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Mount Vernon Cancer Network Clinical Guidelines
for the Management of Lung Cancer
11-1C-103c
Version number as approved and published
Author
Date Written
Reviewed on
Document ratified by NSSG on
0.5
Richard Dent, She Lok, Simon Allen, Sue
Buckingham
August 2011
February 2013 (sarcoma pathway added)
8th August 2011
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These Clinical Guidelines have been agreed by:
Name: Dr Jane Halpin
Position: Chair of Network Board
Organisation: NHS Hertfordshire
Date agreed: 29th September 2011
Name: Dr She Lok
Position: Lung NSSG Chair
Organisation: East & North Herts NHS Trust
Date agreed: 28th September 2011
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Contents
1.
2.
3.
4.
5.
6.
Network Referral Guideline for Primary Care
1.1 Network Referral Guidelines (between MDTs or Network)
Network Guidelines for Diagnosis
2.1 Staging CT Scans
2.2 Bronchoscopy
2.3 Pleural Effusions
2.4 Sputum Cytology
2.5 Ultrasound Guided Biopsies
2.6 Thoracoscopy / Mediastinoscopy / Mediastotomy
2.7 MRI Scans
2.8 Abdominal Ultrasonography
2.9 Isotope Bone Scan
2.10 Solitary Peripheral Lesions
2.11 PET Scans
2.12 Out of Network Referrals
Network Guidelines for Surgery (at Papworth or Harefield Hospitals)
3.1 Guidelines for the Use of Video Assisted Thoracic Surgery (VATS)
3.2 Mediastinoscopy (available at Papworth and Harefield Hospitals)
3.3 Anterior Mediastinotomy (available at Papworth and Harefield Hospitals)
3.4 EBUS / EUS Mediastinal Node Biopsy
3.5 Frozen Section
3.6 Resection of the Lung
3.7 Pre-operative Investigations
3.8 Standard Pneumonectomy
3.9 Extended (Intrapericardial) Resection
3.10 Lobectomy
3.11 Operability and Adjuvant Chemotherapy
3.12 Surgery for Mesothelioma
Network Guidelines – Suggested Follow Up
Small Cell Lung Cancer (SCLC)
5.1 VALG Staging
5.2 Diagnosis and Staging Investigations
5.3 Management
5.3.1 Limited Disease, Good Performance Status
5.3.1.1 General Considerations
5.3.1.2 Dose Schedules
5.3.1.3 Prophylactic Cranial Radiotherapy (PCI)
5.3.2 Patients with Disease Too Large for a Radical Radiotherapy Field
5.3.3 Extensive Disease
5.3.3.1 Good Performance Status
5.3.3.2 Prophylactic Cranial Radiotherapy (PCI)
5.3.4 Poor Performance Status
5.4 Palliative Radiotherapy
5.5 Relapsed Disease
5.6 Follow-up (SCLC)
5.7 Concomitant Radiation Doses
5.8 Chemotherapy Schedules (SCLC)
5.9 Guidelines for G-CSF
5.10 Hickman Lines
Non-Small Cell Lung Cancer (NSCLC)
6.1 TNM Staging
6.1.1 Primary Tumour (T)
6.1.2 Regional Lymph Nodes (N)
6.1.3 Distant Metastasis (M)
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6.2 Stage Grouping
6.3 Diagnosis and Staging Investigations (NSCLC)
6.4 Management of Localised Disease (With Radical Intent)
6.4.1 Surgery
6.4.2 Preoperative Chemotherapy and Radiotherapy
6.4.3 Postoperative Adjuvant Chemotherapy
6.4.4 Postoperative Radiotherapy
6.4.4.1 Indications
6.4.4.2 Radiotherapy
6.4.4.3 Dose Prescriptions
6.4.5 Radical Radiotherapy
6.4.5.1 General Considerations
6.4.5.2 Radiotherapy
6.4.5.3 Dose Prescriptions
6.4.6 Chemotherapy prior to radical radiotherapy
6.5 Management with Palliative Intent
6.5.1 Chemotherapy: First Line
6.5.1.1 Investigations Prior to Chemotherapy
6.5.1.2 Approved regimes
6.5.1.3 Duration of Treatment
6.5.2 Radiotherapy (Thoracic)
6.5.3 Endobronchial Brachytherapy
6.5.4 Special Situations
6.5.4.1 Pancoast Tumours
6.5.4.2 Superior Vena Cava Obstruction
6.5.5 Chemotherapy: Second Line
6.5.6 Palliative Radiotherapy (Non-Thoracic)
6.5.6.1 Bone Metastases
6.5.6.2 Brain Metastases
6.5.6.3 Spinal Cord Compession
6.5.7 Hypercalcaemia
6.6 Follow Up
6.7 Chemotherapy Schedules
Endobronchial Treatment
7.1 Indications for Endobronchial Treatment
7.2 Methods of Treatment
7.2.1 Cryotherapy
7.2.2 Airway Stents
7.2.3 Endobronchial Radiotherapy
7.2.4 Results of Treatment
Palliative Care
8.1 Indications for a Referral
Network Guidelines for Communication of Diagnosis
Network Guidelines – Key Worker Role
Guidelines for Imaging in Suspected Lung Cancer
11.1 The CXR in suspected lung cancer
11.2 CT in suspected lung cancer
11.3 CT/PET in suspected lung cancer
11.4 MRI
11.5 Ultrasound
11.6 Isotope Bone Scanning
11.7 Image guided Biopsy
11.7.1 Flowchart for the role of diagnostic imaging in the diagnosis of lung cancer
11.8 Radiological management in Lung cancer patients
11.9 Role of Radiologist in the Lung MDT
11.10 Follow up imaging in lung cancer
Operational Policy for Respiratory Pathology
12.1 Introduction
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13.
12.2 Description of the service
12.3 Specimen Types
12.4 Specimen Examination
12.5 Reporting Practice
12.6 Mutation Analysis
12.7 Staging
12.8 Multi-disciplinary team meetings
12.9 Audit
12.10 Referral for Review or Second Opinion
12.11 References
Appendices
Appendix 1: Referral form
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Appendix 2: Guidelines for the follow up of solitary nodule
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Appendix 3: Pathways of Trust outside of Network referring patients in
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Appendix 4: Guidance for Follow Up after Successful Surgical Resection of Lung
Carcinoma
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Appendix 5: Lung Cancer Trials at Mount Vernon Cancer Centre
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Appendix 6: Oncological Emergencies
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Appendix 7: Recommendations for vaccinations in patients undergoing
chemotherapy
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Appendix 8: Patient Information leaflets available from the Lynda Jackson Macmillan
Centre
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Appendix 9: Diagnostic algorithm – diagnosis of Lung Cancer
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Appendix 10: Sarcoma Pathway
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1. Network Referral Guideline for Primary Care
A CXR needs to be organised by the GP and be available at the time of referral. Patients presenting with
the following symptoms should have an urgent CXR performed by the GP:
If the CXR is suspicious then a referral should be made to the local chest team (each hospital has a system
in place which picks up abnormal CXR and these patients can be picked up in this manner in addition to
the GP referral). If the CXR is normal but the GP is still concerned then a referral should also be made.
Patients with suspected lung cancer should be referred using the urgent 2 week proforma (shown in
appendix 1).
Patients should be referred while awaiting a CXR if the following applies:
1. Persistent haemoptysis in smokers/ex-smokers older than the age of 40 years
2. Signs of superior vena cava obstruction.
3. Stridor
1.1 Network Referral Guidelines (between MDTs or Network)
If it is necessary to referral patients to another MDT within the same Network or out of Network for an
opinion or intervention, then a detailed referral letter outlining the clinical issues together with the results of
relevant investigations and copies of relevant imaging are sent to the appropriate team.
The progress of the referrals and any outcomes are chased up by the MDT coordinators/lung CNS. The
result of the referral is discussed in the local MDT and the appropriate management plan put in place.
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2. Network Guidelines for Diagnosis
GPs are encouraged to perform urgent CXRs in patients with symptoms and signs suggestive of lung
cancer. Trusts in the network have put in place systems where abnormal CXRs are brought to the attention
of the Lung cancer Team as well as the GP to facilitate an urgent appointment being given to the patient in
out-patients. GPs are encouraged to use the Lung cancer specific referral forms devised by each Trust in
the network for this purpose; appendix 1. These referral proforma are specific to lung cancer and detail
the symptoms and signs which should lead GPs to refer the patient. GPs should organise a CXR while
simultaneously referring the patient if they have not already done so.
2.1 Staging CT Scans
Staging CT scans should always incorporate a contrast-enhanced study, unless there is a medical
contraindication e.g. renal failure. The scan should incorporate the neck, thorax and upper abdomen to
include liver and adrenal glands. The best approach for diagnosis and staging should be discussed for
every patient either at the next MDT or with a specialist radiologist and a test (biopsy) date decided
upon.
2.2 Bronchoscopy
Ideally performed after a staging CT scan to ensure its appropriateness. At least 5 biopsies are
recommended in order to maximise the likelihood of a positive biopsy yield by histology if an
endobronchial lesion is seen. Pathological staging by transbronchial needle aspiration is being
increasingly used and encouraged within the network, especially if CT identifies abnormal mediastinal
nodes. Brushings should always be taken whenever a lesion is seen in addition to biopsies. Trap
lavage specimens add approximately 2% to the total yield for lung cancer. Lavage specimens, if taken,
should be analysed by cytologists only if brushings and biopsies specimens are negative.
Comments should always be made by the bronchoscopist as to the resectability of a tumour. If in
doubt, give the patient any benefit of doubt. All bronchoscopies carried out by SpRs should have a
consultant available to check the findings; biopsy technique etc. Per bronchoscopic and endoscopic
ultrasound exploration of the mediastinum (EBUS) is now available at Watford General Hospital and
referrals can be made from other Trusts within the network for this procedure as an alternative to
referral to major specialist centres. This procedure can improve the accuracy of staging and reduce
other invasive procedures.
2.3 Pleural Effusions
Pleural effusions suspected of malignant origin should be aspirated as soon as possible and 30-50ml
sent for cytological evaluation. If this fails to give a diagnosis, the aspiration should be repeated, and a
CT scan arranged if the patient has not already had one.
If cytology is negative and malignancy is strongly suspected, any pleural mass found on imaging
should be biopsied under radiological control. If diffuse disease is present with no clear mass, medical
or surgical thoracoscopy +/- talc pleurodesis should be requested. Medical thoracoscopy is now
available at the East & North Hertfordshire NHS Trust and referrals are accepted from other sites
within the network for this procedure as a potential alternative to referral for surgical thoracoscopy at
other specialist centres outside the network.
2.4 Sputum Cytology
This remains an important method of diagnosis and should not be forgotten especially in those with
poor performance status and/or co-morbidities which rule out more invasive procedures. This is
available at each hospital.
2.5 Ultrasound Guided Biopsies
Routine ultrasound of the supraclavicular fossae should be considered for diagnostic FNA of any
nodes found, when there are mediastinal glands present on CT thorax and no other diagnostic route is
easily available.
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2.6 Thoracoscopy/Mediastinoscopy/Mediastotomy
To be considered to reach a diagnosis if less invasive techniques are inappropriate or have failed.
2.7 MRI Scans
MRI scans are particularly useful in assessing thoracic wall and bone problems and suspected brain
disease. However, they have no advantage over CT for staging.
2.8 Abdominal Ultrasonography
This is used to confirm the cystic or malignant nature of liver lesions, etc. Waiting time for ultrasound is
less than 7 days.
2.9 Isotope Bone Scan
This is carried out as a staging procedure if the patient has local bony symptoms or weight loss in
excess of 5kg, or an increased alkaline phosphatase. Waiting time for a bone scan is less than 14
days from time of request.
2.10 Solitary Peripheral Lesions
Solitary peripheral lesions 1cm or greater should usually be sampled if there is no contraindication.
The network policy for investigation and follow up of solitary nodules less than 1cm is attached at
appendix 3.
2.11 PET Scans
Positron emission tomography (PET) scanning can increase the accuracy of staging prior to surgery or
radical radiotherapy in up to 30% of cases. A PET scanner is available on site at The Paul Strickland
Centre, Mount Vernon Hospital for patients in the Mount Vernon Cancer Network. Full evaluation with
CT and bronchoscopy/other biopsy technique is still required, but it is becoming preferred practice to
request a PET/CT scan if the diagnostic workup suggests the patient is a candidate for curative
surgery or radical radiotherapy. Confidence in PET scans is growing so that a positive PET scan
uptake in the mediastinum would mean malignant involvement of those mediastinal structures in up to
90% of patients. Positive lesions should be biopsied if the result will affect management. PET or
PET/CT scans should, ideally, be an MDT decision and must be available within 7 days.
2.12 Out of Network Referrals
The Network receives referrals, particularly Oncological and surgical from outside the network. The
pathways for those referring into the Network are seen in appendix 3.
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3. Network Guidelines for Surgery (at Papworth or Harefield Hospitals)
3.1 Guidelines for the Use of Video Assisted Thoracic Surgery (VATS)
VATS is a minimally invasive procedure utilising typically two or three 1cm incisions to perform surgery
in the chest. Minimum requirements are that the patient will tolerate one lung ventilation, at least for
short periods of time, and that the lung will collapse, at least partially, to give surgeons a working
space.
Uses: Surgical obliteration of pneumothorax and pleural effusion by pleurodesis by several means –
abrasion, pleurectomy or chemical adhesion - are all achievable. Surgical treatment of some
empyemas is also possible. Biopsy of many tissues is also possible, from pleurally based disease to
mediastinal tumours, lung biopsy in almost any situation and resection of solitary nodules can be
accomplished. Drainage of pericardial effusion can also be performed.
3.2 Mediastinoscopy (available at Papworth and Harefield Hospitals)
A small procedure used to biopsy masses and lymph nodes in the anterior mediastinum. It can be
performed in the presence of SVC obstruction but with increased risk. Masses in the pre and paratracheal positions can be biopsied, but sub-carinal nodes not so readily. Patient requires only single
lumen intubation so anyone who can be anaesthetised safely is generally suitable. Good for
differentiating sarcoid from other pathologies but can also diagnose TB, lymphomas, carcinomas and
thymic masses. It is anticipated that increasing use of endoluminal ultrasound guided needle biopsy
sampling will reduce the number of patients referred for mediastinoscopy.
3.3 Anterior Mediastinotomy (available at Papworth and Harefield Hospitals)
Similar range of pathologies to above, but used for anterior mediastinal masses which are beyond the
range of the mediastinoscopy. Masses in the hilum can be biopsied readily and large samples taken.
Patients may require double lumen intubation
3.4 EBUS/EUS Mediastinal Node Biopsy
This technique is less invasive than mediastinoscopy/mediastinotomy and may reach sites which can
not be readily reached by these techniques.
3.5 Frozen Section
This is used to give us a rapid answer as to the nature of a lesion not histologically proven prior to
operation. Frozen section service is available at both Papworth Hospital and Harefield Hospital; the
two sites where patients from the Mount Vernon Cancer Network receive their lung cancer surgery.
3.6 Resectiopn of the Lung
May be by pneumonectomy, lobectomy, segmental resection or wedge resection. The type of
resection depends on the type and extent of disease, and underlying lung function. In some cases,
resection of part of the chest wall may be required, with reconstruction and occasionally a
bronchoplastic procedure with sleeve resection of bronchus may allow a lobectomy rather than a
pneumonectomy, although this is rare.
About 90% of resections are carried out for carcinoma, and this is the treatment of choice where the
patient is fit enough to undergo operation, there is no evidence of spread outside the chest and there
is no clinical or investigatory evidence of inoperability.
3.7 Pre-Operative Investigations
(See BTS Guidelines in Thorax 2001; 56: 89-108)
Pre-operative work-up is vitally important and will include simple spirometry followed comprehensive
lung function and gas transfer studies. Estimating post-operative lung function and gas transfer by
considering the number of affected segments and the number being removed can be done in
borderline patients. Assessment should include a cardiovascular assessment, and consideration
should be given to weight loss, performance status and under nutrition. Patients with recent weight
loss of 10% or more are highly likely to have advanced disease and need careful staging and a search
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for a co-morbid disease. All patients should be formally discussed at a MDT meeting. Pre-operative
exercise testing for VO2 max ml/kg/min is not routinely performed.
3.8 Standard Pneumonectomy
The following indicate that a tumour is inoperable,
 Inability to separate the tumour from the aorta or SVC.
 Inability to separate the tumour from the lower end of the trachea.
 Spread of growth along the pulmonary veins so that the vein or atrium can not be divided.
 Inability to separate the tumour from the vertebral bodies.
 Tumour involving the oesophageal mucosa.
Pneumonectomy should include removal of carinal, paratracheal, pretracheal and paraoesophageal
lymph nodes if they appear to be involved. Mortality for pneumonectomy is currently up to 4-9%, but is
much higher in those over 80, when a more limited resection should be considered.
3.9 Extended (Intrapericardial) Resection
This involves the opening of the pericardium around the lung root with division of the pulmonary
vessels within the mediastinum. It may be considered for very central tumours or those with
mediastinal extension.
3.10 Lobectomy
Lobectomy is indicated for carcinoma if the growth is relatively peripheral and confined to one lobe (or
two in the case of middle and either upper or lower right). Lobectomy can also be carried out for lung
abscess, bronchiectasis, benign tumours and other miscellaneous conditions. Mortality rates for
lobectomy are currently ~2.5%.
Careful pre-operative assessment should keep the open and closed thoracotomy rate to below 5%.,
Patients with pleural effusions which contain positive cytology should be deemed inoperable, but a full
assessment of such an effusion by VATS may obtain better samples for analysis and fuller nodal
assessment stations 8 and 9, as well as an assessment of pleural disease.
3.11 Operability and Adjuvant Chemotherapy
Neo-adjuvant chemotherapy is not recommended outside a clinical trial in patients who are resectable,
or even with locally advanced disease. The latter group should be offered chemo/radiotherapy.
Adjuvant chemotherapy for Stage II and IIIA disease appears to confer a significant survival advantage
and should be discussed with each appropriate patient after surgery and pathological staging.
Stage IIIB and IV disease should generally be deemed inoperable.
3.12 Surgery for Mesothelioma
Extrapleural pneumonectomy in limited disease has been the subject of a surgical trial (MARS), the
results are awaited but recruitment ceased pending the results.
Minimally invasive cytoreductive pleurectomy is being performed and has been part of a trial
(MESOVATS). Patients should be identified at MDTs and then co-ordinators should contact Dr Rintoul
at Papworth Hospital who is the current principal investigator. Currently surgery is performed by Mr
Coonar at Papworth Hospital.
Palliative VATS talc pleurodesis can provide diagnosis and treatment of breathlessness due to lung
compression/collapse due to pleural fluid.
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4. Network Guidelines – Suggested Follow Up
Pathway A
For patients at high risk of recurrence, i.e. T2/T3, T1 (N1 or N2) or high SUV score (>20) on PET

