Abdul-Rahman Jazieh
King Abdulaziz Medical City, Riyadh, Saudi Arabia

Correspondence Address:
Abdul-Rahman Jazieh
Department of Oncology (mail code 1777), King Abdulaziz Medical City, P.O. Box 22490, Riyadh 11426
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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Abstract

The Lung Cancer Guidelines Committee developed 2008 Lung Cancer Management Guidelines based on available evidences in the literature. These guidelines are stage-dependent and addressing the most common clinical scenarios. They address diagnosis, work-up, treatment, and follow up of lung cancer.

Keywords: Guidelines, lung cancer, treatment

Lung Cancer Management Guidelines

1. (EL-1) High level: Well-conducted phase III randomized studies or metaanalysis.
2. (EL-2) Intermediate level: Good phase II data or phase III trials with limitations.
3. (EL-3) Low level: Observational/retrospective study/expert opinion.

All Lung Cancer Patients

1. Perform history and physical evaluation and document performance status.
2. Perform the following laboratory tests: complete blood count, differential, liver function test, lactate dehydrogenase, renal function, electrolytes, calcium, magnesium and phosphorus.

1. Obtain total body positron emission tomography/computed tomography (PET/CT) scan.
2. Magnetic resonance imaging (MRI) of the head for stages II-IV (preferred over CT scan).
3. Bone scan not indicated if PET scan is performed unless PET is negative and patient has bone pain and/or over-elevated alkaline phosphates.
4. Perform mediastinoscopy in selected cases, i.e. clinical stages (IB-III).
5. Determine the precise TNM stage.

1. Discuss all new cases in the multidisciplinary conferences.
2. Obtain pulmonary function tests if curative surgery or radiotherapy is considered.

1. Offer available clinical research studies.
2. Counsel about smoking cessation and pulmonary rehabilitation.

Non Small Cell Lung Cancer

1. Surgical resection with lobectomy and mediastinal lymph node sampling.
2. No need for adjuvant chemotherapy (EL-1).
3. If optimal surgery cannot be performed, consider limited surgery (wedge resection or segmentectomy) (EL-1).
4. For positive surgical margins, perform reresection (EL-1). If not possible, offer curative radiotherapy (EL-2).
5. If surgical resection is not possible, offer curative radiotherapy (EL-1).
6. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. Surgical resection with lobectomy and mediastinal lymph node sampling (EL-1) or dissection (EL-3).
2. For lesions ≥4 cm or high-risk features (poorly differentiated, wedge resection, minimal margins, vascular Invasion), consider adjuvant treatment, (EL-2).
3. Chemotherapy of choice: Four to six cycles of cisplatin (carboplatin only if cisplatin is contraindicated) with docetaxel, gemcitabine or venorelbine (EL-1) or carboplatin and paclitaxel x4 cycles.
4. If optimal surgery cannot be performed, consider limited surgery (wedge resection or segmentectomy) (EL-1).
5. For positive surgical margins, perform reresection (EL-1) and if not possible, offer curative radiotherapy (EL-2).
6. If surgical resection is not possible, offer curative radiotherapy (EL-1).
7. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. Surgical resection with lobectomy/pneumonectomy and mediastinal lymph node sampling (EL-1) or dissection (EL-3).
2. Offer adjuvant therapy as per directions in 'Chemotherapy of choice' in the section 'Clinical stage IB' (EL-1).
3. If optimal surgery cannot be performed, consider limited surgery (wedge resection or segmentectomy) (EL-1).
4. For positive surgical margins, perform reresection (EL-1) and if not possible, offer curative radiotherapy (EL-2).
5. If surgical resection is not possible, offer curative radiotherapy (EL-1).
6. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. Surgical resection with lobectomy/pneumonectomy and mediastinal lymph node sampling (EL-1) or dissection (EL-3).
2. Offer adjuvant therapy as per directions in 'Chemotherapy of choice' in the section 'Clinical stage IB' (EL-1).
3. Superior sulcus tumor patients should be induced by cisplatin/etoposide with concurrent radiation therapy followed by surgical resection (EL-2). Assess disease extent by using MRI at baseline and preoperatively.
4. For T3 N0 M0 perform en-bloc resection (EL-1).
5. If optimal surgery cannot be performed, consider limited surgery (wedge resection or segmentectomy) (EL-1).
6. For positive surgical margins, perform reresection (EL-1) and if not possible, offer curative radiotherapy (EL-2).
7. If surgical resection is not possible, offer curative radiotherapy (EL-1).
8. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. For N2 disease, offer reoadjuvant concurrent chemo-radiotherapy (EL-1) or two cycles of chemotherapy alone and assess response. For responders, offer surgery. For nonresponders, offer two cycles of the same chemotherapy or three cycles of taxotere (EL-2) or concurrent chemo-radiotherapy if not given upfront.
2. If positive N2 disease is discovered during surgery by frozen section, abort surgery if pneumonectomy is required (EL-2).
3. For incidental pathological N2 disease, adjuvant chemotherapy is indicated (EL-1). Radiotherapy could be considered (EL-3).
4. For superior sulcus tumor, offer treatment described in the third stage of 'Clinical stage IIB' (EL-2).
5. For non-N2 stage IIIA, offer surgical resection with adjuvant chemotherapy (EL-1). Adjuvant radiotherapy may be considered (EL-3).
6. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. No malignant pleural effusion: Offer concurrent chemo-radiotherapy followed by chemotherapy. Surgical resection for selected cases could be offered.
2. Stage T4 N0 M0: consider induction chemotherapy or chemo-radiotherapy followed by surgical resection.
3. Stage IIIB with pleural effusion: assess the need for thoracentesis and pleurodesis. Offer systemic therapy as per directions in 'Stage IV.'
4. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. No brain metastases/no prior treatment.
   
