Treatment Of Stage I And II Non-Small Cell Lung Cancer: Diagnosis And Management Of Lung Cancer

Publication Date: November 1, 2013
Last Updated: March 14, 2022

Recommendations

General Approach to Stage I and II NSCLC

For patients with clinical stage I and II NSCLC and no medical contraindications to operative intervention, surgical resection is recommended. (1, B)
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For patients with clinical stage I and II NSCLC, it is suggested that they be evaluated by a thoracic surgical oncologist or a multidisciplinary team even if the patients are considered for nonsurgical therapies such as percutaneous ablation or stereotactic body radiation therapy. (2, C)
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For patients with clinical stage I or II NSCLC and who are medically fit, it is recommended that they be treated by a board certified thoracic surgeon with a focus on lung cancer. (1, B)
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Lobectomy—Surgical Issues

For patients with clinical stage I NSCLC, a minimally invasive approach such as videoassisted thoracic surgery (thoracoscopy) is preferred over a thoracotomy for anatomic pulmonary resection and is suggested in experienced centers. (2, C)
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For patients with clinical stage I and II NSCLC, systematic mediastinal lymph node sampling or dissection at the time of anatomic resection is recommended for accurate pathologic staging. (1, B)
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For patients with clinical stage I NSCLC undergoing anatomic resection who have undergone systematic hilar and mediastinal lymph node staging showing intraoperative N0 status, the addition of a mediastinal lymph node dissection does not provide a survival benefit and is not suggested. (2, A)
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For patients with clinical stage II NSCLC undergoing anatomic resection, mediastinal lymph node dissection may provide additional survival benefit over mediastinal lymph node sampling and is suggested. (2, B)
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For patients with clinical stage I or II central NSCLC in whom a complete resection can be achieved, a sleeve or bronchoplastic resection is suggested over a pneumonectomy. (2, C)
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Sublobar Resection

For patients with clinical stage I and II NSCLC, who are medically fit for surgical resection a lobectomy rather than sublobar resection is recommended. (1, B)
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For patients with clinical stage I NSCLC who may tolerate operative intervention but not a lobar resection due to decreased pulmonary function or comorbid disease, sublobar resection is recommended over nonsurgical therapy. (1, B)
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During sublobar resection of solid tumors in compromised patients, it is recommended that margins greater than the maximal tumor diameter for lesions less than 2 cm should be achieved. For tumors larger than 2 cm at least 2 cm gross margins should be sought to minimize the likelihood of a positive margin and/or local recurrence. (1, C)
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In patients with major increased risk of perioperative mortality or competing causes of death (due to age related or other co-morbidities), an anatomic sublobar resection (segmentectomy) over a lobectomy is suggested. (2, C)
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For patients with a clinical stage I predominantly GGO lesion 2 cm, a sublobar resection with negative margins is suggested over lobectomy. (2, C)
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Nonsurgical Treatment Approaches to Stage I NSCLC

For patients with clinical stage I NSCLC who cannot tolerate a lobectomy or segmentectomy, SBRT and surgical wedge resection are suggested over no therapy. (2, C)
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Postoperative (Adjuvant) Therapy

For patients with completely resected pathologic stage IA,B NSCLC, it is recommended that postoperative chemotherapy not be used (outside of a clinical trial). (1, B)
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For patients with completely resected pathologic stage II(N1) NSCLC and good performance status, postoperative platinum-based chemotherapy is recommended. (1, A)
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For patients with completely resected pathologic stage I NSCLC, it is recommended that postoperative radiation therapy should not be used. (1, A)
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For patients with completely resected pathologic stage II NSCLC, it is suggested that postoperative radiation therapy should not be used. (2, A)
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For patients with stage I and II NSCLC and a positive bronchial margin (R1 resection), postoperative radiation therapy is suggested. (2, C)
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Recommendation Grading

Overview

Title

Treatment Of Stage I And II Non-Small Cell Lung Cancer: Diagnosis And Management Of Lung Cancer

Authoring Organization

American College of Chest Physicians

Publication Month/Year

November 1, 2013

Last Updated Month/Year

June 26, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.

Target Patient Population

Patients with stage I / II non-small cell lung cancer (NSCLC)

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D002289 - Carcinoma, Non-Small-Cell Lung, D013903 - Thoracic Surgery, D008175 - Lung Neoplasms, D011878 - Radiotherapy, D018714 - Radiotherapy, Adjuvant

Keywords

lung cancer, non-small cell lung cancer, CT imaging, radiotherapy, Non Small Cell Lung Cancer, non_small_cell_lung_cancer, early stage cancer

Supplemental Methodology Resources

Data Supplement