Last updated March 14, 2022

Special Treatment Issues In Non-Small Cell Lung Cancer: Diagnosis And Management Of Lung Cancer

Recommendations

Pancoast Tumors

In patients with a Pancoast tumor, it is recommended that a tissue diagnosis be obtained prior to the initiation of therapy. (1, C)
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In patients with a Pancoast tumor being considered for curative-intent surgical resection, an MRI of the thoracic inlet and brachial plexus is recommended to characterize possible tumor invasion of vascular structures or the extradural space. (1, C)
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In patients with a Pancoast tumor being considered for curative resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represent a contraindication to resection. (1, C)
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In patients with a potentially resectable Pancoast tumor (and good performance status), it is suggested that preoperative concurrent chemoradiotherapy is given prior to resection. (2, B)
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In patients undergoing resection of a Pancoast tumor, it is recommended that every effort be made to achieve a complete resection. (1, B)
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In patients undergoing resection of a Pancoast tumor, it is suggested that the resection consist of a lobectomy (instead of a nonanatomic wedge resection) as well as the involved chest wall structures. (2, C)
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In patients with an unresectable, but nonmetastatic Pancoast tumor who have good performance status, definitive concurrent chemotherapy and radiotherapy is suggested. (2, C)
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In patients with Pancoast tumors who are not candidates for curative-intent treatment, palliative radiotherapy is suggested. (2, B)
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Tumors Invading the Chest Wall

In patients with an NSCLC invading the chest wall who are being considered for curativeintent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are suggested. (2, C)
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In patients with an NSCLC invading the chest wall, involvement of mediastinal nodes and/or metastatic disease represent a contraindication  to resection, and definitive chemoradiotherapy is suggested for these patients. (2, C)
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At the time of resection of a tumor invading the chest wall, it is recommended that every effort be made to achieve a complete resection. (1, B)
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T4 N0,1 M0 Tumors (Central Tumor With Direct Invasion)

In patients with a clinical T4 N0,1 M0 NSCLC being considered for curative resection, it is recommended that extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) be undertaken. (1, C)
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In patients with a clinical T4 N0, M0 NSCLC without distant metastases being considered for curative resection, it is suggested that invasive mediastinal staging be undertaken. Involvement of mediastinal nodes represents a contraindication to primary resection. (2, C)
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In patients with a clinical T4 N0,1 M0 NSCLC being considered for curative resection, it is suggested that resection be undertaken only at a specialized center. (2, C)
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Additional Nodules and Multiple Primary Lung Cancers

