Non small cell lung cancer medical therapy stage III: Difference between revisions

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{{Non small cell lung cancer}}
{{Non small cell lung cancer}}
 
{{CMG}}; {{AE}} {{Alonso}} {{MV}}
{{CMG}}; {{AE}} {{Alonso}}


==Overview==
==Overview==
 
Therapies for non-small cell lung cancer stage III, depends on 4 categories; Resectable tumors, unresectable tumors, superior sulcus tumors, and tumors that invade the chest wall. Therapies for resectable tumors include [[surgery]], [[neoadjuvant therapy]], and [[adjuvant therapy]]. Alternatively, therapies for unresectable disease only include radiation therapy, and chemoradiation therapy. Therapies for superior sulcus tumors include [[radiation therapy]] alone, [[radiation therapy]] and [[surgery]], concurrent [[chemotherapy]] with [[radiation therapy]] and [[surgery]]. Lastly, therapies for tumors that invade the chest wall include [[surgery]], [[surgery]] and [[radiation therapy]], [[radiation therapy]] alone, and [[chemotherapy]] combined with [[radiation therapy]] and/or [[surgery]].  The treatment of stage III non-small cell lung cancer will be contingent on the extension of the [[tumor]]. [[Chemotherapy]] and/or [[radiation therapy]] should be considered for patients with stage IIIB.


