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Stage IIIA NSCLC Treatment

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Evidence (adjuvant radiation therapy):

Evidence from one large meta-analysis, subset analyses of randomized trials, and one large population study suggest that PORT may reduce local recurrence. Results from these studies on the effect of PORT on OS are conflicting.

  1. A meta-analysis of ten randomized trials that evaluated PORT versus surgery alone showed the following:
    • No difference in OS for the entire PORT group or for the subset of N2 patients.[8][Level of evidence: 1iiA]
  2. Results from a nonrandomized subanalysis of the ANITA trial, comparing 5-year OS in N2 patients who did or did not receive PORT, found the following:[4]
    • Higher survival rates in patients receiving radiation therapy in both the observation and chemotherapy arms (21% vs. 17% and 47% vs. 34%, respectively [statistical tests of comparison were not conducted]).[4]
  3. Results from the Surveillance, Epidemiology, and End Results (SEER) [15] suggest the following:
    • The large SEER retrospective study (N = 7,465) found superior survival rates associated with radiation therapy in N2 disease (HR, 0.855; 95% CI, 0.762–0.959).

There is benefit of PORT in stage IIIA-N2 disease, and the role of PORT in early stages of NSCLC should be clarified in ongoing phase III trials. Further analysis is needed to determine whether these outcomes can be modified with technical improvements, better definitions of target volumes, and limitation of cardiac volume in the radiation portals.[8]

Standard Treatment Options for Unresectable Stage IIIA N2 NSCLC

Standard treatment options for patients with unresectable NSCLC include the following:

  1. Radiation therapy.
    • For treatment of locally advanced unresectable tumor in patients who are not candidates for chemoradiation therapy.
    • For patients requiring palliative treatment.
  2. Chemoradiation therapy.

Radiation therapy

For treatment of locally advanced unresectable tumor

Radiation therapy alone, administered sequentially with chemotherapy and concurrently with chemotherapy, may provide benefit to patients with locally advanced unresectable stage III NSCLC.

Prognosis:

Radiation therapy with traditional dose and fractionation schedules (1.8–2.0 Gy per fraction per day to 60–70 Gy in 6–7 weeks) results in reproducible long-term survival benefit in 5% to 10% of patients and significant palliation of symptoms.[19]

Evidence (radiation therapy for locally advanced unresectable tumor):

  1. One prospective randomized clinical study showed the following:[20]
    • Radiation therapy given continuously (including weekends) as three daily fractions (CHART) improved OS compared with radiation therapy given as one daily fraction.[20][Level of evidence: 1iiA]
    • Patterns of failure for patients treated with radiation therapy alone included both locoregional and distant failures.

Although patients with unresectable stage IIIA disease may benefit from radiation therapy, long-term outcomes have generally been poor because of local and systemic relapse.

For palliative treatment

Radiation therapy may be effective in palliating symptomatic local involvement with NSCLC, such as the following:

  • Tracheal, esophageal, or bronchial compression.
  • Pain.
  • Vocal cord paralysis.
  • Hemoptysis.
  • Superior vena cava syndrome.
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