1. Diagnostic evaluation of non-small lung cancer:
- History and physical examination
- ECOG scoring (performance index evaluation)
- PET with contrast enhanced CT thorax (with special reference to thorax and upper abdomen to include adrenals)
- Bronchoscopy: for central tumours along with bal and brushings
- CT guided trucut biopsy for peripheral tumours or tumours not amenable to bronchoscopic biopsy
- Ebus / mediastinoscopy: it is extremely vital to stage the mediastinum prior to surgery. The test needs to be done only for operable cases
- Pulmonary function test with DLCO.
2. Treatment of non-small cell lung cancer:
a. Early localized:
- Stage I NSCLC: treatment is surgery (lobectomy). This is to be done if the patient has enough respiratory reserve, i.e. expected post-operative FEV1 should be >0.8 or 40% and post-operative DLCO should be >0.8 or 40%.The Lobectomy is performed either through the conventional Thoracotomy or via VATS (Video Assisted Thoracoscopic Surgery).
- Stage II NSCLC: surgery (conventional Thoracotomy or via VATS (Video Assisted Thoracoscopic Surgery) as for stage 1. no adjuvant therapy.
b. Locally Advanced Resectable: Stage IIIA: (T3 N1 Mx) : (T1-3 N2 Mx):
- T3 N1: will be treated with neoadjuvant chemotherapy consisting of two cycles of chemotherapy followed by surgical resection. Adjuvant radiation in case of positive margins.
- N2 Disease: Patients with good performance status, no contra-indication to surgery are to be treated with neoadjuvant chemotherapy for 2 cycles followed by surgery. If patient’s have low performance status or contra-indication to surgery, but have adequate pulmonary function tests then definitive chemo- radiotherapy can be done, otherwise palliative radiotherapy.
c. Locally Advanced Unresectable:
- Patients with good performance status 0-2 and good pulmonary function tests should have combined modality therapy. The patients will receive concurrent chemotradiotherapy (both starting on day 1).
- Patients’ poor performance status 3-4 and/or poor pulmonary function test should receive palliative radiotherapy.
- Metastatic non-small cell lung cancer: treatment is palliative and prognosis poor. Newer targeted agents such as Gefitinib/ Afatinib for EGFR Positive, Crizotinib for ALK Positive and Nivolumab for anti-PD-1 monoclonal antibody may improve the overall survival in a select group of patients. Recurrent pleural effusion: May be subjected to a VATS Pleurodesis (Fig 4) or Pleurx catheter insertion.
1. Non Invasive Thymoma:
Surgical resection via Sternotomy or VATS Mediastinal mass resection (ENBLOC).
2. Invasive Thymoma: Stage 1:
Surgical resection as described above. Radiation therapy only if incompletely resected or poor surgical risk.
3. Stage II, III, IV:
- Operable cases: en block resection neither through midline sternotomy or VATS with post-operative radiotherapy if positive margin.
- Inoperable cases: like Stage III and IV will be treated with three cycles of neoadjuvant chemotherapy followed by radiation therapy and then surgical resection of residual disease if possible.