1. The document outlines guidelines for evaluating and treating early-stage and locally advanced non-small cell lung cancer (NSCLC). 2. For early-stage NSCLC, surgery is the standard treatment if medically safe, while radiotherapy may be considered for those who cannot undergo surgery. Adjuvant chemotherapy is recommended for stage II and III disease. 3. For locally advanced NSCLC, concurrent chemoradiotherapy is the standard treatment for unresectable stage III disease, while combinations of chemotherapy, radiation, and surgery are options for potentially resectable stage III.

1. MANAGEMENT OF
EARLY-STAGE AND
LOCALLY ADVANCED
NSCLC

2. PRETREATMENT EVALUATION :
1. PFTs ( if not previously done )
2. BRONCHOSCOPY
3. PATHOLOGIC MEDIASTINAL LNs EVALUATION
(MEDIASTINOSCOPY ,MEDIASTINOTOMY ,EBUS,EUS,
AND CT-GUIDED BX )
4. PET / CT ( IF PET IS POSITIVE IN THE
MEDIASTINUM LN STATUS NEED PATHOLOGIC
CONFIRMATION ).
5. BRAIN MRI WITH CONTRAST.

4. EARLY-STAGE NSCLC ( STAGE I AND II ):
-STAGE IA ( T1miT1C , N0 ) STAGE IB ( T2a, N0 )
-STAGE IIA( T2b ,N0 ) STAGE IIB ( T1AT2B ,N1) STAGE IIB ( T3, NO )
SURGERY:
• IS STANDARD OF TREATMENT IF NO CI
• FOR PATIENTS WHO CANNOT BE SAFELY OPERATED ON OR REFUSE SURGERY ,
RT CAN BE CONSIDERED.
• WEDGE RESECTION AND SEGMENTECTOMY ARE ASSOCIATED WITH HIGHER
RATES OF LOCAL RECURRENCE THAN LOBECTOMY AND PNEUMONECTOMY .
• ALL PATIENTS SHOULD ALSO UNDERGO COMPLETE IPSILATERAL MEDIASTINAL
LN DISSECTION OR SYSTEMATIC MEDIASTINAL SAMPLING FOR ACCURATE
PATHOLOGIC STAGING .

5. .THE FVC IS MOST COMMONLY USED TO ASSESS SUITABILITY
FOR SURGERY.
A PREDICTED POSTOPERATIVE FVC OF < 1 L OR A
PREOPERATIVE VALUE OF < 2 L FOR A PNEUMONECTOMY OR <
1.5 L FOR A LOBECTOMY USUALLY SUGGEST THE PATIENT IS AT
RISK FOR POSTOPERATIVE COMPLICATIONS .
.LOW DIFFUSION CAPACITY ( <50% OF PREDICTED ) SUGGESTS
AN INCREASED RISK OF POSTOPERATIVE MORBIDITY OR
MORTALITY.

6. DEFINITIVE RADIOTHERAPY:
• FOR PATIENTS WITH EARLY-STAGE LUNG CANCER WHO CANNOT
UNDERGO SURGERY BECAUSE OF POOR PULMONARY RESERVE OR
MEDICAL COMORBIDITIES STEREOTACTIC RADIOSURGERY ( SRS ) IS A
REASONABLE AND EVEN A DESIRABLE OPTION WITH LOCAL CONTROL
RATE OF 90% AND A CANCER-SPECIFIC SURVIVAL RATE OF 88% AT 3 YEARS
• BECAUSE OF A HIGHER RISK OF ADVERSE EFFECTS , SUCH AS BRONCHIAL
STENOSIS , HEMOPTYSIS, AND FISTULA FORMATION , SRS IS USUALLY NOT
PERFORMED WHEN THE TUMOR LIES WITHIN 2 CM OF THE PROXIMAL
BRONCHIAL TREE . THIS TECHNIQUE IS ALSO USUALLY RESTRICTED TO
TUMORS < 5 CM .
• FOR MEDICALLY INOPERABLE PATIENTS WITH TUMORS > 5 CM AND/OR
MODERATELY CENTRAL LOCATION , RADICAL RT USING MORE
CONVENTIONAL OR ACCELERATED SCHEDULES IS RECOMMENDED.

