Abstract
Patients with stage III non-small cell lung cancer (NSCLC) represent a highly heterogenous group with diverse tumor characteristics and degrees of lymph node involvement. As a result, therapeutic approaches to stage III NSCLC are varied, including surgery followed by adjuvant chemotherapy, neoadjuvant therapy followed by surgical resection, or definitive chemoradiation. However, the prognosis for stage III disease remains poor, with ample room for improvement. Advances in immunotherapy and molecular-targeted drugs have led to their introduction into this multimodality treatment framework for improved local and distant control. Notably, adjuvant immune checkpoint inhibition-based consolidation therapy after definitive chemoradiotherapy has been established as a promising new treatment strategy for select stage III NSCLC patients. The numerous possible permutations with multimodality therapy permit treatment to be tailored to each individual patient. This chapter presents the current progress in treatment for stage III NSCLC based on the results of the latest clinical trials.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Detterbeck FC, Boffa DJ, Kim AW, Tanoue LT. The eighth edition lung cancer stage classification. Chest. 2017;151:193–203. https://doi.org/10.1016/j.chest.2016.10.010.
Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK, Gershenwald JE, Compton CC, Hess KR, et al. (Eds.). AJCC Cancer Staging Manual (8th edition). 2017.
Sung H, Ferlay J, Siegel R, Laversannne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71:209–49. https://doi.org/10.3322/caac.21660.
Goldstraw P, Chansky K, Crowley J, Rami-Porta R, Asamura H, Eberhardt WE, et al. The IASLC Lung Cancer Staging Project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer. J Thorac Oncol. 2016;11:39–51. https://doi.org/10.1016/j.jtho.2015.09.009.
Wu FZ, Kuo PL, Huang YL, Tang EK, Chen CS, Wu MT, et al. Differences in lung cancer characteristics and mortality rate between screened and non-screened cohorts. Sci Rep. 2019;9:19386. https://doi.org/10.1038/s41598-019-56025-6.
Postmus PE, Kerr KM, Oudkerk M, Senan S, Waller DA, Vansteenkiste J, et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017;28(Suppl 4):1–21. https://doi.org/10.1093/annonc/mdx222.
Kris MG, Gaspar LE, Chaft JE, Kennedy EB, Azzoli CG, Ellis PM, et al. Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIa completely resected non–small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario Clinical Practice Guideline Update. J Clin Oncol. 2017;35:2960–74. https://doi.org/10.1200/JCO.2017.72.4401.
Van Schil PE, Berzenji L, Yogeswaran SK, Hendriks JM, Lauwers P. Surgical management of stage IIIA non-small cell lung cancer. Front Oncol. 2017;7:249. https://doi.org/10.3389/fonc.2017.00249.
Patel V, Shrager JB. Which patients with stage III non-small cell lung cancer should undergo surgical resection? Oncologist. 2005;10:335–44. https://doi.org/10.1634/theoncologist.10-5-335.
Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(Suppl 5):e166S–90S. https://doi.org/10.1378/chest.12-2395.
National Comprehensive Cancer Network. NCCN Guidelines Version 2.2021 Non-Small Cell Lung Cancer. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf.
Pignon JP, Tribodet H, Scagliotti GV, Douillard JY, Shepherd FA, Stephens RJ, et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol. 2008;26:3552–9. https://doi.org/10.1200/JCO.2007.13.9030.
Pitz CCM, de la Rivière AB, van Swieten HA, Westermann CJJ, Lammers J-WJ, van den Bosch JMM. Results of surgical treatment of T4 non-small cell lung cancer. Eur J Cardiothorac Surg. 2003;24:1013–8. https://doi.org/10.1016/s1010-7940(03)00493-7.
Chambers A, Routledge T, Bille A, Scarci M. Does surgery have a role in T4N0 and T4N1 lung cancer? Interact Cardiovasc Thorac Surg. 2010;11:473–9. https://doi.org/10.1510/icvts.2010.235119.
Reardon ES, Schrump DS. Extended resections of non-small cell lung cancers invading the aorta, pulmonary artery, left atrium, or esophagus: can they be justified? Thorac Surg Clin. 2014;24:457–64. https://doi.org/10.1016/j.thorsurg.2014.07.012.
Garrido P, Gonzalez-Larriba JL, Insa A, Provencio M, Torres A, Isla D, et al. Long-term survival associated with complete resection after induction chemotherapy in stage IIIA (N2) and IIIB (T4N0-1) non small-cell lung cancer patients: the Spanish Lung Cancer Group Trial 9901. J Clin Oncol. 2007;25:4736–42. https://doi.org/10.1200/JCO.2007.12.0014.
