III. Staging
(A) Lu Kaihua, Department of Oncology, The First Affiliated Hospital of Nanjing Medical University
The TNM staging of NSCLC adopts the International Association for the Study of Lung Cancer (IASLC) 2009 7th edition staging criteria (IASLC 2009).
(ii) SCLC
The American Legion Lung Cancer Association’s staging methods for limited and extensive stages were used for patients undergoing non-surgical treatment, and the IASLC 2009 7th edition staging criteria were used for patients with limited stage SCLC undergoing surgery.
IV. Treatment
(I) Treatment principles
The principle of combining multidisciplinary comprehensive treatment and individualized treatment should be adopted, that is, to adopt a multidisciplinary comprehensive treatment model according to the patient’s physical condition, the pathological histological type and molecular typing of the tumor, the extent of invasion and development trend, and to apply surgery, chemotherapy, radiotherapy and molecular targeted therapy in a planned and rational manner, in order to maximize the patient’s survival time, improve survival rate, control tumor The aim is to maximize the survival time, improve the survival rate, control the tumor progression and improve the quality of life of patients.
(B) Surgical treatment
1) Principles of surgical treatment: Anatomical pneumonectomy is the main treatment for early-stage lung cancer, and is also an important method for clinical cure of lung cancer. Lung cancer surgery is divided into complete resection, incomplete resection and indeterminate resection. We should strive for complete resection to achieve complete removal of tumor, reduce metastasis and recurrence, and perform accurate pathological TNM staging and molecular pathological staging to guide comprehensive postoperative treatment. The following surgical principles should be observed for surgically resectable lung cancer.
(1) Comprehensive treatment planning and necessary imaging (clinical staging, especially accurate N-staging) should be completed prior to surgical treatment. The possibility of surgical resection should be fully evaluated and a surgical plan should be developed.
(2) Complete resection of the tumor and regional lymph nodes should be achieved whenever possible, while preserving as much functional normal lung tissue as possible.
(3) Video-assisted thoracic surgery (VATS) is a well-established minimally invasive thoracic surgery technique in recent years, and VATS and other minimally invasive methods are recommended in the absence of contraindications to surgery.
(4) Anatomic pneumonectomy (lobectomy, bronchial and vascular sleeve lobectomy or total pneumonectomy) is feasible depending on the patient’s physical condition. If physical condition does not allow, sublobar resection is performed, of which anatomic lung segmental resection is preferred and wedge resection is also feasible.
(5) Indications for anatomic segmental lung resection or wedge lung resection are.
(i) Patients with advanced age or low lung function, or at major risk for lobectomy.
② CT suggestive of intrapulmonary peripheral type lesion (meaning located in the lateral 1/3 of the lung parenchyma) with a lesion diameter ≤ 50 px and one of the following characteristics: pathologically confirmed adenocarcinoma; CT follow-up of more than 1 year highly suspicious of cancer; CT suggestive of solid component ≤ 50% in ground glass-like shadow.
(iii) Excision of lung tissue with a cut edge ≥ 50px from the lesion margin or a cut edge distance ≥ lesion diameter with intraoperative rapid pathology that is negative for cut edges.
(iv) Systematic sampling of hilar and mediastinal lymph nodes should be performed before deciding on sublobar resection. At present, the sublobar resection for early-stage lung cancer is still in the clinical research stage, and participation in clinical research is encouraged, and it cannot be promoted as a standard procedure.
(6) In addition to complete resection of the primary lesion, systematic resection of each group of hilar and mediastinal lymph nodes (N1 and N2 lymph nodes) should be routinely performed for complete resection (R0 surgery), and the locations should be marked and sent for pathological examination.
At a minimum, the lymph nodes in the 3 mediastinal drainage area (station N2) should be cleared or sampled to ensure whole lymph node resection as much as possible. It is recommended that the right thoracic lymph nodes be cleared to 2R, 3a, 3p, 4R, 7-9 groups of lymph nodes and surrounding soft tissue, and the left thoracic lymph nodes be cleared to 4L, 5-9 groups of lymph nodes and surrounding soft tissue.