Follow up at 4-6 weeks with thoracic surgeon - first visit probably at Papworth

Follow up at 3 months by chest physician:

with chest x-ray at each visit for 2 years

6 monthly CT scan first 2 years

Further follow up dependant on patient’s clinical state but minimal chance of recurrence of
original tumour after 2 years
Pathway B
For patients with low risk of recurrence, i.e. not meeting criteria of high risk

Follow up at 4-6 weeks with thoracic surgeon - first visit probably at Papworth

3 month check up with chest physician then:

3 monthly with x-ray for first year,

6 monthly with x-ray for next year,

further follow up as clinically indicated, minimal chance of recurrence of cancer after that time
It is important that every patient who has surgical resection of lung cancer is discussed after operation at
the multidisciplinary team meeting to ensure a decision is made whether the patient should be followed up
under Pathway A, Pathway B or if the resection has proved to be incomplete, then to allow a decision to be
made as to appropriate further therapy.
For full network guidelines, see appendix 4.
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5. Small Cell Lung Cancer (SCLC)
5.1 VALG Staging
Limited stage:
confined to hemithorax of origin, the mediastinum, and the supraclavicular nodes
which can be encompassed within a tolerable radiotherapy port
Extensive stage: tumour beyond these limits.
It is likely that TNM staging will be introduced for SCLC within 12 months.
5.2 Diagnosis and Staging Investigations
All patients referred for urgent suspected lung cancer should have the following initial investigations:
 Full history and examination
 Full blood count
 U&E
 LFT's
 Bone profile
 LDH
 Chest x-ray
 Bronchoscopy + / - TBNA and EBUS or image-guided needle biopsy
 Histology (preferably) or cytology
 CT thorax and abdomen
 FEV1 and FVC
 In those unfit for bronchoscopy or image-guided needle biopsy, confirmation of diagnosis may
be sought using sputum cytology
 CT or MRI brain scan – necessary to confirm limited stage disease, optional in extensive stage
disease if there are no neurological symptoms
 Bone scan (if indicated)
In symptomatic recurrent disease:
 Full history and examination
 FBC
 U&Es
 LFTs
 Bone profile
 LDH
 CXR
 CT chest and abdomen as appropriate
 Bone scan as appropriate
 CT or MRI brain scan as appropriate
5.3 Management
5.3.1 Limited Disease, Good Performance Status
If disease can be encompassed within a radical radiotherapy field then the patient should be treated
with combined chemoradiotherapy: cisplatin / etoposide with concurrent thoracic radiotherapy. If a
complete response is achieved after 4 cycles of chemotherapy and radiotherapy (assessed on
imaging), no further chemotherapy is required. The maximum number of chemotherapy cycles is 6.
5.3.1.1 GENERAL CONSIDERATIONS
Combination chemotherapy with cisplatin / etoposide requires a measured creatinine clearance.
Ideally radiotherapy would be synchronous with day 1 of the first pulse of chemotherapy, but due to
constraints this may be delayed until day 1 pulse two at the very latest.
Radiotherapy will be undertaken using three-dimensional conformal radiotherapy. The patient is
positioned, immobilised and scanned as for radical radiotherapy in non-small cell lung cancer The
GTV is the primary tumour and involved nodes (> 10mm in short axis diameter. Expansions to CTV
and PTV are as for treatment of non-small cell lung cancer. Treatment is with a single phase using
6MV photons. The treatment plan is verified in the simulator as for non-small cell lung cancer.
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5.3.1.2 DOSE SCHEDULES
Dose should be prescribed to the ICRU reference point / intersection point. Concurrent
chemoradiotherapy: 45Gy in 30 fractions over 19 days treating twice per day (1.5Gy per fraction). The
minimum inter-fraction interval will be 6 hours. Maximum spinal cord dose < 42Gy; maximum lung
dose V20 < 35%; maximum oesophageal length treated 15cm.
5.3.1.3 PROPHYLACTIC CRANIAL RADIOTHERAPY (PCI)
Four weeks after completion of chemotherapy, the patient should be restaged by means of a CT chest,
upper abdomen and brain. Those with a good or complete response should receive PCI 25Gy in 10
fractions over two weeks using lateral opposed fields and 6MV photons with steroid cover. Treatment
is normally delivered in a thermoplastic shell.
5.3.2 Patients with Disease Too Large for a Radical Radiotherapy Field
These patients should be treated with cisplatin / etoposide or carboplatin / etoposide for four to six
cycles. In those achieving complete regression on CT, consolidation radiotherapy to the mediastinum
should be undertaken (40Gy in 15 fractions over three weeks using three dimensional conformal
radiotherapy). Should the planning CT scan show residual disease then radiotherapy is given to the
residual disease and the mediastinum providing normal tissue tolerances are not exceeded. PCI
should be given as above, concurrent with thoracic radiotherapy with steroid cover.
5.3.3 Extensive Disease
5.3.3.1 GOOD PERFORMANCE STATUS
Combination chemotherapy, ideally with a platinum drug, is recommended as first line treatment.
Approved schedules:
 Cisplatin / etoposide
 Carboplatin / etoposide
 CAV (Cyclophosphamide, adriamycin, vincristine) at physicians discretion
 EV (Etoposide, vincristine) at physicians’ discretion
Treatment should be for four – six cycles with a 21 day interval.
Thoracic radiotherapy may be given if there is symptomatic disease after completion of
chemotherapy. Radiotherapy may be given for palliation of symptomatic bone metastases.
5.3.3.2 PROPHYLACTIC CRANIAL RADIOTHERAPY (PCI)
Four weeks after completion of chemotherapy, the patient should be restaged by means of a CT
chest and upper abdomen. In those who achieve any response to chemotherapy PCI should be
offered as it significantly reduces the incidence of symptomatic brain metastases and improves
overall survival. In appropriate cases therefore PCI should be considered 25Gy in 10 fractions
over two weeks using lateral opposed fields and 6MV photons with steroid cover. 20Gy in 5
fractions over 5 days may be used at clinician’s discretion. Treatment is normally delivered in a
thermoplastic shell.
5.3.4 Poor Performance Status
Treat with care. In patients with extensive disease and poor performance status there is an increased
risk of death after the first course of chemotherapy (50% will die within three weeks).
Approved schedules:
 Carboplatin / etoposide
 Carboplatin
 Where appropriate consider palliative radiotherapy or active supportive care e.g. analgesics,
steroids only.
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5.4 Palliative Radiotherapy
If the general condition is poor and the patient is unlikely to tolerate or benefit from chemotherapy then
consider 10Gy midplane dose as a single fraction to the symptomatic primary tumour and mediastinum
and / or an 8Gy single fraction to symptomatic metastatic disease.
5.5 Relapsed Disease
Prognosis is usually poor. If the performance status is poor, prognosis may be so short that only
supportive care may be appropriate. Palliative radiotherapy may be given to symptomatic disease. If
the performance status is good then the patient may benefit from further chemotherapy. Consider 4
courses of topotecan, carboplatin / etoposide or CAV, depending on previous treatment regime
delivered.
5.6 Follow – Up (SCLC)
There is no evidence base for follow up therefore it should be determined by local practice.
5.7 Concomitant Radiation Doses
CTDI and DLP values are recorded on the planning form, KV, mA and mAs exposures are in the
Acuity log book.
The treatment plan is verified in Acuity.
Once treatment has begun 1 full rescan per patient is permitted where clinically required, e.g. weight
loss
Electronic portal images (EPI) are taken as per radiographer work instructions.
However the following must be followed:
Insufficient bony
anatomy on DRR
Sufficient bony
anatomy on DRR
Image template
Number of images
Double exposure (no more than 8cm
symmetric enlarged field image)
Single exposure during treatment.
Therefore no concomitant dose
25 over whole
course
As required
Maximum
concomitant MU
50MU
The clinician acting as practitioner may deem it necessary to justify further concomitant
exposures these will be documented as extra exposures in the clinical notes.
For a treatment routine that involves a conventional CT scan followed by 10 daily MV portal imaging
pairs at 2 MU each (a total MU of 20). The total effective dose is about 20 mSv. Using the ICRP 60 risk
factor of 5% per Sv there is an estimated probability of a 0.1% risk of radiation induced cancer in the
patient’s lifetime.
For the maximum MU stated above of 50 the effective dose (including the CT scan) will be 38mSv;
giving a risk factor of about 0.2%
5.8 Chemotherapy Schedules (SCLC)
a. Cisplatin / etoposide (concurrent chemoradiotherapy)
Cisplatin 60 mg/m2 IV infusion day 1
Etoposide 120 mg/m2 IV infusion days 1, 2 & 3
Repeat every 21 days
b. Cisplatin / etoposide (LS, good PS, too large for concurrent treatment)
Cisplatin 60 mg/m2 IV infusion day 1
Etoposide 120 mg/m2 IV infusion day 1
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Etoposide 100 mg bd PO day 2 & 3
Repeat every 21 days
c. Carboplatin / etoposide
Carboplatin AUC 5 IV day 1
Etoposide 120mg/m2 IV infusion day 1
Etoposide 100mg bd PO days 2 & 3
Repeat every 21 days
d. Topotecan
2.3mg/m2 PO daily on days 1,2,3,4,5
Repeat every 21 days
e. CAV
Cyclophosphamide
Doxorubicin
Vincristine
2
1000 mg/m IV infusion over 10 minutes day 1
50 mg/m2 IV bolus day 1
2
1.2 mg/m (max. 2 mg) IV bolus day 1
Repeat every 21 days
Consider Cyclophosphamide 750mg/m2 and Doxorubicin 40mg/m2 with Vincristine 1.2 mg/m
if performance status 2
2
5.9 Guidelines for G-CSF
Growth factors are not routinely used for lung cancer patients. They can be used to maintain dose
intensity in those patients receiving treatment with curative intent i.e. those on the concurrent
chemoradiotherapy for LS-SCLC and those on adjuvant treatment for NSCLC following an R0
resection.
5.10 Hickman Lines
Warfarin 1mg PO daily is not recommended when a Hickman line is placed
The following Patient Information leaflets are available to be given when appropriate:
No. 3 A guide to Hickman Lines.
15
6. Non-Small Cell Lung Cancer (NSCLC)
6.1 TNM Staging
6.1.1 Primary Tumour (T)
Tx Primary tumour cannot be assessed, or tumour proven by the presence of malignant cells in
sputum or bronchial washings but not visualised by imaging or bronchoscopy
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour 3 cm or less in maximum dimension, surrounded by lung or visceral pleura, and without
bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not the main
bronchus)
T2 Tumour with any of the following:
 more than 3 cm in maximum dimension
 involves main bronchus 2cm or more distal to carina
 invades visceral pleura
 associated with atelectasis or obstructive pneumonitis extending to hilar region, but does
not involve the entire lung
T3 Tumour of any size that directly invades any of the following:
 chest wall (including superior sulcus tumours), diaphragm, mediastinal pleura, parietal
pericardium; OR
 Tumour in the main bronchus less than 2 cm distal to carina but without involvement of the
carina, OR
 with associated atelectasis or obstructive pneumonitis of the entire lung
T4 Tumour of any size invading any of the following:
 mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina OR
 separate tumour nodules in the same lobe OR
 tumour with malignant pleural effusion
6.1.2 Regional Lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastases
N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary
nodes including involvement by direct extension of the primary tumour
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or
supraclavicular lymph node(s)
6.1.3 Distant Metastasis (M)
Mx - Distant metastasis cannot be assessed
M0 -
No distant metastasis
M1 -
Distant metastasis present or nodules in different lobes
6.2 Stage Grouping (AJC)
Stage IA
T1 N0 M0
Stage IB
T2 N0 M0
Stage IIA
Stage IIB
T1 N1 M0
T2 N1 M0
T3 N0 M0
16
Stage IIIA
T1-3 N2 M0
T3 N1 M0
Stage IIIB
T4 N0-3 M0
T1- 4 N3 M0
Stage IV
M1 or nodules in different lobes
6.3 Diagnosis And Staging Investigations (NSCLC)
All patients referred urgently for suspected lung cancer should have the following initial investigations:
 Full history and examination
 Full blood count
 U&E
 LFT's
 Bone profile
 Chest x-ray
 Bronchoscopy + / - TBNA or EBUS or image-guided needle biopsy
 Histology (preferably) or cytology
 CT scan of the thorax and upper abdomen (including liver and adrenal glands)
 FEV1 and FVC
In those unfit for bronchoscopy or image-guided needle biopsy, confirmation of diagnosis may be
sought using sputum cytology
In those patients where radical treatment is contemplated (either with surgery or radiotherapy) full
staging should be completed using:
 PET-CT scan
 Full pulmonary function testing (including TLCO)
 MRI brain (or CT brain with contrast)
In patients where greater than six weeks have elapsed between staging investigations and the start of
treatment, restaging should be undertaken to ensure the patient remains suitable for treatment with
radical intent.
In symptomatic recurrent disease:
 Full history and examination
 FBC
 U&Es
 LFTs
 Bone profile
 CXR
 CT scan of the chest and upper abdomen and bone scan as appropriate
 CT or MRI brain as appropriate
 PFTs if indicated
Patient information leaflet specific to local treatment centre:
Bronchoscopy leaflet
CT guided biopsy leaflet
PET leaflet
6.4 Management of Localised Disease (With Radical Intent)
6.4.1 Surgery
At present, there are no thoracic surgical services within the network. Patients are referred outwith the
network by means of a letter from the supervising clinician to the surgeon of choice (accompanied by
MDS form). The hospitals of referral are Harefield, Papworth, UCH and St Mary’s.
17
The surgeon will review potentially suitable cases locally; otherwise patient will be discussed by the
surgeon at their surgical centre. All surgeons to whom patients are referred follow BTS surgical
resection guidelines
Criteria for operability (not comprehensive) -
stage I and II disease with adequate lung function and
performance status
Criteria for inoperability (not comprehensive) - inadequate respiratory function; medical condition
precluding surgery e.g. CCF, MI less than 6 months
ago, unstable angina; stage IIIb and IV disease.
If the PET-CT scan indicates N0 disease, the surgeon may proceed directly to thoracotomy. Should
the PET-CT scan indicate N1 disease, mediastinoscopy prior to surgery is recommended by NICE. If
the PET-CT scan indicates N2 disease but the suspect nodes are of normal size then a
mediastinoscopy may be performed to confirm the PET scan findings.
Surgery is via lobectomy, bi-lobectomy or pneumonectomy.
If, after staging, the choice of treatment lies between wedge resection and radical radiotherapy, the
best treatment option is still uncertain. This necessitates discussion between surgeon, oncologist and
patient.
6.4.2 Preoperative Chemotherapy and Radiotherapy
These should only be offered within the context of a clinical trial
6.4.3 Postoperative Adjuvant Chemotherapy
This should be discussed with all patients who undergo microscopic complete resection of their lung
cancer with pathological Stage IIA or greater. Treatment should ideally commence within six weeks of
surgery, but this may be difficult to achieve due to recovery times following thoracotomy.
6.4.4 Postoperative Radiotherapy
6.4.4.1 Indications
Routine post-operative radiotherapy should not be considered outside a clinical trial. However,
postoperative radiotherapy may be considered, at clinician’s discretion, in the following
situations:
 Macroscopic incomplete excision
 Microscopic involvement of resection margins
 Pathological N2 disease
6.4.4.2 Radiotherapy
 The patient will be treated using three-dimensional conformal radiotherapy
 A contrast and non-contrast CT planning scan will be performed with the patient in the
treatment position (Document EP3CT. 15)
- supine with arms above the head, using the external immobilization frame, and in
