Chest
Volume 132, Issue 3, Supplement, September 2007, Pages 234S-242S
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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Treatment of Non-small Cell Lung Cancer Stage I and Stage II: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

https://doi.org/10.1378/chest.07-1378Get rights and content

Background

The surgical treatment of stage I and II non-small cell lung cancer (NSCLC) continues to evolve in the areas of intraoperative lymph node staging (specifically the issue of lymph node dissection vs sampling), the role of sublobar resections instead of lobectomy for treatment of smaller tumors, and the use of video-assisted techniques to perform anatomic lobectomy. Adjuvant therapy (both chemotherapy and radiation therapy) and the use of larger fractions of radiotherapy delivered to a smaller area for nonoperative treatment of early stage NSCLC have shown promising results.

Methods

The panel selected the following areas for review based on clinical relevance and the amount and quality of data available for analysis: surgical approaches to resecting early stage NSCLC, methods of lymph node staging at the time of surgical resection, adjuvant chemotherapy in the treatment of early stage NSCLC, and the use of radiation therapy for primary treatment of early stage NSCLC as well as in the adjuvant setting. Recommendations by the multidisciplinary writing committee were based on literature review using established methods.

Results and conclusions

Surgical resection remains the treatment of choice for stage I and II NSCLC, although surgical methods continue to evolve. Adjuvant chemotherapy for patients with stage II, but not stage I, NSCLC is well established. Radiotherapy remains an important treatment for either cases of early stage NSCLC that are medically inoperable or patients who refuse surgery.

Section snippets

Materials and Methods

The Duke Evidence-based Clinical Practice Center searched the literature for studies regarding the issues of lymph node staging vs dissection, surgical treatment of early stage lung cancer, the use of adjuvant chemotherapy in the treatment of early stage lung cancer, and the use of radiation therapy for primary treatment of early stage lung cancer as well as in the adjuvant setting. The Duke Evidence-based Practice Center found insufficient data were available regarding ablative therapies such

Surgical Treatment of Stage I and II NSCLC

There are no randomized clinical trials comparing surgery alone to radiation therapy alone or chemotherapy alone in the treatment of early stage (stage I and II) NSCLC. The concept that surgery offers the best hope of a cure is based on retrospective data (“clinical experience”) as reported in the literature. Based on large series of resected stage I and stage II NSCLC, the prognoses for stage IA, IB, IIA and IIB NSCLC, expressed in terms of 5-year survival rates, are commonly accepted to be 60

Recommendations

1. For patients with clinical stage I and II NSCLC and no medical contraindication to operative intervention, surgical resection is recommended. Grade of recommendation, 1A

2. For patients with clinical stage I and II NSCLC, it is recommended that they be evaluated by a thoracic surgical oncologist with a prominent part of his/her practice focused on lung cancer, even if patients are being considered for nonsurgical therapies such as percutaneous ablation or stereotactic body radiation therapy

Recommendations

3. In patients with stage I and II NSCLC who are medically fit for conventional surgical resection, lobectomy or greater resection are recommended rather than sublobar resections (wedge or segmentectomy). Grade of recommendation, 1A

4. In patients with stage I NSCLC who may tolerate operative intervention but not a lobar or greater lung resection because of comorbid disease or decreased pulmonary function, sublobar resection is recommended over nonsurgical interventions. Grade of recommendation,

Recommendation

5. In patients with stage I NSCLC who are considered appropriate candidates for thoracoscopic anatomic lung resection (lobectomy or segmentectomy), the use of VATS by surgeons experienced in these techniques is an acceptable alternative to open thoracotomy. Grade of recommendation, 1B

The extent of lymph node evaluation at the time of surgical resection of stage I and stage II NSCLC continues to be a matter of debate. Clinical practice varies from visual inspection alone to radical

Recommendation

6. In patients undergoing resection for stage I and II NSCLC, it is recommended that intraoperative systematic mediastinal lymph node sampling or dissection be performed for accurate pathologic staging. Grade of recommendation, 1B

No randomized trials comparing sleeve lobectomy to pneumonectomy have been reported in the literature. The data available consist of retrospective reviews of the outcomes in patients treated with sleeve lobectomy compared with matched or unmatched control subjects

Recommendations

7. For patients with centrally or locally advanced NSCLC in whom a complete resection can be achieved with either technique, sleeve lobectomy is recommended over pneumonectomy. Grade of recommendation, 1B

8. For patients with N1 lymph node metastases (stage II NSCLC) in whom a complete resection can be achieved with either technique, sleeve lobectomy is recommended over pneumonectomy. Grade of recommendation, 1B

Recommendations

9. For patients with completely resected stage IA NSCLC, the use of adjuvant chemotherapy is not recommended for routine use outside the setting of a clinical trial. Grade of recommendation, 1A

10. For patients with completely resected stage IB NSCLC, the use of adjuvant chemotherapy is not recommended for routine use. Grade of recommendation, 1B

11. For patients with completely resected stage II NSCLC and good performance status, the use of platinum-based adjuvant chemotherapy is recommended.

Recommendation

12. For patients with stage I or II NSCLC who are not candidates for surgery (“medically inoperable”) or who refuse surgery, curative intent fractionated radiotherapy is recommended. Grade of recommendation, 1B

Recommendations

13. For patients with completely resected stage IA or IB NSCLC, postoperative radiotherapy is associated with a decreased survival and is not recommended. Grade of recommendation, 1B

14. For patients with completely resected stage II NSCLC, postoperative radiotherapy decreases local recurrence but a survival benefit has not been clearly shown; therefore, postoperative radiotherapy is not recommended. Grade of recommendation, 1B

Conclusions

Although there are no clinical trials comparing surgical resection to other forms of therapy for treating stage I and II lung cancer, extensive clinical experience indicates that the best chance of cure for these tumors comes with surgical resection. Operative outcomes have been found to be better with thoracic surgeons performing lung resection than general surgeons. In patients who can tolerate conventional surgical resection, lobectomy is preferred over sublobar resections. In patients who

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    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml)

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