Non small cell lung cancer medical therapy stage III

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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.

Stage IIIA: T3, N1

Perform a pretreatment evaluation If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan Perform a brain MRI Perform a spine MRI with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or spine

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 OR chemotherapy + radiation therapy

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 If not done, perform pulmonary function tests Perform bronchoscopy (if possible intraoperative) Perform a pathological lymph node evaluation If not done, order PET scan or CT scan Perform a brain MRI Perform a spine MRI with thoracic inlet searching for superior suculus lesions and infiltration to the subclavian vessels or spine

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

Neoadjuvant chemotherapy OR chemotherapy + radiation therapy

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 If not done, order PET scan or CT scan Confirmation tests of lymph node infiltration stage: Thoracoscopy and mediastinoscopy Mediastinotomy Biopsy of the supraclavicular lymph nodes Needle aspiration biopsy Endoscopic ultrasound-guided biopsy Endobronchial ultrasound-guided biopsy Perform a brain MRI

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