Management of Multiple Pure Ground-Glass Opacity Lesions in Patients with Bronchioloalveolar Carcinoma

Cryoablation of a small pulmonary nodule with pure ground-glass opacity: a case report

Treatments for pure ground-glass nodules (GGNs) include limited resection; however, surgery is not always possible in patients with limited pulmonary functional reserve. In such patients, cryoablation may be a suitable alternative to treat a pure GGN. Here, we report our initial experience with cryoablation of a pure GGN that remained after repeated surgical resection in a patient with multiple GGNs. A 5-mm-sized pure GGN in the left lower lobe was cryoablated successfully without recurrence at the 6-month follow-up.

Management of ground-glass opacities: should all pulmonary lesions with ground-glass opacity be surgically resected?

Pulmonary nodules with ground-glass opacity (GGO) are frequently observed and will be increasingly detected. GGO can be observed in both benign and malignant conditions, including lung cancer and its preinvasive lesions. Atypical adenomatous hyperplasia and adenocarcinoma in situ are typically manifested as pure GGOs, whereas more advanced adenocarcinomas may include a larger solid component within the GGO region. The natural history of GGOs has been gradually clarified. Approximately 20% of pure GGOs and 40% of part-solid GGOs gradually grow or increase their solid component, whereas others remain unchanged for years. Therefore, it remains unclear whether all pulmonary lesions with GGO should be surgically resected or whether lesions without changes may not require resection. To distinguish GGOs with growth from those without growth, a 3-year follow-up observation period is a reasonable benchmark based on the data that the volume-doubling time (VDT) of pure GGOs ranges from approximately 600 to 900 days and that of part-solid GGOs ranges from 300 to 450 days. Future studies on the genetic differences between GGOs with growth and those without growth will help establish an appropriate management algorithm.

Survival of a surgical series of lung cancer patients with synchronous multiple ground-glass opacities, and the management of their residual lesions

OBJECTIVES

We reviewed the medical record of a series of patients with synchronous multiple lung cancers (SMLC), in an attempt to identify the optimal treatment strategy for multiple ground-glass opacities (GGOs).

MATERIALS AND METHODS

From 2004 to 2010, 1223 patients underwent complete resection of non-small cell lung cancer. Among these, there were 67 patients (5.5%) with SMLC with at least 1 of the nodules showing GGO appearance. SMLC was divided into the main cancer (MC) which was a main target based on its tumor size or radiological invasiveness and sub-nodules. According to consolidation/tumor ratio (CTR) on thin-section computed tomography, 67 cases were classified into GG-group (MC showing GGO-dominant lesion; CTR≤0.5) and GS-group (MC showing solid-dominant lesion; CTR>0.5).

RESULTS

There were 24 patients in the GG-group (36%) and 43 patients in the GS-group (64%). Surgical resections included 11 sublobar resections (SLs), 32 lobectomies, 19 lobectomy+SLs, and 4 bilobectomies. There were 39 patients with a total of 118 unresected GGOs after the initial surgery. Among them, the frequency of growth was 8% on a per-nodule basis with the median tumor doubling time of 1373 days, and new GGOs emerged in 15 patients (23%). Multivariate analysis demonstrated that larger size of MC and the GS-group was associated with poor prognosis, whereas growth of the residual GGOs, the development of new GGOs, or whether or not all GGOs were treated did not affect survival. The 5-year OS proportions were 95.8% for the GG-group and 68.0% for the GS-group (p=0.009), and 92.4% for a MC of ≤25 mm and 53.6% for a MC of >25 mm (p=0.008).

CONCLUSION

Survival of patients with multifocal GGOs is strongly affected by radiological findings of the MC. Strict surgical control for MC could be most important.

Early lung cancer with lepidic pattern: adenocarcinoma in situ, minimally invasive adenocarcinoma, and lepidic predominant adenocarcinoma

PURPOSE OF REVIEW

This review gives a comprehensive overview on recent developments in the classification of neoplastic lung lesions with lepidic growth patterns, comprising the adenocarcinoma (ADC) precursor lesions atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ (AIS), and minimally invasive adenocarcinoma (MIA) as well as lepidic predominant adenocarcinoma (LPA).