quiet respiration. A sequential technique is used with slice thickness no greater than
5mm at 120kv (Document EP3CT. 7).
- In occasional patients other positions and immobilization techniques may be used
(e.g. apical tumours may benefit from shell construction).
 The CTV will be outlined using information from pre- and post-operative imaging, surgical
notes and histopathology report. In those with macroscopic residual disease, a GTV will be
outlined. GTV will be expanded to CTV using a 5mm margin in all directions. CTV will be
expanded to PTV using a 10mm margin in the antero-posterior and medio-lateral directions
and a 15mm margin cranio-caudally.
6.4.4.3 Dose prescriptions
All doses are prescribed to the ICRU reference point (intersection point).
18
1. CHART – 54Gy in 36 fractions over 12 days. Treatment is delivered 1.5Gy per fraction,
treating three times daily with a minimum six hour interfraction interval (maximum spinal cord
dose 40Gy and maximum V20 < 35%)
2. 50Gy in 20 fractions over four weeks (maximum spinal cord dose 40Gy; maximum V20 <
35%) (smaller volumes preferred)
3. 60Gy in 30 fractions over six weeks (maximum spinal cord dose 48Gy; maximum V20 < 35%)
Leaflets will be given where appropriate
No. 1 An introduction to radiotherapy
No. 5 A guide to radiotherapy at Mount Vernon cancer centre
No. 20 CHART radiotherapy
No. 32 Radiotherapy to the chest
6.4.5 Radical Radiotherapy
Inclusion criteria (not comprehensive)
-
Exclusion criteria (not exhaustive)
-
Performance status 0 or 1
Inoperable Stage 1-3 disease where a radical course of
radiotherapy may be given without exceeding normal
tissue tolerances
Patients who decline surgery or where there is a high
surgical risk due to an unrelated comorbidity may be
considered for treatment
Patients with Stage IV disease
Patients with a cytology positive pleural effusion
Patients with poor respiratory function
Patients unwilling or unable to cooperate with the
planning / treatment process
Treatment should be ideally delivered using CHART (NICE guidance)
6.4.5.1 General considerations
All patients potentially suitable for radical radiotherapy will be discussed at the radical lung
cancer meeting (Monday 8.15am, Radiotherapy Outpatient Clinic 3).
6.4.5.2 Radiotherapy
 The patient will be treated using three-dimensional conformal radiotherapy
 A contrast and non-contrast CT planning scan will be performed with the patient in the
treatment position (Document EP3CT. 15)
- supine with arms above the head, using the external immobilization frame, and in quiet
respiration. A sequential technique is used with slice thickness no greater than 5mm at
120kv (Document EP3CT. 7).
- In occasional patients other positions and immobilization techniques may be used (e.g.
apical tumours may benefit from shell construction).
 The GTV is outlined taking bronchoscopic findings; diagnostic CT scan and PET-CT scan
results, and mediastinoscopic or thoracotomy findings. A 5 mm expansion is performed in all
directions to give the CTV and the CTV will be further expanded by 10mm in the anteroposterior and medio-lateral directions and 15mm in the cranio-caudal direction to give the
PTV.
Treatment will be in a single phase with 6MV photons.
The treatment plan will be verified in the simulator. Images are taken of all treatment fields at
85kv 80mA 5MS and it will be ensured that disease does not move out of the treatment fields
with 2 cine loops of at least three breaths. (Documents Bronchus CTCF ACUITY EP 9.9 and
CINE LOOP EP 9.2).
19
6.4.5.3. Dose prescriptions
All doses will be prescribed to the ICRU reference point / intersection point.
CHART - patients receive 1.5Gy fractions three times per day with a minimum six hour
interfraction interval, over 12 consecutive days starting on a Monday and including the
weekend. Maximum spinal cord dose < 40Gy and maximum V20 < 35%. (As the Dose
Volume Histogram does not give spatial information and the absolute maximum V20
is not known for CHART there may be some discretion regarding the maximum
acceptable V20)
This is the preferred regime.
Where patients refuse CHART or insufficient slots are available, treatment can be given using:
1.
55Gy in 20 fractions over 4 weeks (maximum spinal cord dose < 40Gy; maximum V20 <
32%)
2.
64-66Gy in 32-33 daily 2Gy fractions (NICE recommendation) (maximum spinal cord dose <
44Gy and maximum V20 < 35%)
6.4.6 Chemotherapy prior to radical radiotherapy
This should only be considered in the context of a clinical trial
Leaflets will be given where appropriate
No. 1 An introduction to radiotherapy
No. 5 A guide to radiotherapy at Mount Vernon cancer centre
No. 20 CHART radiotherapy
No. 32 Radiotherapy to the chest
6.5 Management with Palliative Intent
The majority of patients present with incurable disease and are treated with palliative intent. Patients
may have localised disease but have a poor performance status or significant co-morbid conditions or
they may present with disseminated disease. Active supportive care remains is recommended for
patients with minimal symptoms and/or poor performance status.
6.5.1 Chemotherapy: First Line
Chemotherapy should be considered for all patients with PS 0 or 1 who do not fall into a radical
treatment category. Patients with PS2 can receive chemotherapy at clinician’s discretion. Patients
treated with chemotherapy optimally should receive a platinum-containing, two-drug regime. Patients
who have a non-squamous histology should preferentially receive pemetrexed.
6.5.1.1 Investigations prior to chemotherapy:
 FBC
 U&Es
 LFTs
 Bone profile
 Measured GFR (either EDTA or 24hr urine collection) – ideal, but at clinician’s discretion
 Height and weight
6.5.1.2 Approved regimes:
Gemcitabine / carboplatin
Gemcitabine / cisplatin
Pemetrexed / cisplatin
Vinorelbine / carboplatin
Vinorelbine / cisplatin
Paclitaxel / Carboplatin
Docetaxel / cisplatin
Docetaxel / carboplatin
20
Gemcitabine
Vinorelbine
Carboplatin is preferred to Cisplatin in the palliative setting.
6.5.1.3 Duration of treatment:
4 cycles of chemotherapy are recommended. There should be both a subjective and objective
response assessment (using chest X ray or CT scan) to treatment by the start of course 3.
Treatment should be discontinued if there is objective evidence of progressive disease or
significant toxicity. A further objective assessment of disease should be undertaken at the end of
treatment.
Patients with locally advanced disease, initially too great for treatment with surgical resection or
radical radiotherapy, may show such reduction of disease that resection or high dose
radiotherapy may be reconsidered. Such patients should be discussed in the Chest MDT.
In those patients with symptomatic residual disease following chemotherapy, palliative
radiotherapy can be considered.
Leaflets will be given where appropriate
No. 2 An introduction to chemotherapy
Individual cancer backup chemotherapy leaflets (e.g. carboplatin, gemcitabine etc.)
6.5.2 Radiotherapy (Thoracic)
All patients with symptomatic thoracic disease should be considered for immediate palliative
radiotherapy. Higher doses of radiotherapy have been shown to produce a modest survival benefit in
patients with a good performance status and localized disease.
Patients are planned using information available from imaging, usually chest X ray and CT scan, and
bronchoscopy. The treatment position is supine and anterior and posterior opposed fields with 6-10MV
photons are used. The treatment fields should encompass known disease with a margin adequate to
account for respiratory motion. Normal lung may be shielded with multi-leaf collimation. The extent of
disease is often such that the mediastinum will be encompassed in the treatment fields, but not the
contralateral hilum. Usually disease will be encompassed in 12cm x 10cm field. Dose prescriptions
Patients with good PS and no metastases should receive either:
1. 39Gy in 13 fractions over two and a half weeks (daily treatment)
2. 27Gy in 6 fractions over three weeks (treatment twice per week)
3. 20Gy in 5 daily fractions over a week (if more convenient for patient)
Patients with poor performance status or distant metastatic disease should only receive treatment for
thoracic symptoms uncontrolled by medical or chemotherapy treatment. A single fraction of 10Gy midplane dose should be administered to known disease in the chest again using anterior and posterior
opposed fields and 6MV photons. Normal lung may be shielded with multileaf collimation.
Premedication with oral dexamethasone 8mg 30 minutes prior to treatment can reduce / delay the
onset of “flu-like” symptoms sometimes experienced by those receiving large fractions of thoracic
radiotherapy and can be given at physician’s discretion. Metoclopromide 10mg PO may also be given
prior to radiotherapy at physician’s discretion.
At present it is unclear whether patients benefit from immediate multi-modality treatment with
combination chemotherapy and radiotherapy in the palliative setting.
Leaflets will be given where appropriate
No. 1
An introduction to radiotherapy
21
No. 5
No. 32
No. 33
No. 27
No. 11
A guide to radiotherapy at Mount Vernon cancer centre
Radiotherapy to the chest
Coping with a short course of radiotherapy treatment
Coping now that your radiotherapy is finishing.
Skin care after treatment.
6.5.3 Endobronchial Brachytherapy
Endobronchial brachytherapy may be indicated in one of the following situations:
1. Inoperable tumours with predominantly endobronchial symptoms e.g. haemoptysis, or
bronchial obstruction (these patients are referred to Miss Beddow consultant thoracic surgeon
at Harefield Hospital, for initial cryotherapy which is then followed by endobronchial
brachytherapy under the care of Professor Hoskin)
2. Patients with symptoms of cough, haemoptysis or bronchial obstruction after previous external
beam radiotherapy
The dose delivered is 15Gy at 1cm depth in one fraction
Leaflets will be given where appropriate
No: 23a Bronchial brachytherapy
6.5.4 Special Situations:
6.5.4.1 PANCOAST TUMOURS
Consider radical radiotherapy for these tumours, but if they are not suitable then parallel
opposed fields may be used and 27Gy midplane dose administered in 6 fractions over 3 weeks
to the primary tumour and mediastinum followed by a further fraction of 4.5Gy midplane dose to
the tumour excluding the spinal cord. Other acceptable dose prescriptions are 30Gy in 10
fractions over two weeks followed by 15Gy in 5 fractions off cord.
6.5.4.2. SUPERIOR VENA CAVA OBSTRUCTION
In those patients who present with an SVCO effort should be made to obtain a definitive
histological diagnosis prior to stent placement. This is especially important in patients where
there is high probability that the diagnosis may be lymphoma or germ cell tumour where
chemotherapy is the definitive treatment.
If a stent is appropriate patients are referred to appropriate radiological departments for
venography with a view towards stenting, with thrombolysis if necessary. If SVCO is due to
lymphoma or germ cell tumour, venography is still recommended, as there may be superadded
thrombus on stenosis and thrombolysis may be performed but insertion of a stent is not
recommended as the patients are potentially curable and the long-term morbidity of the stents is
not known. Response to stenting is rapid.
Radiologists who offer venography and stenting and thrombolysis include Dr N Demani (WGH);
Dr Mordani (MVH), Dr J Partridge (Harefield Hospital), Drs A Lynn and S Khan at the QE2
Hospital, Welwyn Garden City, Dr Kevin Lotzof at Barnet General Hospital, Dr Warriner at Luton
and Dunstable Hospital and Dr Mark Charig at Wexham Park Hospital.
If not suitable for stent then;
1. NSCLC - treat with palliative radiotherapy ensuring that all the disease that may be
causing venous obstruction is included in the treatment fields. The superior limit of the
fields may therefore need to be superior to D1
2. SCLC – treat as per SCLC protocol, usually with immediate platinum containing
chemotherapy or radiotherapy if poor performance status
22
In patients presenting with SVCO, who gain significant symptomatic benefit from stenting,
palliative treatment, including radiotherapy, can be delayed until staging investigations have been
completed.
6.5.5 Chemotherapy: Second Line
In those patients who remain of good performance status, but have progressive disease, second line
treatment can be considered. Both erlotinib and docetaxel are funded. In general, no more than four
cycles should be given and an objective response assessment sought after two cycles. At clinician’s
discretion single agent vinorelbine or gemcitabine may be used. Pemetrexed can be delivered to
patients with non-squamous histology in the second line (if they have not previously received it) via the
Lilly discount scheme.
6.5.6 Palliative Radiotherapy (Non-Thoracic)
6.5.6.1 BONE METASTASES
Standard treatment for bone pain is an 8Gy single fraction. Consider 20Gy in 5 fractions for
large area. If vertebrae, prescribe to the depth of the spinal cord (usually 4 cm for the dorsal
spine and 5 cm for the lumbar spine, treating posteriorly). If the bore lesion is proximate to the
primary tumour, both can be treated at the same time using a parallel opposed field.
If the cortex is eroded (> 50%) on a long bone e.g. femur or humerus, consider referral to an
orthopaedic surgeon for internal fixation (patient will generally need a life expectancy of > 3
months).
6.5.6.2 BRAIN METASTASES
Radiotherapy to the whole brain can be considered to a dose of 12Gy in two fractions; 20Gy in 5
fractions or 30Gy in 10 fractions depending on performance status with dexamethasone cover
during radiotherapy.
6.5.6.3 SPINAL CORD COMPRESSION
The MRI scan is used to define the level(s) of compression. If there is good residual function
disease is usually treated with 20Gy in five daily fractions, prescribed to depth of the spinal cord
measured from the MRI scan.
If complete paralysis for more than 24 hours treat with single 8Gy fraction for pain relief.
At weekends consider treatment with clinical fields with simulation on Monday.
Leaflets will be given where appropriate
No. 33 Coping with a short course of radiotherapy treatment.
No. 19a Hair loss from radiotherapy treatment.
6.5.7 Hypercalcaemia
Ensure adequate hydration with IV normal saline to promote a diuresis. In those with adequate renal
and cardiovascular reserve, infusions rates of 1L per hour can be used.
Give IV disodium pamidronate 90mg in 500 mls normal saline by slow infusion as a single dose.
 Maximum rate of infusion = 60mg/hour except if renal impairment then maximum rate = 20mg/hour.
Pamidronate takes 4 to 5 days to achieve maximum effect and may be repeated. Mild pyrexia occurs
in approximately 15% of patients at 12 - 24 hours.
6.6 Follow Up
This is an area of controversy, but should be done as per local practice.
23
Close surgical follow-up leads to less <1% of radically treatable recurrences being identified (Liverpool
data). Options include regular oncological / respiratory follow-up (separately or shared); nurse-led
follow-up; patient-led follow-up; discharge to specialist palliative care services. At present the BTS
consider all these options acceptable.
6.7 Chemotherapy Schedules
In all schedules quoted (both for NSCLC and SCLC), the carboplatin dose of AUC 5 should be
prescribed only where a measured creatinine clearance is available. For those patients where the
Cockroft – Gault formula is used, carboplatin should be prescribed at AUC 6.
Where vinorelbine is used, this may be via the oral route in the palliative setting.
a. Gemcitabine / carboplatin
Gemcitabine 1250 mg/m2 IV bolus day 1 and day 8
Carboplatin AUC 5 IV infusion day 1
Repeat every 21 days
b. Gemcitabine / cisplatin
Gemcitabine 1250 mg/m2 IV bolus day 1 and day 8
Cisplatin 80 mg/m2 IV infusion day 1 (with appropriate prehydration)
Repeat every 21 days
c. Pemetrexed / Cisplatin
Pemetrexed 500 mg/m2 IV bolus day 1
Cisplatin 75 mg/m2 IV infusion day 1 (with appropriate prehydration)
Patients require vitamin supplementation: IM vitamin B12 1,000mcgm in the week prior to
cycle one and once every three cycles thereafter and folic acid 5mg (five doses in the seven
days preceding cycle one) and continuing daily thereafter until 21 days following the last
treatment cycle.
