NCCN Guidelines Version 3.2017 NCCN guide 2017 edition thirdNon-Small Cell Lung Cancer non small cell lung cancerDiscussion discussionTreatm
NCCN Guidelines Version 3.2017 NCCN guide 2017 edition third
Non-Small Cell Lung Cancer non small cell lung cancer
Treatment Approaches treatment
Lymph Node Dissection
Lymph node dissection
Stage IIIA N2 Disease
Stage A N2 lesions
Treatment Approaches treatment
Surgery, RT, and systemic therapy are the most commonly used to 3 modalities treat patients with NSCLC. They can be used either alone or in combination depending on the disease status. In the following sections, the clinical trials are described that have led to the standard treatments. surgery, radiotherapy and systemic therapy in patients with non-small cell lung cancer 3 the most commonly used treatment methods. Can be used alone or in combination, depending on the disease. In the following sections, describe the clinical trials that have led to standard treatment.
In general, for patients with stage I or II disease, surgery provides the best chance for cure. Thoracic surgical oncology consultation should be part of the evaluation of any patient being considered for curative local therapy. The overall plan of treatment and the necessary imaging studies should be determined before any nonemergency treatment is initiated. It is essential to determine whether patients can tolerate surgery or whether they are medically inoperable some patients deemed inoperable may; be able to tolerate minimally invasive surgery and/or sublobar resection. Although frailty is an increasingly recognized predictor of surgical and other treatment morbidity, a preferred frailty assessment system has not been established.. Often, surgery offers the best chance of cure for patients with stage I or ii. All patients undergoing radical local therapy should be consulted in the Department of thoracic surgery. The overall treatment plan should be determined and the necessary imaging examinations should be made before starting any non urgent treatment. It is necessary to determine whether or not the patient is able to tolerate surgery or if the patient cannot be operated due to medical factors. Some patients who are not able to undergo surgery can tolerate minimally invasive surgery and / or pulmonary resection. Although it is increasingly recognized that weakness is a predictor of the incidence of complications in surgery and other treatments, the preferred weakness assessment system has not been established.
The Principles of Surgical Therapy are described in the NSCLC algorithm and are summarized here (see the NCCN Guidelines for NSCLC Determination of). Resectability, surgical staging, and pulmonary resection should be performed by board-certified thoracic surgeons who should participate in multidisciplinary clinics and/or tumor boards for patients with lung cancer. Surgery may be appropriate for select patients with uncommon types of lung (cancer eg, superior sulcus, chest wall involvement (see) the NCCN Guidelines for NSCLC Patients with pathologic). Stage II or greater disease can be referred to a medical oncologist for evaluation. For resected stage IIIA, consider referral to a radiation oncologist. Treatment delays, because of poor coor The principles of dination among specialists, should be avoided. surgical treatment in non-small cell lung cancer are described and summarized as follows (see non small cell lung cancer NCCN guidelines). The determination of resectability, surgical staging, and pulmonary resection should be performed by a thoracic surgeon who is certified in a multidisciplinary clinical and / or oncology group of patients with lung cancer. Surgical treatment may be appropriate for some of the less common types of lung cancer (such as the superior pulmonary sulcus and chest wall invasion) (see the NCCN guidelines for non-small cell lung cancer). Pathological grade II or above lesions can be transferred to a medical oncology evaluation. For resectable stage A, consider getting radiation oncologist guidance. Treatment should be avoided because of lack of coordination among experts.
The surgical procedure used depends on the extent of disease and on the cardiopulmonary reserve of the patient. Lung-sparing anatomic resection (sleeve lobectomy) is preferred over pneumonectomy, if anatomically appropriate and if margin-negative resection can be achieved lobectomy or pneumonectomy should be; done if physiologically feasible. Sublobular resection either segmentectomy (preferred) or wedge resection, is appropriate in select patients; the parenchymal resection margins are defined in the NSCLC algorithm (see Principles of Surgical Therapy in the NCCN Guidelines for NSCLC (Resection). Including wedge resection is over ablation. Wide) preferred wedge resection may improve outcomes. Patients with medically inoperable disease Ma Y be candidates for SABR, also known as stereotactic body RT (SBRT) If is considered for. SABR patients at high risk, a multidisciplinary evaluation is recommended (see Stereotactic Ablative Radiotherapy in this Discussion). The operation step used depends on the extent of the lesion and the patients with cardiopulmonary reserve. If can obtain anatomic resection and negative margin right, lung sparing anatomic resection (sleeve lobectomy) is better than pneumonectomy choice; if physiologically feasible, should be performed lobectomy or pneumonectomy. In selected patients, lobular resection or segmentectomy (preferred) or wedge resection is suitable in non-small cell lung cancer; step clear lung resection margin (see the principles of surgical treatment of non-small cell lung cancer in the NCCN guide). Resection (including wedge resection) is preferred over ablation. Large wedge resection improves prognosis. Stereotactic radiotherapy (SABR) may be used in patients with inoperable medical factors, also known as stereotactic radiotherapy (SBRT). For patients with high risk if stereotactic radiotherapy (SABR) is considered, a multidisciplinary evaluation is recommended (see stereotactic radiotherapy in this study).
Lymph Node Dissection lymph node dissection
A randomized trial (ACOSOG Z0030) compared systematic mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in patients with either N0 (no demonstrable metastasis to regional lymph nodes (or) N1 metastasis to lymph nodes in the ipsilateral peribronchial and/or hilar region including direct extension NSCLC In patients with) disease. early-stage disease who had negative nodes by systematic lymph node dissection, complete mediastinal lymph node dissection did not improve survival. Thus, systematic lymph node sampling is appropriate during pulmonary resection one or more nodes should; be sampled from all mediastinal stations. For right-sided cancers, an adequate mediastinal lymphadenectomy should include s Tations 2R, 4R, 7, 8, 9 and For left-sided cancers, stations 4L, 5, 6, 7, 8, 9 and should be sampled. Patients should have N1 and N2 node resection and mapping (American Thoracic Society map with a minimum of) 3 N2 stations sampled or a complete lymph node dissection. The lymph node map from the IASLC may be useful. Formal ipsilateral mediastinal lymph node dissection is indicated for patients undergoing resection for stage IIIA (N2) disease. For patients undergoing sublobular resection, the appropriate N1 and N2 lymph node stations should be sampled unless not technically feasible because sampling would substantially increase the surgical risk. a randomized trial (ACOSOG Z0030) in N0 (regional lymph node has no obvious transfer or transfer (N1) Systematic mediastinal lymph node sampling and thorough dissection of lymph nodes in patients with non - small cell lung cancer were compared to those of patients with non - small cell lung cancer at the same side of the lung and / or hilar lymph nodes, including immediate spread. Thorough dissection of the mediastinal lymph node dissection did not improve survival in patients with systemic lymph node dissection in early stage. Therefore, systematic lymph node sampling is appropriate in pneumonectomy, and one or more lymph nodes should be sampled at all mediastinal sites. For the right lung cancer, appropriate mediastinal lymph node dissection should include 2R, 4R, 7, 8 and 9 stations. For left lung cancer, 4L, 5, 6, 7, 8, and 9 stations should be sampled. Patients should receive resection and drawing N1 and N2 lymph node (ATS map), at least 3 N2 sampling station or radical lymph node dissection. The International Association for the study of lung cancer may be useful in the lymph node mapping. For patients with stage III A (N2) resection, normal ipsilateral mediastinal lymph node dissection is required. For patients with lobular resection, appropriate sampling of N1 and N2 lymph node stations should be appropriate, except that the sampling will greatly increase the risk of surgery and is technically infeasible.
Sublobular resection, either segmentectomy (preferred) or wedge resection, is appropriate in select patients (see Principles of Surgical Therapy in the NCCN Guidelines for NSCLC those who): 1) are not eligible for lobectomy and those with a; 2) peripheral nodule 2 cm or less with very low-risk features. Segmentectomy (preferred) or wedge resection should achieve parenchymal resection margins that are: 1) 2 cm or more or the size of; 2) the nodule or more. in selective patients or segmentectomy (preferred) or wedge resection of sublobular resection is appropriate (see the principles of surgical treatment of non-small cell lung cancer in the NCCN guidelines): 1) no suitable for resection; and 2) around the nodules less than 2cm features very low risk. Segmentectomy (preferred) or wedge resection of lung parenchyma margin should reach: 1) = 2cm; or 2) is more than or equal to the size of the nodule.
Stage IIIA N2 Disease phase III N2 lesions
The role of surgery in patients with pathologically documented stage IIIA (N2) disease is described in the NSCLC algorithm (see Principles of Surgical Therapy in the NCCN Guidelines for NSCLC and summarized here.) Before treatment, it is essential to carefully evaluate for N2 disease using radiologic and invasive staging (ie, EBUS-guided procedures, mediastinoscopy, thorascopic, procedures to discuss whether surgery) and is appropriate in a multidisciplinary team, which should include a board-certified thoracic surgeon. Randomized controlled trials suggest that surgery does not increase survival in these patients. However, one of these trials (EORTC) only enrolled patients with unresectable disease. Most clinicians agree that resection is a Ppropriate for patients with negative preoperative mediastinal nodes and with a single positive node (< 3 cm) found at thoracotomy. Neoadjuvant therapy is recommended for select patients. The optimal timing of RT in trimodality therapy (preoperative with chemotherapy or postoperative is established and controversial.) not In patients with N2 disease of the NCCN Member Institutions 50%, use neoadjuvant chemoradiotherapy whereas 50% use neoadjuvant chemotherapy. However, there is no evidence that adding RT to induction regimens improves outcomes for patients with stage IIIA (N2) disease when compared with using chemotherapy alone. Clinicians also agree that resection is not appropriate for patients with multiple pathologically proven malig Nant lymph nodes greater than 3 cm definitive chemoradiotherapy is recommended for these; patients. surgery in pathologically confirmed A III (N2) to describe the disease status in non-small cell lung cancer (see step in the surgery of non-small cell lung cancer NCCN guide treatment principle, make a summary here). Before the treatment, and traumatic staging using image (i.e. endobronchial ultrasound guided procedures, mediastinoscopy, thoracoscopy) of N2 lesions careful evaluation is necessary, then the multidisciplinary team should include a board certified thoracic surgeon, to discuss whether the operation right. Randomized controlled trials have shown that surgery does not improve survival in these patients. However, one of the trials (EORTC) included only patients with unresectable lesions. For patients with preoperative mediastinal lymph node negative and with a single node positive (< 3cm) found in the open chest, most clinicians agree that resection is appropriate. Neoadjuvant therapy is recommended for selected patients. In triple therapy (preoperative or postoperative chemotherapy), there is no consensus on the optimal timing of radiotherapy. In N2 disease patients, 50% of NCCN's members use neoadjuvant chemoradiotherapy, and 50% use neoadjuvant chemotherapy. However, for patients with stage III A (N2) disease, there was no evidence that radiotherapy was associated with improved outcomes compared with chemotherapy alone. For patients with multiple and pathologically confirmed malignant lymph nodes greater than 3cm, clinicians also agree that resection is not appropriate.
The NCCN Panel believes that surgery may be appropriate for select patients with N2 disease, especially those whose disease responds to induction chemotherapy (see Principles of Surgical Therapy in the NCCN Guidelines for NSCLC it is). However, controversial whether pneumonectomy after neoadjuvant chemoradiotherapy is appropriate. Patients with resectable N2 disease should not be excluded from surgery, because some of them may have long-term survival or may be cured. for stage N2 patients, especially those induced by chemotherapy is effective, the NCCN team believes that the operation may be appropriate (see the principle of surgical treatment of non-small cell lung cancer in the NCCN guide). However, the suitability of lung resection after neoadjuvant chemoradiation is controversial. Patients with resectable stage N2 disease should not be excluded from surgery, as some of them may survive for a long time or may be cured.
Thorascopic Lobectomy thoracoscopic lobectomy
Video-assisted thoracic surgery (VATS), which is also known as thorascopic lobectomy, is a minimally invasive surgical treatment that is currently being investigated in all aspects of lung cancer (see Principles of Surgical Therapy in the NCCN Guidelines for NSCLC Published studies suggest). That thorascopic lobectomy has several advantages over standard thoracotomy. Acute and chronic pain associated with thorascopic lobectomy is minimal thus, this procedure requires; a shorter length of hospitalization. Thorascopic lobectomy is also associated with low postoperative morbidity and mortality, minimal risk of intraoperative bleeding, or minimal locoregional recurrence. Thoracoscopic lobectomy is associated with less morbidity, fewer complica Tions, and more rapid return to function than lobectomy by thoracotomy. of video-assisted thoracoscopic surgery (VATS) also known as thoracoscopic lobectomy, is a minimally invasive surgical treatment, is currently being studied for various aspects of lung cancer (see surgical treatment principles of non-small cell lung cancer in the NCCN guide). Published studies have shown that thoracoscopic lobectomy has several advantages compared to standard thoracotomy. Acute and chronic pain in thoracoscopic lobectomy was the lightest; therefore, this operation requires a shorter hospital stay. In addition, thoracoscopic lobectomy complications and low mortality rate, intraoperative bleeding or minimal risk of local recurrence at least. Thoracoscopic lobectomy than lobectomy has less trauma, fewer complications and faster recovery.
In patients with stage I NSCLC who had thorascopic lobectomy with lymph node dissection the 5-year, survival rate, long-term survival, and local recurrence were comparable to those achieved by routine open lung resection. Thorascopic lobectomy has also been shown to improve discharge independence in older populations and patients at high risk. Data show that thorascopic lobectomy improves the ability of patients to complete postoperative chemotherapy regimens. Based on its favorable effects on postoperative recovery and morbidity thorascopic lobectomy (including robotic-assisted approaches) is recommended in the NSCLC algorithm as an acceptable approach for patients who are surgically resectable (and have no anatomic or surgical contraind Ications as as standard principles) long of thoracic surgery are not compromised (see Principles of Surgical Therapy in the NCCN Guidelines for NSCLC Robotic VATS seems). To more expensive with longer I be operating times than conventional VATS. in thoracic cavity lobectomy and lymph node dissection of non-small cell lung cancer patients, the survival rate of 5 years, the long-term survival rate and local recurrence rate comparable to conventional open resection of the lung. In the elderly and high-risk patients, thoracoscopic lobectomy can also improve the independence of its excretion. Data show that thoracoscopic lobectomy can improve the ability of patients to complete postoperative chemotherapy. The beneficial effect on the rate of postoperative recovery and complications in patients with non-small cell lung cancer based on the work step, recommend thoracoscopic lobectomy (including methods of robot assisted surgery (as) can be removed and no anatomic or surgical contraindications) with an acceptable means, as long as it doesn't damage the principle of standard department of thoracic surgery (see the principles of surgical treatment of non-small cell lung cancer in the NCCN guide). Compared with traditional thoracoscopic surgery, the robotic video assisted thoracoscopic surgery seems to be more expensive and more time - consuming.