Integration of chemotherapy in the management of locally advanced non-small-cell lung cancer

Abstract

About one-third of lung cancer patients present with stage III (locally advanced) non-small cell lung cancer (NSCLC). Locally advanced NSCLC, which accounts for more than 40,000 cases annually in the USA, represents a heterogeneous group of patients and several clinically distinct substages. Surgery is currently still considered the standard of care as initial treatment for patients with operable NSCLC, which includes stages I and II disease, and selected early subsets of IIIA disease. The existence of N2 disease (stage IIIAN2 disease) remains the most controversial area for primary surgical management of NSCLC and generally for the primary therapeutic approach to select. Minimal IIIAN2 disease is defined as single-station lymph node involvement with microscopic foci of disease not clinically apparent on clinical staging. This early-stage disease is usually dis-covered at the time of thoracotomy or at pretreatment mediastinoscopy, and patients with minimal IIIAN2 disease may still be considered as candidates for radical surgery. Tumors with mediastinal involvement beyond that described as minimal IIIAN2 disease constitute the majority of patients presenting with stage IIIA disease; this more advanced, bulky or multistation N2 disease can usually be identified preoperatively and is termed "clinical N2 disease". Patients with clinical IIIAN2 disease have an overall 5-year survival rate of only 10-15%, although this falls to 2-5% in those with bulky mediastinal N2 involvement. Patients with clinical IIIAN2 disease or with stage IIIB disease are generally considered inoperable by primary surgery. The role of surgery following induction therapy in these advanced stage III patients is at the moment not conclusively defined.