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.[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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||