lymph nodes]] contralateral or are there findings suggestive of [[metastatic disease]]?}}
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| {{familytree | | | |,|-|-|^|-|-|.| | | | | |,|-|-|-|^|-|-|-|.| | | |}}
| |
| {{familytree | | | D01 | | | | D02 | | | | D03 | | | | | | D04 | | D01=Yes|D02=No|D03=Yes|D04=No}}
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| {{familytree | |,|-|^|-|.| | | |!| | | |,|-|^|-|.| | | | | |!| | | |}}
| |
| {{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | | | E06 | | | | | E01=[[Metastatic disease]]|E02=Findings suggestive of N3|E03=See treatment|E04=[[Metastatic disease]]|E05=Positive contralateral [[mediastinal]] node infiltration|E06=Does the [[tumor]] infiltrated the ipsilateral [[mediastinal]] [[lymph nodes]]?}}
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| {{familytree | |!| | | |!| | | | | | | |!| | | |!| | | |,|-|^|-|.| | |}}
| |
| {{familytree | F01 | | F02 | | | | | | F03 | | F04 | | F05 | | F06 | | F01=[[Non small cell carcinoma of the lung medical therapy metastatic cancer|Click here for the treatment of metastatic cancer]]|F02=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|F03=[[Non small cell carcinoma of the lung medical therapy metastatic cancer|Click here for the treatment of metastatic cancer]]|F04=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|F05=Yes|F06=No}}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| |}}
| |
| {{familytree | | | | | | | | | | | | | | | | | | | | | G01 | | G02 | | G01=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus Radiation Rherapy|chemotherapy + radiation therapy]]|G02=[[Non small cell carcinoma of the lung medical therapy stage III#Stage IIIA|Click here for the stage IIIA treatment]]}}
| |
| {{familytree/end}}
| |
| | |
| ==Stage IV==
| |
| * 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.
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | A01 | | | | | A01=Is [[Pleural effusion|pleural]] or [[pericardial effusion]] present (suggestive of M1a) or are findings suggestive of systemic [[metastasis]] (M1b) present?}}
| |
| {{familytree | | | |,|-|-|-|^|-|-|-|.| | |}}
| |
| {{familytree | | | B01 | | | | | | B02 | B01=M1a|B02=M1b: solitary site systemic [[metastasis]]}}
| |
| {{familytree | | | |!| | | | | | | |!| | | |}}
| |
| {{familytree | | | C01 | | | | | | C02 | | | C01=<div style="float: left; text-align: left;">Perform the following tests:<br>
| |
| * Perform [[thoracentesis]] and/or [[pericardiocentesis]]<br>
| |
| * Perform a [[thoracoscopy]] if [[thoracocentesis]] is inconclusive
| |
| </div>|C02=<div style="float: left; text-align: left;">Perform the following tests:<br>
| |
| * [[Brain tumor MRI|Brain MRI]]<br>
| |
| * [[Bronchoscopy]]<br>
| |
| * Mediastinal [[lymph node biopsy]]<br>
| |
| * If not previously done, [[PET scan]] or [[CT scan]]</div>}}
| |
| {{familytree | | | |!| | | | | | | |!| | | | |}}
| |
| {{familytree | | | D01 | | | | | | D02 | | | | D01=Is the liquid extracted positive for malignant cells?|D02=Are findings suggestive of [[adrenal]] metastasis or [[brain]] metastasis?}}
| |
| {{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | | |}}
| |
| {{familytree | E01 | | E02 | | E03 | | E04 | | | E01=Yes|E02=No|E03=[[Adrenal]]|E04=[[Brain]]}}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | |}}
