Join Ross Camidge, MD, PhD, Brian Kavanagh, MD, MPH, and Michael Weyant, MD, as they present their multidisciplinary expertise on a range of cases pertaining to Locally Advanced NSCL Cancer: Stage IIIA Managment.

Most patients (85%) with lung cancer are diagnosed with non-small cell lung cancer (NSCLC). This tumor board will discuss stage IIIA NSCLC, because this is an area with the greatest controversy about treatment. Oncologists need to know the nuances of how to select the best treatment for stage IIIA NSCLC, which can be efficiently shown in an interesting tumor board scenario.   The NCCN Guidelines recommend a multidisciplinary approach for patients with NSCLC to ensure the best possible treatment. It is essential to accurately determine the stage of disease before treatment. Unless patients have obvious metastatic disease, thorough pretreatment staging using imaging (e.g., CTs of the chest and upper abdomen, brain MRI, PET/CT scans) and pathologic mediastinal lymph node evaluation is recommended for most patients so that an accurate clinical stage can be used to guide preliminary treatment planning. Locally advanced NSCLC is stage III using the AJCC staging. Patients with stage III NSCLC have heterogenous disease with different amounts of lymph node involvement; thus, recommended treatment varies depending on the extent of disease. Because imaging studies are associated with false-positive nodes, pathologic confirmation of nodal disease is essential to avoid overtreatment. To confirm mediastinal lymph node status, minimally invasive techniques are now available such as EBUS, EUS, mediastinoscopy, and VATS.

Multimodality therapy is recommended for patients with locally advanced NSCLC; radiotherapy alone or surgery alone is not recommended. Multimodality treatment for stage III NSCLC may range from surgery for microscopic disease (followed by adjuvant treatment) to chemoradiation for bulky unresectable disease. For patients with stage IIIB disease, chemoradiation (not surgery) is typically recommended. Decisions about whether surgery is appropriate for patients with stage IIIA disease should be made by board-certified thoracic surgeons whose practice involves a substantial amount of lung cancer surgery (see Principles of Surgical Therapy in the NCCN Guidelines for Non-Small Cell Lung Cancer). Before surgery, it is essential to determine whether patients can tolerate surgery or whether they are medically inoperable.

Surgery may be recommended for patients with stage III disease followed by adjuvant treatment.  Most surgeons agree that patients with preoperative stage IIIA disease may be candidates for surgery if they have a single N2 lymph node less than 3 cm. However, decision-making is more complicated for patients with multiple N2 nodes. Some patients presumed to have N1 disease before surgery may be found to have N2 disease during thoracotomy and therefore treatment planning may change based on surgical and pathologic results. After surgery, adjuvant treatment using either sequential or concurrent chemoradiation is recommended in the NCCN Guidelines. The type of adjuvant treatment depends on several factors, including whether the surgical margins are positive or negative; whether the resection was R0, R1, or R2; comorbidities; performance status; and patient preferences.

Advances in minimally invasive surgical techniques, imaging, and use of multimodality treatment are transforming the management of locally advanced NSCLC. Recent advances permit the rational development of treatment plans and use of multimodality therapy based on the amount of lymph node disease. Patient and physician discussions should include the importance of careful staging before deciding on a treatment plan. Patients should be aware that surgery may not be appropriate based on the results of testing and that treatment plans may need to be revised based on testing.