Staging
Jan 25, 2016
Staging
Staging
Treatment by Stage
For early stage lung cancers, surgery or radiation alone
For larger tumors (>4 cm) and N+, chemotherapy should be added as well
For metastatic disease, chemotherapy and palliative radiation is used
Surgery
Resection remains the preferred local tx modality
For smokers, encourage quitting and waiting 4 weeks smoke-free before surgery
Surgery for Early Stage
Sleeve lobectomy is preferred
Sublobar resection: Segmentectomy is preferred over wedge resection for pts with poor pulm reserve, small nodules of AIS, > 50% ground glass appearance, or long radiological doubling time
Goal of >2 cm margins, and should sample N1/N2 LN stations if possible
VATS vs open thoracotomy
In centers with high volumes of VATS, there are improved early outcomes:
• Reduced pain
• Shortened hospital stay
• Faster recovery
• Fewer complications
• Similar rates of tumor control
Radiation in Early Stage
Stereotactic Body Radiotherapy (SBRT) delivers a high, tumor-ablative dose to the target while minimizing normal tissue dose
In Stage I NSCLC, SBRT shows rates of local tumor control (90-98%) and overall survival 30-80%) comparable to lobectomy
Stage III Controversies
Historically Stage IIIA/B have been considered unresectable and definitive chemotherapy and radiation (concurrently or sequentially) is the tx of choice
Two randomized studies have failed to show an OS benefit in adding surgical resection to chemo and RT, but NCCN guidelines still include it as an option to consider
Breaks from neoadjuvant tx for surgical evaluation should be < 1 week
Resection of Stage IIIA (N2)
In addition to N1/N2 dissection, ipsilateral mediastinal LN dissection should be done
Complete resxn (R0) = free margins, systemic LN sampling or dissections, and the highest mediastinal node taken should be negative for tumor
Incomplete: positive margins, unremoved positive LN’s, or positive pleural or pericardial effusion (R1 if microscopic, R2 if gross residual tumor)
Chemotherapy
Multiple randomized trials show the benefit of chemotherapy in Stage II and III NSCLC (maybe even Stage IB with tumor > 4cm)
Platinum-based doublet:
Cisplatin/etoposide
Cisplatin/vinblastine
Carboplatin/paclitaxel
Pemetrexed for nonsquamous histology, gemcitabine for squamous
M1b, Solitary Site
• For solitary brain metastasis: resection + WBI, or SBI + SRS, or SRS alone
• For adrenal metastasis: resection or RT (SBRT) to metastasis
• Then tx the lung per it’s stage without the metastasis
Advanced or Metastatic Disease
• EGFR and ALK testing for non-squamous histologies
• Bevacizumab + chemotherapy in pts with good performance status
• Erlotinib is first line therapy in pts with EGFR mutation
• Crizotinib is first line therapy in pts who are ALK positive
Targeted Therapies
Bevacizumab (Avastin) – VEGF
Erlotinib (Tarceva) – EGFR
Gefitinib (Iressa) – EGFR
Crizotinib – ALK
These targets are mainly applicable in adenocarcinomas, with most SQCC lacking EGFR mutation and ALK rearrangement
Cetuximab has shown activity in SQCC’s with high EGFR expression (FLEX)
Future Targets for SQCC
In squamous cell NSCLC’s genomic profiling shows potential targets in PI3K pathway, FGFR1 amplifications and DDR2 mutations
ECLIPSE: Phase III trial of carboplatin/gemcitabine =/- iniparib (a PARP inhibitor) is underway
Phase III trial of carboplatin/paclitaxel +/- ipilimumab (targets the inhibition of cytotoxic T cells)
Follow Up
Physical exam and CT scan every 6 months for 2 years
Exam and CT scan every year after that