小细胞肺癌2023.v1-NCCN（英文版）

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)SmallCellLungCancerNCCNGuidelinesforPatients®availableat/patientsVersion1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/28/202211:53:18AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.lCellLungCancer*AparKishorP.Ganti,MD,Chair†Fred&PamelaBuffettCancerCenter*BillyW.Loo,Jr.,MD,PhD/ViceChair§MichaelBassetti,MD§UniversityofWisconsinCarboneCancerCenterAnneChiang,MD,PhD†YaleCancerCenter/SmilowCancerHospitalThomasA.D'Amico,MD¶ChristopherA.D'Avella,MD†nterAfshinDowlati,MD†hensiveCancerCenterRobertJ.Downey,MD¶MartinEdelman,MD†FoxChaseCancerCenterlorsheimKathrynA.Gold,MD†cerCenterJonathanW.Goldman,MD†UCLAJonssonComprehensiveCancerCenterJohnC.Grecula,MD§eCancerCenterJamesCancerHospitalesPanelDisclosuresChristineHann,MD,PhD†kinsWadeIams,MD†Vanderbilt-IngramCancerCenterPuneethIyengar,MD,PhD§MayaKhalil,MD†ÞO'NealComprehensiveCancerCenteratUABRobertE.Merritt,MD¶eCancerCenterJamesCancerHospitalNishaMohindra,MD†JulianR.Molina,MD,PhD†CesarMoran,MD≠TheUniversityofTexasClaireMulvey,MD‡ÞUCSFHelenDillerFamilyCenterChinhPhan,DOΞSaraswatiPokharel,MD≠lParkComprehensiveCancerCenterSonamPuri,MD†‡ÞHuntsmanCancerInstituteattheUniversityofUtahAngelQin,MD†UniversityofMichiganRogelCancerCenterChadRusthoven,MD§UniversityofColoradoCancerCenterJacobSands,MD†DanaFarber/BrighamandWomen'sCancerCenterRafaelSantana-Davila,MD†SeattleCancerCareAllianceMichaelShafique,MD†MoffittCancerCenterSaiamaN.Waqar,MD†SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicinerlyJCassaraMScHughesPhD‡ÞInternal‡Þ†Medicaloncology丰Pathology¥Patientadvocacy三Pulmonarymedicinelcology*DiscussionwritingcommitteememberllLungCancerPanelMembersryoftheGuidelinesUpdatesonandStagingSCLLimitedStage,WorkupandTreatment(SCL-2)ExtensiveStage,PrimaryTreatment(SCL-5)llLungCancerPanelMembersryoftheGuidelinesUpdatesonandStagingSCLLimitedStage,WorkupandTreatment(SCL-2)ExtensiveStage,PrimaryTreatment(SCL-5)owingPrimaryTreatmentandSurveillanceSCLiveDiseaseSubsequentTherapyandPalliativeTherapySCLignsandSymptomsofSmallCellLungCancerSCLAathologicReviewSCLBurgicalResectionSCLCSupportiveCareSCLDplesofSystemicTherapySCLERadiationTherapySCLFgSTorsSeetheNCCNGuidelinesforNeuroendocrineAbbreviations(ABBR-1)lCellLungCancerdexFindanNCCNMemberInstitution:/home/member-institutions.dNCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatment.AnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicaltancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway.TheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2022.Version1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.CONTINUEDVersion1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/28/202211:53:18AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.lCellLungCancerdexersionoftheNCCNGuidelinesforSmallCellLungCancerfromVersioninclude•Initialevaluationpbullet7modified:ConsiderPET/CTscan(skullbasetomid-thigh),iflimitedstageissuspectedorifneededtoclarifyextentofdiseasestagepbullet9modified:Molecularprofiling(onlyforneversmokerspatientswhohaveneversmokedtobaccowithextensive-stageSCLC).•Footnotespadded:WorkupofSCLCshouldbeexpedited,withstudiesdoneinparallelwheneverpossible.(AlsoforSCL-2).pmodified:Molecularprofilingmaybeconsideredinneversmokerspatientswithextensive-stageSCLCwhohaveneversmokedtobaccotohelpclarifydiagnosisandevaluateforpotentialtargetedtreatmentoptions.SCL-2•Additionalworkuppbulletadded:MultidisciplinaryevaluationisrecommendedbeforesurgerypLimitedstageI–IIA(T1–2,N0,M0)pathwaymodified:LimitedstageClinicalstage:I–IIA(T1–2,N0,M0)pLimitedstageIIB–IIIC(T3–4,N0,M0;T1–4,N1–3,M0)pathwaymodified:LimitedstageIIB–IIIC(T3–4,N0,M0;T1–4,N1–3,M0).Considerpathologicalmediastinalstaging(especiallyforcN0)ifitwouldhelpdetermineRTfields•Footnoteremoved:Pathologicmediastinalstagingisnotrequiredifthepatientisnotacandidateforsurgicalresectionorifnon-surgicaltreatmentispursued.SCL-3•Limitedstageclinicalstage:I–IIA(T1–2,N0,M0)•Primarytreatmentppathwayadded:R0ppathwayadded:R1/R2•Adjuvanttherapy,R1/R2pathwayadded:Systemictherapy+concurrentRTSCL-3A•Footnoteadded:SystemictherapymaybeinitiatedfirstiftimetoinitiationofSABRwillbeprolonged.SCL-6•LimitedstageadjuvantRTmodified:Prophylacticcranialirradiation(PCI)orConsiderMRIbrainsurveillance•Surveillance,bullet4modified:MRI(preferred)orCTbrainwithcontrastevery3–4moduringy1,thenevery6moduringy2andaftery2,asclinicallyindicated(regardlessofPCIstatus)•Footnotespfootnotemodified:PCIisnotrecommendedinpatientswithpoorperformancestatusorimpairedneurocognitivefunction.IncreasedcognitivedeclineafterPCIhasbeenobservedinolderadults(≥60years)inprospectivetrials;therisksandbenefitsofPCIversuscloseMRIsurveillanceshouldbecarefullydiscussedwiththesepatients.pfootnotemodified:ThebenefitofPCIisunknownunclearinpatientswhohaveundergonecompleteresectionforpathologicdefinitivetherapyforpathologicstageI(T1-2a,N0,M0)I–IIA(T1–2,N0,M0)SCLC.SeePrinciplesofSurgicalResection(SCL-C)andPrinciplesofRadiationTherapy(SCL-F).SCL-B1of2•PathologicEvaluation,bulletadded:Considermoleculartestinginrarecasesforpatientswhodonotsmoke,lightlysmoke(<10cigarettes/day),orforpathologicdilemma.UPDATESPrintedbyMinTangon8/28/202211:53:18AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.lCellLungCancerdexSCL-C•bullet2,sub-bullet2modified:Forpatientsundergoingdefinitivesurgicalresection,thepreferredoperationislobectomywithmediastinallymphnodedissectionorsystematiclymphnodesampling.•bullet3added:Inpatientswhodonotsmoke,smalllesionsthatarepresumedtobesmallcellcarcinomaonbiopsyshouldberesectedbecausetheyarelikelycarcinoidsthathavebeenmisdiagnosed(seetheNCCNGuidelinesforNeuroendocrineandAdrenalTumors).•bullet5added:IntraoperativediagnosisoflikelySCLCinapatientwithnopriorbiopsy•bullet5psub-bullet1added:ShouldfirstdocompletenodaldissectionofthemediastinumandhilumMediastinallymphnodedissectionorsystematiclymphnodesamplingwithfrozensectionisrecommendedtoassessextentofdiseaseandoverallburdenofdisease.psub-bullet2added:Ifprimarysiteandlymphnodesappearresectable,performanatomicresection,preferablylobectomy.Shouldnotdopneumonectomyifneededtoencompassnodalmetastaticdisease.•bullet7modified:ThebenefitofPCIisunknownunclearinpatientswhohaveundergonecompleteresectiondefinitivetherapyforpathologicstageI(T1-2a,N0,M0);seeSCL-FI–IIA(T1–2,N0,M0).SCLC;considerPCIorbrainMRIsurveillanceforN0.Thesepatientshavealowerriskofdevelopingbrainmetastasesthanpatientswithmoreadvanced,limited-stageSCLC(LS-SCLC),andmaynotbenefitfromPCI.4However,PCImayhaveabenefitinpatientswhoarefoundtohavepathologicstageIIBorIIISCLCaftercompleteresection;therefore,PCIisrecommendedinthesepatientsafteradjuvantsystemictherapy.4,5PCIisnotrecommendedinpatientswithpoorperformancestatusorimpairedneurocognitivefunction.6ThisissueisbeingevaluatedintheongoingNCIcooperativegrouptrialSWOGS1827/MAVERICK(brainMRIsurveillance±PCI),whichincludesthepopulationundergoingsurgicalresection./ct2/show/NCT04155034SCL-E2of5•SCLCSubsequentSystemicTherapytableextensivelyrevised.•Footnotespfootnoteadded:Rechallengingwiththeoriginalregimenorsimilarplatinum-basedregimen,asshownonSCL-E1,shouldbeconsiderediftherehasbeenadisease-freeintervalof3to6months.pfootnoteadded:SeeregimensonSCL-E1.SCL-F1of6•GeneralPrinciples,bullet5modified:UsefulreferencesincludetheACRAppropriatenessCriteriaat*:/quality-safety/appropriateness-criteriaASTROGuidelines.•GeneralTreatmentInformation,limitedstage,bullet4modified:Targetdefinition:RTtargetvolumesshouldbedefinedbasedonthepretreatmentPETscanandCTscanobtainedatthetimeofRTplanning,aswellasanypositivebiopsies.PET/CTshouldbeobtained,preferablywithin4weeksandnomorethan8weeks,beforetreatment.Ideally,PET/CTshouldbeobtainedinthetreatmentposition.SCL-F2of6•Limitedstagepbullet1modified:Historically,clinicallyuninvolvedmediastinalnodeshavebeenincludedintheRTtargetvolume,whereasuninvolvedsupraclavicularnodesgenerallyhavenotbeenincluded.Consensusonelectivenodalirradiation(ENI)isevolving.Severalmoremodernseries,bothretrospectiveandprospective,suggestthatomissionofENIresultsinlowratesofisolatednodalrecurrences(0%–11%,most<5%),particularlywhenincorporatingPETstaging/targetdefinition(1.7%–3%).ENIhasbeenomittedincurrentrecentprospectiveclinicaltrials(includingCALGB30610/RTOG0538andtheEORTC08072[CONVERT]trial).Inclusionoftheipsilateralhiluminthetargetvolume,evenifnotgrosslyinvolved,differsbetweenthesetrialsbutmaybereasonable.pbullet3,sub-bullet3modified:Ifusingonce-dailyconventionallyfractionatedRT,higherdosesof66–70Gyshouldbeusedarepreferred.TworandomizedphaseIIItrialsdidnotdemonstratesuperiorityof66Gyin6.5weeks/2Gydaily(theEuropeanCONVERTtrial)or70Gyin7weeks/2Gydaily(CALGB30610/RTOG0538)over45Gyin3weeks/1.5GyBID,butoverallsurvivalandtoxicityweresimilar.UPDATESCONTINUEDVersion1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/28/202211:53:18AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.lCellLungCancerdexSCL-F3of6•Extensivestagepbullet1modified:DosingandfractionationofconsolidativethoracicRTshouldbeindividualizedwithintherangeof30Gyin10dailyfractionsto60Gyin30dailyfractions,orequivalentregimensinthisrange.uptodefinitivedosingregimensinpatientswithalongerlifeexpectancy.pbullet2modified:Basedontworandomizedtrials,immunotherapyduringandafterchemotherapyisafirst-lineapproach,butthesestudiesdidnotincludeconsolidativethoracicRT.Nevertheless,consolidativethoracicRTafterchemoimmunotherapycanbeconsideredforselectedpatientsasabove,duringorbeforemaintenanceimmunotherapy(therearenodataonoptimalsequencingorsafety).ThebenefitofthoracicRTinthecontextofchemo-immunotherapyisunderevaluationintheRAPTOR/NRGLU007trial.•ProphylacticCranialIrradiationpbullet1modified:InpatientswithLS-SCLCwhohaveagoodresponsetoinitialtherapy,PCIdecreasesbrainmetastasesandincreasesoverallsurvivalinmeta-analysesofpastclinicaltrials.Ofnote,noneofthepaststudiesthathavebeenusedasabasisforPCIrecommendationsinLS-SCLCemployedMRIstagingofthebrainnordidanyutilizePETscansforoverallstaging.However,thebenefitofPCIisunclearinpatientswithstageISCLCthathasbeendefinitivelytreatedpbullet3modified:thebenefitofPCIisunclearinpatientswhohaveundergonecompleteresectiondefinitivetherapyforveryearlystageLS-SCLC,ie,pathologicstageI–IIA(T1–2,N0,M0).PCIisrecommendedorcanbeconsideredforN0.Thesepatientshavealowerriskofdevelopingbrainmetastasesthanpatientswithmoreadvanced,LC-SCLC,andmaynotbenefitfromPCI.BrainMRIsurveillanceshouldbeperformedinpatientsnotreceivingPCI.However,PCImayhaveabenefitinpatientswhoarefoundtohavepathologicstageIIBorIIISCLCaftercompleteresection;therefore,PCIisrecommendedinthesepatientsafteradjuvantsystemictherapy.PCIisnotrecommendedinpatientswithpoorperformancestatusorimpairedneurocognitivefunction.ThisissueisbeingevaluatedintheongoingNCIcooperativegrouptrialSWOGS1827/MAVERICK(brainMRIsurveillance±PCI),whichincludesthepopulationundergoingsurgicalresection./ct2/show/NCT04155034pbullet5modified:Neurocognitivefunction:Increasingageandhigherdosesarethemostpredictivefactorsfordevelopmentofchronicneurotoxicity.IntrialRTOG0212,83%ofpatientsolderthan60yearsofageexperiencedchronicneurotoxicity12monthsafterPCIversus56%ofpatientsyoungerthan60yearsofage(P=.009).PCIisnotrecommendedinpatientswithpoorperformancestatusorimpairedneurocognitivefunction.TheroleofPCIinMRIandPETstagedSCLCinfitpatientswithnormalneurocognitivefunctionisthesubjectofongoingdebate,particularlyinlimitedstage,andisbeingevaluatedinthephaseIIISWOGS1827/MAVERICKtrialcomparingPCI(activecomparator)toMRIsurveillance(experimental)inbothlimitedandextensivestage.ConcurrentsystemictherapyandhightotalRTdose(>30Gy)shouldbeavoidedinpatientsreceivingPCI.SCL-F4of6•BrainMetastasespbullet1modified:BrainmetastasesshouldtypicallybehaveconventionallybeentreatedwithWBRT;however,selectedpatientswithasmallnumberofmetastasesmaybeappropriatelytreatedwithstereotacticradiotherapy(SRT)/radiosurgery(SRS).Acurrentrandomizedtrial,NRGCC009,iscomparingSRStohippocampal-sparingWBRTplusmemantineinthissetting.pbullet4modified:Forpatientswithabetterprognosis(eg,≥4months),hippocampal-sparingWBRTusingIMRTplusmemantineispreferredbecauseitproduceslesscognitivefunctionfailurethanconventionalWBRTplusmemantine.However,patientswithmetastaseswithin5mmofthehippocampi,leptomeningealmetastases,andotherhighriskfeatureswerenoteligibleforhippocampal-sparingWBRTonNRGCC001.CompletebloodcountCBC)•Electrolytes,liverfunctiontests(LFTs),bloodureanitrogen(BUN),creatinine•Chest/abdomen/pelvisCTwithcontrast•BrainMRIa,e(preferred)orCTwith•PET/CTscan(skullbasetoCompletebloodcountCBC)•Electrolytes,liverfunctiontests(LFTs),bloodureanitrogen(BUN),creatinine•Chest/abdomen/pelvisCTwithcontrast•BrainMRIa,e(preferred)orCTwith•PET/CTscan(skullbasetomid-thigh),ifneededtoclarifyextentofeaseafkingcessationcounselingnterventionSeetheNCCNelinesforSmokingCessationMolecularprofiling(onlyforhaveneversmokedtobaccowithextensivestagelCellLungCancerdexelllungcerSCLCordSCLCllcelllungrNSCLConrcytologyimaryorticsiteologyreviewd•HistoryologyreviewdationationWorkupSCLryaIfextensivestageisestablished,furtherstagingevaluationisoptional.However,brainimagingMRI(preferred),orCTwithcontrastshouldbeobtainedinallpatients.bWorkupofSCLCshouldbeexpedited,withstudiesdoneinparallelwheneverpossible.cSeeSignsandSymptomsofSmallCellLungCancer(SCL-A).dSeePrinciplesofPathologicReview(SCL-B).eBrainMRIismoresensitivethanCTforidentifyingbrainmetastasesandispreferredoverCT.fIfPET/CTisnotavailable,bonescanmaybeusedtoidentifymetastases.PathologicconfirmationisrecommendedforlesionsdetectedbyPET/CTthatalterstage.gMolecularprofilingmaybeconsideredinpatientswithextensive-stageSCLCwhohaveneversmokedtobaccotohelpclarifydiagnosisandevaluateforpotentialtargetedtreatmentoptions.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.SCL-1tientsi•Pulmonaryfunctiontests(PFTs)duringevaluationforsurgeryordefinitiveradiationtherapy(RT)•Multidisciplinaryevaluationisrecommendedbeforesurgery•Boneimaging(radiographsorMRI)asappropriateifPET/CTequivocal(considertientsi•Pulmonaryfunctiontests(PFTs)duringevaluationforsurgeryordefinitiveradiationtherapy(RT)•Multidisciplinaryevaluationisrecommendedbeforesurgery•Boneimaging(radiographsorMRI)asappropriateifPET/CTequivocal(considerbiopsyifboneimagingisequivocal)•Unilateralmarrowaspiration/biopsyinselectlCellLungCancerdexSTAGEADDITIONALWORKUPb(SeeST-1forTNMation•Ifpleuraleffusionispresent,thoracentesisisrecommended;ifhoracoscopyhhoracoscopyhLimitedstage:ClinicalstageI–IIA(T1–2,N0,M0)ngjkngjkT1–4,N1–3,M0).Considerpathologicalmediastinalstaging(especiallyforcN0)ifitpsythoracentesisorbonestudiestentwithmalignancyryrybWorkupofSCLCshouldbeexpedited,withstudiesdoneinparallelwheneverpossible.hWhilemostpleuraleffusionsinpatientswithlungcancerareduetotumor,thereareafewpatientsinwhommultiplecytopathologicexaminationsofpleuralfluidarenegativefortumorandfluidisnon-bloodyandnotanexudate.Whentheseelementsandclinicaljudgmentdictatethattheeffusionisnotrelatedtothetumor,theeffusionshouldbeexcludedasastagingelement.Pericardialeffusionisclassifiedusingthesamecriteria.iSelectioncriteriainclude:nucleatedredbloodcells(RBCs)onperipheralbloodsmear,neutropenia,orthrombocytopeniasuggestiveofbonemarrowinfiltration.jSeePrinciplesofSurgicalResection(SCL-C).kMediastinalstagingproceduresincludemediastinoscopy,mediastinotomy,endobronchialoresophagealultrasound-guidedbiopsy,andvideo-assistedthoracoscopy.Ifendoscopiclymphnodebiopsyispositive,additionalmediastinalstagingisnotrequired.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.SCL-2(SeeSCL-4)rqnutL-6)qpursuesurgicalresectionSystemictherapynAssessment+concurrentRTodecisionmadenottoSeeResponsePrintedby(SeeSCL-4)rqnutL-6)qpursuesurgicalresectionSystemictherapynAssessment+concurrentRTodecisionmadenottoSeeResponselCellLungCancerdexTESTINGRESULTSkPRIMARYTREATMENTADJUVANTTREATMENTmR0SystemictherapynTreatmentsamplingSystemictherapynTreatmentconcurrent)R1/R2Systemictherapyn+concurrentRToconcurrent)R1/R2Systemictherapyn+concurrentRToLimitedstage:clinicalstageMedicallyinoperableorPathologicmediastinalstagingj,kpositiveSeeSCL-4PathologicNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.SCL-3ientsreceivingsystemictherapyconcurrentRTresponseassessmentshouldoccuronlyaftercompletionofinitialtherapySCLdonotrepeatscanstoponseduringientsreceivingsystemictherapyconcurrentRTresponseassessmentshouldoccuronlyaftercompletionofinitialtherapySCLdonotrepeatscanstoponseduringinitialtreatmentForpatientsreceivingsystemictherapyaloneorsequentialsystemictherapyfollowedbyRTresponseassessmentbychestabdomen/pelvisCTwithcontrastshouldoccurafterevery2cyclesofsystemictherapyandatcompletionoftherapy(SCL-6).mSelectpatientsmaybetreatedwithsystemictherapy/RTasanalternativetosurgicalresection.rSystemictherapymaybeinitiatedfirstiftimetoinitiationofSABRwillbeprolonged.lCellLungCancerdexpymediastinotomyendobronchialoresophagealpymediastinotomyendobronchialoresophagealultrasoundguidedbiopsyandvideoassistedthoracoscopyIfendoscopiclymphnodebiopsyispositive,additionalmediastinalstagingisnotrequired.esofSystemicTherapySCLEesofSystemicTherapySCLEeceivingadjuvantsystemictherapyRTresponseassessmentshouldoccuronlyaftercompletionofadjuvanttherapySCLdonotrepeatscansto