| |
| {{familytree | F01 | | F02 | | F03 | | F04 | | F01=<div style="float: left; text-align: left;">Local therapy<br>
| |
| * Ambulatory catheter drainage<br>
| |
| * [[Pleurodesis]]<br>
| |
| * Mediastinal window<br>
| |
| PLUS<br>
| |
| Therapy for metastatic disease ([[Non small cell carcinoma of the lung medical therapy metastatic cancer|click here for the treatment of metastatic cancer]])
| |
| </div>|F02=<div style="float: left; text-align: left;">Treat according to tumor stage:<br>
| |
| * [[Non small cell carcinoma of the lung medical therapy#Stage I|I]]<br>
| |
| * [[Non small cell carcinoma of the lung medical therapy#Stage II|II]]<br>
| |
| * [[Non small cell carcinoma of the lung medical therapy#Stage III|III]]<br>
| |
| </div>|F03=Perform a [[needle aspiration biopsy]] for metastasis confirmation|F04=<div style="float: left; text-align: left;">Surgical resection + adjuvant radiation therapy<br>Radiation therapy alone:<br>
| |
| * [[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]] + [[Non small cell carcinoma of the lung radiation therapy#Palliative Radiation Therapy Regimens|Whole brain radiation therapy]]<br>OR<br>
| |
| * [[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]]<br>
| |
| PLUS<br>
| |
| Pathologic evaluation of surgical piece and [[lymph nodes]]</div>}}
| |
| {{familytree | | | | | | | | | |!| | | |!| | | |}}
| |
| {{familytree | | | | | | | | | G01 | | G02 | | | G01=<div style="float: left; text-align: left;">If the [[lung]] disease is curable, administer local therapy for the [[adrenal]] lesion:<br>
| |
| * Surgical [[adrenal]] resection<br>OR<br>
| |
| * [[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]]<br>
| |
| OR<br>
| |
| Administer therapy for metastatic disease in case of not curable lung lesions ([[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|click here for the treatment of metastatic cancer]])
| |
| </div>|G02=What is the TN stage of the lung [[tumor]]?}}
| |
| {{familytree | | | | | | | | | | | |,|-|^|-|.| | |}}
| |
| {{familytree | | | | | | | | | | | H01 | | H02 | | H01=<div style="float: left; text-align: left;">
| |
| * T1-2, No-1<br>
| |
| * T3, N0
| |
| </div>|H02=<div style="float: left; text-align: left;">
| |
| * T1-2, N2<br>
| |
| * T3, N1-2<br>
| |
| * N3, regardless of the T stage<br>
| |
| * T4 regardless of the N stage</div>}}
| |
| {{familytree | | | | | | | | | | | |!| | | |!| | | | | | |}}
| |
| {{familytree | | | | | | | | | | | I01 | | I02 | | | | I01=<div style="float: left; text-align: left;">
| |
| * Surgical resection of lung [[tumor]] + adjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]]<br>OR<br>
| |
| * Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]] + surgical resection or [[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]]<br>OR<br>
| |
| * [[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|Stereotactic ablative radiation therapy]]</div>
| |
| |I02=<div style="float: left; text-align: left;">Administer therapy for metastatic disease in case of not curable lung lesions ([[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|click here for the treatment of metastatic cancer]])</div>}}
| |
| {{familytree/end}}
| |
| | |
| ===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.
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | A01 | | | | | | | | | | A01=What is the site of the recurrence?}}
| |
| {{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | |}}
| |
| {{familytree | B01 | | B02 | | B03 | | B04 | | B05 | | | B01=[[Bronchus|Bronchial]] obstruction|B02=Mediastinal [[lymph node]]|B03=[[Superior vena cava]] obstruction|B04=Severe [[hemoptysis]]|B05=Resectable [[tumor]]}}
| |
| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |}}
| |
| {{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C01=Surgical correction of the obstruction: laser therapy, stent or any other surgical procedure<br>OR<br>[[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]] (external-beam or brachytherapy)<br>OR<br>Photodynamic therapy|C02=Has the patient received [[radiation therapy]]?|C03=[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|Chemotherapy + radiation therapy]]<br>OR<br>External-beam [[Non small cell carcinoma of the lung radiation therapy|radiation therapy]]<br>OR<br>[[Superior vena cava]] stent collocation|C04=Surgery<br>OR<br>[[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]] (external-beam or brachytherapy)<br>OR<br>Laser therapy, photodynamic therapy or [[tumor]] [[embolization]]|C05=[[Tumor]] resection (preferred option)<br>OR<br>[[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]] ([[Non small cell carcinoma of the lung radiation therapy#Stereotactic Ablative Radiotherapy Usual Dosage|stereotactic ablative radiation therapy]] or external-beam [[Non small cell carcinoma of the lung radiation therapy|radiation therapy]])}}
| |
| {{familytree | |!| |,|-|^|-|.| |!| | | |!| | | |!| | | |}}
| |
| {{familytree | |!| D01 | | D02 |!| | | |!| | | |!| | | D01=Yes|D02=No}}
| |
| {{familytree | |!| |!| | | |!| |!| | | |!| | | |!| | | |}}
| |
| {{familytree | |!| E01 | | E02 |!| | | |!| | | |!| | | | E01=Administer systemic therapy ([[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]])|E02=Administer [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]}}
| |
| {{familytree | |`|-|^|-|-|-|^|-|+|-|-|-|^|-|-|-|'| | | |}}
| |
| {{familytree | | | | | | | | | F01 | | | | | | | | | | | F01=Are findings suggestive of disseminated disease present?}}
| |
| {{familytree | | | | | | |,|-|-|^|-|-|.| | | | |}}
| |
| {{familytree | | | | | | G01 | | | | G02 | | | | | G01=Yes|G02=No}}
| |
| {{familytree | | | | | | |!| | | | | |!| | | | | |}}
| |
| {{familytree | | | | | | H01 | | | | H02 | | | | | H01=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]|H02=Observation<br>OR<br>[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of metastatic disease]]}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| ===Metastatic Cancer===
| |
| ====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.
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | | A01 | | | | | A01=What the specific subtype according to the specific histological characteristics of the [[tumor]]?}}
| |
| {{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | |}}
| |
| {{familytree | | | | | B01 | | | | | | | | B02 | | | B01=<div style="float: left; text-align: left; width: 14em; padding:1em;">
| |
| * [[Adenocarcinoma]]<br>
| |
| * [[Large cell carcinoma of the lung]]<br>
| |
| * Not specified non-small cell lung cancer</div>|B02=Squamous cell carcinoma}}
| |
| {{familytree | | | | | |!| | | | | | | | | |!| | | }}
| |
| {{familytree | | | | | |!| | | | | | | | | C02 | | | C02=Is the patient a smoker or former smoker?}}
| |
| {{familytree | | | | | |!| | | | | | | |,|-|^|-|.| | | | |}}
| |
| {{familytree | | | | | |!| | | | | | | Y01 | | Y02 | | | | | Y01=Yes|Y02=No}}
| |
| {{familytree | | | | | |!| | | | | | | |!| | | |!| | | }}
| |
| {{familytree | | | | | Z01 | | | | | | Z02 | | |!| | | | | Z01=Perform specific [[EGFR]] and ALK [[mutation]] testing: What is the specific [[mutation]]?|Z02=Perform specific [[EGFR]] and ALK [[mutation]] testing: Is there a [[mutation]] in any of those genes present?}}
| |
| {{familytree | | | | | |!| | | | | |,|-|^|-|.| |!| | | |}}
| |
| {{familytree | | | | | |!| | | | | W01 | | W02 |!| | | | W01=Yes|W02=No}}
| |
| {{familytree | | | | | |`|-|-|v|-|-|'| | | |`|v|'| | | |}}
| |
| {{familytree | | | | |,|-|-|-|+|-|-|-|.| | | |!|}}
| |
| {{familytree | | | | D01 | | D02 | | D03 | | D04 | | | | D01=Sensitizing [[EGFR]] mutation|D02=ALK mutation|D03=Negative [[EGFR]] and ALK|D04=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Metastatic Squamous Cell Carcinoma|Click here for the squamous cell carcinoma specific treatment]]}}
| |
| {{familytree | | | | |!| | | |!| | | |!| | | | |}}
| |
| {{familytree | | | | E01 | | E02 | | E03 | | | E01=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Positive Sensitizing EGFR Mutation|Click here for the sensitizing EGFR mutation specific treatment]]|E02=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Positive ALK Mutation|Click here for the specific therapy for the ALK mutation specific treatment]]|E03=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Negative EGRF and ALK or Unknown Mutation|Click here for the treatment of negative sensitizing EGFR and ALK mutation metastatic disease]]}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| ====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.
