Staging

TNM interl staging system

Tumor-node-metastasis
Prognosis
Used to stage all px with NSCLC
Used to determine treatment

Treatment
Dependent on the stage
OCCULT AND STAGE 0
Surgical resection
Close follow-up
5% incidence if 2nd primary lung CA

STAGE I & II
SURGICAL RESECTION
Tx of choice for px able to tolerate
procedure
Higher survival rate
Lobectomy > wedge resectx
Local recurrence
Limited resectx, wedge resectx,
segmentectomy
Px with co-morbidities, compromised
pulmo reserve & small peripheral lesions
Pneumonectomy reserved for px with
cental tumors, excellent pulmo reserve

 5-year survival rate

60-80% stage I
40-50% stage II

Mediastinal node dissection

Hilar node resection

RADIATION THERAPY
No role post-op
For px who refuse or are unsuitable
candidates for surgery
Stereotactic body radiation therapy
5cm (isolated pulmo nodules)
3-5 fractions over 1-2 weeks
Dse cntrl rate >90%
60% 5-year survival rate

Cryoablation
3cm
Little data on long-term outcomes

CHEMOTHERAPY
Cisplatin-based adjuvant chemotherapy
Survival worsened in stage IA
Modest improvement of questionable
clinical significance in stage IB
Also detrimental to px with poor
performance statu
Stage IB with 4cm resectx
Neoadjuvant therapy

STAGE III
ABSENT &NONBULKY (N2,N3) LYMPH
NODE DISEASE
TOC: Surgical resectx
followed by adjuvant chemotherapy: px w.
mx LNI
Post operative radiation therapy: w. close or
proxinal airways

KNOWN MEDIASTINAL (N2,N3) LND

Combined-modality approach
Concurrent chemoradiatherapy
Initial tx for stage 3 unsuitable for
resectx

Radiotherapy
Px w. poor performance or w. comorbidities

METASTATIC NSCLC
Standard medical management,
judicious use of pain medication &
appropriate use of radiotherapy and
chemotherapy
Agents that inhibit angiogenesis
Bevacizumab
Significantly higher incidence of toxicities
Progression-free survival but no
improvement in overall survival

Maintenance therapy
switch maintenance therapy,
patients receive four to six cycles of
platinum-based chemotherapy and are
switched to an entirely different regimen

continuation maintenance therapy

patients receive four to six cycles of
platinum-based chemotherapy and then
the platinum agent is discontinued but
the agent it is paired with is continued

 SECOND-LINE CHEMOTHERAPY
Docetaxel, pemetrexed, erlotinid and
crizotinib

IMMUNOTHERAPY
Ipilimumab
Nivolumab and pembrolizumab

SUPPORTIVE CARE
improves both quality of life and mood for
patients with advanced lung cancer
Aggressive pain and symptom control is an
important component for optimal treatment
of these patients.