People who have been following my comments know that I am often questioning the wisdom of surgery in patients who don't fit the usual criteria for resection, which is most commonly pursued in stage I and II NSCLC and is often considered an option for some patients with stage IIIA NSCLC. To provide a very quick review of NSCLC staging, it's a combination of three factors:

1) Tumor (T) stage -- from 1 to 4, going from smallest and easiest to remove to hardest or largest to remove

2) Node (N) stage -- from 0 to 3, going from none to further distances from the main tumor

There's a website called Adjuvant! Online, developed by oncologist Peter Ravdin, that is best known for its use after surgery for breast cancer in assessing the value of post-operative chemo. Because I don't really treat breast cancer, I haven't spent time on the website, but I do know that it's a valued resource among practicing oncologists who care for patients with breast cancer.

In a previous post I described the open question about whether patients with locally advanced NSCLC should receive prophylactic cranial irradiation (PCI) after completing chemo and chest irradiation.

In my last post I covered much of the controversy about whether patients with stage IIIA, N2-node positive NSCLC should be treated with induction therapy (chemotherapy or chemo/radiation) followed by surgery, or an alternative approach of chemo along with radiation delivered at a definitive dose (curative, not just the supplemental, lower doses used in induction therapy).

It's over, and I won (did you doubt me?).

One of the more common approaches to treating stage IIIA NSCLC with N2 lymph nodes (mediastinal, or mid-chest, on the same side as the primary tumor) is chemotherapy or chemoradiation before surgery. For those who recommend induction therapy (treatment before planned resection), there is a pretty even split between those who recommend chemotherapy alone and those who recommend chemo with concurrent radiation. So how do knowledgeable people come to different conclusions, and who is right?

Over the last several years, chemotherapy after surgery has become the standard strategy for improving survival compared to surgery alone, at least for stage II and IIIA patients who don't have mediastinal (N2) lymph nodes involved, and it's often used also for patients with stage IB NSCLC (no lymph nodes, but a larger tumor or tumor involvement with the pleural lining around the lung). However, another approach that has been studied, albeit less so than adjuvant (post-operative) chemotherapy is neoadjuvant (pre-operative, also known as induction) chemotherapy.

Celecoxib (Celebrex) has been studied in combination with chemo for NSCLC and has generated enough promising results to raise expectations but also enough negative data to produce disappointment. Dr.

While brain metastases are common, some patients seem to be at higher risk than others. As previously noted, SCLC has a very high risk of spread to the brain. For NSCLC subtypes, several studies have shown that patients with non-squamous lung cancers have a greater tendency to develop brain metastases than those with squamous cancers, which tend toward more local spread.

There is still plenty of active debate about whether patients with stage III NSCLC who have mediastinal lymph nodes, the ones in the middle of the chest between the lungs but on the same side as the main tumor, should receive surgery in some circumstances or not.