Perioperative Management of Resectable Non-Small-Cell Lung Cancer

Initial Assessment and Staging

A complete history including smoking history, comorbidities, weight loss, performance status, and physical examination should be taken, according to the European Society for Medical Oncology, as part of the initial assessment for patients with suspected non-small-cell lung cancer 1, 2
Contrast-enhanced CT scan of chest and upper abdomen is recommended for initial imaging, as suggested by the European Society for Medical Oncology, to assess the extent of disease 1, 2
PET-CT scan is recommended for mediastinal lymph nodes and distant metastasis assessment, as per the European Society for Medical Oncology guidelines, to determine the stage of the disease 1, 2
Brain imaging (preferably MRI) is suggested for patients eligible for loco-regional treatment, according to the European Society for Medical Oncology, to rule out brain metastases 1, 2
Pathological confirmation of suspect nodes via needle aspiration under endobronchial/endoscopic ultrasound guidance is recommended, as per the European Society for Medical Oncology, for accurate diagnosis 3

Anatomical resection (lobectomy) is preferred over lesser resections, as recommended by the European Society for Medical Oncology, for patients with stage I non-small-cell lung cancer 3
For patients unfit for surgery, stereotactic ablative radiotherapy (SABR) is the non-surgical treatment of choice, according to the European Society for Medical Oncology, for stage I non-small-cell lung cancer 3, 4
Sub-lobar resection may be considered for pure ground-glass opacity lesions or adenocarcinomas in situ, as suggested by the European Society for Medical Oncology, for patients with stage I non-small-cell lung cancer 3

Definitive concurrent chemotherapy and radiotherapy is the preferred treatment, as recommended by the European Society for Medical Oncology, for patients with locally advanced stage III non-small-cell lung cancer 4, 5
Cisplatin-based regimens (e.g., cisplatin-etoposide or cisplatin-vinorelbine) delivered concurrently with radiotherapy are recommended, according to the European Society for Medical Oncology, for patients with locally advanced stage III non-small-cell lung cancer 4

Two-drug, platinum-based chemotherapy combined with vinorelbine, gemcitabine, or a taxane is recommended, as per the European Society for Medical Oncology, for patients with stage IV non-small-cell lung cancer and good performance status 5, 6
For non-squamous tumors, cisplatin should be the treatment of choice, according to the European Society for Medical Oncology, for patients with stage IV non-small-cell lung cancer 7
Pemetrexed is preferred to gemcitabine in patients with non-squamous tumors, as suggested by the European Society for Medical Oncology, for patients with stage IV non-small-cell lung cancer 7

First-line treatment with a TKI (erlotinib or gefitinib) should be prescribed to patients with tumors bearing an activating EGFR mutation, as recommended by the European Society for Medical Oncology, for patients with non-small-cell lung cancer 7

For patients with PS 2, single-agent chemotherapy with gemcitabine, vinorelbine, or taxanes represents an option, though platinum-based combinations may also be considered, according to the European Society for Medical Oncology, for patients with non-small-cell lung cancer 7, 2
Poor PS (3-4) patients should be offered best supportive care in the absence of tumors with activating EGFR mutations, as suggested by the European Society for Medical Oncology, for patients with non-small-cell lung cancer 7, 2

Follow-up visits every 3-6 months during the first 2-3 years, then annually thereafter, are recommended, as per the European Society for Medical Oncology, for patients with non-small-cell lung cancer 4
History and physical examination, chest CT, and to a lesser extent, chest X-ray are appropriate follow-up tools, according to the European Society for Medical Oncology, for patients with non-small-cell lung cancer 4
Smoking cessation should be offered to all patients, as this leads to superior treatment outcomes, as recommended by the European Society for Medical Oncology, for patients with non-small-cell lung cancer 4

Careful assessment of cardiac and pulmonary function is necessary before considering surgical resection to estimate risk of operative morbidity, as suggested by the European Society for Medical Oncology, for patients with non-small-cell lung cancer 3