Best Oncologist in Vizag | Best Surgical Oncologist in Vizag

05 May 2024

Management of NSCLC

Work up

Treatment Modalities

Surgery
- Open vs. VATS or Robotic-assisted Approaches
- Lobectomy vs. Pneumonectomy vs. Sublobar Resection
Systemic Therapy
- Chemotherapy
- Targeted Therapy
- Immunotherapy
Radiation
- External Beam Radiation Therapy
  - 3-Dimensional Conformal Radiation Therapy (3-D CRT)
  - Intensity Modulated Radiation Therapy (IMRT)
- Stereotactic Body Radiation Therapy (SBRT/SABR)
- Proton Therapy (PT)

Basic Principles of Surgical Selection

The definition of medically inoperable varies substantially between surgeons
PFTs that suggest a patient should tolerate surgery include:
- Pre-op FEV1 >1.8-2 L (or ≥80% predicted) if patient needs a pneumonectomy
- Pre-op FEV1 >1.2-1.5L if patient needs a lobectomy
- Predicted post-op FEV1 >800 mL (>40% predicted)
- DLCO > 50-60%
- Resection of tumor in a dominant area of emphysema may have less impact on post-op lung function
Patients with cardiac risk factors should have a preoperative cardiologic evaluation
Contemporary 30-day mortality rates are 1-3% for lobectomy or sublobar resection and 2-11% for pneumonectomy

Active smokers have a mildly increased risk of post-op complications

Management of Stage I + II NSCLC

-Surgery alone is the standard treatment choice !

-Lobectomy: optimal procedure

-Wedge resection: 3x LR/ 30% more mortality (Ginsberg 1995) but newer series show no worse outcome with limited surgery (Lee 2003, El Sherif 2006)

-Wedge resection for small tumors (<3cm) and elderly patients

-No randomized trials, but excellent results (randomized trial 'Surgery-Radiotherapy' underway)

-Adjuvant Cisplatin-based ChT for stage II for stage IB data is conflicting

-No adjuvant radiotherapy after radical surgery (i.e. RO)

Definitive Radiotherapy for Stage I + II NSCLC

-Alternative for comorbid patients who are not fit for surgery

-For patients who refuse surgery