RECENT FINDINGS

The concept of a continuum between the precursor lesions AAH and AIS to MIA and frankly invasive ADC is backed by a wealth of recent data showing a gradual decrease in overall survival from 100% for AAH, AIS, and MIA to moderately lower rates for LPA. Further, it has been shown that the morphologic categorization of these tumors can be done with reasonable reliability and that nonmucinous lepidic tumors show distinct molecular alterations with high rates of epidermal growth factor receptor mutations. Importantly, lepidic tumor growth is also mirrored by specific characteristics in computed tomography images, arguing for a combined assessment of histomorphology and imaging data for an optimized classification of lepidic neoplasms.

SUMMARY

The validity and clinical importance of the novel concept of ADC precursor lesions and LPA have been confirmed by clinical, radiological, morphological, and molecular data. Thereby, it has evolved into a valuable tool to aid in clinical decision-making.

Surveillance of the Remaining Nodules after Resection of the Dominant Lung Adenocarcinoma is an Appropriate Follow-Up Strategy

INTRODUCTION

Adenocarcinomas, commonly present as a dominant lesion (DL) with additional nodules in the ipsilateral or contralateral lung. We sought to determine the fate and management of the secondary nodules and to assess the risk of these nodules using the Lung CT Screening Reporting and Data System (Lung-RADS) criteria and the National Comprehensive Cancer Network (NCCN) Guidelines to determine if surveillance is an appropriate strategy.

METHODS

We retrospectively evaluated patients with lepidic growth pattern adenocarcinoma and secondary nodules from 2000 to 2013. Risk assessment of the additional lesions was completed with a simplified model of Lung-RADS and NCCN-Guidelines.

RESULTS

Eighty-seven patients underwent resection of 87 DLs (Group 1) concurrently with 60 additional pulmonary nodules (Group 2), while 157 non-DLs were radiologically surveyed over a median follow-up time of 3.2 years (Group 3). Malignancy was found in 29/60 (48%) nodules in Group 2. Whereas, only 9/157 (6%) of the lesions in Group 3 enlarged, 4 of which (2.5% of total) were found to be malignant, and then treated, while the remaining nodules continued surveillance. After applying the Lung-RADS and NCCN simplified models, nodules in Group 2 were at higher risk for lung cancer than those in Group 3.

CONCLUSION

In patients with lepidic growth pattern adenocarcinoma associated with multiple secondary nodules, surveillance of the remaining nodules, after resection of the DL, is a reasonable strategy since these nodules exhibited a slow rate of growth and minimal malignancy. In contrast, nodules resected from the ipsilateral lung at the time of the DL, harbor malignancy in 48%. Risk assessment models may provide a useful and standardized tool for clinical assessment of pulmonary nodules.

The lung adenocarcinoma guidelines: what to be considered by surgeons

In 2011 the International Association for the Study of Lung Cancer (IASLC), the American Thoracic Society (ATS), and the European Respiratory Society (ERS), have proposed a new subclassification of lung adenocarcinomas. This new classification was founded on an evidence-based approach to a systematic review of 11,368 citations from the related literature. Validation has involved projects relating to histologic and cytologic analysis of small biopsy specimens, histologic subtyping, grading, and observer variation among expert pathologists. As enormous resources are being spent on trials involving molecular and therapeutic aspects of adenocarcinoma of the lung, the development of standardized criteria is of great importance and should help advance the field, increasing the impact of research, and improving patient care. This classification is needed to assist in determining patient therapy and predicting outcome. The 2011 IASLC/ATS/ERS adenocarcinoma classification can have an impact on TNM staging. It may help in comparing histologic characteristics of multiple lung adenocarcinomas to determine whether they are intrapulmonary metastases versus separate primaries. Use of comprehensive histologic subtyping along with other histologic characteristics has been shown to have good correlation with molecular analyses and clinical behavior. Also, it may be more meaningful clinically to measure tumor size in lung adenocarcinomas that have a lepidic component by using invasive size rather than total size to determine the size T factor.

