Treatment tree of NSCLC adapted fr NCCN guidelines_Treatment
2017-05-05 11:43:07 0 举报Treatment tree of NSCLC adapted from NCCN guidelines（Screeing）
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NSCL-3
ALK rearrangement discoveredduring frst-line chemotherapy
see NSCL-13 or 16
Systemic
See subsequent therapyfor multiple lesions
Sensitizing EGFRmutation positive
Response or stable disease
Symptomatic
Observation
• Chest CT with contrast • Brain MRI with contrast• PET/CT
• Consider local therapy• Continue erlotinib orafatinib or geftinibor• See subsequent therapyfor multiple lesions
Other site
Tumor response evaluation
NSCL-25
Severe hemoptysis
Progression
R2
extrathoracic metastatic disease
Treat as 2 primary lung tumors if both curable
Multiple lesions
Pathological mediastinal nodal evaluation and surgical resectionORSABR
R1
Best Best supportive care
complete definitive RT+chemotherapy
surgery
Continuation maintenance • Bevacizumab (category 1)• Pemetrexed (category 1)• Bevacizumab + pemetrexed• Gemcitabine (category 2B)orSwitch maintenance(category 2B)• PemetrexedorClose observation
Pembrolizumab(category 1)
Stage Ⅳ(M 1a) (pleural or pericardial effusion)
Positive
NSCL-2
Medically inoperable
Low risk of becoming symptomatic
N2-3
N0-1
Stage Ⅳ(M 1b) (limitied sites with resectable lung lesion)（NSCL-13 ）
Disease outside of chest
Reresection (preferred)• External-beam RT or SABR
Observation
Stereotectic radiosurgery(SRS) alone ORsurgical resection，if symptomatic or warranted for diagnosis，followed by SRS or whole brain RT(WBRT)
Operable
Best supportive care or clinical trial.
NSCLC
EGFR mutationdiscoveredduring frst-linechemotherapy
No disease outside of chest
definitve concurrent chemoradiation(category 1)
Observe
Reresection(preferred)±ChemotherapyORRT ±Chemotherapy(chemotherapy for stage ⅡA)
Postive midiastinal nodes
PS 0-2
Asymptomatic
Chemotherapy
Contralateral mediastinal node negative
Endobronchialobstruction
Definitive concurrent chemoradiation（category 1）
EGFR mutationdiscoveredprior to frst-linechemotherapy
N3 positive
• Consider local therapy and continue crizotinib or ceritinibor• Ceritinibss or alectinib• See NCCN Guidelines for CNS Cancers
Definitive RT or chemoradiation
NSCL-16
unresectable
Solitary lesions(metachronus)
RT(if not given) ± chemotherapy
Definitve concurrent chemoradiation(category 1)ORInduction chemotherapy ±RT
PS 3-4
Isolatedlesion
1.Chest CT with contrast2.FDG PET/CT scan (if not previously done)3.Brain MRI with contrast
Systemic therapy
NSCL-24
No apparent progression
concurrent chemoradiation or chemotherapy
definitve concurrent chemoradiation
Margins positive
Margins negative(R0)
• Consider local therapy• Continue crizotinib or ceritinib
Definitive local therapy possible
ALK rearrangement discoveredprior to frst-line chemotherapy
surgical reevaluation including chest CT with or without contrast ±PET/CT
NSCL-7
Pathological mediastinal nodal evaluation and surgical resectionORDefinitive RT or chemoradiation
Any combination of the following:• Laser/stent/other surgery• External-beam RT or brachytherapy• Photodynamic therapy
• Consider local therapy• Continue crizotinib or ceritinibor• Ceritinib or alectinib
Treatment of thoracic disease
1.PFTs(if not previously done)2.Bronchoscopy（intraoperative preferred）3.Consider pathologic mediastinal lymph node evaluation4.FDG PET/CT scan (if not previously done)
Squamous cell carcinoma
Margin negative(R0)
Multiplelesions
N2
Margin positive
T790M testing
ALK rearrangementpositive
see system therapy(NSCL-16)
Reresection+ChemotherapyORChemoradiation(sequential or concurrent)
Concurrent chemoradiation
Negative
ROS1 positive
• Concurrent chemoradiation(if not previously given)• External-beam RT• SVC stent
Consider adjuvant chemotherapy(category 2B) for high risk stage ⅠB-ⅡB
Reresection+ChemotherapyORConcurrent chemoradiation
see initial treatment for stage Ⅰ-ⅢA NSCL-8
Consider systemic therapy (NSCL-17) and restaging to confirm non-progressionORProceed for definitive therapy
Parenchymal sparing resection (preferred)ORRadiationORAblation
Margin positive(R1，R2)
• External-beam RT or brachytherapy• Laser or photodynamic therapy orembolization• Surgery
