Staging and Multidisciplinary Management of Patients with Early-Stage Non–Small Cell Lung Cancer

Publication Date: June 9, 2023
Last Updated: August 15, 2023

Optimal diagnosis and staging

Appropriate staging of patients with newly diagnosed lung cancer should include CT and PET imaging. In addition, brain imaging and invasive mediastinal staging should be performed where clinically indicated. (I, B-R)
573
Thorough lymph node assessment is imperative for accurate pathologic staging and optimal oncologic outcomes. Intraoperative lymphadenectomy should include at least 3 mediastinal stations and 1 hilar nodal station. (I, B-R)
573
Lobectomy remains the standard-of-care resection strategy for operable patients. However, anatomic sublobar resection may be acceptable for tumors determined to be low risk for nodal involvement based on size or radiographic/histopathologic features. It may also be an acceptable approach for patients who are high risk for lobectomy. (I, A)
573
Early initiation of molecular sequencing and other biomarker analyses is recommended to select optimal preoperative and postoperative treatment regimens in locally advanced patients. (I, A)
573

Neoadjuvant therapy

For medically operable patients with oncologically resectable stage III NSCLC with N2 disease for whom surgery is planned, preoperative systemic therapy without radiotherapy is recommended. For those patients with superior sulcus tumors and no evidence of N2 disease, neoadjuvant concurrent chemoradiotherapy is preferred. (IIa, B-NR)
573
Platinum-based chemotherapy doublet in combination with immunotherapy is the preferred neoadjuvant regimen for medically operable patients with resectable stage II and III NSCLC, lacking EGFR and ALK alterations, regardless of PD-L1 status. Neoadjuvant platinum-based chemotherapy doublet alone is recommended for patients with a contraindication to immunotherapy. (I, B-R)
573
For eligible patients with resectable and medically operable stage II and III NSCLC without EGFR or ALK alterations, neoadjuvant platinum-based chemotherapy with immunotherapy is preferred over adjuvant therapy. (IIa, C-EO)
573

Adjuvant therapy

All patients with NSCLC with pathologic stage IB-III (eighth edition) should be referred to medical oncology for discussion of adjuvant systemic therapy after lung resection. (I, A)
573
For resected patients with NSCLC without pathologic nodal disease, high-risk features (lymphovascular invasion [LVI], visceral pleural invasion [VPI], larger tumor size, positive margin, inadequate nodal sampling) should prompt consideration of medical oncology referral and adjuvant therapy. (IIa, C-LD)
573
All resected stage IB-IIIA lung adenocarcinomas should undergo comprehensive testing for molecular alterations, and all patients with resected stage II-IIIA should undergo tumor PD-L1 staining. (I, A)
573
All resected stage II-IIIA lung squamous cell carcinomas should undergo PD-L1 staining. (I, A)
573
All patients with resected IB-IIIA lung adenocarcinoma AND with EGFR mutations should be referred to medical oncology for discussion of adjuvant osimertinib, whether or not adjuvant cytotoxic chemotherapy is considered possible/desired. (I, B-R)
573
All patients with resected II-IIIA NSCLC patients with PD-L1 staining ≥1% should be referred to medical oncology for consideration of adjuvant immunotherapy after adjuvant chemotherapy. (I, B-R)
573
Postoperative radiation therapy to the mediastinum should not be routinely given to resected patients with NSCLC with incidental/unforeseen (ie, “surprise”) pathologic N2 disease. (I, A)
573

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Staging and Multidisciplinary Management of Patients with Early-Stage Non–Small Cell Lung Cancer

Authoring Organization

American Association for Thoracic Surgery

Publication Month/Year

June 9, 2023

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Document Objectives

Novel targeted therapy and immunotherapy drugs have recently been approved for use in patients with surgically resectable lung cancer. Accurate staging, early molecular testing, and knowledge of recent trials are critical to optimize oncologic outcomes in these patients.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Management

Diseases/Conditions (MeSH)

D008175 - Lung Neoplasms, D008168 - Lung

Keywords

lung cancer, non-small cell lung cancer, non-small-cell lung carcinoma (NSCLC), NSCLC, Non Small Cell Lung Cancer, early stage cancer, non–small cell lung cancer, early

Source Citation

Expert Consensus Panel; Kidane B, Bott M, Spicer J, Backhus L, Chaft J, Chudgar N, Colson Y, D'Amico TA, David E, Lee J, Najmeh S, Sepesi B, Shu C, Yang J, Swanson S, Stiles B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Staging and multidisciplinary management of patients with early-stage non-small cell lung cancer. J Thorac Cardiovasc Surg. 2023 Sep;166(3):637-654. doi: 10.1016/j.jtcvs.2023.04.039. Epub 2023 Jun 10. PMID: 37306641.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
149
Literature Search Start Date
September 14, 2021
Literature Search End Date
March 31, 2022