ABSTRACT
A joint initiative by the British Thoracic Society and the
Society for Cardiothoracic Surgery in Great Britain and
Ireland was undertaken to update the 2001 guidelines for
the selection and assessment of patients with lung cancer
who can potentially be managed by radical treatment.

SYNOPSIS OF RECOMMENDATIONS

SECTION 1: SELECTION OF PATIENTS FOR
RADICAL TREATMENT
1.1 Diagnosis and staging
1.1.1 Imaging
1. View all available historical images at the onset
of the diagnostic pathway and review them prior to
treatment. [C]
2. Ensure contemporaneous imaging is available at
the time of radical treatment. [C]
3. Ensure a CTscan that is <4 weeks old is available
at the time of radical treatment of borderline
lesions. [D]
4. Arrange a CT scan of the chest, lower neck and
upper abdomen with intravenous contrast medium
administration early in the diagnostic pathway for
all patients with suspected lung cancer potentially
suitable for radical treatment. [C]
5. Avoid relying on a CT scan of the chest as the
sole investigation to stage the mediastinal lymph
nodes. [B]
6. Ensure positron emission tomography (PET)-CT
scanning is available for all patients being considered
for radical treatment. [B]
7. Offer radical treatment without further mediastinal
lymph node sampling if there is no significant
uptake in normal sized mediastinal lymph nodes on
PET-CT scanning. [C]
8. Evaluate PET positive mediastinal nodes by
further mediastinal sampling. [C]
9. Confirm the presence of isolated distant
metastases/synchronous tumours by biopsy or
further imaging in patients being considered for
radical treatment. [C]
10. Consider MRI or CT scanning of the head in
patients selected for radical treatment, especially in
stage III disease. [C]
11. Evaluate patients with features suggestive of
intracranial pathology by an initial CT scan of the
head followed by MRI if normal or MRI as an
initial test. [C]
12. Biopsy adrenal lesions that show abnormal
uptake on PET-CT scanning before radical treatment.
[D]
13. RR The role of PET-CT scanning in patients
with small cell lung cancer considered suitable for
radical treatment should be evaluated in clinical
trials.
1.1.2 Endoscopic procedures for diagnosis and staging
14. When obtaining diagnostic and staging samples,
consider the adequacy of these in the context of
selection of patients for targeted therapy. [D]
15. Ensure biopsy samples are taken in adequate
numbers and size where there is negligible additional
risk to the patient. [D]
16. Use transbronchial needle aspiration (TBNA)
and endobronchial ultrasound/endoscopic ultrasound
(EBUS/EUS)-guided TBNA as an initial
diagnostic and staging procedure according to
findings on CT or PET-CT scans. [C]
17. Consider EBUS/EUS-guided TBNA to stage the
mediastinum. [C]
18. Confirm negative results obtained by TBNA
and EBUS/EUS-guided TBNA by mediastinoscopy
and lymph node biopsy where clinically appropriate.
[C]
19. RR The use of narrow band and autofluorescence
imaging should be investigated in clinical
trials.
1.1.3 7th Edition of TNM for lung tumours
20. The 7th edition of the TNM classification of
lung cancer should be used for staging patients
with lung cancer. [B]
21. The IASLC international nodal map should be
used in the assessment and staging of lymph node
disease. [C]
1.2 Management of specific disease subsets
1.2.1 T3 disease
22. Offer patients with T3N0e1M0 disease radical
treatment. [D]
1.2.2 T4 disease
23. Consider selected patients with T4N0e1M0 disease for
radical multimodality treatment. [D]
24. RR Consider clinical trials of radical treatment for T4
disease.
1.2.3 N2 disease
25. Consider radical radiotherapy or chemoradiotherapy in
patients with T1e4N2 (bulky or fixed) M0 disease. [B]
26. Consider surgery as part of multimodality management in
patients with T1e3N2 (non-fixed, non-bulky, single zone) M0
disease. [B]
27. RR Consider further randomised trials of surgery added to
multimodality management in patients with multi-zone N2
disease to establish if any subgroups of patients might benefit
more from the addition of surgery.
1.2.4 N3 disease
28. RR Consider clinical trials of radical treatment for patients
with T1e4N3M0 disease.
1.2.5 M1 disease
29. RR Consider clinical trials of radical treatment for patients
with M1a and M1b disease.
1.2.6 Bronchioloalveolar carcinoma
30. Offer suitable patients with single-site bronchioloalveolar
carcinoma anatomical lung resection. [C]
31. Consider multiple wedge resections in suitable patients with
a limited number of sites of bronchioloalveolar carcinoma. [C]
1.2.7 Open and close thoracotomy
32. Surgical units should have an open and close thoracotomy
rate of around 5%. [D]