See Treatment according to clinical stage (NSCL-2)
Pathologic mediastinal lymph nodes evaluation
surgery+chemotherapy
Diffuse brain metastases
• Adenocarcinoma• Large Cell• NSCLC not otherwise specifed (NOS)
Prior RT
Locoregionalrecurrence
Chemotherapy(category 1)ORSequential chemotherapy + RT
OR
See First-line therapy optionsAdenocarcinoma (NSCL-24)Squamous cell carcinoma (NSCL-25)
metastatis disease
Local
NSCL-17
Continuation maintenance(category 2B)• GemcitabineorSwitch maintenance(category 2B)• DocetaxelorClose observation
Definite RT including SABR
Consider systemic therapy if not already given (NSCL-17)
Findings at surgery
See Adjuvant Treatment (NSCL-3)
Chemoradiation(sequential or concurrent)
surgical exploration and resection + mediastinal lymph node dissection or systematic lymph node sampling
Multiple lung cancers
Brain
Bone metastasis
NSCL-11
Metastatic disease
see stage ⅢA（NSCL 7） orⅢB（NSCL 11）
Stage Ⅳ(M 1b) (dissemiated metastases)
Definite RT including stereostactic ablative radiotherapy（SABR）
Evidence of disseminated disease
see stage ⅢA（NSCL-7） orⅢB（NSCL-11）
YES
see systematic treatment for metastatic disease NSCL-17
Negative midiastinal nodes
T790M+
superior sulcus tumor(T4 extension，N0-1)
Erlotinibll (category 1)orAfatinibll (category 1)orGeftinibll (category 1)
Distantmetastases
See First-line therapy optionsAdenocarcinoma (NSCL-24)Squamous cell carcinoma (NSCL-25)orPD-L1 expression positive (≥50%)See First-Line Therapy (NSCL-23)
preoperative concurrent chemoradiation
Osimertinib (category 1)(if not previously given)
N0
surgery(preferred)
Reresection(preferred)ORRT (category 2B)
Multiple metastases
• Molecular testing\u0017EGFR mutation testing(category 1)\u0017ALK testing (category 1)\u0017ROS1 testing\u0017Testing should be conducted as part of broad molecular profling• PD-L1 testing
Disseminated metastases
Palliative external-beam RT
see NSCL-15
Crizotinib
Definitive local therapy not possible
Difinitive therapy forthoracic disease feasible
NSCL-6
surgery± chemotherapy(category 2B)±RT(if not given)
thoracentesis or pericardiocentesis ± thoracoscopy if thoracentesis indeterminate
see treatment according to TNM stage(NSCL-8)
Multiplelesion
PS 2-4
Systematic
see treatment for stage ⅢA NSCL-6
see treatment for metastatic limited sites (NSCL-13)，or distant disease NSCL-16
• Consider local therapy• Osimertinib (if T790M+)(category 1)or• Continue erlotinib or afatinib or geftinib
Superior vena cava(SVC) obstruction
Systemic therapy (NSCL-17)
Surgical resection + mediastinal lymph node dissection or systematic lymph node sampling
Limited metastasis
Definite chemoradiation
Progression
4–6 cycles (total)
High risk of becoming symptomatic
Ceritinib or alectinibSee First-line therapy options forAdenocarcinoma (NSCL-24) orSquamous cell carcinoma (NSCL-25)
Chemotherapy(category 1)ORSequential chemotherapy+RT(N2 only)
NSCL-8
see systematic therapy for metastatic disease (NSCL-17)
Reresection
chemotherapy
NSCL-15
PS 0-1
superior sulcus tumor(T3 invasion，N0-1)
Crizotinib (category1)orCeritinib (category 1)
observe
see NSCL-11
possibly resectable
Resectable
Localized symptoms
Limited metastasesconfirmed
N1
Definitive local therapy for metastatic sites if not already given
resectable
Chemotherapy(category 1)
No evidence of disseminated disease
• Establish histologic subtype with adequate tissue for molecular testing (consider rebiopsy if appropriate)• Smoking cessation counseling• Integrate palliative care (See NCCN Guidelines for Palliative Care)
If previously not done1.Brain MRI with contrast2.FDG PET/CT scan 3.Pathologic confirmation of metastatic lesion，if possible
superior sulcus tumor
No prior RT
NO
ObserveOR Chemotherapy for high risk patients
Palliative chemotherapy ± local palliative therapyOR Observe
Definitve concurrent chemoradiation
Resectable recurrence
1.PFTs(if not previously done)2.Bronchoscopy3.Pathologic mediastinal lymph node evaluation4.Brain MRI with contrast5.MRI with contrast of spine+thoracic inlet for superior sulcus lesion abutting the spine or subclavian vessels6.FDG PET/CT scan (if not previously done)
Mediastinal lymphnode recurrence
N3 negative
T790M-
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