Diagnosis and management of pulmonary nodules

There are an increased number of pulmonary nodules discovered on CT scan images in part due to those performed for lung cancer screening. Risk stratification and patient involvement is critical in determining management ranging from interval imaging to invasive biopsy or surgery. A definitive diagnosis requires tissue biopsy. The choice of a particular biopsy technique depends on the risks/benefits of the procedure, the diagnostic yield and local expertise. This review will focus on the evaluation and management of pulmonary nodules based on the Fleischner Society and American College of Chest Physician guidelines. There have been recent changes to both societies' recommendations for incidental detection of solid and subsolid nodules, risk stratification, imaging, minimally invasive diagnostic techniques and definitive surgical options.

Outcomes after stereotactic body radiotherapy for lung tumors, with emphasis on comparison of primary lung cancer and metastatic lung tumors

Background

The goal of this study was to determine the prognostic factors associated with an improved overall outcome after stereotactic body radiotherapy (SBRT) for primary lung cancer and metastatic lung tumors.

Methods

A total of 229 lung tumors in 201 patients were included in the study. SBRT of 45 Gy in 3 fractions, 48 Gy in 4 fractions, 60 Gy in 8 fractions or 60 Gy in 15 fractions was typically used to treat 172 primary lungs cancer in 164 patients and 57 metastatic lung tumors in 37 patients between January 2001 and December 2011. Prognostic factors for local control (LC) and overall survival (OS) were analyzed using a Cox proportional hazards model.

Results

The median biologically effective dose was 105.6 Gy based on alpha/beta = 10 (BED10). The median follow-up period was 41.9 months. The 3-year LC and OS rates were 72.5% and 60.9%, and the 5-year LC and OS rates were 67.8% and 38.1%, respectively. Radiation pneumonitis of grades 2, 3 and 5 occurred in 22 petients, 6 patients and 1 patient, respectively. Multivariate analyses revealed that tumor origin (primary lung cancer or metastatic lung tumor, p < 0.001), tumor diameter (p = 0.005), BED10 (p = 0.029) and date of treatment (p = 0.011) were significant independent predictors for LC and that gender (p = 0.012), tumor origin (p = 0.001) and tumor diameter (p < 0.001) were significant independent predictors for OS.

Conclusions

SBRT resulted in good LC and tolerable treatment-related toxicities. Tumor origin and tumor diameter are significant independent predictors for both overall survival and local control.

Pure ground-glass opacity neoplastic lung nodules: histopathology, imaging, and management

OBJECTIVE

The purpose of this article is to discuss histologic diagnosis of pure pulmonary ground-glass opacity nodules (GGNs), high-resolution CT (HRCT) findings and pathologic correlation, and management.

CONCLUSION

When pure GGNs are greater than 15 mm in diameter with nodularity or have high pixel attenuation (>-472 HU), the nodules are more likely to be invasive adenocarcinomas. Sublobar resection with a secured safety margin and without nodal dissection is performed for HRCT-suggested pure-GGN invasive adenocarcinomas and has a 100% 5-year survival rate.

Clinicopathology and genetic profile of synchronous multiple small adenocarcinomas: implication for surgical treatment of an uncommon lung malignancy

PURPOSE

Synchronous multiple small adenocarcinomas are detected more frequently than in the past; however, the genetic profile, treatment, and prognosis of patients remain unclear. For treatment decisions and prognostic applications, we evaluated epidermal growth factor receptor (EGFR), p53, and KRAS somatic mutations in synchronous multiple small lung adenocarcinomas.

METHODS

The presence of EGFR, p53, and KRAS somatic mutations was determined in 64 synchronous multiple lung adenocarcinomas ≤2 cm in maximal dimension. Mutational analysis was performed on DNA extracted from paraffin-embedded tumors.