Repeat every 21 days
d. Vinorelbine / Carboplatin
Vinorelbine 60 mg/m2 PO day 1 and day 8
Carboplatin AUC 5 IV infusion day 1
Repeat every 21 days
e. Vinorelbine / Cisplatin
i. JBR.10
Vinorelbine 25mg/m2 IV bolus weekly for 16 weeks
Cisplatin 50 mg/m2 IV infusion day 1 and day 8
Repeat every 28 days for 4 cycles
ii. ANITA
Vinorelbine 25mg/m2 IV bolus weekly for 16 weeks
Cisplatin 100 mg/m2 IV infusion day 1
Repeat every 28 days for 4 cycles
iii. Palliative
Vinorelbine 25mg/m2 IV bolus day 1 and 8
Cisplatin 75 mg/m2 IV infusion day 1
24
Repeat every 21 days
f. Docetaxel / Cisplatin
Docetaxel 75 mg/m2 IV infusion day 1
Cisplatin 75 mg/m2 IV infusion day 1 (with adequate prehydration)
Premedication: 8mg bd dexamethasone oral 3 days, starting night before + 8mg IV 1 hour
prior to infusion.
Repeat every 21 days
g. Docetaxel / Carboplatin
Docetaxel 75 mg/m2 IV infusion day 1
Carboplatin AUC 5 IV infusion day 1
Premedication: 8mg bd dexamethasone oral 3 days, starting night before + 8mg IV 1 hour
prior to infusion.
Repeat every 21 days
h. Docetaxel
Docetaxel 75 mg/m2 IV infusion day 1
Premedication: 8mg bd dexamethasone oral 3 days, starting night before + 8mg IV 1 hour
prior to infusion.
Repeat every 21 days
i. Vinorelbine (single agent)
Vinorelbine 25 - 30mg/m2 IV bolus day 1 and day 8
Vinorelbine 60 mg/m2 PO day 1 and 8 (increased on second cycle to 80 mg/m2 PO day 1 and
8)
Repeat every 21 days.
j. Gemcitabine (single agent)
Gemcitabine 1250 mg/m2 IV bolus day 1 and day 8
Repeat every 21 days
k. Pemetrexed
Pemetrexed 500 mg/m2 IV infusion over ten minutes day 1
Repeat every 21 days
Patients require vitamin supplementation: IM vitamin B12 1,000mcgm in the week prior to
cycle one and once every three cycles thereafter and folic acid 5mg (five doses in the seven
days preceding cycle one) and continuing daily thereafter until 21 days following the last
treatment cycle.
l. Erlotinib
150mg PO od continuously
Patients receiving this regime need to be seen every 4 weeks with a FBC; U&Es and LFTs. Dose
should be reduced to 100mg PO od or drug stopped if develop grade 3 / 4 toxicity. Objective
evidence of progression should be sought on the development of new symptoms and / or every
three months.
25
7. Endobronchial Treatment
Dr Vladimir Anikin provides a service based at Harefield Hospital for cryotherapy, stent insertion and
requires referral to the Brompton Hospital in London.
7.1 Indications for Endobronchial Treatment
Treatment is only offered to patients whose main symptoms are due to endobronchial disease. The
benefits of treatment vary according to the level of obstruction, being most marked in patients with
centrally situated tumours, e.g. trachea, main carina and proximal main bronchi, but diminish with
more peripheral obstruction. Patients are likely to benefit from treatment if patent airways supplying
viable lung tissue exist beyond the point of obstruction.
7.2 Methods of Treatment
7.2.1 Cryotherapy
This is given with a Neodymium YAG laser under general anaesthesia. Intra-luminal tumour is first
coagulated and then debrided with large biopsy forceps. Due to the haemostatic properties of the
laser, treatment is achieved relatively bloodlessly.
7.2.2 Airway stents
We now use a variety of airway stents for different situations. For newly diagnosed patients with airway
narrowing that may improve once they have completed chemotherapy and/or radiotherapy, we use
covered expandable metal stents that can be removed when no longer required. This avoids the risk of
a delayed foreign body reaction in the airway which may develop after several years.
For patients with limited life expectancy (who have usually relapsed after oncological treatment), we
use Gianturco stents. These stents cannot be removed once deployed, but their expansile properties
usually provide excellent palliation for the remainder of the patient’s life.
7.2.3 Endobronchial radiotherapy
This is administered under intravenous sedation with topical anaesthesia. After placing an after loading
catheter bronchoscopically within the involved airway, a high activity Iridium-192 source is loaded by
remote control into the catheter and then placed alongside the tumour. The dose of radiation falls off
steeply with distance, according to the inverse square law, such that very high doses are delivered to
the tumour and peribronchial tissues but negligible doses to the lung parenchyma, spinal cord and
oesophagus. Treatment is completed within 10-15 minutes, enabling doses of up to 10Gy to be
delivered in a single fraction at 1cm radius from the source. Treatment has the advantages of being
simple and easy to administer and can be offered on a day case basis. This can be given after
external beam treatment and radical doses may be delivered in certain circumstances.
7.2.4 Results of Treatment
All three treatment modalities have been shown to lead to significant improvements in symptoms of
breathlessness, and in indices of lung function and performance status. Laser treatment and airway
stenting are particularly useful in patients with impending asphyxia due to tracheal obstruction. The
improvement is immediate and enables subsequent management to be offered electively and in
greater safety. In some situations, it is possible to offer curative tracheal resections after laser
treatment.
The important limitation of laser treatment is that the response may be relatively short lived. However,
the period of symptomatic relief may be prolonged with the addition of endobronchial radiotherapy
such that two thirds of patients require no further airway treatment during their lifetime.
26
8.
Palliative Care
A significant number of lung cancer patients may require palliative care from diagnosis. All clinicians should
have core palliative care skills. Not every patient with lung cancer who has pain or other symptoms needs
to be referred for specialist palliative care. A great deal of palliative care will be delivered by the hospital
and primary health care teams. The approach to palliative care incorporates the best in physical, social,
psychological and spiritual care for patients and their families. Optimising pain and symptom control is
important, also integrating care in the hospital and home.
The patient can be referred to the hospital palliative care team at each trust or to the community teams run
by the primary care trusts. Liaison is often via the lung cancer nurse specialist.
8.1 Indications for a Referral
Referrals are accepted at any time in response to a request for:
 Assistance with the management of pain and symptom control.
 Help managing the interface between acute and palliative strategies.
 Advice/support for emotional, psychological or spiritual distress of patients and/or their carers
related to their disease.
 Assistance with care planning, especially in relation to discharging dying patients or those with
complex needs.
 Help in caring for those who are terminally ill.
 Clarification of ethical dilemma related to palliative care.
27
9. Network Guidelines for Communication of Diagnosis
Investigations should be complete and a decision to treat made within 31 calendar days of patient referred.
The patient will be seen whenever possible by the same doctor throughout their diagnostic pathway and if
possible the lung cancer nurse specialist should be present and support the patient through their diagnostic
pathway. Junior doctors should be encouraged to read the BTS document ‘What to tell a patient with lung
cancer’ and all clinicians should have training in breaking bad news (ideally having attended the Advanced
Communication Programme). If the patient is going to be given the diagnosis of lung cancer, a relative,
partner or friend is invited together with a lung cancer nurse, specialist/palliative care nurse or another
experienced member of staff, whenever possible. The patient can be introduced to future carers at this
point e.g. surgeon, radiotherapist, oncologist, and palliative care nurse if they are ready for this. The GP is
informed by telephone or fax on the day of diagnosis by a member of the clinical team.
28
10.
Network Guidelines – Key Worker Role
Each patient will be offered a Key Worker identified by the Lung Cancer Clinical Nurse Specialist in
agreement with the patient. The Key worker will help to co-ordinate the patients care plan and assist them
accessing information & advice. The patient will be given written contact details for the key worker. The key
worker may change i.e. a patient entered into a clinical trial may have the research nurse as the key worker
initially. Patients who are undergoing surveillance for early lung cancer detection again may have the early
lung cancer research nurse as the key worker. Patients who are receiving active symptom control only may
have the palliative care clinical nurse specialist /nurse consultant as the key worker.
29
11. Guidelines for Imaging in Suspected Lung Cancer
The role of imaging departments is to support the Lung MDT in the prompt diagnosis and staging of
patients with suspected lung cancer. MVCN Guidelines are based on NICE Clinical Guideline 24
(Diagnosis and treatment of lung cancer -2005). The network acknowledges that local practice will vary
slightly in the absence of clear evidence, in response to patient choice, local preferences and expertise.
Appointment times should ensure that no patient breaches the 62 day cancer target
11.1 The CXR in suspected lung cancer
 CXR will be the initial investigation of choice for most patients. Imaging departments should have a
low threshold for justification of CXR in a symptomatic patient. There is no indication for CXR
screening for lung cancer.
 There should be no unnecessary delay in the appointment and report for CXR.
 Each unit should have a robust alert mechanism in place for suspicious CXR to ensure prompt
referral to chest physician / MDT.
11.2 CT in suspected lung cancer
 Patients with suspected lung cancer on CXR should be referred by the MDT / chest physician for
staging CT of chest and abdomen. With an equivocal CXR (e.g. prominent hilum) it is reasonable
for CT to be arranged by the patient’s GP.
 Units may put a fast track mechanism in place for CT appointments. All cases of suspected cancer
should undergo CT within 2 weeks.
 CT should ideally be performed prior to bronchoscopy
 CT protocols should be set locally, the minimum requirement is for contrast enhanced CT of Chest
and abdomen (supraclavicular regions should be included). Head CT may also be included in the
initial staging study.
 The reporting radiologist is not required to be a lung MDT radiologist.
11.3 CT /PET in suspected lung cancer.
 Two main indications.
o Assessment of solitary pulmonary nodules – greater than 1cm.
o Staging of NSCLC – Patients undergoing work up for radical treatment.
 The MDT may opt for CT/PET in other circumstances eg assessment of suspected Mesothelioma
or post treatment follow up.
 CT/PET images and report should be available for review at MDT.
11.4 MRI
 Should be available for staging in selected cases, eg apical tumours. Scanning protocol should be
set locally.
 May be used for assessment of equivocal liver or brain lesions
 Is the modality of choice for cord compression.
11.5 Ultrasound
 May be useful in the assessment of equivocal liver lesions.
11.6 Isotope Bone scanning
 For the evaluation of bony metastatic disease
11.7 Image guided Biopsy
 All centres should have the capacity for CT and ultrasound guided biopsy. Cases for biopsy should
all go through the MDT where the most appropriate target site can be determined.
 CT guided lung biopsy service should comply with the BTS guidance on lung biopsy. Core biopsy
is desirable, this may be supplemented by or substituted with FNA in some cases.
 Ultrasound guided biopsy may be targeted to pleural and peripheral lung lesions, nodal or liver
deposits. It is the evaluation of choice for abnormal supraclavicular nodes.
30
11.7.1 Flowchart for the role of diagnostic imaging in the diagnosis of lung cancer
See Appendix 9.
11.8 Radiological management in Lung cancer patients
 Each unit should have arrangements in place for SVC stenting when required. Not all radiology
departments will offer this service so patients may need to be transferred.
 MDTs should be aware of selection criteria for percutaneous radiofrequency ablation and consider
referral to Harefield Hospital for this procedure as a management option.
11.9 Role of Radiologist in the Lung MDT
 Review of imaging for all cases prior to the meeting to confirm report accuracy, identify errors /
omissions and stage patients using the IASLC TNM system.
 Present imaging findings to the MDT
 Advise the MDT on image guided biopsy
 Feed back errors to the reporting radiologist.
11.10 Follow up imaging in lung cancer
 CT is the modality of choice in evaluating response to treatment
 There is no current indication for routine CT follow up, CXR follow up may be employed.
Sue Buckingham
Simon Allen
June 2010
31
12. Operational Policy for Respiratory Pathology
12.1 Introduction
This policy takes into account the relevant Royal College of Pathologists’ (RCPath) minimum dataset for
Lung Pathology and the Tissue Pathway for Pulmonary Pathology. It describes how this dataset and
guidelines are to be interpreted within the Mount Vernon Cancer Network (MVCN) and describes recent
changes in practice.
The MVCN comprises three main Hospital Trusts: West Hertfordshire Hospitals NHS Trust (WHHT), East
and North Hertfordshire NHS Trust (E&NH) and Luton and Dunstable NHS Foundation Trust (L&D).
All lung cancer cases should be reviewed by the local Multi-disciplinary Team (MDT). There should be a
Network Lead pathologist but each Trust should have a local lead pathologist for pulmonary cancer
pathology. The Lead pathologist for the Network should also attend the Tumour Site-Specific Group
(TSSG) meetings. All the leads should participate in a relevant EQA scheme and in local audit, including
correlation between biopsy and resection, where relevant. There is currently no accepted national lung
cancer EQA. Specimens should be reported to an agreed timeframe to enable case discussion at a
planned lung cancer MDT meeting.
12.2 Description of the Service
Each Trust in the Network produces pulmonary biopsy and cytology specimens but none undertake
thoracic surgery, which is performed at Harefield Hospital (for patients from L&D and WHHT) and Papworth
(for patients from E&NH).
12.3 Specimen Types
Histopathology
Bronchial biopsies
Transbronchial biopsies
Transthoracic (often CT-guided) biopsies
Pleural biopsies
Lymph node biopsies
Cell blocks from Cytology samples
Cytology
Bronchial washings
Bronchial lavage
Bronchial brushings
Trans-bronchial needle aspirates (TBNA) - direct slides
liquid-based
Pleural effusions
12.4 Specimen Examination
Each pathology service should have a defined protocol for all the above types of specimen (some of which
may be included under more generic headings), taking into account the RCPath guidance. The protocols
should be subject to regular review by the relevant lead pathologist.
NB. It is now recommended that residual Cytology specimens in positive cases are processed to
cell block to enable further testing including immunohistochemistry and, particularly, mutational
analysis. It is therefore important to liaise with clinical colleagues to facilitate the delivery of liquid
based specimens wherever possible and to have a robust system in place in the laboratory for cell
block production.
12.5 Reporting Practice
There has been a recent major proposed change in the classification of lung adenocarcinomas by the
International Association for the Study of Lung Cancer (IASLC) in association with the American Thoracic
Society and the European Respiratory Society. This was published in the Journal of Thoracic Oncology in
February 2011 and is available free of charge (see link below). This is partly driven by advances in lung
cancer therapies which require non-small cell carcinomas (NSCLC) to be separated accurately into
32
squamous carcinoma and adenocarcinoma, wherever possible. This is elaborated in the most recent (April
2011) RCPath guidelines and dataset (link below in references) but the essential points for biopsy and
cytology specimens are as follows:






