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Oncology · ESMO

Lung cancer

ESMO
A
Source:ESMO Clinical Practice Guidelines on Non-Small-Cell Lung Cancer (2023, Pocket 2024) and Small-Cell Lung Cancer (2021, Pocket 2024)
Verified Apr 2026
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Red Flags

  • Massive haemoptysis (>200 mL/24 h or hypoxic compromise) — emergency bronchoscopy + interventional radiology; secure airway[1]
  • Superior vena cava obstruction (face/arm swelling, headache, distended chest veins) — urgent radiotherapy or stenting; high-dose corticosteroid in lymphoma[1]
  • Spinal cord compression (back pain, weakness, sphincter disturbance) — emergency MRI; high-dose corticosteroid; radiotherapy or surgery within 24 h[1]
  • Tumour lysis syndrome with high-burden disease starting therapy — IV fluid, allopurinol or rasburicase, electrolyte monitoring; nephrology consult[1]

First-line treatment

Interventions

  • Multidisciplinary tumour board for all[1]
    Thoracic surgical, medical, radiation oncology, pulmonology, pathology, radiology, palliative care; treatment driven by histology, molecular profile, stage, performance status
  • Stage I–II NSCLC — curative surgery[1]
    Lobectomy with mediastinal lymph node sampling/dissection; sublobar resection (segmentectomy) for selected ≤2 cm peripheral; SABR for medically inoperable; adjuvant osimertinib (EGFR+) or atezolizumab (PD-L1 ≥1%) per stage
  • Stage III NSCLC — concurrent chemoradiation + immunotherapy[1]
    Concurrent platinum-based chemoradiation followed by durvalumab consolidation × 1 year (PACIFIC); selected resectable IIIA undergo surgery + neoadjuvant chemoimmunotherapy (CheckMate 816)
  • Stage IV NSCLC — driver mutation drives first-line[1]
    EGFR mutation: osimertinib. ALK: alectinib/lorlatinib. ROS1: entrectinib/repotrectinib. BRAF V600E: dabrafenib + trametinib. KRAS G12C: sotorasib/adagrasib (later line). MET, RET, NTRK, HER2 — targeted agents. PD-L1 ≥50% no driver: pembrolizumab. Chemoimmunotherapy otherwise
  • SCLC management[1]
    Limited stage: concurrent platinum-etoposide + thoracic RT + prophylactic cranial irradiation. Extensive stage: platinum-etoposide + atezolizumab or durvalumab; consider PCI or active brain MRI surveillance

