Managing the Patient With Borderline Resectable Lung Cancer
Despite recent therapeutic advances, lung cancer continues to be one of the leading causes of cancer-related mortality. Of the various histologic subtypes, non–small-cell lung cancer (NSCLC) is the most common-accounting for approximately 85% of all lung cancers-and will be the focus of this article. In general, the treatment of lung cancer may include surgery, radiation therapy, systemic therapy (eg, chemotherapy with or without targeted therapy), or a combination of the above. Surgery continues to offer the best chance of long-term cure. The initial treatment of stage I and II NSCLC usually entails surgical resection, whereas stage IV disease is primarily treated with systemic agents, in light of the lack of curative potential with surgery and/or radiation therapy alone. It is locally advanced NSCLC, including stage IIIA and IIIB disease, that continues to pose a therapeutic dilemma, given its heterogeneous nature.
Locally advanced non–small-cell lung cancer is a heterogeneous group of diseases encompassing both stage IIIA and IIIB disease. The treatment options vary, including surgery, chemotherapy, neoadjuvant concurrent chemoradiation, definitive chemoradiation, radiation, and various combinations of the above. Optimal therapy for each patient group is controversial; however, previous trials have shown efficacy of various treatments for different stages. Surgery as initial therapy is beneficial for patients with stage T3, N1 or T3-4, N0-1 disease due to satellite lesions within the same lung. Chemotherapy should be used for diseases minimally involving the mediastinal lymph nodes, whereas concurrent induction chemoradiation is a good option for bulky nodal disease prior to planning a resection. Concurrent definitive chemoradiation or definitive radiation should be reserved for patients who are not candidates for a surgical resection. Most importantly, the treatment strategy for stage IIIA/IIIB disease should involve a multimodality approach individualized to the patient’s disease stage, age, underlying medical conditions, and performance status.
TABLE 1
TNM Descriptions Based on 1997 Staging System for Lung Cancer
Despite recent therapeutic advances, lung cancer continues to be one of the leading causes of cancer-related mortality. Of the various histologic subtypes, non–small-cell lung cancer (NSCLC) is the most common-accounting for approximately 85% of all lung cancers-and will be the focus of this article. In general, the treatment of lung cancer may include surgery, radiation therapy, systemic therapy (eg, chemotherapy with or without targeted therapy), or a combination of the above. Surgery continues to offer the best chance of long-term cure. The initial treatment of stage I and II NSCLC usually entails surgical resection, whereas stage IV disease is primarily treated with systemic agents, in light of the lack of curative potential with surgery and/or radiation therapy alone. It is locally advanced NSCLC, including stage IIIA and IIIB disease, that continues to pose a therapeutic dilemma, given its heterogeneous nature.
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