The overall management for stage IIIA disease really boils down to essentially two different strategies. One is chemoradiation, and the second is a surgical approach in which you would either use chemotherapy or chemoradiation prior to surgery, and maybe in some cases, following surgery. There is not an agreed-upon standard in this regard — we’ve had several trials looking at the role of surgery in stage IIIA disease, specifically in those patients who have N2, or lymph nodes that are positive on the same side of the tumor that reside in the mediastinum.
From these two experiences, one of which employed preoperative chemoradiation, the other employed preoperative chemotherapy alone, this surgical arm, relative to the radiotherapy arm, did not show a long-term survival advantage as a result of surgery. So surgery remains controversial in this setting — not to say that there are not selected patients in which surgery should be considered, but I think they have to be very highly selected in this particular setting.
Now, getting back to one of the points we discussed earlier — that’s the heterogeneity of the disease. Often, we’ll find that patients undergo preoperative staging, which is very important. One must define the pathologic contents of the mediastinal lymph nodes prior to deciding about taking that patient to the operating room. I would say that if you can document N2, or certainly N3 disease, that the initial maneuver should not be surgical resection of that patient. However, there are patients in whom preoperative assessment of the mediastinal lymph nodes does not detect mediastinal disease, but while in the operating room at the time of resection, microscopic N2 disease or unsuspected N2 disease is found.
I think most surgeons, if possible, if they could do a complete resection, and resect all the involved lymph nodes, I would agree that would be the right thing to do, and in that case I think there is a clear role for postoperative adjuvant chemotherapy in resected N2 disease, in consideration of postoperative radiotherapy, depending upon the nature and the extent of the N2 disease.