RESULTS

Five-year disease-free survival (DFS) was 86.1 %, and overall survival was 95.8 %. EGFR, p53, and KRAS mutations were detected in 41 (64.1 %), 8 (12.5 %), and 4 (6.3 %) patients, respectively. The high frequency of genetic mutations resulted in a high discrimination rate of tumor clonality (68.8 %; 44/64) in the study group. Fourteen (31.8 %) patients were assessed as having the same clonality, whereas 30 (68.2 %) patients had different clonality, which further supported the concept of field cancerization. Multivariate analysis showed lymph node metastasis (p = 0.003) and smoking (p = 0.011) were significantly correlated with tumor relapse. Surgical method, clonality, and tumor location were not correlated with tumor relapse.

CONCLUSIONS

Whether these tumors are different or the same clonal, sublobar resection of each lesion can achieve long-term DFS and is the treatment of choice for synchronous multiple small lung adenocarcinomas. Patients with lymph node metastasis are at risk of relapse and adjuvant chemotherapy is indicated.

Surgical management of pulmonary adenocarcinoma presenting as a pure ground-glass nodule

OBJECTIVES

With recent advances in radiology, the detection of ground-glass nodules (GGNs) has become increasingly common. However, there still is no consensus on management, especially on the need for systemic lymph node (LN) dissection. The purpose of this study was to evaluate the surgical outcomes on the basis of the extent of resection of the primary lesion and mediastinal LN dissection and to carefully suggest appropriate treatment strategies in the patients with pulmonary adenocarcinoma presenting as pure ground-glass opacities.

METHODS

From January 2006 to December 2010, 1267 patients with pulmonary adenocarcinoma, including adenocarcinoma in situ, underwent curative-intent surgical resection. Among these patients, pure GGNs were confirmed in 48 patients on preoperative chest computed tomography (CT) by an experienced radiologist, and 42 underwent systemic LN dissection or sampling. We retrospectively reviewed the perioperative data and postoperative outcomes.

RESULTS

The median age of the patients was 56 (range, 35-78) years, and 26 (54.2%) patients were male. The median size of the nodules was 12 (5-30) mm, and 8 (16.7%) had multiple lesions at the time of operation. The median duration between the initial diagnosis and operation was 4 (0-45) months. Preoperative positron emission tomography/CT was taken in 36 (75.0%) patients, which showed no significant metabolic uptake. For curative resection, lobectomy was performed in 32 (66.7%) patients, segmentectomy in 4, and wedge resection in 12. Clear resection margins were reported in all patients. Forty-two patients underwent systemic mediastinal LN dissection or sampling, and the median number of dissected LNs was 23 (7-53). No LN was reported as positive for malignancy. The median follow-up duration after the first operation was 39 (23-77) months, and there were no cases of late mortality, local recurrence or nodal recurrence. Recurrent GGNs have been developed in 6 (12.5%) patients.

CONCLUSIONS

For pure GGNs, limited resection can be performed when complete resection is obtained, as it was sufficient for cure and especially because there is high probability of multiple lesions. We were unable to demonstrate any additional therapeutic benefit with mediastinal LN dissection in patients with pure GGNs.

The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

The current Lung Cancer Stage Classification system is the seventh edition, which took effect in January 2010. This article reviews the definitions for the TNM descriptors and the stage grouping in this system.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

A dominant adenocarcinoma with multifocal ground glass lesions does not behave as advanced disease

BACKGROUND

Invasive lung adenocarcinomas increasingly present with synchronous, multifocal, in situ lesions that appear as ground glass opacities (GGOs). The optimal approach in this circumstance (often nonsmokers) remains unclear. We evaluated a general strategy of anatomic resection of the dominant tumor (DT) and wedge resection of accessible ipsilateral GGOs.

METHODS

This is a retrospective review of 39 patients with suspected multifocal in situ adenocarcinomas and 1 DT in a predominantly Caucasian population. Mean follow-up is 30.7 months.