SECTION 2: SURGERY
2.1 Assessment of the risks of surgery
2.1.1 Risk assessment for operative mortality
33. Consider using a global risk score such as Thoracoscore to
estimate the risk of death when evaluating and consenting
patients with lung cancer for surgery. [C]

2.1.2. Risk assessment for cardiovascular morbidity
34. Use the American College of Cardiology guidelines 2007 as
a basis for assessing perioperative cardiovascular risk. [C]
35. Avoid lung resection within 30 days of myocardial infarction.
[B]
36. Seek a cardiology review in patients with an active cardiac
condition or $3 risk factors or poor cardiac functional capacity.
[C]
37. Offer surgery without further investigations to patients with
#2 risk factors and good cardiac functional capacity. [B]
38. Begin optimisation of medical therapy and secondary
prophylaxis for coronary disease as early in the patient
pathway as possible. [C]
39. Continue anti-ischaemic treatment in the perioperative
period including aspirin, statins and b blockade. [B]
40. Discuss management of patients with a coronary stent
with a cardiologist to determine perioperative antiplatelet
management. [C]
41. Consider patients with chronic stable angina and conventional
ACC/AHA indications for treatment (coronary artery
bypass grafting and percutaneous coronary intervention) for
revascularisation prior to thoracic surgery. [C]

2.1.3 Assessment of lung function
42. Measure lung carbon monoxide transfer factor in all patients
regardless of spirometric values. [C]
43. Offer surgical resection to patients with low risk of
postoperative dyspnoea. [C]
44. Offer surgical resection to patients at moderate to high risk
of postoperative dyspnoea if they are aware of and accept the
risks of dyspnoea and associated complications. [D]
45. Consider using ventilation scintigraphy or perfusion
scintigraphy to predict postoperative lung function if a ventilation
or perfusion mismatch is suspected. [C]
46.Consider using quantitative CTorMRI to predict postoperative
lung function if the facility is available. [C]
47. Consider using shuttle walk testing as functional assessment
in patients with moderate to high risk of postoperative
dyspnoea using a distance walked of >400 m as a cut-off for
good function. [C]
48. Consider cardiopulmonary exercise testing to measure peak
oxygen consumption as functional assessment in patients with
moderate to high risk of postoperative dyspnoea using >15 ml/
kg/min as a cut-off for good function. [D]
49. RR Further studies with specific outcomes are required to
define the role of exercise testing in the selection of patients for
surgery.

2.1.4 Postoperative quality of life/dyspnoea
50. Avoid pneumonectomy where possible by performing
bronchoangioplastic resection or non-anatomical resection. [C]
51. Avoid taking pulmonary function and exercise tests as sole
surrogates for quality of life evaluation. [C]
52.Whenestimating quality of life, use a validated instrument.[D]

2.2 Surgical approach
2.2.1 Pulmonary resection
53. Employ segment counting to estimate postoperative lung
function as part of risk assessment for postoperative dyspnoea.
[D]
54. Consider patients with moderate to high risk of postoperative
dyspnoea for lung parenchymal sparing surgery. [D]
55. Consider bronchoangioplastic procedures in suitable patients
to preserve pulmonary function. [D]
56. Consider patients with limited pulmonary reserve for
sublobar resection as an acceptable alternative to lobectomy. [B]
57. RR Consider randomised trials of segmental resection versus
wedge resection.
58. Consider patients with concomitant lung cancer within
severe heterogeneous emphysema for lung resection based on
lung volume reduction surgery criteria. [B]
2.2.2 Lymph node management
59. Perform systematic nodal dissection in all patients undergoing
resection for lung cancer. [A]
60. Remove or sample a minimum of six lymph nodes or
stations. [D]

2.3 Chemotherapy
2.3.1 Preoperative chemotherapy
61. Patients with resectable lung cancer should not routinely be
offered preoperative chemotherapy. [B]
2.3.2 Postoperative chemotherapy
62. Offer postoperative chemotherapy to patients with TNM 7th
edition T1e3N1e2M0 non-small cell lung cancer. [A]
iii2 Thorax 2010;65(Suppl III):iii1eiii27. doi:10.1136/thx.2010.145938
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63. Consider postoperative chemotherapy in patients with TNM
7th edition T2e3N0M0 non-small cell lung cancer with tumours
>4 cm diameter. [B]
64. Use a cisplatin-based combination therapy regimen in
postoperative chemotherapy. [A]
65. RR Consider further trials of novel chemotherapeutic agents
in conjunction with surgical resection.

