NSCLC

NCCN Guidelines

Treatment
Stage Tests needed
Initial Adjuvant
All stages Medical history and physical exam

Complete blood count and chemistry
profile

CT scan

Laboratory tests of fluid or tissue
Stage I PET/CT scan Lung tumor and lymph node surgery After surgery:

Brain MRI X surgery: radiation therapy Stage IA:
No cancer in the margins: start survivorship
Bronchoscopy care plan
Cancer in the margins: another surgery
TTNA (Trans-thoracic needle (preferred) or radiation therapy
aspiration); Mediatinoscopy; EBUS-
TBNA (endobronchial ultrasound Stage IB:
guided trans-bronchial needle No cancer in the margins: start survivorship
aspiration); EUS-FNA (endoscopic care plan or chemotherapy
ultrasound guided fine needle Cancer in the margins: another surgery
aspiration); Thoracentesis; (preferred) + chemotherapy or radiation
Pericardiocentesis; Thoracoscopy therapy + chemotherapy

Lung function tests if surgery may be After radiation therapy:
an option
Stage IA: start survivorship care plan

Stage IB: consider chemotherapy


Stage II PET/CT scan No invasion by tumor: After surgery:

Brain MRI Lung tumor or lymph node surgery Stage IIA (with scores of T2B, N0, M0):
No cancer in the margins: start survivorship
MRI of spine and thoracic inlet (if X surgery: radiation (N0) or chemoradiation care plan or chemotherapy
superior sulcus tumor) (N1) therapy
Cancer in the margins: : another surgery
Bronchoscopy Other invasive tumors: (preferred) + chemotherapy) or
Surgery: surgery, preoperative chemoradiation
TTNA (Trans-thoracic needle chemoradiation + surgery or preoperative
aspiration); Mediatinoscopy; EBUS- chemotherapy + surgery Stage IIA or IIB with scores of
TBNA (endobronchial ultrasound T1a, N1, M0
guided trans-bronchial needle X surgery: chemoradiation T1b, N1, M0
aspiration); EUS-FNA (endoscopic T2a, N1, M0
ultrasound guided fine needle T2b, N1, M0
aspiration); Thoracentesis; T3, N0, M0:
Pericardiocentesis; Thoracoscopy
Lung function tests if surgery may be No cancer in the margins: chemotherapy
an option
Cancer in the margins (microscope):
another surgery + chemotherapy or
chemoradiation

Cancer in the margins (naked eye): another
surgery + chemotherapy or chemoradiation

Stage II with N0 disease: chemotherapy

Superior sulcus tumors:
Treatment:
Preoperative chemoradiation, surgery and
adjuvant chemotherapy (if for surgery)

X surgery: chemoradiation

Other invasive tumors: after surgery:

If there is no preoperative treatment and
No cancer in the margins: chemotherapy
Cancer in the margins (microscope):
another surgery + chemotherapy, or
chemoradiation
Cancer in the margins (naked eye): another
surgery + chemotherapy, or
chemoradiation

If there is a preoperative treatment and:
No cancer in the margins: start survivorship
care plan
Cancer in margins: another surgery
Stage III PET/CT scan No invasion by tumor: N0 or N1: No invasion by tumor: N0 or N1:
Surgery: lung tumor and lymph node After surgery:
Brain MRI surgery No cancer in the margins: chemotherapy
X surgery: chemoradiation Cancer in the margins: chemoradiation
MRI of spine and thoracic inlet (if
superior sulcus tumor) No invasion by tumor: N2 or N3 disease: After induction treatment for N2 disease:
Stage IIIA (N2): No cancer growth: surgery followed by
Bronchoscopy (if Stage IIIA) X surgery: chemoradiation radiation therapy + chemotherapy
Surgery: induction chemotherapy + Local growth only: radiation therapy +
TTNA (Trans-thoracic needle radiation therapy chemotherapy
aspiration); Mediatinoscopy; EBUS-
TBNA (endobronchial ultrasound Stage IIIB (N2 or N3): After surgery of upstaged N2 disease:
guided trans-bronchial needle X surgery: chemoradiation chemoradiation
aspiration); EUS-FNA (endoscopic
ultrasound guided fine needle If superior sulcus tumor: chemoradiation Other invasive tumors: after surgery:
aspiration); Thoracentesis; No preoperative treatment and:
Pericardiocentesis; Thoracoscopy Treatment after chemoradiation: surgery: No cancer in the margins: chemotherapy
surgery followed by more chemotherapy
 (center-Stage IIIA); (center, above Tumor is too big, no surgery: complete Cancer in the margins: another surgery +
the collarbone or neck-Stage IIIB) radiation therapy followed by more chemotherapy or chemoradiation
chemotherapy
Lung function tests if surgery may be X surgery: start survivorship care plan Preoperative treatment:
an option No cancer in the margins: start survivorship
Other invasive tumors: care plan
Surgery: surgery (preferred) , preoperative Cancer in the margins: another surgery
chemoradiation + surgery or peroperative
chemotherapy + surgery
X surgery: chemoradiation