(7) Normally, the pulmonary veins and pulmonary arteries should be treated sequentially intraoperatively, and the bronchi should be treated last, or the order of treatment should be decided according to the actual intraoperative situation.
(8) Bronchial sleeve lobectomy is the extent of resection performed to preserve as much lung tissue and lung function as possible under the condition of intraoperative rapid pathological examination to ensure negative margins (including bronchial, pulmonary artery or venous dissection), and the postoperative quality of life is better than that of patients undergoing total pneumonectomy.
(9) For patients with recurrence or isolated lung metastasis 6 months after complete lung cancer resection, resection of the recurrent lateral residual lung or lung metastasis is feasible if the extra-pulmonary distant metastasis and cardiopulmonary function and other organic conditions allow.
(10) Patients with stage I and stage II NSCLC whose cardiopulmonary function is assessed to be inoperable may choose radical radiation therapy, radiofrequency ablation therapy and drug therapy.
2. Indications for surgery: (1) Stage I, II and part of stage IIIA (T1-2N2M0; T3N1-2M0; T4N0-1M0 completely resectable) NSCLC and stage I SCLC (T1-2N0M0). (2) Some stage IV NSCLC with solitary contralateral lung metastasis and solitary brain or adrenal metastasis. (3) Intrapulmonary nodules with high clinical suspicion of lung cancer, which cannot be diagnosed qualitatively by various examinations, can be surgically explored.
(3) Contraindications for surgery: (1) Poor systemic condition, and the function of important organs such as heart, lung, liver and kidney cannot tolerate surgery. (2) Most of the diagnosed stage IV, most of the stage IIIB and some of the stage IIIA NSCLC.
(3) Radiotherapy
Radiotherapy for lung cancer includes radical radiotherapy, palliative radiotherapy, adjuvant radiotherapy and prophylactic radiotherapy, etc.
1. Principles of radiotherapy.
(1) Radical radiotherapy is applicable to patients with Karnofsky functional status score ≥ 70, including early stage NSCLC, unresectable locally advanced NSCLC and limited stage SCLC that are inoperable due to medical or (and) personal factors.
(2) Palliative radiotherapy is indicated for symptom reduction of both primary and metastatic foci of advanced lung cancer. Postoperative whole brain radiotherapy can be performed for patients with surgically resected single brain metastases from NSCLC and chest radiotherapy for extensive stage SCLC.
(3) Adjuvant radiotherapy is indicated for patients with preoperative radiotherapy, positive postoperative radiotherapy cut margins (R1 and R2); patients with insufficient surgical exploration or those with close surgical cut margins; for patients with positive postoperative pN2, participation in clinical studies of postoperative radiotherapy is encouraged.
(4) The design of postoperative radiotherapy should refer to the patient’s surgical pathology report and surgical records.
(5) Prophylactic radiotherapy is applicable to whole brain radiotherapy for SCLC patients with effective systemic therapy.
(6) The scope of concurrent radiotherapy: for inoperable stage IIIA and IIIB patients, the recommended concurrent radiotherapy regimens are EP regimen (pegylated glycosides + cisplatin), NP regimen (vincristine + cisplatin) and paclitaxel-containing regimen. If the patient cannot tolerate, sequential radiotherapy can be administered.
(7) Patients receiving radiotherapy have increased potential side effects and should be informed prior to treatment. Radiation therapy should be designed and delivered with attention to the protection of the lung, heart, esophagus and spinal cord. Unplanned interruption of radiotherapy due to improper management of toxic side effects should be avoided as much as possible during treatment.
(8) Advanced radiotherapy techniques such as 3D conformal radiotherapy, intensity-modulated radiotherapy or image-guided radiotherapy should be used, and stereotactic body radiation therapy (SBRT) is recommended to be carried out under excellent radiophysical conditions.
(9) Enhanced CT localization or PET-CT localization is recommended for radiotherapy target area outlining. The tumor target area can be outlined in the enhanced CT localization image by referring to the tumor bioimaging of PET-CT.
(10) Patients receiving radiotherapy or radiochemotherapy should be given adequate monitoring and supportive treatment during treatment breaks.