In patients with two foci typical of a primary lung cancer (either proven or suspected, ie, solid, spiculated masses), it is suggested that identification of these as second primary lung cancers (SPLCs) (either synchronous or metachronous) should be based on the judgment of a multidisciplinary team, taking into account clinical, radiologic, and (if available) cytologic/histologic features. (2, C)
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In patients with two primary NSCLCs (synchronous or metachronous) being considered for curative surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. (1, B)
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In patients (not suspected of having a second focus of cancer) who are found intraoperatively to have a second cancer in a different lobe, resection of each lesion is suggested, provided the patient has adequate pulmonary reserve and there is no N2 nodal involvement. (1, C)
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In patients with suspected or proven lung cancer and an additional (suspected) tumor nodule within the same lobe, it is recommended that no further diagnostic workup of the additional nodule is undertaken. (1, B)
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In patients with an additional (suspected) tumor nodule within the same lobe as a suspected or proven primary lung cancer, it is recommended that evaluation of extrathoracic metastases and confirmation of the mediastinal node status should be carried out as dictated by the primary lung cancer alone and not modified due to the presence of the additional lesion. (1, C)
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In patients with NSCLC and an additional focus of cancer within the same lobe (and no mediastinal or distant metastases), resection via a lobectomy is the recommended treatment. (1, B)
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In patients with suspected or proven lung cancer and an ipsilateral different lobe nodule(s), it is recommended that the judgment of a multidisciplinary team should reasonably exclude the possibility that this represents a benign lesion or a synchronous primary lung cancer, taking into account clinical, radiologic, and (if available) cytologic/histologic features. (1, C)
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In patients with an ipsilateral different lobe tumor nodule(s), it is suggested that evaluation for possible extrathoracic metastases (eg, PET and brain MRI/CT) should be carried out. (2, C)
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In patients with an ipsilateral different lobe tumor nodule(s), it is suggested that invasive evaluation to rule out mediastinal node involvement should be carried out. (2, C)
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In patients with NSCLC and an ipsilateral different lobe tumor nodule(s) (and no mediastinal or distant metastases), resection of each lesion is recommended, provided the patient has adequate pulmonary reserve. (1, B)
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In patients with a contralateral lobe tumor nodule(s), it is suggested that evaluation of extrathoracic metastases (eg, PET and brain MRI/CT) and invasive evaluation to rule out mediastinal node involvement should be carried out. (2, C)
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In patients with NSCLC and a contralateral lobe tumor nodule(s) (and no mediastinal or distant metastases), resection of each lesion is suggested, provided the patient has adequate pulmonary reserve. (2, C)
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In patients with multiple lesions that are at least partially ground glass and are suspected to be malignant, it is suggested that these are classified as multifocal lung cancer (MFLC). (2, C)
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In patients with suspected or proven MFLC who have a negative clinical evaluation and normal mediastinum by CT, it is suggested that distant and mediastinal staging are not routinely necessary. (2, C)
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In patients with suspected or proven MFLC, it is suggested that curative-intent treatment should be pursued. (2, C)
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In patients with suspected or proven MFLC, it is suggested that sublobar resection of all lesions suspected of being malignant be performed, if feasible. (2, C)
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Isolated Brain Metastasis

In patients with an isolated brain metastasis from NSCLC being considered for curative treatment, invasive mediastinal staging and extrathoracic imaging (either whole-body PET or abdominal CT plus bone scan) are suggested. (2, C)
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In patients with no other sites of metastases and a synchronous resectable N0,1 primary NSCLC, resection or radiosurgical ablation of an isolated brain metastasis is recommended (as well as resection of the primary tumor). (1, C)
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In patients with no other sites of metastases and a previously completely resected primary NSCLC ( metachronous presentation), resection or radiosurgical ablation of an isolated brain metastasis is recommended. (1, C)
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In patients who have undergone a curative resection of an isolated brain metastasis, adjuvant whole-brain radiotherapy (WBRT) is suggested. (2, B)
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In patients who have undergone a curative resection of an isolated brain metastasis, adjuvant chemotherapy is suggested. (2, B)
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Isolated Adrenal Metastasis

In patients with an isolated adrenal metastasis from NSCLC being considered for curativeintent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are suggested. (2, C)
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In patients with a synchronous resectable N0,1 primary NSCLC and an isolated adrenal metastasis, with no other sites of metastases, resection of the primary tumor and the adrenal metastasis is recommended. (1, C)
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In patients with no other sites of metastases and a previously completely resected primary NSCLC ( metachronous presentation), resection of an isolated adrenal metastasis is recommended. (1, C)
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In patients who have undergone a curative resection of an isolated adrenal metastasis, adjuvant chemotherapy is suggested. (2, B)
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Recommendation Grading

Overview

Title

Special Treatment Issues In Non-Small Cell Lung Cancer: Diagnosis And Management Of Lung Cancer

Authoring Organization

Publication Month/Year

November 1, 2013

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

Target Patient Population

Patients with particular forms of non-small cell lung cancer

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient, Radiology services

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D002289 - Carcinoma, Non-Small-Cell Lung, D008175 - Lung Neoplasms, D010178 - Pancoast Syndrome

Keywords

lung cancer, non-small cell lung cancer, Non Small Cell Lung Cancer, non_small_cell_lung_cancer