RESULTS

Forty-nine percent of patients had no or minimal smoking history; 21% were Asian. The resected DT was pathologically "bronchioloalveolar carcinoma" (26%), minimally invasive adenocarcinoma (5%), adenocarcinoma with bronchioloalveolar features (41%), or moderate well-differentiated adenocarcinoma (28%). The p stage of the DT was IA in 20, IB in 15, and IIA in 4, with mean diameter of 2.6 cm. Thirty-two patients (82%) underwent anatomic resection of the DT; 7 (18%) underwent wedge resection. The mean number of GGOs present initially was 2.7 (range, 1 to 7) with a 5.2-mm mean diameter. An unresected nodule increased in size during follow-up in only 9 patients (23%). The mean diameter growth among these was 3.2 mm, with mean doubling time of 49 months. New GGOs (range, 1 to 8) developed in 16 patients (41%), all of which remained at 7 mm or less. Distant metastasis developed in 2 patients (5.2%); only 1 patient has required intervention for progression of a GGO. The overall survival is 100%.

CONCLUSIONS

Patients with limited, multifocal, in situ adenocarcinomas and a clinical N0 DT enjoy prolonged survival with generally anatomic resection of the DT and wedge resection of accessible GGOs. These patients should not be considered to harbor T4 or M1a disease.

Approach to the patient with multiple lung nodules

It can be difficult to determine whether a patient with more than a single, "solid" lung nodule suspicious for malignancy is suffering from synchronous primary tumors or intrapulmonary metastasis. For this reason, if resection can be performed an aggressive approach is often warranted after demonstrating no mediastinal nodal disease. Increasing evidence suggests that the survival of a patient with a single, invasive lepidic-predominant adenocarcinoma depends on the stage of the invasive tumor, not on the presumed multiple in situ tumors. A suggested clinical approach to each of these types of multifocal tumors, solid and lepidic, is proposed in this article.

[Sublobar curative resection for non-small-cell lung cancer]

It has been proved that lobectomy for lung cancer of less than 3 cm is superior to sublobar resection (segmentectomy and wedge resection) in the Lung Cancer Study Group trial published in 1995. Lobectomy is therefore recommended, with lymph node resection. Nevertheless, some publications have shown identical or close results after segmentectomy for tumors of less than 2 cm, and after wedge resection for tumors of less than 1 cm. It is likely that local recurrences are avoided by respecting a macroscopic margin of more than 2 cm around the tumor. A new trial comparing lobectomy and sublobar resection has been ongoing since 2007 for tumors of less than 2 cm. Persistent ground glass opacities are now often discovered after screening, either pure or with a small solid component, and correspond to an in situ or a micro-invasive adenocarcinoma, that can be removed with sublobar resection without recurrence.

Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society

This report is to complement the original Fleischner Society recommendations for incidentally detected solid nodules by proposing a set of recommendations specifically aimed at subsolid nodules. The development of a standardized approach to the interpretation and management of subsolid nodules remains critically important given that peripheral adenocarcinomas represent the most common type of lung cancer, with evidence of increasing frequency. Following an initial consideration of appropriate terminology to describe subsolid nodules and a brief review of the new classification system for peripheral lung adenocarcinomas sponsored by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society (ATS), and European Respiratory Society (ERS), six specific recommendations were made, three with regard to solitary subsolid nodules and three with regard to multiple subsolid nodules. Each recommendation is followed first by the rationales underlying the recommendation and then by specific pertinent remarks. Finally, issues for which future research is needed are discussed. The recommendations are the result of careful review of the literature now available regarding subsolid nodules. Given the complexity of these lesions, the current recommendations are more varied than the original Fleischner Society guidelines for solid nodules. It cannot be overemphasized that these guidelines must be interpreted in light of an individual's clinical history. Given the frequency with which subsolid nodules are encountered in daily clinical practice, and notwithstanding continuing controversy on many of these issues, it is anticipated that further refinements and modifications to these recommendations will be forthcoming as information continues to emerge from ongoing research.