2. Indications for radiotherapy for NSCLC: Radiotherapy can be used for radical treatment of early-stage NSCLC patients who cannot be treated surgically due to medical reasons, preoperative and postoperative adjuvant treatment for operable patients, local treatment for patients with locally advanced lesions that cannot be resected, and important palliative treatment for patients with advanced incurable disease.
SBRT is recommended for patients with stage I NSCLC who are medically unsuitable for surgery or who refuse surgery, and is an effective radical treatment.
The tolerated dose of radiotherapy for organ tissues such as spinal cord, esophagus, trachea, heart, chest wall and brachial plexus nerve should be carefully evaluated when planning SBRT.
For patients with surgically treated NSCLC with negative postoperative surgical margins and positive mediastinal lymph nodes (pN2 stage), in addition to the usual postoperative adjuvant chemotherapy, the addition of postoperative radiotherapy is recommended, with a suggested sequence of chemotherapy followed by sequential radiotherapy.
For pN2 stage tumors with positive margins, simultaneous postoperative chemotherapy is recommended if the patient is physically able to do so. For patients with positive margins, radiotherapy should be started as early as possible.
For patients with stage II-III NSCLC who cannot undergo surgery due to medical reasons, conformal radiotherapy combined with concurrent chemotherapy should be given if physically possible.
For patients with clinical promise, radiotherapy or concurrent radiotherapy should be given with a more conformal radiotherapy plan and more aggressive supportive therapy to minimize interruptions in treatment duration or reduction in treatment dose.
For patients with stage IV NSCLC with extensive metastases, some patients may receive radiation therapy to both primary and metastatic sites for palliative reduction.
SBRT may be considered for treatment of residual primary and/or oligometastases for potential curative effect when there is significant benefit from systemic therapy.
3. Indications for radiotherapy for SCLC: Combined radiotherapy and chemotherapy is the standard of care for limited-stage SCLC. Patients with limited stage SCLC are recommended to undergo synchronized chemoradiotherapy with initial treatment or 2 cycles of induction chemotherapy followed by synchronized chemoradiotherapy. If the patient cannot tolerate it, sequential chemoradiotherapy is also available.
If the disease permits, radiation therapy for limited-stage SCLC should be started as early as possible and can be considered in conjunction with the first or second cycle of chemotherapy. If the risk of lung injury due to radiation therapy is too high due to the size of the lesion, radiation therapy can be considered in conjunction with the 3rd cycle of chemotherapy.
For patients with extensive stage SCLC, the addition of chest radiotherapy after the control of distant metastases by chemotherapy can also improve tumor control rate and prolong survival.
4. Prophylactic brain irradiation: For patients with limited-stage SCLC, prophylactic brain irradiation is recommended after complete remission of intrathoracic lesions, and for patients in partial remission. If chemotherapy is effective in extensive SCLC, prophylactic brain irradiation can also reduce the risk of brain metastasis in SCLC.
The recommended time for prophylactic brain irradiation is approximately 3 weeks after all chemoradiotherapy, preceded by an enhanced brain MRI to rule out brain metastases, and a whole brain radiation dose of 25 Gy in 10 fractions over 2 weeks.
The decision of whole brain prophylactic irradiation for SCLC should be fully discussed between the doctor and the patient, and the pros and cons should be weighed according to the situation of each patient.
5. Palliative radiotherapy for patients with advanced lung cancer: The main purpose of palliative radiotherapy for patients with advanced lung cancer is to address local compression symptoms due to primary foci or metastases, pain due to bone metastases, and neurological symptoms due to brain metastases. For such patients, hypofractionated irradiation technique can be considered to make it more convenient for patients to receive treatment, and at the same time can relieve symptoms more rapidly.
6. Treatment effectiveness: The evaluation of the efficacy of radiation therapy is performed according to the WHO Response Evaluation Criteria for Solid Tumors (RECIST).
7. Protection: With conventional radiotherapy techniques, attention should be paid to the protection of the lung, heart, esophagus and spinal cord in order to avoid serious radiation damage to vital organs of the body. Acute radiation lung injury should refer to the grading standard for acute radiation injury of the International Collaborative Group on Radiation Therapy for Oncology.