What are the recommended follow-up guidelines for patients with lung cancer after lobectomy (surgical removal of a lung lobe) or sABR (stereotactic ablative radiation therapy)?

Follow-Up Guidelines for Lung Cancer After Lobectomy/SABR

For lung cancer patients treated with lobectomy or SABR, surveillance should include history, physical examination, and contrast-enhanced chest CT every 6 months for 2-3 years, then annually thereafter to detect recurrences and second primary tumors. 1

Standard Follow-Up Protocol

After Surgical Resection (Lobectomy)

• First 2-3 years:
  • Clinical visits every 6 months including:
    • History and physical examination
    • Contrast-enhanced chest CT at 12 and 24 months 1
• After 2-3 years:
  • Annual visits including:
    • History and physical examination
    • Chest CT scan to detect second primary tumors 1

After Stereotactic Ablative Radiotherapy (SABR)

• First 3 years:
  • Follow-up visits every 6 months including:
    • History and physical examination
    • Contrast-enhanced chest CT scans 1
  • More frequent monitoring may be needed in centers where SABR was recently implemented to benchmark treatment outcomes 1
• After 3 years:
  • Annual visits with chest CT 1

Special Considerations for SABR Follow-Up

• Radiation-induced lung changes on CT are common after SABR (54-79% early changes, 80-100% late changes) and can mimic recurrence 1
• When recurrence is suspected based on CT findings:
  • Selective use of FDG-PET is recommended 1
  • SUV max above 5 at ≥6 months post-SABR suggests high risk of local recurrence 1
  • Biopsy is strongly recommended before salvage therapy due to high false-positive rates on PET 1

Important Monitoring Targets

• Treatment-related complications:

  • After surgery: surgical site complications, pulmonary function
  • After SABR: radiation pneumonitis, chest wall pain, rib fracture 1, 2

• Disease recurrence patterns:

  • Local recurrence (highest risk in first 2 years)
  • Regional nodal recurrence
  • Distant metastases 1

• Second primary lung cancers:

  • Risk increases from 1% to 3% per patient per year during first 3 years 1
  • Risk does not diminish over time, necessitating long-term surveillance 1

What Not to Do

• Routine PET-CT surveillance is not recommended as it has not demonstrated survival benefit despite better sensitivity for recurrence detection 1
• Chest X-ray alone is insufficient for adequate surveillance

Additional Recommendations

• Smoking cessation should be offered to all patients as it leads to superior treatment outcomes 1
• The preferred approach combines behavioral techniques with pharmacotherapy 1
• Follow-up frequency can be tailored for patients not suitable for salvage treatment 1

The evidence supporting these recommendations is primarily based on prospective cohort studies (Level III evidence) with strong recommendations (Grade A/B) from the European Society for Medical Oncology (ESMO) guidelines 1.