GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer

Table 10 Summary of recommendations

Diagnosis	Level of evidence, grade of recommendation
If lung cancer is suspected, refer patient to a rapid diagnostic service for evaluation by a multidisciplinary team	II, C
PET-CT is recommended for initial staging in patients with stage I-III disease who are candidates for radical treatment	I, A
EBUS/EUS is recommended for clinical staging in patients with enlarged lymph nodes without distant metastases, with or without PET uptake	I, C
EBUS/EUS is recommended for stating in patients with positive PET-CT scans and normal-sized lymph nodes without distant metastases	I, A
Histological confirmation of the mediastinum by EBUS/EUS is recommended in central tumours, tumours > 3 cm, and N1 cases	I, C
Histological confirmation is required in cases with a single metastatic lesion and positive PET-CT	II, A
Brain MRI is recommended in candidates for curative-intent treatment	II, A
VAMS should be performed when EBUS/EUS findings are not evaluable	I, B
Differentiation between adenocarcinomas and squamous cell carcinomas is recommended even for small biopsies or cytology	I, B
EGFR mutations and ALK rearrangements should be assessed in patients with stage IV, non-squamous cell carcinomas. This determination should be performed in all cases (regardless of smoking status) and in all non-smokers independently of tumour histology	I, B
Early stage NSCLC - SBRT
Inoperable	II, A
Operable	III, C
High surgical risk	III, A
Locally-advanced disease
Concomitant radiotherapy: This is the treatment of choice for unresectable stage IIIA/IIIB with ECOG 0-1 and weight loss < 5% in 3 mo	I, A
60-66 Gy in 30-33 daily fractions of 2 Gy/fx and 2-4 ChT cycles	I, A
Platinum-based ChT	I, A
Treatment should be completed in < 7 wk	III, B
Sequential radiotherapy
If concomitant treatment is not possible, the alternative is sequential CRT	I, A
Treatment should be completed in a short period of time	I, A
Neoadjuvant radiotherapy
Assessment by a multidisciplinary team is recommended	IV, C
In potentially-resectable upper sulcus tumours, the recommended approach is neoadjuvant CRT followed by surgery	III, A
This approach can be considered in potentially-resectable T3/T4 tumours, but only in well-selected cases at experienced centres	III, B
Surgery must be performed within 4 wk after completion of RT	III, B
Adjuvant radiotherapy
Not recommended in early stage disease with complete resection (R0)	I, A
It should be considered if resection is incomplete or margins are involved (R1)	IV, B
Not recommended as standard in R0 cases with N2 involvement	I, A
In N2 disease, adjuvant RT could be considered based on risk factors for local recurrence	IV, C
If adjuvant ChT and RT are both administered, the recommended sequence is ChT followed by RT	V, C
Altered fractionation schemes
Accelerated hyperfractionation schemes provide better disease control than conventional RT	I, A
Recommended fractionation schemes for RT administered alone or sequentially after ChT: 55 Gy (20 fx, 2.75 Gy), 60 Gy (20 fx, 3 Gy), 60 Gy (15 fx, 4 Gy), 45-50 Gy (15 fx, 3-3.33 Gy)	II, A
If RT administered concurrently with ChT in patients with good performance status: 55 Gy (20 fx 2.75 Gy)	II, B
General considerations: There is no evidence to support prophylactic WBRT in stage III disease	II, A

PET-CT: Positron emission tomography-computed tomography; fx: Fractions; MRI: Magnetic resonance imaging; EGFR: Epidermal growth factor receptor; ALK: Anaplastic lymphoma kinase; NSCLC: Non-small cell lung cancer; ECOG: Eastern Cooperative Oncology Group; ChT: Chemotherapy; CRT: Conformal radiotherapy; RT: Radiotherapy; WBRT: Whole-brain radiotherapy.