This is the current release of the guideline.

This guideline updates a previous version: Detterbeck FC, Jones DR, Kernstine KH, Naunheim KS. Presentations of lung cancer with special treatment considerations. Chest 2003 Jan;123(1 Suppl):244S-58S.

Definitions for the strength of evidence and recommendation grades (1A-2C) follow the recommendations.

Pancoast Tumors

Definition: Lung cancers that occur in the apex of the chest and invade apical chest wall structures are called superior sulcus tumors, or Pancoast tumors.

1. In patients with a Pancoast tumor, it is recommended that a tissue diagnosis be obtained before initiation of therapy. Grade of recommendation, 1C
2. In patients who have a Pancoast tumor and are being considered for curative intent surgical resection, an magnetic resonance imaging (MRI), of the thoracic inlet and brachial plexus is recommended to rule out tumor invasion of unresectable vascular structures or the extradural space. Grade of recommendation, 1C
3. In patients with a Pancoast tumor involving the subclavian vessels or vertebral column, it is suggested that resection be undertaken only at a specialized center. Grade of recommendation, 2C
4. In patients who have a Pancoast tumor and are being considered for curative resection, invasive mediastinal staging and extrathoracic imaging (head computed tomography [CT]/MRI plus either whole-body positron emission tomography [PET] or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
5. In patients with a potentially resectable, nonmetastatic Pancoast tumor (and good performance status), it is recommended that preoperative concurrent chemoradiotherapy be given before resection. Grade of recommendation, 1B
6. In patients who undergo resection of a Pancoast tumor, it is recommended that every effort be made to achieve a complete resection. Grade of recommendation, 1A
7. It is recommended that resection of a Pancoast tumor consist of a lobectomy (instead of a nonanatomic wedge resection) as well as the involved chest wall structures. Grade of recommendation, 1C
8. In patients with either a completely or incompletely resected Pancoast tumor, postoperative radiotherapy is not recommended because of lack of demonstrated survival benefit. Grade of recommendation, 2C
9. In patients who have an unresectable but nonmetastatic Pancoast tumor and good performance status, definitive concurrent chemotherapy and radiotherapy is recommended. Grade of recommendation, 1C
10. In patients who have Pancoast tumors and are not candidates for curative intent treatment, palliative radiotherapy is recommended. Grade of recommendation, 1B

T4N0, 1M0 Tumors

11. In patients who have a clinical T4N0,1M0 non-small cell lung cancer (NSCLC) and are being considered for curative resection, it is recommended that invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) be undertaken. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
12. In patients with a T4N0, 1M0 NSCLC, it is recommended that resection be undertaken only at a specialized center. Grade of recommendation, 1C

Satellite Nodules and Multiple Primary Lung Cancers (MPLCs)

Table: Definition of Satellite Nodules, MPLCs and Pulmonary Metastases

Synchronous Nodules of Cancer in the Same Lobe

13. In patients with suspected or proven lung cancer and a satellite nodule within the same lobe, it is recommended that no further diagnostic workup of a satellite nodule be undertaken. Grade of recommendation, 1B
14. In patients with a satellite lesion within the same lobe as a suspected or proven primary lung cancer, evaluation of extrathoracic metastases and confirmation of the mediastinal node status should be performed as dictated by the primary lung cancer alone and not modified because of the presence of the satellite lesion. Grade of recommendation, 1C
15. In patients with NSCLC and a satellite focus of cancer within the same lobe (and no mediastinal or distant metastases), resection via a lobectomy is the recommended treatment. Grade of recommendation, 1B

Synchronous Second Primary Lung Cancer

Definition: A synchronous second focus of lung cancer in a different lobe is easily defined as a second primary lung cancer when the two sites are of different histologic types. One proposed requirement for classification as synchronous second primary lung cancers is that there be no mediastinal node involvement and no sites of distant metastases when the two cancers are of the same histologic type.

16. In patients who have two synchronous primary NSCLCs and are being considered for curative surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
17. In patients suspected of having two synchronous primary NSCLCs, a thorough search for an extrathoracic primary cancer is recommended to rule out the possibility that both of the lung lesions represent metastases. Grade of recommendation, 1C
18. In patients (not suspected of having a second focus of cancer) who are found intraoperatively to have a second cancer in a different lobe, resection of each lesion is recommended, provided that the patient has adequate pulmonary reserve and there is no N2 nodal involvement. Grade of recommendation, 1C

Metachronous Second Primary Lung Cancer

Definition: A metachronous second focus of lung cancer is easily defined as a second primary lung cancer when the two tumors are of different histologic types. When they are of the same type, the second focus can be reliably defined as a second primary when there is no evidence of systemic metastases and at least a 4-year interval between the two.

19. In patients who have a metachronous NSCLC and are being considered for curative surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C

Isolated Brain Metastasis

20. In patients who have an isolated brain metastasis from NSCLC and are being considered for curative resection of a stage I or II lung primary tumor, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
21. In patients with no other sites of metastases and a synchronous resectable N0,1 primary NSCLC, resection or radiosurgical ablation of an isolated brain metastasis is recommended (as well as resection of the primary tumor). Grade of recommendation, 1C
22. In patients with no other sites of metastases and a previously completely resected primary NSCLC (metachronous presentation), resection or radiosurgical ablation of an isolated brain metastasis are recommended. Grade of recommendation, 1B
23. In patients who have undergone a curative resection of an isolated brain metastasis, adjuvant whole-brain radiotherapy (WBRT) is suggested, although there are conflicting and insufficient data regarding a benefit with respect to survival or the rate of recurrent brain metastases. Grade of recommendation, 2B
24. In patients who have undergone curative resections of both the isolated brain metastasis and the primary tumor, adjuvant chemotherapy may be considered. Grade of recommendation, 2C

Isolated Adrenal Metastasis

25. In patients who have an isolated adrenal metastasis from NSCLC and are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
26. In patients with a synchronous resectable N0,1 primary NSCLC and no other sites of metastases, resection of the primary tumor and an isolated adrenal metastasis is recommended. Grade of recommendation, 1C
27. In patients with no other sites of metastases and a previously completely resected primary NSCLC (metachronous presentation), resection of an isolated adrenal metastasis is the recommended treatment when the disease-free interval is > 6 months and complete resection of the primary NSCLC has been achieved. Grade of recommendation, 1C

Tumors That Invade the Chest Wall

28. In patients who have an NSCLC invading the chest wall and are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection, and definitive chemoradiotherapy is recommended for these patients. Grade of recommendation, 2C
29. At the time of resection of a tumor invading the chest wall, we recommend that every effort be made to achieve a complete resection. Grade of recommendation, 1B

Definitions:

Quality of Evidence Scale

High - Randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies*

Moderate - RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies*

Low or very low - Observational studies or case series

*Although the determination of magnitude of the effect based on observational studies is often a matter of judgment, the guideline developers offer the following suggested rule to assist this decision: a large effect would be a relative risk > 2 (risk ratio < 0.5) [which would justify moving from weak to moderate], and a very large effect is a relative risk > 5 (risk ratio < 0.2) [which would justify moving from weak to strong]. There is some theoretical justification in the statistical literature for these thresholds (the magnitude of effect that is unlikely or very unlikely to be due to residual confounding after adjusted analysis). However, once the decision is made, authors should be explicit in justifying their decisions.

Grade of Recommendations Scale

Relationship of Strength of the Supporting Evidence to the Balance of Benefits to Risks and Burdens

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2003 Jan (revised 2007 Sep)

American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians (ACCP) Expert Panel on Lung Cancer Guidelines

Primary Authors: K. Robert Shen, MD; Bryan F. Meyers, MD, FCCP; James M. Larner, MD; David R. Jones, MD, FCCP

American Association for Bronchology - Disease Specific Society
American Association for Thoracic Surgery - Medical Specialty Society
American College of Surgeons - Medical Specialty Society
American Society for Therapeutic Radiology and Oncology
Asian Pacific Society of Respirology - Disease Specific Society
Oncology Nursing Society - Professional Association
Society of Thoracic Surgeons - Medical Specialty Society
World Association of Bronchology - Disease Specific Society

This is the current release of the guideline.

This guideline updates a previous version: Detterbeck FC, Jones DR, Kernstine KH, Naunheim KS. Presentations of lung cancer with special treatment considerations. Chest 2003 Jan;123(1 Suppl):244S-58S.

This NGC summary was completed by ECRI on September 3, 2003. The information was verified by the guideline developer on October 1, 2003. This NGC summary was updated by ECRI Institute on November 28, 2007. The updated information was verified by the guideline developer on December 21, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.