| |
| | |
| '''Positive Sensitizing EGFR Mutation'''
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | | | | | | | E01 | | | | | | | | |E01=Was the mutation discovered before the initiation of first line therapy?}}
| |
| {{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | |}}
| |
| {{familytree | | | | | | | | | | | | F01 | | | | F02 | | |F01=Yes|F02=No|}}
| |
| {{familytree | | | | | | | | | | | | |!| | | | | |!| | | }}
| |
| {{familytree | | | | | | | | | | | | G01 | | | | G02 | | |G01=Initiate erlotinib or afatinib|G02=Suspend or complete [[chemotherapy]] and initiate erlotinib or afatinib<br>'''OR'''<br> Add erlotinib or afatinib to chemotherapy regimen|}}
| |
| {{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | | |}}
| |
| {{familytree | | | | | | | | | | | | | | | H01 | | | | | | | | |H01=Did the [[tumor]] progress or respond?|}}
| |
| {{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | }}
| |
| {{familytree | | | | | | | | | | | | I01 | | | | I02 | | | |I01=[[Tumor]] progression|I02=Positive response or stable [[tumor]]}}
| |
| {{familytree | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | |}}
| |
| {{familytree | | | | | | | | J01 | | | | | | J02 | | | | | |J01=Symptomatic disease|J02=Asymptomatic disease}}
| |
| {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | |!| | | | | | | |}}
| |
| {{familytree | | | | K01 | | | | | | K02 | | K03 | | | | |K01=Systemic [[metastasis]]|K02=Brain [[metastasis]]|K03=Continue treatment}}
| |
| {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| |!| | | | | | | |}}
| |
| {{familytree | | L01 | | L02 | | L03 | | L04 |!| | | | |L01=Multiple [[metastasis]]|L02=Single [[metastasis]]|L03=Multiple [[metastasis]]|L04=Single [[metastasis]]}}
| |
| {{familytree | | |!| | | |!| | | |!| | | |!| |!| | | | |}}
| |
| {{familytree | | M01 | | M02 | | M03 | | M04 |!| | | | |M01=Continue treatment, consider local therapy|M02=Continue treatment, consider [[Non small cell carcinoma of the lung radiation therapy#Palliative Radiation Therapy Regimens|whole brain radiation therapy]]|M03=Continue treatment, consider local therapy|M04=Consider [[Non small cell carcinoma of the lung chemotherapy#Cisplatin Based Therapy|platinum based chemotherapy]] <br>with or without<br> [[Bevacizumab]] <br>AND/OR<br> Erlotinib}}
| |
| {{familytree | | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|'| | | |}}
| |
| {{familytree | | | | | | | | | | N01 | | | | | | | | N01=If findings suggestive of progression of the disease are present, [[Non small cell carcinoma of the lung medical therapy metastatic cancer#Third Line Therapy|click here for the third line therapy]]}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| '''Positive ''ALK'' Mutation'''
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | |A01=Was the [[mutation]] discovered before the initiation of first line therapy?}}
| |
| {{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | | |}}
| |
| {{familytree | | | | | | | | | | | | F03 | | | | F04 | | | | | | | |F03=Yes|F04=No}}
| |