The term “bronchiolo-alveolar carcinoma” should no longer be used, being replaced by
“adenocarcinoma with a lepidic growth pattern” for those tumours growing along pre-existing alveolar
walls
If there is morphological evidence of squamous carcinoma or adenocarcinoma, the case should be
reported as such, describing a subtype if apparent
If there is evidence based on immunohistochemical or mucin stains of squamous carcinoma or
adenocarcinoma, the case should be reported as NSCLC, favour squamous carcinoma or NSCLC,
favour adenocarcinoma
The most useful stains in this regard are likely to be mucin stains and TTF-1 (generally positive in
adenocarcinomas, though 25% of adenocarcinomas may be negative for TTF-1) and CK5 and p63
(generally positive in squamous carcinomas)
If only two stains are possible, TTF-1 and p63 are the most likely to be useful
For cytology specimens (in addition to the above comment about cell blocks):
o The report should indicate if the diagnosis is definite or equivocal
o The report should be as precise as possible
o Papanicolaou staining should be used (apart from on-site rapid
o assessment)
12.6 Mutation Analysis
The tyrosine kinase inhibitors (TKI) gefitinib (Iressa) and erlotinib (Tarceva) are licensed for the treatment
of locally advanced or metastatic NSCLC which harbours “activating” Epidermal Growth Factor Receptor
(EGFR) mutations, usually L858R or del19. Tumours which are reported as adenocarcinoma or NSCLC,
favour adenocarcinoma should be tested for EGFR mutation. The mutation and TKI response rate of
tumours reported as squamous carcinomas or NSCLC, favour squamous carcinoma is much lower than
that in adenocarcinomas and the testing of squamous tumours yields a very low rate of positive results.
The molecular test can be performed on paraffin block (including Cytology cell block) material as well as
cytology slides or fluid preparations (depending on testing lab protocols) and the process can detect 1% of
mutated DNA in a background of wild-type DNA.
Other mutations which may become clinically relevant in the future include KRAS (generally in codons 12,
13 or 61), where a positive mutation reliably predicts lack of response to TKI therapy, and detection of the
EML4/ALK translocation, a possible target for the drug crizotinib.
Currently, these tests are performed at UCL (for WHHT) and Source Bioscience
(for L&D and E&NH).
12.7 Staging
Tumours will be staged according to the TNM classification of tumours (7th edition, UICC).
12.8 Multi-disciplinary team meetings
Each Trust will have a weekly MDT meeting in which biopsies and other local specimens will be discussed.
The local lead pathologist or a deputy will be present at these meetings.
12.9 Audit
All pathologists reporting pulmonary cancer specimens should participate in a relevant EQA scheme
(though there is, as yet, no national Lung Cancer EQA scheme and general EQA schemes will suffice for
now) and in local audit (including an assessment of consistency where more than one pathologist
participates in service provision). Audit may take the form of:




completeness of datasets
systematic logging of diagnostic agreement/disagreement during review of cases for MDTMs
correlation of tumour type between cytology and histology specimens and between cytology/biopsy and
resection specimens, where relevant
33


