Metastatic Non–Small Cell Lung Cancer Clinical Practice Guidelines (2018)

European Society for Medical Oncology

Reviewed and summarized by Medscape editors

November 02, 2018

Staging and Risk Assessment

A complete history—including a precise smoking history and comorbidities, weight loss, performance status (PS), and physical examination—must be recorded.

Standard laboratory tests, including routine hematology, renal and hepatic functions, and bone biochemistry tests are required.

Routine use of serum tumor markers, such as carcinoembryonic antigen (CEA), is not recommended.

Contrast-enhanced CT scan of the chest and upper abdomen, including the liver and the adrenal glands, should be carried out at diagnosis.

Central nervous system (CNS) imaging should be considered at diagnosis for all patients with metastatic disease and is required for patients with neurological symptoms or signs. MRI is more sensitive than CT.

If bone metastases are clinically suspected, bone imaging is required.

Bone scan or positron emission tomography (PET), ideally coupled with CT, can be used for detection of bone metastasis. PET-CT is the most sensitive modality in detecting bone metastasis.

NSCLC is staged according to the Union for International Cancer Control (IUCC) system (8th edition).

In patients with a solitary metastatic site on imaging studies, efforts should be made to obtain cytological or histological confirmation of stage IV disease.

Response evaluation is recommended after two to three cycles of chemotherapy or immunotherapy, using the same initial radiographic investigation that demonstrated tumor lesions. The same procedure and timing (every 6–9 weeks) should be applied for the response evaluation in patients treated with targeted therapies and/or immunotherapy. Follow-up with PET is not routinely recommended, due to its high sensitivity and relatively low specificity.

Measurements and response assessment should follow Response Evaluation Criteria in Solid Tumors (RECIST) v1.1. The adequacy of RECIST in evaluating the response to EGFR or ALK TKI in respective genetically driven NSCLC is debatable.

In the case of immune checkpoint inhibitor therapy, RECIST should be used, although immune-related, immune, or immune-modified RECIST may have a role in the overall assessment of therapy.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.