==Medical Therapy for Stage III Non-Small Cell Lung Cancer==
==Medical Therapy for Stage III Non-Small Cell Lung Cancer==
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{{familytree | E03 | | | | | | | | | | | E04 | | | | | | E03=<div style="float: left; text-align: left;">Superior suculus tumor</div>|E04=<div style="float: left; text-align: left;">Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]</div>}}
{{familytree | E03 | | | | | | | | | | | E04 | | | | | | E03=<div style="float: left; text-align: left;">Superior suculus tumor</div>|E04=<div style="float: left; text-align: left;">Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]</div>}}
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{{familytree | |!| | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | |}}
{{familytree | F01 | | | | | F02 | | | | | | | | | F03 | | F01=<div style="float: left; text-align: left;">T3 (Invasion to adjacent structures), N0</div>|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]] <br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
{{familytree | F01 | | | | | F02 | | | | | | | | | F03 | | F01=<div style="float: left; text-align: left;">T3 (Invasion to adjacent structures), N0</div>|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]] <br>OR<br>[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
{{familytree | |!| | | | | | |!| | | | | | | | | | |!| | | |}}
{{familytree | |!| | | | | | |!| | | | | | | | | | |!| | | |}}
{{familytree | G01 | | | | | G03 | | | | | | | | | G04 | | | G01=<div style="float: left; text-align: left;">Neoadjuvant chemotherapy</div>|G02=T4|G03=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G04=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual tumor</div>}}
{{familytree | G01 | | | | | G03 | | | | | | | | | G04 | | | G01=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]]</div>|G02=T4|G03=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G04=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual tumor</div>}}
{{familytree | |!| | | |,|-|-|^|-|-|.| | | | | | | |!| | | |}}
{{familytree | |!| | | |,|-|-|^|-|-|.| | | | | | | |!| | | |}}
{{familytree | H01 | | H03 | | | | H04 | | | | | | H05 | | | H01=<div style="float: left; text-align: left;">Surgery + adjuvant [[Non small cell carcinoma of the lung chemotherapychemotherapy]]</div>|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
{{familytree | H01 | | H03 | | | | H04 | | | | | | H05 | | | H01=<div style="float: left; text-align: left;">Surgery + adjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]]</div>|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
{{familytree | | | | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | | | | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| | |}}
{{familytree | | | | | I04 | | I05 | | I06 | | I07 | | I08 | | I03=No|I04=Adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
{{familytree | | | | | I04 | | I05 | | I06 | | I07 | | I08 | | I03=No|I04=Adjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
{{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}}
{{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}}
{{familytree | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy, followed by chemotherapy|Chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
{{familytree | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]]<br>OR<br>[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy, followed by chemotherapy|Chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
{{familytree/end}}
{{familytree/end}}
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{{familytree | | | | | | | | | | C01 | | | | | | C02 | | C01=Yes|C02=No}}
{{familytree | | | | | | | | | | C01 | | | | | | C02 | | C01=Yes|C02=No}}
{{familytree | | | | | | | | | | |!| | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | |!| | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | D01 | | | | | | D02 | D01=Where is the tumor located?|D02=Definitive chemotherapy}}
{{familytree | | | | | | | | | | D01 | | | | | | D02 | D01=Where is the [[tumor]] located?|D02=Definitive [[Non small cell lung cancer chemotherapy|chemotherapy]]}}
{{familytree | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{familytree | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | |}}
{{familytree | | | E01 | | | | | | | | | | | | | E02 | | | E01=Superior suculus|E02=Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br [[Mediastinum]]}}
{{familytree | | | E01 | | | | | | | | | | | | | E02 | | | E01=Superior suculus|E02=Proximal airway <br>OR<br> [[Chest wall]] <br>OR<br> [[Mediastinum]]}}
{{familytree | | | |!| | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|.|}}
{{familytree | | | |!| | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|.|}}
{{familytree | | | F01 | | | | | | | F02 | | | | | | | | | F03 | |F01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell carcinoma of the lung chemotherapy|chemotherapy]] <br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
{{familytree | | | F01 | | | | | | | F02 | | | | | | | | | F03 | |F01=Initiate neoadjuvant [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|F02=<div style="float: left; text-align: left;">Preferred option: Surgery + pathological determination of microscopic residual [[tumor]]</div>|F03=<div style="float: left; text-align: left;">Neoadjuvant [[Non small cell lung cancer chemotherapy|chemotherapy]] <br>OR<br>[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]</div>}}
{{familytree | | | |!| | | | | | | | |!| | | | | | | | | | |!| | |}}
