Non Small Cell Lung Ca (NSCLC)

Non Small Cell Lung CA (NSCLC)
1. Staging and Inx
- CT chest and upper adrenals
- pulmonary function tests
- bronchoscopy
- mediastinoscopy
- PET CT
- brain MRI (Stage II onwards)
- MRI of spine + thoracic inlet for superior sulcus lesions abutting spine/subclavian vessels (Stage III)
- pathologic confirmation of N3 disease in Stage IIIB: mediastinoscopy/supraclavicular lymph node biopsy, thoracoscopy, needle biopsy, EUS/EBUS biopsy
- pleural/pericardial effusion: thoracocentesis/pericardiocentesis if indicated +/- thoracoscopy if thoracentesis indeterminate

2. JH guidelines
a. Gem/Carbo
b. Alimta
c. Docetaxel
d. Vinorelbine/cisplatin

3. Adjuvant regimens
a. cisplatin 50mg/m2 D1&8, vinorelbine 25mg/m2 D1/8/15/22 every 28 days for 4 cycles
b. cisplatin 100mg/m2 D1, vinorelbine 30mg/m2 D1/8/15/22 every 28 days for 4 cycles
c. cisplatin 75-80mg/m2 D1; vinorelbine 25-30mg/m2 D1+8 every 21 days for 4 cycles
d. cisplatin 100mg/m2 D1, etoposide 100mg/m2 D1-3 every 28 days for 4 cycles
e. cisplatin 80mg/m2 on D1/22/43/62, vinblastine 4mg/m2 D1/8/15/22 then every 2 wks after day 43 every 21 days for 4 cycles
f. cisplatin 80mg/m2 D1, gemcitabine 1000mg/m2 on D1&8
g. cisplatin 75mg/m2, docetaxel 75mg/m2 every 21 days
h. comorbidities/unable to tolerate cisplatin: paclitaxel 200mg/m2 D1, carboplatin AUC6 D1

4. Concurrent chemoRT
a. cisplatin 50mg/m2 D1/8/29/36, etoposide 50mg/m2 D1-5, 29-33, concurrent thoracic RT (total dose 61 Gy)
b. cisplatin 100mg/m2 D1 & 29, vinblastine 5mg/m2/weekly x 5, concurrent thoracic RT 60Gy (preferred)
c. paclitaxel 45-50mg/m2 weekly over 1 hour, caarboplatin AUC = 2mg/mL/min over 30min weekly, concurrent thoracic RT 63 Gy/7wks/34 fractions

5. Sequential chemoRT
a. cisplatin 100mg/m2 on D1 & 29, vinblastine 5mg/m2/weekly on D1/8/15/22/29, followed by RT with 60Gy in 30 fractions beginning on day 50
b. paclitaxel 200mg/m2 every 3 weeks over 3 hours, 2 cycles and carboplatin AUC 6, 2 cycles followed by thoracic RT 63 Gy beginning day 42

6. Concurrent chemoRT
a. cisplatin 50mg/m2 D1/8/29/36, etoposide 50mg/m2 days 1-5 and 29-33, concurrent thoracic RT (total dose, 61 Gy), docetaxel started 4-6 wk after chemoradiation at initial dose of 75mg/m2 x 3 doses every 3 weeks
b. paclitaxel 45-50mg/m2 weekly, carboplatin AUC2, concurrent thoracic RT 63Gy, followed by 2 cycles of paclitaxel 200mg/m2 and carboplatin AUC6

7. Therapy for recurrence and mets
a. PS 0-1: chemotherapy +/- bevaxizumab, cisplatin/pemetrexed, cetuximab/vinorelbine/cisplatin
b. PS 2: cetuximab/vinorelbine/cisplatin or chemotherapy
(tumour response evaluation – cycle 2 – tumour response/SD: 4-6 cycles total or pemetrexed for non-squamous – progression)

8. Progressive disease
a. Second line: docetaxel/pemetrexed/erlotinib
b. Third line: Erlotinib

9. IHC markers
- TTF-1= primary lung carcinoma
- pulmonary adenocarcinoma: CK7+, CK20-
- CDX-2: mets GI malignancies
- PSA, prostatic acid phosphatase
- gross cystic disease fluid protein 15: adenocarcinoma of breasy origin
- chromogranin, synaptophysin: neuroendocrine tumour of lung i.e. carcinoid
- adenocarcinoma: CEA, B72.3, Ber-EP4, MOC31
- mesothelioma: WT-1, calretinin, D2-40, cytokeratin 5/6
- nonmucinous BAC: TTF1, CK7+, CK20-
- aberrant mucinous BAC: CK20/7+, TTF1 negative
- K-ras mutations: intrinsic TKI resistance