Adjuvant RT for N3 NSCLCa.

[Reaganite]

3cm RUL NSCLCa resected. Final path shows negative margins, but mediastinal levels 4R, 7, 10 AND 4L are involved with disease. Postop RT? Fields? (Not a case I saw in person; just came across this in a textbook and realized I've never considered a patient with N3 disease).

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[Seldon1985]

Hmm, first of all, I'm surprised it got that far. Was an EBUS done pre-op/what did it show? If we get referred a patient like this (which we do) we've consider chemoRT I think. Toxicity will indeed be higher with bilateral disease...

 

[Palex80]

1. Was a complete mediastinal lymphadenectomy done?
2. How many nodes excised?
3. All levels covered by surgical procedure?


If 1-3: yes, then:
Yes, I would treat. 50.4/1.8 basically all mediastinal node levels actually, you can barely spare out something, besides level 6 or so (it may help limit dose to the left upper lobe a bit).

This patient will definetely benefit from postOP chemo, so he should get this ASAP. I would treat with RT after chemo is completely done.

 

[deleted4401]

Agree with Palex. The old post op fields were pretty big, as were the old SCLC fields. With conformal techniques, shouldn't be so bad. But N3 is bad news. Well, all of lung cancer is bad news.

 

[medgator]

1. Was a complete mediastinal lymphadenectomy done?
2. How many nodes excised?
3. All levels covered by surgical procedure?


If 1-3: yes, then:
Yes, I would treat. 50.4/1.8 basically all mediastinal node levels actually, you can barely spare out something, besides level 6 or so (it may help limit dose to the left upper lobe a bit).

This patient will definetely benefit from postOP chemo, so he should get this ASAP. I would treat with RT after chemo is completely done.

What if there was gross ECE? Just curious to hear your thoughts. I've typically seen that as an indication to go for concurrent rather than sequential post-op therapy.

 

[Palex80]

I am not aware of any data pointing out that you need to do concurrent RCT as adjuvant treatment for ECE in resected stage III NSCLC.
I would actually only do concurrect RCT in R1-resected patients.

 

[medgator]

I am not aware of any data pointing out that you need to do concurrent RCT as adjuvant treatment for ECE in resected stage III NSCLC.
I would actually only do concurrect RCT in R1-resected patients.

You're right. It has to do with the + margin, not ECE. One has to wonder though if gross ECE would warrant more aggressive therapy. \\\

Actually, the NCCN (US guidelines) say that an R1 resection (microscopic + margin) can get sequential treatment while an R2 resection (macroscopic residual disease) should get concurrent chemoRT.