| {{familytree | | | | | | | | | | | | |!| | | | | |!| | | |}}
| |
| {{familytree | | | | | | | | | | | | G03 | | | | G04 | | | | |G03=Initiate crizotinib|G04=Suspend or complete [[chemotherapy]] and initiate crizotinib|G05=Progression|G06=Positive response or stable tumor}}
| |
| {{familytree | | | | | | | | | | | | |`|-|-|v|-|-|'| | | |}}
| |
| {{familytree | | | | | | | | | | | | | | | H01 | | | | | | | | |H01=Did the [[tumor]] progress or respond?}}
| |
| {{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | |}}
| |
| {{familytree | | | | | | | | | | | | I01 | | | | I02 | | | | | | | |I01=[[Tumor]] progression|I02=Positive response or stable [[tumor]]}}
| |
| {{familytree | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | |}}
| |
| {{familytree | | | | | | | | J01 | | | | | | J02 | | | | | | | | | |J01=Symptomatic disease|J02=Asymptomatic disease}}
| |
| {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | |!| | | | | | | | | | | |}}
| |
| {{familytree | | | | K01 | | | | | | K02 | | K03 | | | | | | | | |K01=Systemic [[metastasis]]|K02=Brain [[metastasis]]|K03=Continue treatment or change to certinib according to the degree of disease}}
| |
| {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| |!| | | | | | | | | | | |}}
| |
| {{familytree | | L01 | | L02 | | L03 | | L04 |!| | | | | | | | |L01=Multiple [[metastasis]]|L02=Single [[metastasis]]|L03=Multiple [[metastasis]]|L04=Single [[metastasis]]}}
| |
| {{familytree | | |!| | | |!| | | |!| | | |!| |!| | | | | | | | |}}
| |
| {{familytree | | M01 | | M02 | | M03 | | M04 |!| | | | | | | | |M01=Continue treatment, consider local therapy|M02=Continue treatment, consider [[Non small cell carcinoma of the lung radiation therapy#Palliative Radiation Therapy Regimens|whole brain radiation therapy]]|M03=Continue treatment, consider local therapy|M04=Initiate certinib <BR>OR<BR> Consider [[Non small cell carcinoma of the lung chemotherapy#Cisplatin Based Therapy|platinum based chemotherapy]] <br>with or without<br> [[Bevacizumab]] <br>AND/OR<br> Erlotinib}}
| |
| {{familytree | | |`|-|-|-|^|-|-|-|+|-|-|-|^|-|'| | | |}}
| |
| {{familytree | | | | | | | | | | N01 | | | | | | | | N01=If findings suggestive of progression of the disease are present, [[Non small cell carcinoma of the lung medical therapy metastatic cancer#Third Line Therapy|click here for the third line therapy]]}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| '''Negative ''EGRF'' and ''ALK'' or Unknown Mutation'''
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | C02 | | | | | | | |C02=Which is the [[mutation]] present?|C02=What is the performance status (PS) of the patient?}}
| |
| {{familytree | | | | | |,|-|-|-|+|-|-|-|.| | | | | |}}
| |
| {{familytree | | | | | D03 | | D04 | | D05 | | | | |D03=0-1|D04=2|D05=3-4}}
| |
| {{familytree | | | | | |!| | | |!| | | |!| | | | | |}}
| |
| {{familytree | | | | | E03 | | E04 | | E05 | | | | | | |E03=Doublet [[chemotherapy]]<BR> OR <BR> [[Bevacizumab]] + [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]] <BR> OR <BR> [[Cetuximab]]/[[vinorelbine]]/[[cisplatin]]|E04=[[Chemotherapy]]|E05=Supportive care}}