   1.1. Good performance status 0-1 and some borderline 2: Offer platinum doublet (cisplatin or carboplatin with docetaxel, paclitaxel or gemcitabine) (EL-1).
   
   1.1.1. In nonsquamous cell lung cancer and no contraindication to bevacizumab, consider carboplatin/paclitaxel/bevacizumab/avastin (EL-1).
   
   1.2. Poor performance status 2 and 3: Consider erlotinib. If unavailable, consider single-agent therapy (EL-2).
   
   1.3. Performance status of 4: Palliative care.



2. Previously treated patients: Consider erlotinib, premetrexed or docetaxel (EL-1) if not used as first line.
3. For third-line therapy, consider erlotinib (EL-1).



4. With brain metastases:
   
   4.1. refer to radiation oncology for local treatment of the central nervous system (CNS) disease.
   
   4.2. after CNS disease control, start systemic therapy as in instruction 2 above.



5. Follow-up and surveillance as per directions in 'Follow-up of non small cell lung cancer.'

1. For resected tumor stage I-III: Every 6 months for 2 years and then annually for 5 years.
2. Stage III treated with combined therapy: Evaluate every 3-4 months for 2 years and then annually for 5 years.
3. Stage IV: Evaluation every 2-3 months.

Small Cell Lung Cancer

1. Offer cisplatin/etoposide with radiation therapy and then consolidate with two cycles of cisplatin/etoposide (EL-1). May substitute cisplatin with carboplatin in patients with neuropathy, renal dysfunction or hearing problems.
2. After definitive therapy with CR or near CR, offer prophylactic cranial irradiation (EL-1).
3. For a very limited stage (T1-2 N0 confirmed by mediastinoscopy), offer surgical resection followed by chemotherapy, radiotherapy and prophylactic brain radiotherapy (EL-2).
4. Follow-up and surveillance as per directions in 'Follow-up and surveillance.'

1. Offer cisplatin/etoposide x6 cycles (EL-1).
2. For previously treated patients who relapsed in less than 6 months from initial treatment, offer topotecan (EL-1) or cyclophosphamide adriamycin and vincristin (CAV), or camptozar.
3. For relapse after 6 months from initial treatment, may use original regimen.
4. Follow-up and surveillance as per directions in 'Follow-up and surveillance.'

1. Evaluation includes history and physical examination and laboratory data and CT scan of the chest.
2. Limited stage: Evaluation every 3 months for the first 2 years and then annually for 5 years.
3. Extensive stage: Evaluation every 2 months for the first 2 years.