Measurement of focal ground-glass opacity diameters on CT images: interobserver agreement in regard to identifying increases in the size of ground-glass opacities

PURPOSE

To evaluate interobserver agreement in regard to measurements of focal ground-glass opacities (GGO) diameters on computed tomography (CT) images to identify increases in the size of GGOs.

MATERIALS AND METHODS

Approval by the institutional review board and informed consent by the patients were obtained. Ten GGOs (mean size, 10.4 mm; range, 6.5-15 mm), one each in 10 patients (mean age, 65.9 years; range, 58-78 years), were used to make the diameter measurements. Eleven radiologists independently measured the diameters of the GGOs on a total of 40 thin-section CT images (the first [n = 10], the second [n = 10], and the third [n = 10] follow-up CT examinations and remeasurement of the first [n = 10] follow-up CT examinations) without comparing time-lapse CT images. Interobserver agreement was assessed by means of Bland-Altman plots.

RESULTS

The smallest range of the 95% limits of interobserver agreement between the members of the 55 pairs of the 11 radiologists in regard to maximal diameter was -1.14 to 1.72 mm, and the largest range was -7.7 to 1.7 mm. The mean value of the lower limit of the 95% limits of agreement was -3.1 ± 1.4 mm, and the mean value of their upper limit was 2.5 ± 1.1 mm.

CONCLUSION

When measurements are made by any two radiologists, an increase in the length of the maximal diameter of more than 1.72 mm would be necessary in order to be able to state that the maximal diameter of a particular GGO had actually increased.

Approach to the ground-glass nodule

The detection of ground-glass opacity (GGO) is increasingly common. Sufficient data have been accumulated to formulate recommendations for observation, intervention, and treatment modalities. However, an understanding of many nuances and uncertainties in the available data is needed to avoid making management errors. This article discusses the range of possible entities, risk factors and characteristics that help make a presumptive clinical diagnosis, how often and for how long these should be followed when and how a biopsy should be done, how these lesions should be treated, and how multifocal GGOs should be approached.

[Bronchiolar-alveolar carcinoma: From concept to innovative therapeutic strategies]

Bronchioloalveolar carcinoma (BAC) is a primary pulmonary adenocarcinoma (ADC) developped from the terminal respiratory unit. Its restrictive definition adopted by the 1999 WHO pathological classification needs a complete tumor resection to exclude any signs of histological invasion. Although IIIB-IV tumors were excluded from the strict WHO definition of BAC, the first international workshop on BAC in 2004 had focussed on the need to include in the same spectrum of disease pure BAC and ADC with BAC feature (ADC-WBF). BAC and ADC-WBF affect more frequently women, non-smokers and Asian people than other non-small cell carcinoma. Their predominant lepidic and aerogenous tumor progression results in a frequent pneumonic, multifocal or diffuse presentation and explains why death is more frequently related to bilateral pulmonary involvement than extrathoracic metastasis. Natural history is slower and prognosis better than for other ADC. Within this entity, there are different cytological subtypes: mucinous, non-mucinous and mixed and according to them different clinical and biological phenotypes, with different sensitivity to therapeutic agents. At present, the diagnosis, the staging and the therapeutic strategy does not differ from that of non-small lung carcinoma cells. In localized forms, surgical resection remains the best therapeutic option for localized tumors. In diffuse forms, high frequency of epidermal growth factor receptor (EGFR) expression on tumor cells and its gene amplification and/or mutation as well as a particular sensitivity of this entity to EGFR tyrosine kinase inhibitors offer new strategy of therapeutical management in patients with non-resectable tumor. However, the place of chemotherapy has recently been revisited in this entity known until now as chemoresistant tumors. The results are being evaluated. It is necessary to continue therapeutic trials to determine criteria for choosing a first-line TKI or conventional chemotherapy in that entity. Cytological subtype will probably have an important role to play in this choice.