1.Comprehensive treatment of stage I non-small cell lung cancer.
(1) Preferred surgical treatment includes lobectomy plus hilar and mediastinal lymph node dissection, which can be performed in open chest or VATS and other procedures.
(2) For patients with poor lung function, anatomical lung segmental or wedge resection plus hilar and mediastinal lymph node dissection can be considered.
(3) Postoperative adjuvant chemotherapy is not suitable for patients with completely resected stage IA lung cancer.
(4) The routine application of postoperative adjuvant chemotherapy is not recommended for completely resected stage IB patients.
(5) Re-operation is recommended for stage I lung cancer with positive cut margins. For patients who cannot be operated again for any other reason, postoperative chemotherapy plus radiotherapy is recommended.
2. Comprehensive treatment of stage II non-small cell lung cancer.
(1) Preferred surgical treatment includes lobectomy, double lobectomy or total pneumonectomy plus hilar and mediastinal lymph node dissection.
(2) Anatomic lung segmental or wedge resection plus hilar and mediastinal lymph node dissection can be considered for patients with poor lung function.
(3) Postoperative adjuvant chemotherapy is recommended for completely resected stage II non-small cell lung cancer.
(4) Whole chest wall resection should be performed when the tumor invades the mural pleura or chest wall. The extent of resection should be at least 50px from the upper and lower margins of the nearest rib, and the length of resection of the invaded rib should be at least 125px from the tumor.
(5) Re-operation is recommended for stage II lung cancer with positive margins, and postoperative chemotherapy plus radiotherapy is recommended for patients who cannot be operated again for any other reason.
3. Comprehensive treatment of stage III non-small cell lung cancer.
Locally advanced non-small cell lung cancer is defined as lung cancer with TNM stage III. Adopting an integrated treatment model is the best choice for the treatment of III non-small cell lung cancer. Locally advanced NSCLC is divided into two categories: resectable and unresectable. Among them.
(1) resectable locally advanced non-small cell lung cancer includes.
(1) patients with NSCLC in T3N1, where surgery is preferred and adjuvant chemotherapy is administered after surgery.
(2) Surgical resection for patients with stage N2 lung cancer is controversial. In cases where imaging reveals a single group of enlarged mediastinal lymph nodes, or two groups of enlarged mediastinal lymph nodes without fusion estimated to be completely resectable, preoperative mediastinoscopy is recommended, and preoperative neoadjuvant chemotherapy is administered after a clear diagnosis, followed by surgery.
③Some patients with T4N0-1: a) Satellite nodes in the same lung lobes: In the new staging, this type of lung cancer is T3 stage, and the preferred treatment is surgical resection, and preoperative neoadjuvant chemotherapy with postoperative adjuvant chemotherapy is also an option. b) Other resectable T4N0-1 stage non-small cell lung cancer, neoadjuvant chemotherapy may be preferred as appropriate, and surgical resection is also an option. In case of complete resection, postoperative adjuvant chemotherapy is considered. If the margins are positive, postoperative radiotherapy and platinum-containing regimen chemotherapy are administered.
Treatment of supraglottic sulcus tumor: For some patients with operable sulcus tumor, simultaneous radiotherapy followed by surgery + adjuvant chemotherapy is recommended. For inoperable supraglottic sulcular lung tumors, radiotherapy plus chemotherapy will be administered.
(2) Unresectable locally advanced non-small cell lung cancer includes.
(i) Non-small cell lung cancer with imaging suggestive of mass-like shadows in the mediastinum and positive mediastinoscopy.
②Most non-small cell lung cancers of T4 and N3.
③Patients with T4N2-3.
④Patients with metastatic pleural nodules, malignant pleural fluid and malignant pericardial effusion, which have been newly staged as M1, are not suitable for surgical resection. Thoracoscopic pleural biopsy or pleural fixation may be used in some cases.
4.Treatment of stage IV non-small cell lung cancer.
Before starting treatment for stage IV lung cancer, it is recommended to obtain tumor tissues for testing whether the epidermal growth factor receptor (EGFR) is mutated or not, and to formulate corresponding treatment strategies according to the EGFR mutation status.
Stage IV lung cancer is mainly treated with systemic therapy, and the treatment aims to improve patients’ quality of life and prolong life.
(1) Treatment of isolated metastatic stage IV lung cancer.
(1) For isolated brain metastasis and resectable non-small cell lung cancer, the brain lesion can be surgically removed or treated with stereotactic radiation therapy, while the primary lesion in the chest is treated according to the principle of staging.
(2) Isolated adrenal metastasis and lung lesion is resectable non-small cell lung cancer, the adrenal lesion can be considered for surgical resection, and the primary lesion in the chest is treated according to the principle of staging.
(3) Isolated nodules in the contralateral lung or other lung lobes of the same lung can be treated according to the respective staging of the two primary tumors.
(2) Systemic treatment of stage IV lung cancer.
①For stage IV non-small cell lung cancer with EGFR-sensitive mutations, first-line treatment with gefitinib or erlotinib is recommended.
②For stage IV non-small cell lung cancer with EGFR wild-type or unknown mutation status, systemic chemotherapy with two platinum-containing agents should be started as early as possible if the functional status score is PS=0 to 1. For patients not suitable for platinum-based therapy, non-platinum-based two-drug combination chemotherapy may be considered.
(iii) Patients with advanced non-small cell lung cancer with PS=2 should receive single agent chemotherapy, but there is no evidence to support the use of cytotoxic analog chemotherapy for patients with PS>2.
④Current evidence does not support the use of age factors as a basis for selecting chemotherapy regimens.
⑤ For non-small cell lung cancer that has failed first-line chemotherapy, second-line chemotherapy with doxorubicin and pemetrexed, and second- or third-line oral therapy with gefitinib or erlotinib are recommended.
(vi) Stage IV non-small cell lung cancer with a score of PS>2 may be treated with best supportive care only, as appropriate.
In addition to systemic therapy, appropriate local treatments can be chosen for specific local conditions in order to improve symptoms and quality of life.