proportion of cases reported as NSCLC, NOS
correlation of tumour type with EGFR mutation
The results of the audit process should be discussed with all pathologists who participate in service
delivery.
12.10 Referral for Review or Second Opinion
The practice at WHHT, L&D and E&NH has been to refer to pathologists at the Royal Brompton and
Harefield NHS Trust for second or expert opinions.
12.11 References
1. Revised TNM staging for Lung Cancer (TNM7): http://www.atcs.jp/pdf/2009_15_1/4.pdf
2. Proposed IASLC/ATS/ERS classification of lung cancer
http://journals.lww.com/jto/Fulltext/2011/02000/International_Association_for_the_Study_of_Lung.4.aspx
3. Royal College of Pathologists, Dataset for Lung Cancer Histopathology
Reports, April 2011:
http://www.rcpath.org/resources/pdf/g048datasetlungapril11.pdf
4. Royal College of Pathologists, Tissue Pathways for Pulmonary Pathology,
May 2008:
http://www.rcpath.org/resources/pdf/g063tissuepathwaypulmonaryfinal_may08.pdf
34
Mount Vernon
Cancer Network
Appendix 1
URGENT TWO WEEK REFERRAL. SUSPECTED LUNG CANCER
This form to be used only if the patient fulfils the following criteria.
PATIENT DETAILS
Surname
GP DETAILS
Title
Forename (s)
Name
Practice Code
DOB
Age
Telephone
NHS Number
UBRN
Fax
Address
Postcode
Practice name/address
Telephone
Home
Postcode
Work
Translator required
Mobile
Specify language
Confirm that the patient has been given a 2-week wait referral information leaflet.
Confirm that the patient understands this is a referral to rule out suspected cancer.
Confirm that the patient is willing and able to attend in the next 2 weeks.
HAEMOPTYSIS IN SMOKER / EX SMOKER AGE > 40 yrs
CXR SUGGESTIVE OF MALIGNANCY
Report attached
Clinical Indicators –
haemoptysis
dyspnoea
chest signs
hoarseness
weight loss
unexplained finger clubbing
unexplained, persistent (>4wks) cough
cervical/supraclavicular lymphadenopathy
metastatic disease suspected, specify site:
SIGNS OF SVC OBSTRUCTION –
swelling of face/neck
fixed elevation of JVP
STRIDOR (consider emergency referral)
chest/shoulder pain
Additional information / other reasons for requesting urgent referral.
Current smoker
Ex-smoker
Exposure to asbestos
Smoking related COPD
Previous history of Ca
Specify site:
Please attach (if appropriate) printout of PMH, drugs and any other relevant information.
FAX East & North Herts NHS Trust: 01438 781835
If you have not received acknowledgement within 48hrs (Mon-Fri) please telephone 2/52 Wait Supervisor on
01438 285206.
FAX West Herts Hospitals Trust: 01727 897492
FAX Luton & Dunstable NHS Foundation Trust: 01582 497910 or 497911
FOR HOSPITAL USE ONLY
Date referral received:
1st appt date:
If 1st appt not accepted give reason/s:
nd
2 appt date:
35
Urgent “2 week wait” referral to Hospital
Why have I been referred to the hospital?
Your General Practitioner (GP) or Dentist has
asked for an urgent hospital appointment for
you, because you have symptoms that might
indicate cancer.
Does this mean I have cancer?
After the examination, we find that most
patients who come to us do not have cancer,
but another condition.
So why has my GP referred me?
GP’s can diagnose and treat most complaints
and illnesses themselves. However, on some
occasions they need to arrange for you to
have a hospital assessment, so that you can
see a specialist hospital doctor. The “two
week wait” appointment system was
introduced so that you can have
investigations done and be seen as quickly
as possible.
There could be several reasons why your
doctor has sent you for a special test, for
instance,




Your symptoms need further investigation
The treatment already prescribed has not
worked
Investigations your GP arranged have shown
some abnormal results
To make sure you don’t have a serious
disease.
Will I need any tests?
You may require specialised tests and these
tests may take place either before your first
appointment with the specialist hospital
doctor, or during it. This will help the doctor to
understand the cause of your symptoms.
Mount Vernon
Cancer Network
It is very important that you are available to
attend an appointment within two weeks of
seeing your GP. Please tell your GP if you if
you are likely to be away, or unable to attend
hospital for any reason, within two weeks
after you have seen your GP.
The hospital will send you an appointment
letter within a week; if there is not sufficient
time to send you a letter they will contact you
by phone.
Let your GP surgery know if you have not
heard from the hospital a week after you
have seen your GP.
If you are unable to attend the appointment
sent to you, please phone the hospital
immediately. It is important that you arrange
another date and time if you have to cancel
an appointment.
Your Hospital Appointment
At your first appointment, based on the
information from your GP and your
consultation with the hospital doctor, the
clinic staff will give you more information
about what will happen next.
Please feel free to bring someone with
you to your appointment.
If you have any queries regarding the
arrangements for your appointment,
please telephone the hospital you have
been referred to on one of the numbers
below Monday to Friday 8.30am - 5.00pm
East & North Herts NHS Trust:
Two-week-wait office: 01438 285206
West Herts Hospitals Trust:
Two-week-wait office: 01727 897199
What do I need to do now?
Make sure that your GP has your correct
address and telephone number, including
mobile number, if possible.
Luton & Dunstable Hospital Trust
Outpatient Appointment line: 0845 1270193
Further Information
NHS Choices (Guide to waiting times)
www.nhs.uk/
NICE (Clinical Guidelines, Referral for
Suspected Cancer) www.nice.org.uk
36
Appendix 2
Trust Guideline
for
Follow up of Pulmonary Nodules
A guideline recommended for use
In:
Medical department, mainly outpatients
By:
Medical staffing, mainly respiratory physicians
For:
Patients found to have solitary pulmonary nodules
Key Words:
Pulmonary, nodule, chest x-ray
Written by:
Dr S Buckingham (Consultant Radiologist)
Dr R Dent (Consultant Chest Physician)
Supported by:
Dr C Prendergast (Consultant Radiologist)
Dr I Chakravorty, Dr S Lok, Dr T Win & Aman Coonar (Consultant Chest Physicians)
Approved by:
Not Applicable
…………………………………..……….…… Chairman
……………………………………….…..…… Date
Ratified by Clinical Guidelines Steering Group:
…………………………………..……….…… Chairman
………………………………………….…..… Date
Guideline issued:
October 2009
To be reviewed before:
September 2011
To be reviewed by:
Consultant Radiologist & Chest Physician
Guideline supersedes:
Not Applicable
Location of archived copy:
Not Applicable
CGSG Guideline Registration No.
{Regn. No.}
Version No. {Version No.}
37
INTRODUCTION
The current guidelines on the follow-up of pulmonary nodules are based on the Fleischner Society
guidelines published in 2005. They are based on the best current evidence from the results of various
lung cancer screening trials around the world.
Until recently, it has been the accepted standard practice to regard all noncalcified pulmonary nodules
as potentially malignant lesions that require close monitoring until proved stable over a period of 2 years
[1;2]. This approach was adopted prior to the widespread use of computed tomography (CT) and was
based on the observation that a substantial proportion of noncalcified nodules that were detected at
chest radiography turned out to be lung cancers. These nodules were almost all larger than 5 mm in
diameter, and most were in the 1–3-cm range.
Since the introduction of helical CT in the early 1990s and multi–detector row CT in the late 1990s, the
detection of focal rounded pulmonary opacities ("nodules") as small as 1–2 mm in diameter has
become routine. In fact, the majority of smokers who undergo thin-section CT have been found to have
small lung nodules, most of which are smaller than 7 mm in diameter [3]. However, the clinical
importance of these extremely small nodules differs substantially from that of larger nodules detected
on chest radiographs, in that the vast majority are benign. This issue has been highlighted in several
recent publications on CT screening for lung cancer, and the positive relationship of lesion size to
likelihood of malignancy has been clearly demonstrated [4].
It is important to realise that follow-up strategies from the lung cancer screening programs are not
directly applicable to everyday practice [5-7]. Subjects who undergo lung cancer screening in most
countries are selected on the basis of age, substantial smoking history, absence of serious co morbid
disease, and willingness to participate in all necessary follow-up imaging and intervention. Also, these
programs tend to take an aggressive approach to follow-up and early intervention, with a view to
achieving the highest possible cure rate while gaining further insight into the behaviour and
characteristics of small malignant lesions. Therefore, patients whose nodules are detected incidentally
during the course of CT performed for other reasons should not necessarily be treated in the same way
as subjects in a screening program.
Nonetheless, although CT screening has not as yet been proved to help reduce mortality from lung
cancer, these programs provide an important source of information for determining the optimal
management of "incidental" nodules detected in other situations.
Our intent is to provide practical guidelines for the management of small pulmonary nodules that are
detected during the course of CT examinations performed for purposes other than lung cancer
screening. We recognize that this issue is complex and difficult to reduce to a simple algorithm. We
also realize that the definition of a pulmonary nodule is itself elusive, and that not all focal opacities
qualify as nodules. Yet, we believe that there is a practical need in the medical community for guidance
in this area.
38
BACKGROUND
On screening scans smokers > 50 years 50% have at least one non-calcified lung nodule
on CT. Also 10% develop a new nodule within a year, and in 12% a nodule is detected at
follow-up that was missed on initial CT [8].
Recommendations by the Fleischner Society, Radiology Nov 2005
The guidelines apply to the following;



Incidental nodule, e.g. no known malignancy
adult patients > 35 years
size = average of length and width
Search for previous CT scan, CXR
Patients classified as high-risk patients:
- smoking hx or other risk factors (asbestos, uranium, radon)
Patients classified as low-risk patients:
- minimal or no smoking hx or other risk factors
Recommendations by the Fleischner Society, Radiology Nov 2005
HIGH-RISK PATIENTS:
Smoking hx or other risk factors (asbestos, uranium, radon)
Nodule size Recommendation
≤ 4 mm
f-u at 12 months, if no change: stop! (unless non-solid, part-solid)
>5-6 mm
f-u at 6-12 and (if no change) 18-24 months
>7-8 mm
f-u at 3-6, 9-12, 24 months (if no change)
≥ 9 mm
f-u- at 3, 9, 24 months (CE-CT, PET, Bx)
LOW-RISK PATIENTS:
Minimal or no smoking hx or other risk factors
Nodule size Recommendation
≤ 4 mm
no f-u
>5-6 mm
f-u at 12 months, if no change: stop! (unless non-solid, part-solid)
>7-8 mm
f-u at 6-12 and (if no change) 18-24 months
≥ 9 mm
f-u at 3, 9, 24 months (CE-CT, PET, Bx)
39
WHAT IF PATIENT HAS A PREVIOUS MALIGNANCY?
The guidelines DO NOT apply to people with malignancy.
If the patient has a known malignancy then clearly follow-up is different and determined by
the relevant MDT decisions. Pertinent factors include site of primary, cell type, stage, and
whether early detection of lung metastases will affect care.
Special consideration should be given to known metastases for which metastectomy is
indicated (e.g. isolated colorectal lung mets, sarcoma etc), and this would be necessitate
a dual MDT approach.
Very aged population with other serious co-morbid conditions
This category has not been addressed separately in the Fleischner guidelines, but is one
of the major problems plaguing the reporting radiologist. This is because the radiologist is
not privy to the patient’s co morbid conditions at the time of reporting, and cannot make
judgments on this.
This is a difficult area and one which we should reach a consensus view.
My own feeling is that when reporting scans on the very elderly (arbitrarily over 80 years)
we should not give specific follow-up instructions, but rather describe the nodules and give
some guidance as to the likely of malignancy (e.g. sub centimetre 95% will be benign).
This then leaves the clinician to judge the appropriateness of follow-up in their patients.
Even in smokers the % of nodules smaller than 4mm that will eventually turn into lethal
cancers is very low (<1%), 1% for those 4-7mm, where-as for those in the range of 820mm the % is approx. 10-20% and 50% for those larger than 20mm.
Technical note
The follow-up of such nodules should be with a low dose, thin section, unenchanced
protocol. I suggest that 45 mAS be used, which is similar to the dose given form screening
CT for lung cancer.
Who should perform follow-up
1) It is the belief of this review that if only a 1 year follow-up scan is being recommended by
the reporting radiologist then the patient can stay with the referring clinician (GP or hospital
specialist). If there is doubt whether the reporting radiologist has the full clinical information at
the time of reporting a clear caveat should be noted in the report.
40
E.g.; the above recommendation is assuming that the patient does not have a history
of malignancy. If the patient does then they should be referred back to their oncologist,
or if they are no longer under oncological follow-up then they should be referred to a
chest physician.
2) Where a 3 or 6 month follow-up is being recommended by the reporting radiologist
referral to the chest team is indicated.
41
SUMMARY
These guidelines are just that - to act as guidance for clinicians and radiologists when
confronted with the problem of the non-calcified pulmonary nodule.
This will continue to evolve and be a growing area in radiology particularly with more
complex CT examinations being performed (e.g. CTPA and cardiac CT) with increasing
frequency [9;10].
I would like to finish by emphasizing that small (≤ 10 mm) nodules are common
 95 % benign
 non-invasive management required
 Follow-up (spontaneously resolving nodules)
 (contrast-enhanced CT / PET)
Pulmonary nodules > 10 mm are rare
 High proportion of malignancy
 Immediate / invasive work-up usually required
Computer-assisted volumetry evolving
42
GUIDELINES FOR MANAGEMENT OF INCIDENTAL PULMONARY NODULES –
EAST AND NORTH HERTFORDSHIRE NHS TRUST
The guideline applies to the following:

Incidental nodules, e.g. no known previous malignancy

Adult patient >35 years
NB. Patients over 80 particularly with co-morbidities may require a different
approach.

