Assessment by thoracic surgery with appropriate diagnostic imaging is required prior to any therapy and after induction therapy. The Lung Tumour Group recommends that such cases be referred to surgeons with experience in combined modality therapy of lung cancer to minimize risks of treatment-related morbidity and mortality.

The optimal sequencing of chemotherapy, radiotherapy and/or surgery for potentially resectable stage III lung cancer is still controversial.

The role of pre-operative chemotherapy has been evaluated in a meta-analysis conducted by Burdett et al.¹ This systematic review encompasses all randomized controlled trials enrolling patients with stage I-III NSCLC who had pre-operative platinum-based chemotherapy. The trials were heterogeneous and several included post-operative chemotherapy and/or radiotherapy. The 5 year absolute benefit in survival for stage IIIA disease was 6-7% and stage IIIB 3-5%. This data demonstrates the benefit of chemotherapy when added to definitive surgical management however, the timing, neoadjuvant versus adjuvant, remains controversial.

Tri-modality therapy with induction chemoradiation followed by surgical resection has been reported to generate 20% 6-year survival rates in selected IIIA and IIIB NSCLC. The evaluation of surgery in the trimodality approach was the subject of an intergroup trial, INT 0139.² Patients with stage III, N2 positive disease were treated with concurrent cisplatin/etoposide and radiotherapy to 45 Gy. If there was no evidence of progression at re-evaluation, they were randomized to continued radiotherapy to 60 Gy or surgical resection followed by consolidation with 2 further cycles of cisplatin/etoposide. The median overall survival was not statistically significantly different, 22.2 months and 23.6 months respectively. However, subgroup analysis of patients who underwent trimodality with a lobectomy versus matched patients who underwent chemoradiotherapy alone indicated a survival benefit with the former approach. This benefit in overall survival was not observed in patients who required pneumonectomy. The trimodality approach may be discussed with carefully selected stage III patients and requires evaluation by a multidisciplinary team before it is adopted.

References
1. Burdett S, Stewart LA, Rydzewska L: A systematic review and meta-analysis of the literature: chemotherapy and surgery versus surgery alone in non-small cell lung cancer. J Thorac Oncol 1:611-21, 2006

2. Albain KS, Swann RS, Rusch VR, et al: Phase III study of concurrent chemotherapy and radiotherapy (CT/RT) vs CT/RT followed by surgical resection for stage IIIA(pN2) non-small cell lung cancer (NSCLC): Outcomes update of North American Intergroup 0139 (RTOG 9309). J Clin Oncol (Meeting Abstracts) 23:7014-, 2005