| |
| {{familytree | | | | | |`|-|v|-|'| | | | | | | | | | |}}
| |
| {{familytree | | | | | | | F05 | | | | | | |F05=What was the [[tumor]] response to the treatment?}}
| |
| {{familytree | | | | |,|-|-|^|-|-|-|-|.| |}}
| |
| {{familytree | | | | G05 | | | | | | G06 | | | |G05=Progression|G06=Positive response or stable [[tumor]]}}
| |
| {{familytree | | | | |!| | | | | | | |!| | | | | |}}
| |
| {{familytree | | | | |!| | | | | | | Z01 | | | | | | |Z01=Administer 4-6 cycles and assess progression of the disease}}
| |
| {{familytree | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
| |
| {{familytree | | H03 | | H04 | | H05 | | | H06 | | | |H03=PS 0-2|H04=PS 3-4|H05=[[Tumor]] progression|H06=Positive response or stable [[tumor]]}}
| |
| {{familytree | | |!| | | |!| | | |!| | | | |!| | | | | |}}
| |
| {{familytree | | I05 | | I06 | | I07 | | | I08 | | | | | |I05=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]|I06=Provide supportive care|I07=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]|I08=Continuation maintenance ([[cetuximab]] or [[gemcitabine]]) <br>OR<br> Switch maintenance (erlotinib or [[decetaxel]]) <br>OR<br> Close observation}}
| |
| {{familytree | | |!| | | | | | | |!| | | | |!| | | | | | | |}}
| |
| {{familytree | | |!| | | | | | | |!| | | | K01 | | | | | |K01=Initiate [[docetaxel]] or [[pemetrexed]] or erlotinib or [[gemcitabine]]}}
| |
| {{familytree | | |`|-|-|-|-|-|-|-|+|-|-|-|-|'| | | | |}}
| |
| {{familytree | | | | | | | | | | L01 | | | | | | | | | L01=If findings suggestive of progression of the disease are present, [[Non small cell carcinoma of the lung medical therapy metastatic disease#Third Line Therapy|click here for the third line therapy]]}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| ==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.
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | A01 | | | | | | A01=What is the performance status of the patient?}}
| |
| {{familytree | | | |,|-|-|^|-|-|.| | | | |}}
| |
| {{familytree | | | B01 | | | | B02 | | | | | | B01=PS 0-2|B02=PS 3-4}}
| |
| {{familytree | | | |!| | | | | |!| | | |}}
| |
| {{familytree | | | C01 | | | | C02 | | | | | C01=If not previously used, administer any of the following:<br>
| |
| * Docetaxel<br>
| |
| * Erlotinib<br>
| |
| * Gemcitabine<br>
| |
| * Pemetrexed
| |
| |C02=Administer erlotinib or provide suportive care}}
| |
| {{familytree | | | |!| | | | | | | | | | | |}}
| |
| {{familytree | | | D01 | | | | | | | | | D01=What is the performance status of the patients after the treatment?}}
| |
| {{familytree | |,|-|^|-|.| | | | | |}}
| |
| {{familytree | E01 | | E02 | | | | | | E01=PS 0-2 (stable [[tumor]])|E02=PS 3-4 ([[tumor]] progression)}}
| |
| {{familytree | |!| | | |!| | | | | | |}}
| |
| {{familytree | F01 | | F02 | | | | | F01=Provide supportive care or try experimental treatments|F02=Provide supportive care}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| ==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.