{{familytree | | | |!| | | | | | | | |!| | | | | | | | | | |!| | |}}
{{familytree | | | G01 | | | | | | | G02 | | | | | | | | | G03 | | | G01=Perform a surgical evaluation: Is the [[tumor]] resectable?|G02=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G03=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual tumor</div>}}
{{familytree | | | G01 | | | | | | | G02 | | | | | | | | | G03 | | | G01=Perform a surgical evaluation: Is the [[tumor]] resectable?|G02=<div style="float: left; text-align: left;">Are margins from the surgical piece positive or negative for residual [[tumor]]?</div>|G03=<div style="float: left; text-align: left;">Perform surgery + pathological determination of residual [[tumor]]</div>}}
{{familytree | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | | | |!| |}}
{{familytree | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | | | |!| |}}
{{familytree | H01 | | H02 | | H03 | | | | H04 | | | | | | H05 | | | | | H01=Yes|H02=No|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
{{familytree | H01 | | H02 | | H03 | | | | H04 | | | | | | H05 | | | | | H01=Yes|H02=No|H03=Negative (R0)|H04=<div style="float: left; text-align: left;">Positive: Is the residual [[tumor]] microscopic (R1) or macroscopic (R2)</div>|H05=Are margins from the surgical piece positive or negative for residual [[tumor]]?}}
{{familytree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| |}}
{{familytree | |!| | | |!| | | |!| | | |,|-|^|-|.| | | |,|-|^|-|.| |}}
{{familytree | I01 | | I02 | | I04 | | I05 | | I06 | | I07 | | I08 | | I01=[[Tumor]] extraction + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]|I02=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|I04=Adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
{{familytree | I01 | | I02 | | I04 | | I05 | | I06 | | I07 | | I08 | | I01=[[Tumor]] extraction + adjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]]|I02=Definitive [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|I04=Adjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]]|I05=Microscopic (R1)|I06=Macroscopic (R2)|I07=Negative (R0)|I08=Positive (R1-2)}}
{{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy, followed by chemotherapy|Chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell carcinoma of the lung chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
{{familytree | | | | | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J02=Initiate definitive [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J03=[[Tumor]] resection + adjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]], followed or not by [[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy, followed by chemotherapy|Chemotherapy]]|J04=[[Tumor]] resection + adjuvant [[Non small cell lung cancer chemotherapy|Chemotherapy]]<br>OR<br>[[Non small cell lung cancer chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|J05=Observation|J06=[[Tumor]] resection}}
{{familytree/end}}
{{familytree/end}}
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{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | | | E06 | | | | | E01=[[Metastatic disease]]|E02=Findings suggestive of N3|E03=See treatment|E04=[[Metastatic disease]]|E05=Positive contralateral [[mediastinal]] node infiltration|E06=Does the [[tumor]] infiltrated the ipsilateral [[mediastinal]] [[lymph nodes]]?}}
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | | | E06 | | | | | E01=[[Metastatic disease]]|E02=Findings suggestive of N3|E03=See treatment|E04=[[Metastatic disease]]|E05=Positive contralateral [[mediastinal]] node infiltration|E06=Does the [[tumor]] infiltrated the ipsilateral [[mediastinal]] [[lymph nodes]]?}}
{{familytree | |!| | | |!| | | | | | | |!| | | |!| | | |,|-|^|-|.| | |}}
{{familytree | |!| | | |!| | | | | | | |!| | | |!| | | |,|-|^|-|.| | |}}
{{familytree | F01 | | F02 | | | | | | F03 | | F04 | | F05 | | F06 | | F01=[[Non small cell carcinoma of the lung medical therapy#Metastatic disease|Click here for the treatment of metastatic disease]]|F02=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|F03=[[Non small cell carcinoma of the lung medical therapy#Metastatic disease|Click here for the treatment of metastatic disease]]|F04=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|F05=Yes|F06=No}}
{{familytree | F01 | | F02 | | | | | | F03 | | F04 | | F05 | | F06 | | F01=[[Non small cell lung cancer medical therapy metastatic cancer|Click here for the treatment of metastatic cancer]]|F02=Definitive [[Non small cell lung cancer chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|F03=[[Non small cell lung cancer medical therapy metastatic cancer|Click here for the treatment of metastatic cancer]]|F04=Definitive [[Non small cell lung cancer chemotherapy#Chemotherapy plus Radiation Therapy|chemotherapy + radiation therapy]]|F05=Yes|F06=No}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | G01 | | G02 | | G01=Definitive [[Non small cell carcinoma of the lung chemotherapy#Chemotherapy plus radiation therapy|chemotherapy + radiation therapy]]|G02=[[Non small cell carcinoma of the lung medical therapy#Stage IIIA|Click here for the stage IIIA treatment]]}}
{{familytree | | | | | | | | | | | | | | | | | | | | | G01 | | G02 | | G01=Definitive [[Non small cell lung cancer chemotherapy#Chemotherapy plus Radiation Rherapy|chemotherapy + radiation therapy]]|G02=[[Non small cell lung cancer medical therapy stage III#Stage IIIA|Click here for the stage IIIA treatment]]}}
{{familytree/end}}
{{familytree/end}}


==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Disease]]
[[Category:Disease]]
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[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Lung cancer]]
[[Category:Lung cancer]]
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Oncology]]
 
[[Category:Medicine]]
{{Tumors}}
[[Category:Pulmonology]]
[[Category:Surgery]]

Latest revision as of 23:23, 23 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2] Maria Fernanda Villarreal, M.D. [3]

Overview

Therapies for non-small cell lung cancer stage III, depends on 4 categories; Resectable tumors, unresectable tumors, superior sulcus tumors, and tumors that invade the chest wall. Therapies for resectable tumors include surgery, neoadjuvant therapy, and adjuvant therapy. Alternatively, therapies for unresectable disease only include radiation therapy, and chemoradiation therapy. Therapies for superior sulcus tumors include radiation therapy alone, radiation therapy and surgery, concurrent chemotherapy with radiation therapy and surgery. Lastly, therapies for tumors that invade the chest wall include surgery, surgery and radiation therapy, radiation therapy alone, and chemotherapy combined with radiation therapy and/or surgery. The treatment of stage III non-small cell lung cancer will be contingent on the extension of the tumor. Chemotherapy and/or radiation therapy should be considered for patients with stage IIIB.

Medical Therapy for Stage III Non-Small Cell Lung Cancer

The algorithms for the treatment of stage III non small cell carcinoma of the lung are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.[1]

Stage IIIA: T3, N1

 
 
 
 
 
 
Perform a pretreatment evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Where is the tumor located?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Superior suculus tumor
 
 
 
 
 
 
 
 
 
 
Proximal airway
OR
Chest wall
OR
Mediastinum
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T3 (Invasion to adjacent structures), N0
 
 
 
 
Preferred option: Surgery + pathological determination of microscopic residual tumor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neoadjuvant chemotherapy
 
 
 
 
Are margins from the surgical piece positive or negative for residual tumor?
 
 
 
 
 
 
 
 
Perform surgery + pathological determination of residual tumor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery + adjuvant chemotherapy
 
Negative (R0)
 
 
 
Positive: Is the residual tumor microscopic (R1) or macroscopic (R2)
 
 
 
 
 
Are margins from the surgical piece positive or negative for residual tumor?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adjuvant Chemotherapy
 
Microscopic (R1)
 
Macroscopic (R2)
 
Negative (R0)
 
Positive (R1-2)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor resection + adjuvant chemotherapy
OR
chemotherapy + radiation therapy, followed or not by Chemotherapy
 
Tumor resection + adjuvant Chemotherapy
OR
chemotherapy + radiation therapy
 
Observation
 
Tumor resection
 


IIIA: T4, N0-1

 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a pretreatment evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the tumor resectable?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Where is the tumor located?
 
 
 
 
 
Definitive chemotherapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Superior suculus
 
 
 
 
 
 
 
 
 
 
 
 
Proximal airway
OR
Chest wall
OR
Mediastinum
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate neoadjuvant chemotherapy + radiation therapy
 
 
 
 
 
 
Preferred option: Surgery + pathological determination of microscopic residual tumor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a surgical evaluation: Is the tumor resectable?
 
 
 
 
 
 
Are margins from the surgical piece positive or negative for residual tumor?
 
 
 
 
 
 
 
 
Perform surgery + pathological determination of residual tumor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Negative (R0)
 
 
 
Positive: Is the residual tumor microscopic (R1) or macroscopic (R2)
 
 
 
 
 
Are margins from the surgical piece positive or negative for residual tumor?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor extraction + adjuvant Chemotherapy
 
Definitive chemotherapy + radiation therapy
 
Adjuvant Chemotherapy
 
Microscopic (R1)
 
Macroscopic (R2)
 
Negative (R0)
 
Positive (R1-2)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumor resection + adjuvant Chemotherapy
OR
chemotherapy + radiation therapy, followed or not by Chemotherapy
 
Tumor resection + adjuvant Chemotherapy
OR
chemotherapy + radiation therapy
 
Observation
 
Tumor resection
 


Stage IIIB

 
 
 
 
 
 
 
 
 
 
 
Perform a pretreatment evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the tumor T1-3 or is it T4?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
T1-3, N3
 
 
 
 
 
 
 
 
 
 
 
T4
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the infiltration to lymph nodes meet the criteria for N3 or are there findings suggestive of metastatic disease?
 
 
 
 
 
 
 
 
 
 
 
Is the infiltration to the mediastinal lymph nodes contralateral or are there findings suggestive of metastatic disease?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Metastatic disease
 
Findings suggestive of N3
 
See treatment
 
Metastatic disease
 
Positive contralateral mediastinal node infiltration
 
 
 
Does the tumor infiltrated the ipsilateral mediastinal lymph nodes?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Click here for the treatment of metastatic cancer
 
Definitive chemotherapy + radiation therapy
 
 
 
 
 
Click here for the treatment of metastatic cancer
 
Definitive chemotherapy + radiation therapy
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Definitive chemotherapy + radiation therapy
 
Click here for the stage IIIA treatment
 

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