Size is based on the average of length and width
NB. Always search for previous chest x-ray, CT scan or other imaging to
compare
High Risk Patients: smoking history or other risk factors – asbestos, uranium or radon
exposure
Low Risk Patients: minimal or no smoking history or other risk factors
Nodule size
High Risk Patient
Low Risk Patient
 4mm
Follow up at 12 months, if no
change, discharge (unless nonsolid, part solid)
No follow-up necessary
5mm – 6mm
Follow-up 6 monthly for 2 years
then discharge if no change
Follow-up at 12 months and
discharge is no change (unless nonsolid, part solid)
7mm – 8mm
Follow-up 3 monthly for 2 years
then discharge if no change
Follow-up 6 monthly for 2 years and
discharge is no change
9mm – 10mm
Follow-up 6 monthly for 2 years
Follow-up 6 monthly for 2 years
> 10mm
Investigate – high proportion of malignancy, immediate investigation
with volumetic metric CT, possible PET scan and biopsy / removal
Follow up will be by low dose, thin section, unenhanced protocol (45 mAS)
NB.

If definite increase in size detected, investigate further.

Where frequent follow-up is being recommended, referral to the chest team is
indicated; where greater interval than 6 month, it is reasonable not to involve chest
team
43
REFERENCE LIST
1.
Ost D, Fein AM, Feinsilver SH. Clinical practice. The solitary pulmonary nodule. N
Engl J Med 2003; 348:2535-2542
2.
Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule.
Chest 2003; 123:89S-96S
3.
Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of
malignancy in solitary pulmonary nodules. Application to small radiologically
indeterminate nodules. Arch Intern Med 1997; 157:849-855
4.
Henschke CI, Yankelevitz DF, Naidich DP, et al. CT screening for lung cancer:
suspiciousness of nodules according to size on baseline scans. Radiology 2004;
231:164-168
5.
Aberle DR, Gamsu G, Henschke CI, Naidich DP, Swensen SJ. A consensus
statement of the Society of Thoracic Radiology: screening for lung cancer with helical
computed tomography. J Thorac Imaging 2001; 16:65-68
6.
Swensen SJ, Jett JR, Hartman TE, et al. Lung cancer screening with CT: Mayo Clinic
experience. Radiology 2003; 226:756-761
7.
Henschke CI, Naidich DP, Yankelevitz DF, et al. Early lung cancer action project:
initial findings on repeat screenings. Cancer 2001; 92:153-159
8.
Macmahon H, Austin JH, Gamsu G, et al. Guidelines for management of small
pulmonary nodules detected on CT scans: a statement from the Fleischner Society.
Radiology 2005; 237:395-400
9.
Lindell RM, Hartman TE, Swensen SJ, et al. Five-year lung cancer screening
experience: CT appearance, growth rate, location, and histologic features of 61 lung
cancers. Radiology 2007; 242:555-562
10. Silvestri GA, Nietert PJ, Zoller J, Carter C, Bradford D. Attitudes towards screening for lung
cancer among smokers and their non-smoking counterparts. Thorax 2007; 62:126-130
44
Appendix 3
Lung Cancer Diagnosis Pathway
Week 2
Week 1
Week 3
Lung
Cancer
Diagnosis
GP
Referrals
1st Respiratory
Appointment*
A&E and
clinic
referrals
(within two weeks)
Diagnostic tests:
MDT
FOB & CT
(performed on the
same day)
Potential
clinical trial
patients are
identified**
TBNA & X-Ray
2nd Respiratory
Appointment
Further
Investigation
Required
2nd Respiratory
Appointment
Harefield Hospital
Mediastinoscopy,
VATS/Biopsy
Hillingdon
Hospital
Spirometry,
Bone and brain scan,
Image guided biopsy,
TBNA
Mount Vernon
Hospital
Pet scan
MDT Results
Potential clinical trial
patients are identified
Lung Cancer Diagnosis
3rd Respiratory
Appointment
45
* Inpatients are seen within two working days. The first appointment is always on a Thursday, the diagnostic tests then begin five
days later.
** Designated Lung MDT member responsible for integration of research and recruitment to clinical trials is Dr C Lemon.
Palliative/ Symptomatic
Treatment
Dr. Y Saunders
Lung Cancer Treatment Pathway
Palliative/Symptomatic
Follow-up
Clinical Trials Recruitment
Lung Follow up Clinic
Dr. Y. Saunders & Lung CNS
Re-Referral to surgeon
oncologist, respiratory
physician as appropriate for
second line treatment
46
Palliative
follow -up
Radical Surgical Treatment
Palliative Surgical Treatment
Hillingdon Hospital
Mr Anikin
Harefield Hospital
Once with
oncologist
(Dr Lemon)
Clinical Trial Recruitment
Treatmen
t Module
Treatment
arranged
Oncology
Dr C. Lemon
Mount Vernon Cancer Centre
NSCLC Palliative Treatment
Chemotherapy & Radiotherapy
SCLC Chemotherapy & Radiotherapy
Mesothelioma chemotherapy
Radical
Radiotherapy
Follow up
At Hillingdon
Hospital
with Dr Lemon
Clinical Trial Recruitment
Surgical
Follow up
(for Radical Patients)
Non-surgical Radical Treatment
Dr J. Dixon
Mount Vernon Cancer Centre
At Harefield Hospital
with Mr Anikin
Clinical Trial Recruitment
After completing first course of treatment, all patients are referred to the
National Cancer Survivorship nurse-led clinic
47
GUIDANCE FOR FOLLOW UP AFTER SUCCESSFUL SURGICAL RESECTION OF LUNG CARCINOMA
East & North Herts NHS Trust
APPENDIX 4
Appendix 4
Trust Guideline
for
Guidance for Follow Up after Successful Surgical Resection of
Lung Carcinoma
A guideline recommended for use
In:
Respiratory Service, Lister and QEII
By:
Respiratory physicians and thoracic surgeons and their junior staff
For:
Patients who have ha successful complete resection of their lung cancer
Key Words:
Lung cancer, resection, follow up
Written by:
Dr R Dent
Consultant Respiratory Physician
Supported by:
Dr I Chakravorty, Dr S Lok, Dr T Win (Consultant Chest Physicians)
Dr C Prendergast & Dr S Buckingham (Consultant Radiologists)
Dr A Coonar (Thoracic Surgeon)
Approved by:
Not Applicable
…………………………………..……….…… Chairman
……………………………………….…..…… Date
Ratified by Clinical Guidelines Steering Group:
…………………………………..……….…… Chairman
………………………………………….…..… Date
Guideline issued:
October 2009
To be reviewed before:
September 2011
To be reviewed by:
Consultant Respiratory Physician
Guideline supersedes:
Not Applicable
Location of archived copy:
Not Applicable
CGSG Guideline Registration No.
{Regn. No.}
Version No. 01
48
GUIDANCE FOR FOLLOW UP AFTER SUCCESSFUL SURGICAL RESECTION OF LUNG CARCINOMA
East & North Herts NHS Trust
Introduction
Even with intensive pre-operative staging the recurrence rate for patients who have had a successful
resection of lung carcinoma is disappointingly high. At 5 years, 40% will have had no recurrence, 10% will
have had a recurrence but will still be alive and 50% will have died either because of relapse or co-morbidity.
Adjuvant therapy given at the time of surgery has decreased the number of patients who relapse without any
increase in co-morbidity and clearly more research is required into the place of adjuvant chemotherapy in
general.
Nature of Relapses
70-80% of relapses are systemic. However, with adjuvant chemotherapy the reduction has been in both
local recurrence and systemic recurrence.
Second primaries occur at the rate of perhaps 1-2% per year per patient.
In one series, of 100 resections, 50 were alive at 5 years, 30 had relapsed of which 20 were recurrence, 5
local and 5 a combination of distant and local: 20 had died of co-morbidity. Of the distant relapses, it is
occasionally possible to do a metastectomy with curative intent. The survival after resection of a second
primary is similar to the survival rate following a resection of an operable primary.
Case for Regular Follow Up of Patients after a Successful Resection
By detecting recurrence early, when patients are still asymptomatic, the argument goes that radical salvage
therapy is likely to be more possible with a decreased cancer recurrence related death rate. The argument
against such screening is the morbidity related to doing the tests and the effect on the quality of life of such
regular tests. There is of course the matter of cost.
There is at the moment, no hard evidence on the benefits of follow up.
Chance of Relapse
Increased by greater tumour size and stage, e.g. T3N1 more likely to recur that T1N0.
Biological aggressiveness, e.g. SUV score on PET
Timing of Recurrences
Most within 24 months; occasionally between 24 and 36 months, very seldom after 36 months.
Suggested Follow up Protocols
ACCP;
NCNN;
ASCO;
Belgium;
France;
6 monthly with clinical assessment and imaging
3 to 4 monthly with chest x-ray, annual CT
3 monthly, only imaging if symptoms
3 monthly with x-ray, CT optional each 6 months, all agree much less follow up required after 2
years
3 monthly follow up with x-ray, 6 monthly CT scan and bronchoscopy,
Randomised Trial Proposed to Compare Different Follow up Regimes
(France)
Clinical plus chest x-ray
Clinical plus chest x-ray plus CT scan plus bronchoscopy
The aim is to include 1,700 patients in 102 centres
49
GUIDANCE FOR FOLLOW UP AFTER SUCCESSFUL SURGICAL RESECTION OF LUNG CARCINOMA
East & North Herts NHS Trust
References
1. New England Journal 2004; 350: 351-360
Cisplatin-Based Adjuvant Chemotherapy in Patients with Completely Resected Non-Small Cell Lung
Cancer
2. Journal of Clinical Oncology 1999; 17: 3201-3206
Prognostic Importance of the Standardised Uptake Value on F-Fluoro-2-Deoxy-Glucose-Position
Emission Tomography Scan in Non-Small Cell Lung Cancer: An Analysis of 125 Cases
3. Annals of Thoracic Surgery 1995; 60: 1563-1570
Is Follow-up of Lung Cancer Patients After Resection Medically Indicated and Cost-Effective?
4. Annals of Thoracic Surgery 2000; 70: 1185-1190
Relevance of an Intensive Postoperative Follow-up After surgery for Non-Small Cell Lung Cancer
5. Journal of Thoracic Oncology 2007; 6: 499-505
Clinical Stage 1 Non-Small Cell Lung Cancer Including FDG-PET Imaging: Sites and Time to
Recurrence
6. Journal of Thoracic Oncology 2006; 1: 611-621
A Systemic Review and Meta-analysis of the Literature: Chemotherapy and Surgery versus Surgery
Alone in Non-Small Cell Lung Cancer
50
GUIDANCE FOR FOLLOW UP AFTER SUCCESSFUL SURGICAL RESECTION OF LUNG CARCINOMA
East & North Herts NHS Trust
Guidelines for Suggested Follow Up of Patients
Following Successful Resection of Lung Carcinoma
Pathway A
For patients at high risk of recurrence, i.e. T2/T3 or high SUV score (>20)on PET

Follow up at 4-6 weeks with thoracic surgeon - first visit probably at Papworth

Follow up at 3 months by chest physician:

with chest x-ray at each visit for 2 years

6 monthly CT scan first 2 years

Further follow up dependant on patient’s clinical state but minimal chance of
recurrence of original tumour after 2 years
Pathway B
For patients with low risk of recurrence, i.e. not meeting criteria of high risk

Follow up at 4-6 weeks with thoracic surgeon - first visit probably at Papworth

3 month check up with chest physician then:

3 monthly with x-ray for first year,

6 monthly with x-ray for next year,

further follow up as clinically indicated, minimal chance of recurrence of cancer
after that time
It is important that every patient who has surgical resection of lung cancer is discussed
after operation at the multidisciplinary team meeting to ensure a decision is made whether
the patient should be followed up under Pathway A, Pathway B or if the resection has
proved to be incomplete, then to allow a decision to be made as to appropriate further
therapy.
51
APPENDIX 5
LUNG CANCER TRIALS AT MOUNT VERNON CANCER CENTRE
PALLIATIVE
1.
QUARTZ (NSCLC)
Inoperable brain metastases in those with uncertain benefit of radiotherapy randomised to
dexamethasone alone versus dexamethasone plus 20Gy/5#
2.
Fragmatic (NSCLC and SCLC)
Standard management (ASC; radiotherapy; chemotherapy; or surgery) +/- DALTEPARIN sc for
24 weeks
3.
Lungstar (SCLC)
Double blind study of standard chemotherapy +/- pravastatin or placebo
4.
Axitinib (NSCLC Phase II)
Pemetrexed plus cisplatin + / - axitinib in stage IIIb / IV non-squamous NSCLC
5.
TS Study
Pemetrexed plus cisplatin in non-squamous NSCLC
RADICAL
1.
Convert
Patients with LS-SCLC and fit for radical concurrent chemoradiotherapy are randomised
between 45Gy in 30# over three weeks treating twice daily or 66Gy in 33# over six and half
weeks treating once daily
2.
Proclaim
Concurrent chemotherapy with cisplatin / pemetrexed versus cisplatin / etoposide for those with
radically treatable NSCLC
Appendix 6
ONCOLOGICAL EMERGENCIES
THE NEUTROPENIC PATIENT
All patients receiving chemotherapy should be warned of the risk of neutropenia and infection and
advised that, in the event of feeling unwell or becoming pyrexial, they seek urgent medical advice from
the Mount Vernon Cancer Centre and have an urgent FBC.
In hours:
Out of hours:
contact Chemotherapy Suite
contact on-call ST1 / 2
Definition of Severe Neutropenia
Neutrophils
< 1.0 x 109/litre and expected to fall (i.e. after chemo)
or < 0.5 x 109/litre
Definition of a febrile neutropenic event
One temperature reading > 38.5º C or two temperature readings > 38º C one hour apart.
NB. Patients in septicaemia shock (i.e. unwell, tachycardic +/- hypotension) may not be pyrexial but will
require intravenous antibiotics and supportive management for shock
Investigations for all suspected neutropenic patient
Urgent FBC
U&Es
Culture - blood culture from peripheral and all lumens of any central line
MSU
Stool if diarrhoea
Swabs - throat and any skin lesions
CXR
02 saturation (pulse oximeter)
Management of afebrile neutropenic patients who are well
If prophylaxis is to be used Ofloxacin 400mg bd orally for duration of neutropenia.
The following Patient Information leaflet is available:
No. 22 Neutropenia
MANAGEMENT OF FEBRILE NEUTROPENIC PATIENT
Severely neutropenic febrile patient
1.
INITIAL TREATMENT AFTER TAKING APPROPRIATE CULTURES
In all patients commence:
Ceftazidime 2 g IV tds
Oral nystatin suspension 1 ml qds to be swallowed
Fluconazole 50mgs od.
or
Modifications:
(i) Patient severely unwell
Add gentamicin 80-120 mg IV loading dose then 80 mg IV tds depending on renal function (see
below)
Gentamicin dosage: In a shocked patient, renal function may be severely impaired and the
serum creatinine must be obtained before giving further doses. Levels should be taken in all
patients after 3 doses but should be considered earlier if renal function is severely impaired.
(ii) Hickman line present
Add Teicoplanin 400mg IV 12 hourly x 3 doses then 400mg IV od. Continue for 10 days.
(iii) Splenectomised patient (at risk of pneumococcus)
Add Benzylpenicillin 2 megaunits 4 hourly and arrange immunisation if not previously given.
(iv) Oral sepsis or diarrhoea
Add metronidazole 500 mg IV tds.
(v) Herpes infection
Consider adding Acyclovir 10mg/kg 8 hourly IV.
SEPTICAEMIC SHOCK
(i) Give colloid-Haemaccel or PPF - 500 mls over 15 mins x 2.
(ii) Take cultures and then give IV antibiotics immediately.
(iii) If anaemic, transfuse as appropriate.
(iv) Monitor - pulse, BP, temperature, urine output (urine output should be maintained at > 80-100
ml per hour).
(v) If hypotension persists, insert CVP line and commence dopamine infusion via central line. If
there is an inadequate response then consider transferring patient to ITU and giving
dobutamine or noradrenaline.
2.
SUBSEQUENT TREATMENT
1.
Modify antibiotics as appropriate according to any culture results. The registrar should
discuss any problems with the consultant microbiologist from Hillingdon. Second line
broad-spectrum antibiotic will normally be Meropenem 1g IV 8 hourly.
2.
If fever persists for 48 hours after commencing antibiotics and there is suspected fungal
infection
Give 1mg test dose initially - if no reaction give amphotericin 0.25 mg/kg IV in Dextrose
infused over 6 hours via a central venous line or Hickman line and then escalate to 0.5
mg/kg on second day. Further escalation to 1 mg/kg may be necessary if aspergillus is
suspected or isolated.
NB. Amphotericin is highly nephrotoxic. Pethidine may be required for acute reactions.
Monitor U&Es and creatinine daily, especially for hypokalaemia, and correct any
abnormalities as appropriate.
Liposomal amphotericin may be considered after failure of treatment with amphotericin
or if impaired renal function but only after discussion with Consultant Microbiologist and
Clinical Director (or Consultant Haematologist for H.S.U. patients).
In patients with neutrophil count > 0.5 x 109/L or without central venous access
Itraconazole 200mg po bd may be considered. Fluconazole is only effective against
candida species and not aspergillus whereas Itraconazole is effective against both.
THROMBOCYTOPENIA
Patients receiving chemotherapy should also be warned of risk of thrombocytopenia.
Consider administering platelets if:
(i)
Platelets 15-30 x 109/litre and patient has signs of bleeding or is septic.
(ii)
Platelets < 15 x 109/litre.
(iii)
Platelets are <50 x 109/L and the patient requires a lumbar puncture or other invasive
procedure.
Administration of any platelets needs to be discussed with Haematologist. In all cases try to give
advance warning of anticipated needs. This is particularly important at weekends.
Appendix 7
RECOMMENDATIONS FOR VACCINATIONS IN PATIENTS
UNDERGOING CHEMOTHERAPY
The following recommendations were suggested (Jan.2004) for all patients undergoing chemotherapy:
1)
Live vaccines may replicate in immunosuppressed patients, and are therefore not
recommended in patients who:
A: have received chemotherapy or generalised radiotherapy in the last 6 months, or
B: have received a bone marrow transplant in the last 6 months, or
C: have received the equivalent of 40mgs Prednisolone for 1 week or more – should not
receive live vaccines for 3 months after immunosuppressive treatment stopped.
2)
Inactivated vaccines are considered safe in chemotherapy patients, although patients should
be warned that protection provided may not be adequate due to reduced immune response. In
particular, the ‘flu vaccine has been found to be safe, and reasonably effective in patients
undergoing chemotherapy.
The recommendation for receiving ‘flu vaccines are as follows:
All patients receiving chemotherapy of any sort should be offered ‘flu vaccines, especially if they are
over 65 years or have co-morbid respiratory or cardiac conditions.
Patient should ideally be vaccinated 2 or more weeks before chemotherapy starts; however, it is safe to
vaccinate patients between courses of chemotherapy.
Appendix 8
PATIENT INFORMATION LEAFLETS AVAILABLE FROM THE LYNDA
JACKSON MACMILLAN CENTRE
The following patient information leaflets have been written in collaboration with all the MVH
oncologists, health professionals, patients and carers.
They are available from the Lynda Jackson Macmillan Centre for patients with lung cancer, and should
be given as and when appropriate by the treating teams. They are listed here in order of logical use.
No. 1
No. 5
A guide to radiotherapy
An introduction to Mount Vernon cancer centre
No. 42
An introduction to the chemotherapy unit
No. 2
A guide to chemotherapy treatment
Chemotherapy regimens fact sheets.
No. 19
Hair loss from chemotherapy treatment
No. 3
Hickman line
No. 33
No. 19a
Coping with a short course of radiotherapy
Hair loss from radiotherapy treatment
No .11
No. 27
No. 22
Skin care after treatment
Coping now that your radiotherapy treatment is finishing
Neutropenia
No. 18
No. 36
No. 30
Coping with Cancer (support groups)
Self help for cancer patients
Ways of getting to Mount Vernon Hospital. Also MAP.
Also Helpful Hints fact sheets on constipation, diarrhoea, fatigue.
(All created by and available from the Lynda Jackson Macmillan Centre. Any of these leaflets can be
made specific to other DGHs.)
Appendix 9 - Diagnostic algorithm (extracted from NICE clinical Guideline 24)
Appendix 10:
London and South East Sarcoma Network
Shared Care Pathway for Soft Tissue Sarcomas Presenting to Site
Specialised MDTs
Lung /chest wall sarcomas incl. pulmonary metastatectomy
Background
Sarcomas that arise in the lung de novo are extremely rare; however those arising in the chest wall are more
common and may arise in bone or soft tissue. This guidance is to provide direction for the management of
patients with lung/chest wall sarcomas that may present to the lung MDT, orthopaedic services or via
primary or secondary care services. The guidance refers to the care of patients in the London and South
East Sarcoma Network and therefore recognises that specialist services for soft tissue sarcomas are
provided by the Sarcoma Unit at The London Sarcoma Service provided through joint working of UCLH and
RNOH. All bone sarcomas are managed by the London Sarcoma Service (see www.lsesn.nhs.uk and SAG
Constitution for referral pathway for bone sarcomas).
The rarity of lung/chest wall sarcomas and the potential complexity of this surgery requires close cooperation between the sarcoma and referring MDT’s. The first aim of this pathway is to ensure timely
discussion between referring MDTs, the sarcoma MDT and the specialist sarcoma thoracic surgical service
based at The Royal Brompton Hospital (RBH). A weekly video-conferenced MDM to discuss all sarcoma
patients potentially requiring thoracic surgery takes place between clinicians from UCLH and RBH. All
planned surgery will be performed by the RBH specialist sarcoma thoracic surgeons. All suspected primary
bone sarcomas of the chest wall should be referred to the diagnostic service at RNOH (see
www.lsesn.nhs.uk and SAG Constitution for pathway) and then discussed at the sarcoma thoracic MDT
attended by members of the LSS sarcoma MDT for management to be decided.
Surgery alone may be performed in primary bone sarcomas where there is no known benefit for other
modalities such as chondrosarcoma or small low grade soft tissue sarcomas in accordance with STS
guidelines. In other cases combined modality treatment is indicated. Ewing’s sarcomas and osteosarcomas
arising from the chest wall/rib are well recognised and require close co-operation with the sarcoma MDT to
ensure optimal combined modality therapy and appropriate timing of surgery.
Patients who may require pulmonary metastatectomy will be discussed at the sarcoma thoracic MDM and
surgery undertaken at RBH. Palliative pleurodeses may be discussed at this meeting but may be undertaken
with local thoracic surgical services if appropriate.
Principals
This guidance is being developed in accordance with the relevant measures in the Manual for Cancer
Services: Sarcoma Measures and Manual for Cancer: Lung Measures. They are also written in accordance
with the LSESN referral guidelines (see www.lsesn.nhs.uk) and the LSESN Patient Management Policy.
1) Referral
All lung/chest wall sarcoma patients presenting to a local lung MDT or secondary care should be referred to
the sarcoma MDT nominated in the local network lung cancer operational policy. It is recommended that all
suspected chest wall or lung sarcomas are referred through sarcoma diagnostic pathways (see
www.lsesn.nhs.uk and SAG Constitution for pathways)
2) Review by Sarcoma MDT
a) Pathology
All sarcomas arising in the lung/ chest wall will have pathology review undertaken by the nominated
specialist sarcoma pathology service (for details see MDT operational policies).
b) Management
Management of all new soft tissue sarcomas will be discussed with the sarcoma MDT. Early referral
from the time of suspicion or biopsy is recommended. All new bone sarcomas will be referred at time
of suspicion to the London Sarcoma Service for the diagnostic pathway and discussed at the
sarcoma MDT. Discussion at the sarcoma thoracic MDT should then follow and referral to the RBH
made in accordance with below.
3) Site of Definitive Treatment
Surgical excision should be performed at the designated sarcoma thoracic surgery centre (Royal Brompton
Hospital). Discussion and close co-operation between the sarcoma and cardio-thoracic MDTs will take place
to determine the appropriate timing for definitive excision.
Chemotherapy and radiotherapy will be undertaken by designated practitioners as agreed by the SAG.
4) Recurrence
All recurrent lung/chest wall sarcomas will be discussed and reviewed by the sarcoma MDT.
Presentation
Diagnosis
Treatment
Follow up
Role and Responsibility
Lung MDT/Clinic
Sarcoma MDT/Clinic
Refer suspected sarcomas for
diagnosis.
Refer all chest wall bone sarcomas
to RNOH for biopsy.
Assess and diagnosis of primary lung Review pathology of all new cases
tumours if no suspicion of sarcoma.
of lung/chest wall sarcoma
Onward referral of tumours with
Clinical review of all new cases
biopsies indicating sarcoma
Palliative pleurodesis
Need for neo /-adjuvant
chemotherapy and/or radiotherapy.
All chemotherapy
All radiotherapy
Excision when agreed by thoracic
and sarcoma MDT’s at designated
sarcoma thoracic centre (Royal
Brompton Hospital).
Definitive excision of all lung/chest
wall sarcomas;
re-excision of all incompletely
excised or recurrent sarcomas
Initial post-operative assessment at
Royal Brompton Hospital
Patients to be followed up by
sarcoma MDT/clinic .Follow up in
accordance with sarcoma follow up
guidelines of all patients treated by
the sarcoma MDT
Pathway Summary:
Local Lung MDT
Secondary care


Assess new cases of suspected lung/chest wall cancer
Notify sarcoma MDT of all new cases of lung/chest wall sarcoma
Patients under 24 will also
be referred to the teenage
and young adult or
paediatric MDTs as
appropriate
GP
Suspected lung /chest wall sarcoma
suspected bone sarcoma
suspected soft tissue sarcoma
Follow soft
tissue
pathway and
guidelines
All histology reviewed by Specialist
Sarcoma Pathologist
sarcoma thoracic MDT (Royal
Brompton Hospital) Videolinked with UCLH
LSS Sarcoma MDT
LSS MDT Coordinator Contact details:
Ucl-tr.LondonSarcomaService:nhs.net
Tel: 020 3447 4821
Pre-operative chemo and/or
radiotherapy (UCH)
Definitive Excision at RBH
Referral to London
Sarcoma Service (RNOH)
See bone
presentation
and diagnostic
pathway –
BIOPSY TO BE
CARRIED OUT
AT RNOH
LSS Sarcoma MDT
Pre-operative chemo and/or
radiotherapy (UCH)
Sarcoma thoracic MDT and /or
sarcoma MDT - Review histology
Post-operative chemo and/or radiotherapy
Follow up
Recurrence
Follow Up according to agreed bone/soft tissue MDT
guidelines and LSESN sarcoma follow-up guidelines