| |
| | |
| {{familytree/start}}
| |
| {{familytree | | | | | | | | | A01 | | | | A01=Is there suspicion of multiple lung cancers?}}
| |
| {{familytree | | | | | | | |,|-|^|-|.| | |}}
| |
| {{familytree | | | | | | | B01 | | B02 | | | B01=Yes|B02=No}}
| |
| {{familytree | | | | | | | |!| | | |!| | | | |}}
| |
| {{familytree | | | | | | | C01 | | C02 | | | | C01=<div style="text-align: left; padding:1em;">Perform the following tests:<br>
| |
| * If not previously done, [[PET scan]] or [[CT scan]]<br>
| |
| * Contrast chest [[CT]]<br>
| |
| * [[Brain tumor MRI|Brain MRI]]
| |
| </div>|C02=Administer treatment according to the TNM stage of the [[tumor]]}}
| |
| {{familytree | | | | | | | |!| | | | | | | |}}
| |
| {{familytree | | | | | | | D01 | | | | | D01=Is the disease is confined to the [[chest]] or is there systemic proliferation?}}
| |
| {{familytree | | | | | |,|-|^|-|.| | | | |}}
| |
| {{familytree | | | | | E01 | | E02 | | | | E01=Disease confined to the [[chest]]|E02=Systemic proliferation}}
| |
| {{familytree | | | | | |!| | | |!| | | |}}
| |
| {{familytree | | | | | F01 | | F02 | | | F01=Assess the [[mediastinal]] [[lymph nodes]] in order to determine the N stage of the [[tumor]]|F02=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of systemic metastasis]]}}
| |
| {{familytree | | | | | |!| | | | | |}}
| |
| {{familytree | | | | | G01 | | | | | G01=What is the N stage of the [[tumor]]?}}
| |
| {{familytree | | | |,|-|^|-|.| | |}}
| |
| {{familytree | | | H01 | | H02 | | | H01=N0-1|H02=N2-3}}
| |
| {{familytree | | | |!| | | |!| | | |}}
| |
| {{familytree | | | I01 | | I02 | | | I01=Is the patient symptomatic?|I02=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of systemic metastasis]]}}
| |
| {{familytree | |,|-|^|-|.| | | | | |}}
| |
| {{familytree | J01 | | J02 | | | | | J01=Yes|J02=No}}
| |
| {{familytree | |!| | | |!| | | | | |}}
| |
| {{familytree | |!| | | K01 | | | | | K01=Is the lesion a solitary nodule or are there multiple nodules?}}
| |
| {{familytree | |!| |,|-|^|-|.| | |}}
| |
| {{familytree | |!| L01 | | L02 | | L01=Solitary nodule|L02=Multiple nodules}}
| |
| {{familytree | |!| |!| | | |!| | |}}
| |
| {{familytree | |!| |!| | | M01 | | | M01=What is the risk of turning into a symptomatic disease?}}
| |
| {{familytree | |!| |!| |,|-|^|-|.| |}}
| |
| {{familytree | |!| |!| N01 | | N02 | |N01=High|N02=Low}}
| |
| {{familytree | |`|-|+|-|'| | | |!| | |}}
| |
| {{familytree | | | O01 | | | | O02 | | O01=Is definitive local therapy possible?|O02=Observation}}
| |
| {{familytree | |,|-|^|-|.| | | |!| | | |}}
| |
| {{familytree | P01 | | P02 | | |!| | | | P01=No|P02=Yes}}
| |
| {{familytree | |!| | | |!| | | |!| | | |}}
| |
| {{familytree | Q01 | | Q02 | | |!| | | | Q01=Consider palliative chemotherapy with or without local [[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]]|Q02=<div style="text-align: left; padding:1em;">Administer one of the following treatments:<br>
| |
| * Preferred option: Parenchymal sparing resection<br>
| |
| * [[Non small cell carcinoma of the lung radiation therapy|Radiation therapy]]<br>
| |
| * Ablation therapy</div>}}
| |
| {{familytree | |!| | | |`|-|v|-|'| | | |}}
| |
| {{familytree | R01 | | | | R02 | | | | R01=[[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|Click here for the treatment of systemic metastasis]]|R02=Go to the appropriate algorithm according to the characteristics of the disease: [[Non small cell carcinoma of the lung medical therapy metastatic cancer#local or regional recurrence|local or regional recurrence]] or [[Non small cell carcinoma of the lung medical therapy metastatic cancer#Medical Therapy for Metastatic Non Small Cell Lung Cancer|metastasis]]}}
| |
| {{familytree/end}}
| |
| <br>
| |
| | |
| | |
| | |
| ==References==
| |
| {{reflist|2}}
| |
| [[Category:Disease]]
| |
| [[Category:Types of cancer]]
| |
| [[Category:Pulmonology]]
| |
| [[Category:Lung cancer]]
| |
| [[Category:Oncology]]
| |
