What are the treatment options for lung cancer?

Treatment of Lung Cancer

Surgical resection with ipsilateral mediastinal lymph node dissection is the standard treatment for early-stage non-small cell lung cancer (NSCLC), while platinum-based chemotherapy combined with immunotherapy or targeted therapy forms the backbone of treatment for advanced disease. 1, 2

Non-Small Cell Lung Cancer (NSCLC)

Early-Stage Disease (Stage I-II)

Surgical Management:

• Lobectomy or pneumonectomy with lymph node dissection is the foundation of curative treatment for stage I (T1-2N0) and stage II (T1-2N1, T3N0) NSCLC 1, 3
• Pneumonectomy carries higher surgical risk but provides better oncologic outcomes compared to lesser resections 1
• Conservative resection (segmentectomy or wedge resection) should be reserved exclusively for elderly patients or those with significant respiratory dysfunction 1, 3
• Preoperative evaluation must include VO2 max determination, with an operability threshold of approximately 15 ml/kg/min 1, 3
• Severe vascular disease must be treated before proceeding with lung surgery 1, 3

Important Caveat: Age alone is not an absolute contraindication to surgery in carefully selected patients 1, 3

Postoperative Management:

• Adjuvant radiotherapy is NOT indicated for completely resected stage I and II N0-N1 tumors (Level A evidence) 4, 1, 3
• Adjuvant chemotherapy efficacy remains unproven and should only be administered within randomized clinical trials 4, 3

Radiotherapy as Alternative:

• For patients with medical contraindications to surgery or who refuse surgery, curative external-beam radiotherapy with doses exceeding 60 Gy is the alternative treatment (Level C evidence) 4
• For peripheral stage IA tumors, radiotherapy can be directed to the primary tumor volume alone without including the mediastinum 4

Locally Advanced Disease (Stage IIIA)

Resectable Stage IIIA:

• Complete surgical excision with extensive lymph node dissection is an option for carefully selected patients 1, 3
• Neoadjuvant chemotherapy containing cisplatin plus at least one other drug can be administered to stage IB, II, and IIIA tumors (Level C evidence) 4, 1
• Multidisciplinary consultation is the only standard in this rapidly evolving treatment area 4, 3

Unresectable Stage IIIA:

• Short-term induction chemotherapy with cisplatin plus at least one other drug, combined with external-beam radiotherapy at optimal dose, is the standard treatment 1, 3
• Concurrent chemoradiotherapy is preferred for patients with good performance status 3

Critical Pitfall: Do not routinely administer chemotherapy or radiochemotherapy when complete tumor excision is uncertain—these patients should be enrolled in randomized clinical trials 4

Resectable NSCLC (Tumors ≥4 cm or Node Positive)

• Platinum-containing chemotherapy combined with pembrolizumab as neoadjuvant treatment, followed by pembrolizumab monotherapy as adjuvant treatment after surgery is FDA-approved 2
• For Stage IB (T2a ≥4 cm), II, or IIIA NSCLC, pembrolizumab monotherapy is approved as adjuvant treatment following resection and platinum-based chemotherapy 2

Advanced/Metastatic Disease (Stage IIIB-IV)

First-Line Treatment:

For nonsquamous NSCLC without EGFR or ALK alterations:

• Pembrolizumab combined with pemetrexed and platinum chemotherapy is FDA-approved as first-line treatment 2

For squamous NSCLC:

• Pembrolizumab combined with carboplatin and either paclitaxel or paclitaxel protein-bound is FDA-approved as first-line treatment 2

For PD-L1 expressing tumors (TPS ≥1%) without EGFR or ALK alterations:

• Pembrolizumab monotherapy is FDA-approved for first-line treatment of stage III (not candidates for surgery/chemoradiation) or metastatic disease 2

For patients with disease progression after platinum-based chemotherapy:

• Pembrolizumab monotherapy for tumors expressing PD-L1 (TPS ≥1%) 2
• Patients with EGFR or ALK alterations must have disease progression on FDA-approved targeted therapy before receiving pembrolizumab 2

Traditional Chemotherapy:

• Platinum-based doublet chemotherapy (combined with vinorelbine, gemcitabine, or taxane) prolongs survival, improves quality of life, and controls symptoms in patients with good performance status 1

Oligometastatic Disease:

• For solitary brain metastasis, surgical resection and/or radiotherapy can be beneficial, with 5-year survival rates of approximately 10-20% 1
• For solitary adrenal metastasis with resectable lung tumor, surgical resection has resulted in long-term survival in select cases 1

Malignant Pleural Mesothelioma

• Pembrolizumab combined with pemetrexed and platinum chemotherapy is FDA-approved as first-line treatment for unresectable advanced or metastatic disease 2

Follow-Up Surveillance

Post-Surgical Monitoring:

• Spiral chest CT with or without contrast every 6-12 months for 2 years, then annually 1, 3

During Chemotherapy:

• Assess response after 2-3 cycles by repeating initial radiographic tests 1, 3
• Measure and report response using RECIST 1.1 criteria 1, 3

Radiographic Stability:

• Stability for 2 years provides strong presumptive evidence of benignity, as malignant solid nodules typically double in volume in less than 400 days 5

Multidisciplinary Care

Essential Team Composition:

• Early involvement of pulmonary medicine, thoracic surgery, medical oncology, radiation oncology, palliative care, radiology, and pathology expedites evaluation and reduces unnecessary testing 3
• Multidisciplinary consultation is the standard of care in this rapidly changing field 4, 1, 3