Despite many earlier studies, the optimal treatment recommendations in the various clinical presentations of stage IIIA (N2) disease are unclear. Hopefully, as the current phase III trials accrue and mature and the much-needed, subsequent randomized trials with newer chemotherapy agents and radiotherapy schemata are started and completed, more definitive treatment guidelines will emerge. Until that time, it is critically important that whenever possible the clinician who manages locally advanced NSCLC enroll their patients in every available clinical trial.
A. Incidental (Occult) N2 Disease Found at Thoracotomy
1. Surgical Consideration: In patients with an occult single-station mediastinal node metastasis that is recognized at thoracotomy and when a complete resection of the nodes and primary tumor is technically possible, then proceed with the planned lung resection and a mediastinal lymphadenectomy. Level of evidence: poor; benefit: small; grade of recommendation: C canadian health&care mall
2. Surgical Consideration: In every patient undergoing a lung resection for lung cancer, systematic mediastinal lymph node sampling or complete mediastinal lymph node dissection must be performed. Level of evidence: good; benefit: substantial; grade of recommendation: A
3. Adjuvant Radiotherapy: In the patient with fully resected stage IIIA lung cancer, there is no definite improvement in survival with adjuvant postoperative radiotherapy, but it significantly reduces local recurrence and should be considered in selected patients. Level of evidence: fair; benefit: small; grade of recommendation: C
4. Adjuvant Chemotherapy: In the patient with fully resected stage IIIA lung cancer, adjuvant chemotherapy administered alone might offer a very modest survival advantage, but this modality should not be routinely utilized outside of a clinical trial. Level of evidence: poor; benefit: small; grade of recommendation: I
5. Adjuvant Chemoradiotherapy: In the patient with fully resected stage IIIA lung cancer, based on randomized clinical trials to date, there is no survival benefit appreciated by adding postoperative adjuvant chemotherapy to adjuvant radiotherapy. Therefore, the routine use of combined postoperative chemotherapy and radiotherapy is not recommended, and should not be employed outside of a clinical trial. Level of evidence: fair; benefit: none; grade of recommendation: D