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Section: Gaps in Your Workup

Requires Urgent Intervention

• Neuro-oncology consultation and stereotactic radiosurgery (SRS) evaluation indicated for multiple intracranial hemorrhagic lesions with mass effect; assess candidacy for hypofractionated stereotactic radiotherapy (HSRT) versus whole-brain radiotherapy (WBRT) versus observation based on lesion size, location, and proximity to eloquent cortex per NCCN Guidelines for CNS Cancers
• Neurosurgical evaluation for potential craniotomy and tumor debulking if lesions demonstrate progressive mass effect with midline shift or herniation risk; coordinate with neuro-oncology regarding timing relative to systemic therapy initiation
• Comprehensive genomic profiling (CGP) of primary lung tumor and accessible brain lesion(s) via next-generation sequencing (NGS) to identify actionable mutations (EGFR, ALK, ROS1, BRAF, MET, KRAS, TP53, STK11/LKB1); assess PD-L1 expression via immunohistochemistry (IHC) per NCCN Guidelines for Non-Small Cell Lung Cancer, Version 7.2024; obtain circulating tumor DNA (ctDNA) analysis if tissue sampling contraindicated
• Complete staging workup including contrast-enhanced chest/abdomen/pelvis CT, brain MRI with and without gadolinium, and 18F-FDG PET/CT to establish TNM classification and identify additional metastatic disease; document AJCC stage per 8th edition criteria

Clinically Beneficial

• Pulmonary function testing (PFT) including spirometry, diffusion capacity (DLCO), and body plethysmography to quantify baseline respiratory reserve and assess chemotherapy tolerance; calculate ECOG performance status (0-4 scale) to determine candidacy for platinum-doublet chemotherapy versus single-agent or supportive care approaches
• Nutritional assessment by registered dietitian specializing in oncology; evaluate for cancer cachexia, assess albumin and prealbumin levels, and establish enteral/parenteral support protocols if indicated prior to systemic therapy initiation
• Formal performance status evaluation using ECOG or Karnofsky scales to stratify treatment intensity; patients with ECOG 0-1 are candidates for aggressive multimodal therapy, while ECOG 2-3 patients may require modified regimens or palliative approaches per NCCN Guidelines
• Genetic counseling referral for assessment of hereditary cancer predisposition syndromes (Lynch syndrome, hereditary diffuse gastric cancer, familial adenomatous polyposis) and discussion of germline testing implications for family members

Merits Multidisciplinary Discussion

• Obtain second opinion from neuro-oncology specialist at NCI-designated comprehensive cancer center regarding optimal sequencing of cranial radiotherapy and systemic chemotherapy; consider concurrent versus sequential chemoradiation approaches per NCCN Guidelines for Early and Locally Advanced Non-Small Cell Lung Cancer, Version 7.2024
• Palliative care consultation for symptom management, advance care planning, and quality-of-life optimization; establish goals-of-care discussion documenting patient preferences regarding resuscitation status, escalation of care, and acceptable toxicity thresholds
• Clinical trial screening via ClinicalTrials.gov and institutional trial databases for eligibility in phase II/III studies evaluating novel targeted agents (e.g., osimertinib for EGFR-mutant disease, alectinib for ALK-rearranged disease), immunotherapy combinations (e.g., durvalumab consolidation post-chemoradiation per PACIFIC trial paradigm), or investigational agents targeting identified molecular alterations
• Family meeting facilitation by palliative care team, social work, and primary oncologist to establish shared decision-making framework, clarify treatment goals (curative versus life-prolonging versus comfort-focused), and document code status and surrogate decision-maker designation

This information is for educational purposes only. Always consult your healthcare team for personalized medical advice and decisions.