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Non-small-cell lung cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

2009; Elsevier BV; Volume: 20; Linguagem: Inglês

10.1093/annonc/mdp132

1569-8041

G. D’Addario, Enriqueta Felip,

Medical Imaging Techniques and Applications

The crude incidence of lung cancer in the European Union is 52.5/100 000 per year, the mortality 48.7/100 000 per year. Among men the rates are 82.5 and 77.0/100 000 per year, among women 23.9 and 22.3/100 000 per year, respectively. Non-small-cell lung cancer (NSCLC) accounts for 80% of all cases. About 90% of lung cancer mortality among men (and 80% among women) is attributable to smoking. Pathological diagnosis should be made according to the WHO classification. The main NSCLC tumor groups are adenocarcinoma, squamous cell carcinoma and large-cell carcinoma. Histological or cytological specimens can be obtained from the primary tumor, lymph node or distant metastases or malignant effusions. The least invasive procedure should be used. •Complete history and physical examination, CT scan of the chest and upper abdomen.•MRI of the brain if abnormal neurologic findings (to be substituted by CT scan if MRI not available).•Bone scan in the presence of bone pain, elevated serum calcium, or elevated alkaline phosphatase levels. •Whole-body FDG-PET scan if available. In case of pathological mediastinal lymph node uptake, biopsy of an abnormal node is recommended (required if positivity would affect curative treatment, i.e. N3 lymph node).•If FDG-PET not available or result inconclusive: biopsy of mediastinal lymph nodes ≥1 cm in short axis.•Biopsy of mediastinal lymph nodes can be obtained by mediastinoscopy, transbronchial needle aspiration, ultrasound-guided bronchoscopy with fine needle aspiration, and /or endoscopic esophageal ultrasound-guided fine needle aspiration.•MRI of the brain for clinical stage III patients (to be substituted by CT scan if MRI not available) planned for definitive local treatment.•Bone scan if FDG-PET not available for clinical stage III patients planned for definitive local treatment.•In patients with a single metastatic lesion on imaging studies, biopsy should be attempted to prove metastatic disease if otherwise curatively treatable.•Cytology of pleural / pericardial effusions in patients otherwise curatively treatable. Patients with NSCLC shall be staged according to the UICC 6 system and be grouped into the risk categories shown in Table 1.Table 1Occult carcinomaTx N0 M0Stage 0Tis N0 M0Stage IAT1 N0 M0Stage IBT2 N0 M0Stage IIAT1 N1 M0Stage IIBT2 N1 M0T3 N0 M0Stage IIIAT1, T2 N2 M0T3 N1, N2 M0Stage IIIBAny T N3 M0T4 Any N M0Stage IVAny T Any N M1 Open table in a new tab •Surgical resection in functionally fit patients (lobectomy/pneumonectomy plus systematic mediastinal lymph node sampling or lymphadenectomy).•Cisplatin-based adjuvant combination chemotherapy is recommended in stage II and IIIA [I, A], and can be considered in selected stage IB patients (T > 4 cm).•Preoperative cisplatin-based combination chemotherapy can be considered in patients with stage IIIA–N2 disease [II, B].•Postoperative radiotherapy may be considered in patients not radically resected.•Postoperative radiotherapy is not recommended for patients with radically resected Stage I and II disease [I, A] and can be considered for patients with resected stage IIIA disease.•Curative conformal radiotherapy as a single modality is to be considered in patients unfit for standard surgery.•Platinum-based chemotherapy, preferably concurrent with thoracic radiotherapy, is the standard treatment for selected patients with locally advanced, unresectable stage III NSCLC and adequate pulmonary function. •First-line treatment with a two-drug, platinum-based chemotherapy combined with a new agent (vinorelbine, gemcitabine, taxanes, or pemetrexed in patients with predominantly non-squamous cell carcinoma histology) is considered the standard treatment in patients with good performance status [I, A]. Non-platinum based combination chemotherapy of new agents can be considered alternatively.•In the first-line treatment of selected, advanced, non-squamous NSCLC patients, one randomized trial showed that the combination of bevacizumab with paclitaxel-carboplatin achieved longer progression-free survival and overall survival than chemotherapy alone. In another, randomized trial the gemcitabine-cisplatin-bevacizumab combination obtained longer progression-free survival than gemcitabine-cisplatin, without differences in median survival.•In a randomized trial, the addition of cetuximab to cisplatin-vinorelbine as first-line therapy has shown a modest improvement in overall survival, but not in progression-free survival, in EGFR immunohistochemistry positive NSCLC patients.•In the first-line treatment of patients with tumors harboring EGFR mutation, EGFR tyrosine kinase inhibitors should be considered, pending results of ongoing randomized trials.•In frail elderly patients and in patients with performance status 2, single-agent chemotherapy might be considered [II, B].•Timing and duration of palliative first-line treatment: chemotherapy should be initiated while the patient is in good performance status. The role of chemotherapy beyond four to six cycles has to be established.•Resection of single metastases can be considered in selected cases [III, B].•For the palliative treatment of multiple brain metastases, whole brain radiotherapy is recommended. Second-line systemic treatment (docetaxel, erlotinib, or pemetrexed in patients with predominantly non-squamous histology) should be considered in appropriately selected patients [I, A]. Response evaluation is recommended after two or three cycles of chemotherapy by repetition of the initial radiographic tests showing tumor lesions. The optimal approach to post-treatment management of patients with NSCLC, including the role of radiologic evaluations, is controversial. For patients receiving intent-to-cure treatment, history and physical examination should be performed every 3–6 months during the first 2 years, and every 6–12 months thereafter and radiologic evaluations should be considered at these time points. Levels of evidence [I–V] and grades of recommendation [A–D] as used by the American Society of Clinical Oncology are given in square brackets. Statements without grading were considered justified standard clinical practice by the expert authors and the ESMO faculty.