First-line drug therapy

DrugClassAdultPaediatricNotes
Osimertinib[1]Third-generation EGFR tyrosine kinase inhibitor80 mg PO once daily—First-line for EGFR exon 19 deletion or L858R; adjuvant in resected stage IB–IIIA EGFR+; CNS-active; QTc, ILD, cardiotoxicity monitoring
Pembrolizumab[1]Anti-PD-1 monoclonal antibody200 mg IV every 3 weeks or 400 mg every 6 weeks × up to 2 years—Stage IV NSCLC with PD-L1 ≥50% as monotherapy; combine with chemotherapy regardless of PD-L1; immune-related adverse events (pneumonitis, colitis, endocrinopathies, hepatitis)
Cisplatin or carboplatin + pemetrexed (non-squamous)[1]Platinum doublet chemotherapyCisplatin 75 mg/m² or carboplatin AUC 5–6 + pemetrexed 500 mg/m² IV every 3 weeks × 4–6 cycles, then maintenance pemetrexed—Standard chemotherapy backbone for NSCLC non-squamous; folic acid + B12 with pemetrexed; renal dose adjustment for cisplatin
Carboplatin + paclitaxel (squamous NSCLC) or + pembrolizumab[1]Platinum doublet ± immunotherapyCarboplatin AUC 5–6 + paclitaxel 175–200 mg/m² IV every 3 weeks × 4 cycles, then pembrolizumab maintenance—Squamous NSCLC; combine with pembrolizumab regardless of PD-L1; hypersensitivity, neuropathy
Cisplatin/carboplatin + etoposide (SCLC)[1]Platinum doublet chemotherapyCisplatin 60–80 mg/m² or carboplatin AUC 5 + etoposide 100 mg/m² IV days 1–3 every 3 weeks × 4 cycles—Standard chemotherapy backbone for SCLC; combine with atezolizumab or durvalumab in extensive stage; concurrent thoracic radiotherapy in limited stage
Osimertinib[1]
Third-generation EGFR tyrosine kinase inhibitor
Adult
80 mg PO once daily
Paediatric
—
First-line for EGFR exon 19 deletion or L858R; adjuvant in resected stage IB–IIIA EGFR+; CNS-active; QTc, ILD, cardiotoxicity monitoring
Pembrolizumab[1]
Anti-PD-1 monoclonal antibody
Adult
200 mg IV every 3 weeks or 400 mg every 6 weeks × up to 2 years
Paediatric
—
Stage IV NSCLC with PD-L1 ≥50% as monotherapy; combine with chemotherapy regardless of PD-L1; immune-related adverse events (pneumonitis, colitis, endocrinopathies, hepatitis)
Cisplatin or carboplatin + pemetrexed (non-squamous)[1]
Platinum doublet chemotherapy
Adult
Cisplatin 75 mg/m² or carboplatin AUC 5–6 + pemetrexed 500 mg/m² IV every 3 weeks × 4–6 cycles, then maintenance pemetrexed
Paediatric
—
Standard chemotherapy backbone for NSCLC non-squamous; folic acid + B12 with pemetrexed; renal dose adjustment for cisplatin
Carboplatin + paclitaxel (squamous NSCLC) or + pembrolizumab[1]
Platinum doublet ± immunotherapy
Adult
Carboplatin AUC 5–6 + paclitaxel 175–200 mg/m² IV every 3 weeks × 4 cycles, then pembrolizumab maintenance
Paediatric
—
Squamous NSCLC; combine with pembrolizumab regardless of PD-L1; hypersensitivity, neuropathy
Cisplatin/carboplatin + etoposide (SCLC)[1]
Platinum doublet chemotherapy
Adult
Cisplatin 60–80 mg/m² or carboplatin AUC 5 + etoposide 100 mg/m² IV days 1–3 every 3 weeks × 4 cycles
Paediatric
—
Standard chemotherapy backbone for SCLC; combine with atezolizumab or durvalumab in extensive stage; concurrent thoracic radiotherapy in limited stage

Safety-net

  1. Smoking cessation at any stage of cancer treatment improves outcomes — utilise NRT, varenicline, behavioural support; do not use vaping as substitute[1]
  2. On immunotherapy: any new symptom (rash, diarrhoea, breathlessness, jaundice, headache, fatigue) — same-day medical review (immune-related adverse event)[1]
  3. Palliative care should be integrated early — improves symptom control, mood, and even survival in metastatic NSCLC[1]

Referral criteria

  • Suspected lung cancer (haemoptysis, weight loss, persistent cough ≥3 weeks, mass on imaging)Rapid lung cancer pathway with thoracic oncology and imaging[1]
  • Confirmed lung cancerMultidisciplinary thoracic oncology team[1]
  • Oncological emergency (SVCO, spinal cord compression, tumour lysis, brain metastasis with raised ICP)Emergency department; oncology and relevant subspecialty[1]
  • Eligible for low-dose CT screeningPulmonology / NCD clinic with imaging access[1]

Clinical summary

Diagnosis, biomarker-driven treatment of NSCLC and SCLC, immunotherapy, and palliative care for adults with lung cancer.

References

  1. 1.ESMO Clinical Practice Guidelines on Non-Small-Cell Lung Cancer (2023, Pocket 2024) and Small-Cell Lung Cancer (2021, Pocket 2024) (2024)

On this page

  • Red flags
  • First-line treatment
  • Safety-net
  • Referral
  • References