Non small cell lung cancer medical therapy stage III: Difference between revisions
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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>}} | ||
{{familytree | |!| | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | |}} | {{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 | {{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 [[Non small cell | {{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>}} | ||
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{{familytree | H01 | | H03 | | | | H04 | | | | | | H05 | | | H01=<div style="float: left; text-align: left;">Surgery + adjuvant [[Non small cell | {{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 | {{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)}} | ||
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{{familytree | | | | | | | | | J03 | | J04 | | J05 | | J06 | | J01=Initiate neoadjuvant [[Non small cell | {{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}} | ||
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{{familytree | | | | | | | | | | C01 | | | | | | C02 | | C01=Yes|C02=No}} | {{familytree | | | | | | | | | | C01 | | | | | | C02 | | C01=Yes|C02=No}} | ||
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{{familytree | | | | | | | | | | D01 | | | | | | D02 | D01=Where is the [[tumor]] located?|D02=Definitive [[Non small cell | {{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 | {{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>}} | ||
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{{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 | {{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 | {{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}} | ||
<br> | <br> | ||
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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 | {{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}} | ||
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{{familytree | | | | | | | | | | | | | | | | | | | | | G01 | | G02 | | G01=Definitive [[Non small cell | {{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}} | ||
Revision as of 15:15, 2 March 2016
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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, will depend 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
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Where is the tumor located? | |||||||||||||||||||||||||||||||||||||||||||||||||
Superior suculus tumor | |||||||||||||||||||||||||||||||||||||||||||||||||
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
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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
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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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||