Adenocarcinoma of the lung medical therapy stage III

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [2]

Stage III

  • 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
 


References

  1. Lung cancer. National Comprehensive Cancer Network 2015. http://www.nccn.org/professionals/default.aspx

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