I. Selection of radiation treatment plan.
Standardized radiotherapy is implemented according to the Ministry of Health’s “Norms for the diagnosis and treatment of primary lung cancer (2011):
1.When surgical treatment cannot be received for medical reasons or other reasons, radical radiotherapy can be selected for stage I cases; for stage II III cases, synchronous radiotherapy is preferred, sequential radiotherapy can also be selected, and simple radical radiotherapy is performed when it cannot be tolerated.
2.For T3/T4,N0/N1,M0 tumor in the upper lung sulcus, preoperative synchronous radiotherapy should be performed, followed by surgical resection + chemotherapy; if it is decided that the tumor cannot be resected, radical synchronous radiotherapy should be performed.
3.For stage IV cases, systemic therapy is the main treatment, and radiotherapy can be used as local treatment for primary or metastatic lesions; for brain metastasis cases, radiotherapy is preferred for the management of intracranial lesions, using whole brain irradiation or stereotactic radiotherapy for single and few lesions, or the combination of both.
4. For cases that achieve R0 resection after surgery and positive mediastinal lymph nodes (N2), adjuvant chemotherapy or radiotherapy can be chosen after surgery. For residual tumor (R1 or R2 resection), simultaneous radiotherapy, sequential radiotherapy or radiotherapy can be chosen. In cases with positive cut margins, radiotherapy should be started as early as possible.
5.Stage II-III (limited stage) small cell lung cancer is given priority to synchronous radiotherapy, and prophylactic whole brain irradiation is performed for those in complete remission; stage IV (extensive stage) is performed for those with effective chemotherapy.
6. Palliative radiotherapy: If indicated, for primary or metastatic lesions and symptoms such as pain and pressure, palliative external irradiation therapy can be selected as appropriate to improve the quality of survival.
Second, the clinical pathway standard hospitalization day is ≤ 54 days.
Third, the entry pathway criteria.
1. The first diagnosis is in accordance with ICD-10: C34 with Z51.0, Z51.0 with Z85.101 primary lung cancer disease code.
2.No contraindication to radiotherapy.
3.When the patient is combined with other diseases, but no special treatment is needed during hospitalization nor does it affect the implementation of the clinical pathway process for the first diagnosis, the patient can enter the pathway.
IV. Preparation before radiation therapy.
1.Required examination items.
(1) Routine blood, routine urine, routine stool.
(2) liver function, kidney function, electrolytes.
(3) pulmonary function, electrocardiogram, arterial blood gas analysis.
(4) Sputum cytology, fiberoptic bronchoscopy.
(5) Imaging: X-ray chest film, chest CT (plain + enhanced scan), abdominal ultrasound or abdominal CT, whole-body bone scan, cranial MRI or enhanced CT.
2. Depending on the patient’s condition, the following items may be selected.
(1) mediastinoscopy or EBUS.
(2) Percutaneous lung puncture biopsy.
(3) Echocardiography, 24-hour ambulatory ECG.
(4) Tests related to cardiovascular diseases.
(5) Tumor marker examination.
3.Risk assessment of radiotherapy.
V. Radiotherapy treatment plan.
1.Target area determination: The radiotherapy plan should be based on the CT simulated images of the same body position, and the use of intravenous contrast agent is recommended to increase the accuracy. The target area should include GTV (CT-visible lesion), micro lesion margin (CTV), range of motion of the target area, and positioning error to obtain the final PTV.
2.Treatment modality: Radical treatment and preoperative or postoperative radiotherapy should adopt conformal or conformal intensity modulated radiotherapy techniques.
3.Dose selection: preoperative radiotherapy dose 45-50Gy, 1.8-2Gy conventional segmentation; radical radiotherapy generally requires 60-74Gy, stereotactic body radiotherapy (SBRT) dose 5-12.5Gy/time, 4-12 times; simultaneous chemotherapy is 60-70Gy, 2Gy conventional segmentation; postoperative radiotherapy R0 cases 50- 54Gy for R0 cases, 54-60Gy for R1 cases, 60-70Gy for R2 cases, and 1.8-2Gy conventional fractionation. Palliative treatment aims to alleviate symptoms, and the total dose can be reduced appropriately.
4. Organ protection: The dose volume histogram of the endangered organs should be routinely evaluated to limit their irradiated dose. The recommended normal tissue dose limits for conventional segmentation 3D conformal radiotherapy or intensity modulated radiotherapy techniques are: spinal cord <50 Gy, whole lung V20 <37%, whole lung mean dose <20 Gy, heart V40 <100%, V45 <67%, V60 <33%, esophagus mean dose <34 Gy, brachial plexus total dose <66 Gy. For post-pneumonectomy patients, their lung tissue radiation For post-pneumonectomy patients, their lung tissue radiation tolerance may be significantly reduced, and stricter normal lung tissue dose limits should be considered to minimize radiation dose. In cases after lobectomy, the remaining whole lung V20 is <25%; in cases after total lung resection, the healthy lung V20 is <10%.
5. The chemotherapy regimen of simultaneous radiotherapy was implemented according to the “Standard for the diagnosis and treatment of primary lung cancer (2011)”.
VI. In-treatment examinations and other treatments.
1.Weekly physical examination at least 1 time.
2.Weekly rechecking of blood routine.
3.Closely observe the condition and give strong supportive treatment for acute toxic reactions to avoid treatment interruption and dose reduction due to treatable toxic reactions.
4. Review imaging examinations during treatment according to the condition and adjust or reposition the treatment plan as appropriate.
VII. Post-treatment review.
1.Blood routine, liver function, kidney function, tumor markers.
2. According to the patient’s condition, review of chest CT, abdominal ultrasound or CT, cranial MRI, whole body bone scan may be considered.
VIII. Discharge criteria.
1.Complete all radiation treatment plan, or cannot continue radiation treatment due to objective reasons.
2.No serious toxic reactions requiring hospitalization.
3.No other comorbidities/complications that require hospitalization.