Shien K, Toyooka S, Kiura K, Matsuo K, Soh J, Yamane M, et al. Induction chemoradiotherapy followed by surgical resection for clinical T3 or T4 locally advanced non-small cell lung cancer. Ann Surg Oncol. 2012;19:2685–92. https://doi.org/10.1245/s10434-012-2302-x.
Daly BD, Ebright MI, Walkey AJ, Fernando HC, Zaner KS, Morelli DM, et al. Impact of neoadjuvant chemoradiotherapy followed by surgical resection on node-negative T3 and T4 non-small cell lung cancer. J Thorac Cardiovasc Surg. 2011;141:1392–7. https://doi.org/10.1016/j.jtcvs.2010.12.011.
Lococo F, Cesario A, Margaritora S, Dall’Armi V, Nachira D, Cusumano G, et al. Induction therapy followed by surgery for T3-T4/N0 non-small cell lung cancer: long-term results. Ann Thorac Surg. 2012;93:1633–40. https://doi.org/10.1016/j.athoracsur.2012.01.109.
Uramoto H, Shimokawa H, Hanagiri T, Ichiki Y, Tanaka F. Factors predicting the surgical outcome in patients with T3/4 lung cancer. Surg Today. 2014;44:2249–54. https://doi.org/10.1007/s00595-014-0861-0.
Rendina EA, Venuta F, De Giacomo T, et al. Induction chemotherapy for T4 centrally located non-small cell lung cancer. J Thorac Cardiovasc Surg. 1999;117:225–33.
De Leyn P, Dooms C, Kuzdzal J, Lardinois D, Passlick B, Rami-Porta R, et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg. 2014;45:787–98. https://doi.org/10.1093/ejcts/ezu028.
Pataer A, Kalhor N, Correa AM, Raso MG, Erasmus JJ, Kim ES, et al. Histopathologic response criteria predict survival of patients with resected lung cancer after neoadjuvant chemotherapy. J Thorac Oncol. 2012;7:825–32. https://doi.org/10.1097/JTO.0b013e318247504a.
Chaft JE, Shyr Y, Sepesi B, Forde PM. Preoperative and postoperative systemic therapy for operable non-small-cell lung cancer. J Clin Oncol. 2022;40:546–55. https://doi.org/10.1200/JCO.21.01589. Epub 2022 Jan 5.
Marulli G, Battistella L, Mammana M, Calabrese F, Rea F. Superior sulcus tumors (Pancoast tumors). Ann Transl Med. 2016;4:239. https://doi.org/10.21037/atm.2016.06.1.
Ramnath N, Dilling TJ, Harris LJ, Kim AW, Michaud GC, Balekian AA, et al. Treatment of stage III non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(Suppl 5):e314S–40S. https://doi.org/10.1378/chest.12-2360.
van Meerbeeck JP, Kramer GW, Van Schil PE, Legrand C, Smit EF, Schramel F, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer. J Natl Cancer Inst. 2007;99:442–50. https://doi.org/10.1093/jnci/djk093.
Albain KS, Swann RS, Rusch VW, Turrisi AT III, Shepherd FA, Smith C, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet. 2009;374:379–86. https://doi.org/10.1016/S0140-6736(09)60737-6.
Eberhardt WE, Pottgen C, Gauler TC, Friedel G, Veit S, Heinrich V, et al. Phase III study of surgery versus definitive concurrent chemoradiotherapy boost in patients with resectable stage IIIA(N2) and selected IIIB non-small-cell lung cancer after induction chemotherapy and concurrent chemoradiotherapy (ESPATUE). J Clin Oncol. 2015;33:4194–201. https://doi.org/10.1200/JCO.2015.62.6812.
Xu XL, Dan L, Chen W, Zhu SM, Mao WM. Neoadjuvant chemoradiotherapy or chemotherapy followed by surgery is superior to that followed by definitive chemoradiation or radiotherapy in stage IIIA (N2) nonsmall-cell lung cancer : a meta-analysis and system review. Onco Targets Ther. 2016;9:845–53. https://doi.org/10.2147/OTT.S95511.
Liang J, Bi N, Wu S, Chen M, Lv C, Zhao L, et al. Etoposide and cisplatin versus paclitaxel and carboplatin with concurrent thoracic radiotherapy in unresectable stage III non-small cell lung cancer: a multicenter randomized phase III trial. Ann Oncol. 2017;28:777–83. https://doi.org/10.1093/annonc/mdx009.