2.4 Postoperative radiotherapy
66. Postoperative radiotherapy (PORT) is not indicated after R0
complete resection. [A]
67. Consider PORT for patients with residual microscopic
disease at the resection margin where the benefit of reduction
in local recurrence outweighs the risk of mortality and
morbidity related to PORT. [C]
68. Use CT-planned three-dimensional conformal radiotherapy
for patients receiving PORT. [B]
69. Consider PORTafter completion of adjuvant chemotherapy.
[B]
70. RR Randomised trials looking at the effect of PORT in pN2
non-small cell lung cancer are recommended.

SECTION 3: RADICAL RADIOTHERAPY
3.1 Assessment of the risks of radiotherapy
3.1.1 Risks of radical radiotherapy
71. Perform three-dimensional treatment planning in patients
undergoing radical thoracic radiotherapy. [B]
72. A clinical oncologist specialising in lung oncology should
determine suitability for radical radiotherapy, taking into
account performance status and comorbidities. [D]
73. RR Clinical trials of radical radiotherapy should include
measures of lung function, outcome and toxicity.

3.2 Radiotherapy and chemoradiotherapy regimens
3.2.1 Early stage disease
74. Offer radical radiotherapy to patients with early stage
non-small cell lung cancer who have an unacceptable risk of
surgical complications. [B]
75. Consider CHART as a treatment option in patients with
early stage non-small cell lung cancer and unacceptable risk of
surgical complications. [A]
76. Consider stereotactic body irradiation in patients with early
stage non-small cell lung cancer and unacceptable risk of surgical
complications. [C]
3.2.2 Locally advanced disease
77. Offer chemoradiotherapy to patients with locally advanced
non-small cell lung cancer and good performance status who are
unsuitable for surgery. [A]
78. Offer selected patients with good performance status
concurrent chemoradiotherapy with a cisplatin-based chemotherapy
combination. [A]
79. Offer patients unsuitable for concurrent chemoradiotherapy
sequential chemoradiotherapy. [A]
80. Consider CHART as a treatment option for patients with
locally advanced non-small cell lung cancer. [A]

3.3 Other radical treatment
81. RR Randomised controlled trials are recommended
comparing conventional radical treatment (surgery, radical
radiotherapy) with other radical treatments where there is
evidence of efficacy in case series.
82. Consider alternative radical treatment in early stage lung
cancer in patients at high risk of morbidity and mortality with
conventional radical treatment. [D]
83. Consider radical brachytherapy in patients with early
invasive mucosal or submucosal non-small cell lung cancer. [D]

SECTION 4: SMALL CELL LUNG CANCER
4.1 Chemoradiotherapy
84. Offer selected patients with T1e4N0e3M0 limited stage
small cell lung cancer both chemotherapy and radiotherapy. [A]
85. Offer patients with T1e4N0e3M0 limited stage small cell
lung cancer and good performance status concurrent chemoradiotherapy.
[A]
86. Recommended treatment options for concurrent chemoradiotherapy
are twice daily thoracic radiotherapy (45 Gy in
3 weeks) with cisplatin and etoposide and 40 Gy once daily
delivered in 3 weeks. [A]
87. Offer patients unsuitable for concurrent chemoradiotherapy
sequential chemoradiotherapy. [A]
88. Offer prophylactic cranial irradiation to patients with
response to treatment and stable disease. [A]

4.2 Surgery
89. Consider patients with T1e3N0e1M0 small cell lung cancer
for surgery as part of multi-modality management. [D]
90. Surgical management of patients with T1e3N2M0 small cell
lung cancer should only be considered in the context of a clinical
trial. [C]

SECTION 5: PROVISION OF TREATMENT OPTIONS91. All available treatment options, including those that are the
subject of research, should be discussed with patients and their
carers and the risks and benefits presented so that they may
make an informed choice. [D]