Treatment of Stage IIIA lung cancer is controversial.

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Patients with Stage IIIA with chest wall invasion are candidates for surgery, with resection of the lung cancer plus removal of the ribs invaded by tumor and reconstruction of the ensuing chest wall defect.

If the cancer invades the uppermost portion of the rib cage, "superior sulcus tumor" preoperative radiation therapy is indicated. Cures in this group of IIIA patients are in the range of 20-35%.

Stage IIIA NSCLC with mediastinal node involvement is a more difficult issue. Most surgeons in the U.S. feel that this stage of tumor should not be treated with surgery alone. After proving N2 status with mediastinoscopy, most patients are treated with radiation therapy alone or with radiation therapy and chemotherapy. In my experience such treatment results in a five year survival of 3%. Because of this low survival, it is my belief that carefully selected patients with IIIA N2 disease should have surgical resection, followed by radiation therapy or chemoradiation therapy within a research protocol. The selection is based on the extent of disease as seen on CT scan. This decision must be made by an experienced surgeon.

Surgical resection of limited N2 disease is safe and feasible, and results in cure of approximately 25% of such patients. Adjuvant radiation therapy is indicated. Because the risk of distant metastasis is very high in these patients, it is my practice to refer them for consideration of adjuvant chemotherapy in an approved research protocol.

If the N2 disease seen on CT scan is "bulky" then the chance of complete resection at the time of surgery is very small and surgery is not indicated.

Neoadjuvant chemotherapy or chemo-radiation therapy for patients with "bulky" N2 disease or IIIB disease has been proven to be feasible in a number of studies, which suggest an improvement in survival over historical experience. Such neoadjuvant therapy is still unproven and should be done within the confines of a research protocol if possible.

It is also important to understand that this treatment has a higher risk and should be done at a center with an established team of experienced surgeons, radiation therapists and oncologists.

Image: Recurrence of NSCLC in right paratracheal lymph nodes following wedge resection of a right upper lobe lung cancer.

My personal experience with the treatment of Stage III lung cancer can be seen in two abstracts, one presented in August at the 8th World Lung Cancer Conference in Dublin Ireland, and a second submitted to the Society of Surgical Oncologists.

Right Mediastinal Lymph Node Dissection

More information on advanced stage lung cancer

Further information on mediastinal node dissection

For further information on Superior Sulcus Tumor Pancoast Tumor--Surgery

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