Senan S, Brade A, Wang LH, Vansteenkiste J, Dakhil S, Biesma B, et al. PROCLAIM: randomized phase III trial of pemetrexed-cisplatin or etoposide-cisplatin plus thoracic radiation therapy followed by consolidation chemotherapy in locally advanced nonsquamous non-small-cell lung cancer. J Clin Oncol. 2016;34:953–62. https://doi.org/10.1200/JCO.2015.64.8824.
Pignon JP, Stewart LA. Randomized trials of radiotherapy alone versus combined chemotherapy and radiotherapy in stages IIIa and IIIb nonsmall cell lung cancer: a meta-analysis. Cancer. 1996;77:2413–4. https://doi.org/10.1002/(SICI)1097-0142(19960601)77:11<2413::AID-CNCR34>3.0.CO;2-Y.
Marino P, Preatoni A, Cantoni A. Randomized trials of radiotherapy alone versus combined chemotherapy and radiotherapy in stages IIIa and IIIb nonsmall cell lung cancer. A meta-analysis. Cancer. 1995;76:593–601. https://doi.org/10.1002/1097-0142(19950815)76:4<593::aid-cncr2820760409>3.0.co;2-n.
Pritchard RS, Anthony SP. Chemotherapy plus radiotherapy compared with radiotherapy alone in the treatment of locally advanced, unresectable, non-small-cell lung cancer. A meta-analysis. Ann Intern Med. 1996;125:723–9. https://doi.org/10.7326/0003-4819-125-9-199611010-00003.
Belani CP, Choy H, Bonomi P, Scott C, Travis P, Haluschak J, et al. Combined chemoradiotherapy regimens of paclitaxel and carboplatin for locally advanced non-small-cell lung cancer: a randomized phase II locally advanced multi-modality protocol. J Clin Oncol. 2005;23:5883–91. https://doi.org/10.1200/JCO.2005.55.405.
Aupérin A, Péchoux C, Rolland E, Curran WJ, Furuse K, Fournel P, et al. Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small-cell lung cancer. J Clin Oncol. 2010;28:2181–90. https://doi.org/10.1200/JCO.2009.26.2543.
Zatloukal P, Petruzelka L, Zemanova M, Havel L, Janku F, Judas L, et al. Concurrent versus sequential chemoradiotherapy with cisplatin and vinorelbine in locally advanced non-small cell lung cancer: a randomized study. Lung Cancer. 2004;46:87–98. https://doi.org/10.1016/j.lungcan.2004.03.004.
Perez CA, Stanley K, Rubin P, Kramer S, Brady L, Perez-Tamayo R, et al. A prospective randomized study of various irradiation doses and fractionation schedules in the treatment of inoperable non-oat-cell carcinoma of the lung. Preliminary report by the Radiation Therapy Oncology Group. Cancer. 1980;45:2744–53. https://doi.org/10.1002/1097-0142(19800601)45:11<2744::aid-cncr2820451108>3.0.co;2-u.
Bradley JD, Paulus R, Komaki R, Masters G, Blumenschein G, Schild S, et al. A randomized phase III comparison of standard-dose (60 Gy) versus high-dose (74 Gy) conformal chemoradiotherapy with or without cetuximab for stage III non-small cell lung cancer: results on radiation dose in RTOG 0617. J Clin Oncol. 2013;31(Suppl):7501. https://doi.org/10.1200/jco.2013.31.15_suppl.7501.
Bradley JD, Paulus R, Komaki R, Masters G, Blumenschein G, Schild S, et al. Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): a randomised, two-by-two factorial phase 3 study. Lancet Oncol. 2015;16:187–99. https://doi.org/10.1016/S1470-2045(14)71207-0.
Hong JC, Salama JK. Dose escalation for unresectable locally advanced non-small cell lung cancer: end of the line? Transl Lung Cancer Res. 2016;5:126–33. https://doi.org/10.3978/j.issn.2218-6751.2016.01.07.
Bradley JD, Hu C, Komaki R, Masters G, Blumenschein G, Schild S, et al. Long-term results of NRG Oncology RTOG 0617: standard- versus high-dose chemoradiotherapy with or without cetuximab for unresectable stage III non-small-cell lung cancer. J Clin Oncol. 2020;38:706–14. https://doi.org/10.1200/JCO.19.01162.
Yom SS, Liao Z, Liu HH, Tucker SL, Hu CS, Wei X, et al. Initial evaluation of treatment-related pneumonitis in advanced-stage non-small-cell lung cancer patients treated with concurrent chemotherapy and intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2007;68:94–102. https://doi.org/10.1016/j.ijrobp.2006.12.031.