7. ADJUVANT CHEMOTHERAPY:
- ADJUVANT CHEMOTHERAPY SHOULD BE OFFERRED TO ALL PATIENTS
WITH GOOD PS , WITH COMPLETELY RESECTED STAGE II AND STAGE III
NSCLC .
- FOR PATIENTS WITH NO LN INVOLVEMENT AND A PRIMARY TUMOR
SMALLER THAN 4CM ( STAGE I ) , ADJUVANT CHEMOTHERAPY IS NOT
RECOMMENDED .
- FOR NODE-NEGATIVE TUMORS LARGER THAN 4 CM ( STAGE IIA) THE
CALGB 9633 TRIAL SUGGESTED A BENEFIT OF ADJUVANT
CHEMOTHERAPY AND IT SHOULD BE CONSIDERED PARTICULARLY IN
THE SETTING OF HIGH-RISK FACTORS SUCH AS VASCULAR INVASION ,
VISCERAL PLEURAL INVOLVEMENT , WEDGE RESECTION , POORLY
DIFFERENTIATED TUMORS, AND UNKNOWN LN STATUS.

14. ADJUVANT OSIMERTINIB:
ADAURA TRIAL :

20. ADJUVANT IMMUNOTHERAPY:

25. POST-OPERATIVE RADIOTHERAPY:
- PORT IS NOT RECOMMENDED IN COMPLETELY RESECTED CASES.
- PORT SHOULD BE DISCUSSED IF R1 RESECTION ( POSITIVE RESECTION
MARGIN , CHEST WALL ).
- PORT SHOULD BE CONSIDERED AFTER COMPLETE SURGICAL
RESECTION AND ADJUVANT CHEMOTHERAPY FOR N2 DISEASE.
- RT SHOULD FOLLOW CHEMOTHERAPY WHEN BOTH ARE GIVEN IN
THE ADJUVANT SETTING.

27. PANCOAST TUMOR :
• PANCOAST OR SUPERIOR SULCUS, TUMORS IN THE UPPER LOBE
ADJOINING THE BRACHIAL PLEXUS .
• FREQUENTLY ASSOCIATED WITH HORNER SYNDROME , OR SHOULDER
AND ARM PAIN.
• BEST MANAGEMENT FOR T3-T4, NO-N1, M0 SUPERIOR SULCUS
NSCLC :
PREOPERATIVE CONCURRENT CHEMORADIATION  SURGERY 
2 CYCLES OF CONSOLIDATIVE CHEMOTHERAPY.

28. LOCALLY ADVANCED NSCLC ( STAGE III ) :
STAGE IIIA ( T1aT2b, N2 ) ( T3, N1) ( T4, N0N1)
STAGE IIIB ( T1aT2b, N3 ) ( T3T4, N2)
STAGE IIIC (T3T4, N3 )

29. -RESECTABLE STAGE III NSCLC :
.THE OPTIMAL TREATMENT OF RESECTABLE , NONBULKY ( <2 CM MEDIASTINAL LNE)
WITHOUT MULTISTATION MEDIASTINAL LNE, STAGE IIIA ,GENERALLY CONSISTS OF
SYSTEMIC THERAPY ( CHEMOTHERAPY ) COMBINED WITH A LOCAL APPROACH ( RT
AND/OR SURGERY ).
.POSSIBLE COMBINATIONS INCLUDE :
1.SURGERY FOLLOWED BY ADJUVANT CHEMOTHERAPY WITH OR WITHOUT THORACIC
RADIATION ( FOR INCIDENTALLY NOTED STAGE III).
2.NEOADJUVANT CHEMOTHERAPY ( OR CHEMORADIATION ) FOLLOWED BY SURGERY (
WITH OR WITHOUT POSTOPERATIVE THORACIC RADIATION )
3.CONCURRENT OR SEQUENTIAL CHEMOTHERAPY WITH DEFINITIVE RT.
NB:
.IN GENERAL THE ACCEPTED STANDARD REMAINS CONCURRENT DEFINITIVE CHEMORADIATION.

30. -UNRESECTABLE STAGE III NSCLC :
• PATIENTS WITH STAGE IIIA DISEASE AND EXTENSIVE MEDIASTINAL
INVOLVEMENT OR STAGE IIIB, IIIC DISEASE.

34. FOLLOW UP AND SURVIVORSHIP:
• PATIENTS TREATED WITH RADICAL INTENT SHOULD BE FOLLOWED FOR
TREATMENT-RELATED COMPLICATIONS, DETECTION OF TREATABLE
RELAPSE, OR OCCURRENCE OF SECOND PRIMARY LUNG CANCER.
• SURVEILLANCE EVERY 6 MONTHS FOR 2 YEARS WITH HISTORY, PHYSICAL
EXAMINATION AND CONTRAST-ENHANCED CHEST CT AT LEAST AT 12 AND
24 MONTHS, THEREAFTER EVERY 12 MONTHS IS RECOMMENDED.

35. THANK YOU