Stage IV PET/CT scan Overactive EGFR mutation:
First line: Any: Erlotinib, Afatinib, Gefitinib
Brain MRI
Second or third line: stay on first line
Bronchoscopy (only one distant site) targeted therapy + local treatment, switch
to osimertinib or start treatment of
Histologic Typing, biomarker testing: histological type
EGFR (epidermal growth factor
receptor), ALK (anaplastic lymphoma ALK gene rearrangement:
kinase) First line: Crizotinib

Testing of marker: PD-L1 (other Second and third line:
treatments haven’t worked) Stay on crizotinib + local treatment
Or start treatment of histological type

Unknown or no EGFR, ALK, or ROS1
biomarkers – adrenocarcinoma, large cell,
unknown types
First line: doublet chemotherapy or
Bevacizumab + chemotherapy,
chemotherapy or supportive care

Maintenance treatment:
 Continuation: bevacizumab, pemetrexed,
bevacizumab + pemetrexed, or gemcitabine
Switch: erlotinib or pemetrexed
Either type: observation

Chemotherapy regimens for Neoadjuvant and Adjuvant Therapy: Stage I and II

Day Drugs Frequency

1 Cisplatin 50 mg/m + Vinorelbine 25 mg/m2
2

8 Cisplatin 50 mg/m2 + Vinorelbine 25 mg/m2

Every 28 days for 4 cycles
15 Vinorelbine 25 mg/m2
22 Vinorelbine 25 mg/m2

1 Cisplatin 100 mg/m2 + Vinorelbine 30 mg/m2
8 Vinorelbine 30 mg/m2
Every 28 days for 4 cycles
15 Vinorelbine 30 mg/m2
22 Vinorelbine 30 mg/m2

1 Cisplatin 75-80 mg/m2 + Vinorelbine 25-30 mg/m2
Every 21 days for 4 cycles
8 Vinorelbine 25-30 mg/m2

1 Cisplatin 100 mg/m2 + Etoposide 100 mg/m2
2 Etoposide 100 mg/m2 Every 28 days for 4 cycles
3 Etoposide 100 mg/m2

1 Cisplatin 80 mg/m2 + Vinblastine 4 mg/m2
8 Vinblastine 4 mg/m2
15 Vinblastine 4 mg/m2
22 Cisplatin 80 mg/m2 + Vinblastine 4 mg/m2 Every 21 days for 4 cycles
29 Vinblastine 4 mg/m2 then every 2 weeks after day 43
43 Cisplatin 80 mg/m2
64 Cisplatin 80 mg/m2

 1 Cisplatin 75 mg/m2 + Gemcitabine 1250 mg/m2
Every 21 days for 4 cycles
8 Gemcitabine 1250 mg/m2

2 2
1 Cisplatin 75 mg/m + Docetaxel 75 mg/m Every 21 days for 4 cycles

2 2
Cisplatin 75 mg/m + Pemetrexed 500 mg/m (for
1 Every 21 days for 4 cycles
nonsquamous; without specific histology subtype)

Chemotherapy regimens for patients with comorbidities or patients not able to tolerate Cisplatin
1 Paclitaxel 200 mg/m2 + Carboplatin AUC 6 IV Every 21 days

Chemotherapy regimens used with Radiation therapy: Stage IIIa and IIIb

Day Drugs RT/Frequency

Concurrent chemotherapy/RT regimens
1 Cisplatin 50 mg/m2
1-5 Etoposide 50 mg/m2
8 Cisplatin 50 mg/m2
Concurrent thoracic RT
29 Cisplatin 50 mg/m2
29-33 Etoposide 50 mg/m2
36 Cisplatin 50 mg/m2

1 Cisplatin 100 mg/m2
29 Cisplatin 100 mg/m2 Concurrent thoracic RT
Weekly for 5 weeks Vinblastine 5 mg/m2

Every 21 days for 4 cycles
1 Carboplatin AUC 5 IV + Pemetrexed 500 mg/m2
Concurrent thoracic RT

Every 21 days for 3 cycles
1 Cisplatin 75 mg/m2 + Pemetrexed 500 mg/m2
Concurrent thoracic RT

Sequential chemotherapy/ RT regimens
Cisplatin 100 mg/m2 + Vinblastine 5
1
mg/m2/weekly
8 Vinblastine 5 mg/m2/weekly
15 Vinblastine 5 mg/m2/weekly Followed by RT
22 Vinblastine 5 mg/m2/weekly
Cisplatin 100 mg/m2 + Vinblastine 5
29
mg/m2/weekly

1 Paclitaxel 200 mg/m2 over 3 hours Every 3 weeks for 2 cycles
Carboplatin AUC 6 over 60 minutes followed by thoracic RT

Concurrent chemotherapy/RT followed by chemotherapy
Paclitaxel 45-50 mg/m2 weekly
Carboplatin AUC 2, concurrent thoracic RT
Followed by 2 cycles of Paclitaxel 200 mg/m2

and Carboplatin AUC 6

1 Cisplatin 50 mg/m2
1-5 Etoposide 50 mg/m2
8 Cisplatin 50 mg/m2
29 Cisplatin 50 mg/m2
29-33 Etoposide 50 mg/m2
36 Cisplatin 50 mg/m2
Concurrent thoracic RT followed by Cisplatin 50
mg/m2 and Etoposide 50 mg/m2 x 2 additional
cycles

SCLC NCCN Guidelines