Kamran SC, Yeap BY, Ulysse CA, Cronin C, Bowes C, Durgin B, et al. Assessment of a contralateral esophagus-sparing technique in locally advanced lung cancer treated with high-dose chemoradiation: a phase 1 nonrandomized clinical trial. JAMA Oncol. 2021;7:910–4. https://doi.org/10.1001/jamaoncol.2021.0281.
Chun SG, Hu C, Choy H, Komaki R, Timmerman RD, Schild SE, et al. Impact of intensity-modulated radiation therapy technique for locally advanced non-small-cell lung cancer: a secondary analysis of the NRG oncology RTOG 0617 randomized clinical trial. J Clin Oncol. 2017;35:56–62. https://doi.org/10.1200/JCO.2016.69.1378.
Koshy M, Malik R, Spiotto M, Mahmood U, Rusthoven CG, Sher DJ. Association between intensity modulated radiotherapy and survival in patients with stage III non-small cell lung cancer treated with chemoradiotherapy. Lung Cancer. 2017;108:222–7. https://doi.org/10.1016/j.lungcan.2017.04.006.
Jegadeesh N, Liu Y, Gillespie T, Fernandez F, Ramalingam S, Mikell J, et al. Evaluating intensity-modulated radiation therapy in locally advanced non-small-cell lung cancer: results from the national cancer data base. Clin Lung Cancer. 2016;17:398–405. https://doi.org/10.1016/j.cllc.2016.01.007.
Chang YJ, Verma V, Li M, Zhang W, Komaki R, Lu C, et al. Proton beam radiotherapy and concurrent chemotherapy for unresectable stage III non-small cell lung cancer: final results of a phase 2 study. JAMA Oncol. 2017;3:e172032. https://doi.org/10.1001/jamaoncol.2017.2032.
Nguyen QN, Ly NB, Komaki R, Levy LB, Gomez DR, Chang JY, et al. Long-term outcomes after proton therapy, with concurrent chemotherapy, for stage II-III inoperable non-small cell lung cancer. Radiother Oncol. 2015;115:367–72. https://doi.org/10.1016/j.radonc.2015.05.014.
Oonishi K, Ishikawa H, Nakazawa K, Shiozawa T, Mori Y, Nakamura M, et al. Long-term outcomes of high-dose (74 GyE) proton beam therapy with concurrent chemotherapy for stage III non-small-cell lung cancer. Thorac Cancer. 2021;12:1320–7. https://doi.org/10.1111/1759-7714.13896.
Liao ZX, Lee JJ, Komaki R, Gomez DR, O’Reilly MS, Fossella FV, et al. Bayesian adaptive randomization trial of passive scattering proton therapy and intensity-modulated photon radiotherapy for locally advanced non-small-cell lung cancer. J Clin Oncol. 2018;36:1813–22. https://doi.org/10.1200/JCO.2017.74.0720.
Daly ME, Monjazeb AM, Kelly K. Clinical trials integrating immunotherapy and radiation for non–small-cell lung cancer. J Thorac Oncol. 2015;10:1685–93. https://doi.org/10.1097/JTO.0000000000000686.
Reckamp K, Radman MW, Dragnev KH, Minichiello K, Villaruz LC, Faller B, et al. Phase II randomized study of ramucirumab and pembrolizumab versus standard of care in advanced non-small-cell lung cancer previously treated with immunotherapy-Lung-MAP S1800A. J Clin Oncol. 2022;40:2295–306. https://doi.org/10.1200/JCO.22.00912.
Durm GA, Jabbour SK, Althouse SK, Liu Z, Sadiq AA, Zon RT, et al. A phase 2 trial of consolidation pembrolizumab following concurrent chemoradiation for patients with unresectable stage III non-small cell lung cancer: Hoosier Cancer Research Network LUN 14-179. Cancer. 2020;126:4353–61. https://doi.org/10.1002/cncr.33083.
Garassino M, Gadgeel S, Esteban E, Felip E, Speranza G, Domine M, et al. Patient-reported outcomes following pembrolizumab or placebo plus pemetrexed and platinum in patients with previously untreated, metastatic, non-squamous non-small-cell lung cancer (KEYNOTE-189): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Oncol. 2020;21:387–97. https://doi.org/10.1016/S1470-2045(19)30801-0.
Peters S, Spigel D, Ahn M, Tsuboi M, Chaft J, Harpole D, et al. MERMAID-1: A phase III study of adjuvant durvalumab plus chemotherapy in resected NSCLC patients with MRD+ post-surgery. J Thorac Oncol. 2021;16(Suppl 3):S258–9. https://doi.org/10.1016/j.jtho.2021.01.376.
Provencio M, Nadal E, Insa A, GarcÃa-Campelo MR, Casal-Rubio J, Dómine M, et al. Neoadjuvant chemotherapy and nivolumab in resectable non-small-cell lung cancer (NADIM): an open-label, multicentre, single-arm, phase 2 trial. Lancet Oncol. 2020;21:1413–22. https://doi.org/10.1016/S1470-2045(20)30453-8.
Provencio M, Serna-Blasco R, Nadal E, Insa A, GarcÃa-Campelo MR, Casal-Rubio J, et al. Overall survival and biomarker analysis of neoadjuvant nivolumab plus chemotherapy in operable stage IIIA non-small-cell lung cancer (NADIM phase II trial). J Clin Oncol. 2022;40:2924. https://doi.org/10.1200/JCO.21.02660.
Forde PM, Spicer J, Lu S, Provencio M, Mitsudomi T, Awad MM, et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022;386:1973–85. https://doi.org/10.1056/NEJMoa2202170.
Grimaldi AM, Simeone E, Giannarelli D, Muto P, Falivene S, Borzillo V, et al. Abscopal effects of radiotherapy on advanced melanoma patients who progressed after ipilimumab immunotherapy. Onco Targets Ther. 2014;3:e28780. https://doi.org/10.4161/onci.28780.
Franzi S, Mattioni G, Rijavec E, Croci GA, Tosi D. Neoadjuvant chemo-immunotherapy for locally advanced non-small-cell-lung cancer: a review of the literature. J Clin Med. 2022;11:2629. https://doi.org/10.3390/jcm11092629.
Antonia SJ, Villegas A, Daniel D, Vicente D, Murakami S, Hui R, et al. Durvalumab after chemoradiotherapy in stage III non-small-cell lung cancer. N Engl J Med. 2017;377:1919–29. https://doi.org/10.1056/NEJMoa1709937.
Antonia SJ, Villegas A, Daniel D, Vicente D, Murakami S, Hui R, et al. Overall survival with durvalumab after chemoradiotherapy in stage III NSCLC. N Engl J Med. 2018;379:2342–50. https://doi.org/10.1056/NEJMoa1809697.
Spigel DR, Faivre-Finn C, Gray JE, Vicente D, Planchard D, Paz-Ares L, et al. Five-year survival outcomes from the PACIFIC trial: durvalumab after chemoradiotherapy in stage III non-small-cell lung cancer. J Clin Oncol. 2022;40:1301–11. https://doi.org/10.1200/JCO.21.01308.
Qin Q, Peng B, Li B. The impact of epidermal growth factor receptor mutations on the efficacy of definitive chemoradiotherapy in patients with locally advanced unresectable stage III non-small cell lung cancer: a systematic review and meta-analysis. Expert Rev Anticancer Ther. 2019;19:533–9. https://doi.org/10.1080/14737140.2019.1621754.
Blumenschein GR Jr, Paulus R, Curran WJ, Robert F, Fossella F, Werner-Wasik M, et al. Phase II study of cetuximab in combination with chemoradiation in patients with stage IIIA/B non-small-cell lung cancer: RTOG 0324. J Clin Oncol. 2011;29:2312–8. https://doi.org/10.1200/JCO.2010.31.7875.
Govindan R, Bogart J, Stinchcombe T, Wang X, Hodgson L, Kratzke R, et al. Randomized phase II study of pemetrexed, carboplatin, and thoracic radiation with or without cetuximab in patients with locally advanced unresectable non-small-cell lung cancer: Cancer and Leukemia Group B trial 30407. J Clin Oncol. 2011;29:3120–5. https://doi.org/10.1200/JCO.2010.33.4979.
Kelly K, Chansky K, Gaspar LE, Albain KS, Jett J, Ung YC, et al. Phase III trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage III non–small-cell lung cancer: SWOG S0023. J Clin Oncol. 2008;26:2450–6. https://doi.org/10.1200/JCO.2007.14.4824.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Kitazawa, S., Gregor, A., Yasufuku, K. (2023). Treatment of Stage III Non-small Cell Lung Cancer. In: MacRosty, C.R., Rivera, M.P. (eds) Lung Cancer. Respiratory Medicine. Humana, Cham. https://doi.org/10.1007/978-3-031-38412-7_7
Download citation
DOI: https://doi.org/10.1007/978-3-031-38412-7_7
Published:
Publisher Name: Humana, Cham
Print ISBN: 978-3-031-38411-0
Online ISBN: 978-3-031-38412-7
eBook Packages: MedicineMedicine (R0)