Stage 3a/b - do lymph nodes need to be clear before surgery? - 1245881

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Stage 3a/b - do lymph nodes need to be clear before surgery? - 1245881

My 58 year old mother has just been diagnosed with non-small cell squamous lung cancer. She is very fit and has excellent results from her lung function test. She quit smoking 8 years ago and only has the symptom of a dry cough. She developed this cough 18 months ago, was given a clear xray which we have since found out was not clear at all! An xray last month showed a big shadow. And biopsy, CT and PET scans revealed she has a 10cm tumour in her left lower lobe. It is right next to the pericardium but not wrapped around any of the heart. She also has cancerous cells in two lymph nodes in the middle of the chest but on the same side as her tumour. She has been staged at t4 n2 m0. Although another consultant has argued she is T3. So we're not sure if this makes her stage 3a or b. We live in the UK.

The hospital are suggesting chemo one day a week every 3 weeks and possible radiation inbetween. They say if the tumour shrinks and we can completely clear the lymph nodes, then surgery will become an option.

My question is whether in your experience, lymph nodes (on the same side as the tumour) need to be completely clear before surgery? I am confused as to why they cannot remove these lymph nodes with the tumour. Is it worth us seeking a second opinion or is this standard?

Due to my mother's current great health, I want to ensure she is offered the most aggressive and productive treatment.

Thank you for any advice.

certain spring
Reply To: Stage 3a/b – do lymph nodes need to be clear before

Hallo cherryblossom, and welcome to Grace. I thought I'd answer as I'm in the UK too, whereas it's still early morning in the US.
Of course you need a doctor to answer your question properly, as staging is quite a technical subject. But I wanted to say that I am sorry to hear about your mother. It must have been a big shock. Once you have more clarity about whether her cancer would be stage IIIa or b, we have a lot of information available that may be helpful, and a lot of people in the same boat who can offer their experience and support. Best wishes.

Reply To: Stage 3a/b – do lymph nodes need to be clear before

Thank you for the welcome certain spring. From what I've been reading, it seems mum is stage 3b but only because the tumour is against the heart. It seems if we can shrink the tumour and it moves away from the heart, she would then become stage 3a. I think!

Certain spring - am I right in reading that you tested positive for mutation? I asked the doctor if they tested mum for EGFR and they said no there was no point as that doesn't apply to nsclc squamous carcinoma!?

Wishing you all the best and great results.

Reply To: Stage 3a/b – do lymph nodes need to be clear before

Hello cherryblossom, I'm know how very difficult this is for everyone and want to lend support. Dr. West has often stated that this stage of cancer is difficult to pinpoint just the right treatment and doctors have differing opinions on the matter. It has been shown that a multi-disciplinary group of doctors working on a case like this has the best results. So though it sounds like your mom's doctor has a good plan a second opinion at a cancer center with a specialty in lung cancer is always reasonable.

Below is a link to a podcast/transcript that discusses n2 node involvement. I think it will give you a good place to start your understanding of your mom's situation.

This is a link to a blog/post about 2nd opinions.

Please let us know of further questions and to update us on your mom.
forum moderator

Dr West
Reply To: Stage 3a/b – do lymph nodes need to be clear before

Here are a couple of key links that describe how we approach stage III NSCLC:

Locally advanced (stage III) NSCLC is a situation in which there is plenty of room for debate, even among experts, on an optimal strategy, in part because patient situations are so heterogeneous. Most experts really disfavor pursuing surgery if it's a very dubious case for a good resection, and I think that's the case most of the time when anyone thinks the primary tumor is T4. At the same time, many leading experts really think nearly all patients with anything more than one N2 node, or certainly more than one nodal area (station) are better served by a non-surgical approach.

In terms of how to approach patients who aren't ideal for surgery but still have regionally localized and potentially curable NSCLC, chemo and radiation are ideally combined and given concurrently, with radiation given to a full, definitive dose of at least 60 Gray (Gy, the unit of radiation dose) and often more like 64-66 Gy (most typically given once daily for 6-7 weeks). Sometimes, centers in the UK have a more "casual" approach (trying to be diplomatic here) to lung cancer treatment that I would argue falls below what most of the world considers as optimal treatment, so I think it's probably very helpful for patients and caregivers to have an idea of those global standards of best practice and not accept a path of least resistance if it falls below that standard.

Good luck.

-Dr. West

Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

Reply To: Stage 3a/b – do lymph nodes need to be clear before

I do believe had my Lymph nods shown up on my Pet Scan my Surgeon and Oncologist would have approached my Tumor differently. For which I wouldn't have been Happy. I wanted the Tumor out as quickly as possible so to have to do Chemo and Radiation before surgery would have been very difficult for me to deal with. The Surgeon and Lung Dr. Kept apologizing to me for not catching the lymph nodes before hand. Well it has been a full year since my DX and I am still NED! And Very, Very Happy about that! Q

certain spring
Reply To: Stage 3a/b – do lymph nodes need to be clear before

Good morning cherryblossom. I am sorry for everything you are facing with your mum.
To answer your question, NHS doctors generally test for EGFR (and ALK, the other mutation for which there is a targeted drug) only in patients with adenocarcinoma. It is unusual to find EGFR in a squamous tumour - the odds are said to be perhaps 1:100. I was incredibly lucky, but I was also at a point where we had no options left. We were asked to pay for the test which seemed fair enough. It's done with biopsy tissue from the tumour. Given my experience, I would always suggest that people get it done if they can, as long as they're fully aware that it's a long shot. It might be worth considering if your mother doesn't, in the end, have surgery. I'm sorry she is facing these discussions and uncertainties. Once treatment starts life becomes (strangely) easier, because everyone just gets on with it. Best wishes.