Management of stage III non-small cell lung cancer
- Steven E Schild, MD
Steven E Schild, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- Mayo Clinic College of Medicine
- Suresh S Ramalingam, MD
Suresh S Ramalingam, MD
- Director of Medical Oncology
- Department of Hematology and Medical Oncology
- Emory University, Winship Cancer Institute
- Eric Vallières, MD, FRCSC
Eric Vallières, MD, FRCSC
- Section Editor — Lung Cancer
- Surgical Director of the Lung Cancer Program
- Swedish Cancer Institute
- Section Editors
- Rogerio C Lilenbaum, MD, FACP
Rogerio C Lilenbaum, MD, FACP
- Section Editor — Lung Cancer
- Yale Cancer Center
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
- James R Jett, MD
James R Jett, MD
- Section Editor — Lung Cancer
- Professor of Medicine Emeritus
- National Jewish Health
Development of a treatment plan for a patient with lung cancer depends upon the cell type (small cell versus non-small cell), an assessment of the patient's overall medical condition, and the tumor stage.
Stage III non-small cell lung cancer (NSCLC) includes a highly heterogeneous group of patients with differences in the extent and localization of disease. Many aspects of the treatment of stage III disease are controversial. Unfortunately, the data supporting treatment approaches in specific patient subsets are often subject to a number of limitations, for example that the trials involved heterogeneous patient populations; the definition of stage III disease has changed over time; and early studies were frequently inadequately powered to detect small differences in therapeutic outcome, were not randomized, or had limited duration of follow-up. Major improvements in therapy, including the use of more active chemotherapy agents and refinements in radiation and surgical techniques, also limit the interpretation of earlier clinical trials. Finally, improvements in pretreatment staging have led to reclassification of patients with relatively minimal metastatic disease as stage IV rather than stage III, leading to a prolonging in the apparent overall survival of both stage III and IV patients .
Taking these study limitations into consideration, the treatment approach for stage III disease presented here is consistent with guidelines from the American Society for Radiation Oncology (ASTRO) [2,3], which have been endorsed by American Society of Clinical Oncology (ASCO) .
The initial approach to staging of NSCLC and its implications for prognosis are discussed separately. (See "Overview of the initial evaluation, diagnosis, and staging of patients with suspected lung cancer" and "Tumor, Node, Metastasis (TNM) staging system for lung cancer".)
The management of malignant effusions (classified as stage IV disease in the seventh and eighth editions of the Tumor, Node, Metastasis [TNM] staging system) and the systemic treatment of advanced disease are discussed separately. (See "Management of malignant pleural effusions" and "Pericardial disease associated with malignancy" and "Overview of the treatment of advanced non-small cell lung cancer".)
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- TNM staging system
- Mediastinal evaluation
- NO KNOWN MEDIASTINAL INVOLVEMENT
- Clinical settings
- - T3N1 disease
- - Multiple tumor nodules
- - T4N0-1 disease
- - Clinical stage I/II, pathologic stage III
- Adjuvant therapy
- - Adjuvant systemic therapy
- - Adjuvant postoperative RT
- MEDIASTINAL (N2, N3) INVOLVEMENT
- N2 disease
- - Chemoradiotherapy
- - Surgery in a select subset
- N3 disease
- Choice of chemotherapy
- Administration of radiation
- - Dose and method of delivery
- - Fractionation schedule
- Approaches not routinely used
- SPECIAL CONSIDERATIONS
- Older adult patients
- Poor performance status
- POSTTHERAPY SURVEILLANCE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS