Guidelines on Treatment of Stage IIIB

Non-small Cell Lung Cancer *

James R. Jett, Walter J. Scott, M. Patricia Rivera and William T. Sause

Chest 2003;123;221S-225S
DOI 10.1378/chest.123.1_suppl.221S
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© 2003 American College of Chest Physicians
Guidelines on Treatment of Stage IIIB
Non-small Cell Lung Cancer*
James R. Jett, MD, FCCP; Walter J. Scott, MD, FCCP;
M. Patricia Rivera MD, FCCP; and William T. Sause, MD, FACR

Stage IIIB includes patients with T4, any N, M0, and any T, N3, M0. Surgery may be indicated
only for carefully selected T4N0M0 patients with or without neoadjuvant chemotherapy or
chemoradiotherapy. Patients with N3 lymph node involvement are not considered as surgical
candidates. For patients with unresectable disease, good performance score, and minimal weight
loss, treatment with combined chemotherapy and radiotherapy has resulted in better survival
than treatment with radiotherapy alone. Multiple daily fractions of radiotherapy have not
resulted in improved survival compared with standard fractionation once daily. Concurrent
chemoradiotherapy appears to be associated with improved survival compared with sequential
chemotherapy and radiotherapy. Treatment of stage IIIB due to malignant pleural effusion is
addressed in the section that deals with stage IV disease. (CHEST 2003; 123:221S–225S)

Key words: NSCLC stage IIIB; stage IIIB; unresectable lung cancer; unresectable NSCLC

Abbreviations: CHART ⫽ continuous hyperfractionated accelerated radiotherapy; Fx ⫽ fractions; NSCLC ⫽ non-

small cell lung cancers; PS ⫽ performance score; RTOG ⫽ Radiation Therapy Oncology Group

S mors,
tage IIIB disease includes patients with T4 tu-
any N, M0, and any T, N3, M0. It is
estimated that 10 –15% of all patients are stage IIIB
at the time of diagnosis. The treatment options
depend on the extent of disease and include surgery
alone in carefully selected patients or a combination
of chemotherapy and radiotherapy. Surgical resec-
tion after induction therapy may be appropriate in
selected patients. Radiotherapy alone has been used
in the past but should be limited to patients with
poor performance score. Chemotherapy alone is not
a good treatment option except for patients with
malignant pleural effusion (discussed in the section
on stage IV disease).
Methods
This section of the evidence-based guidelines is
based on an extensive review of the medical litera-
ture, including 8 guidelines, 5 meta-analyses, and 20
manuscripts and abstracts, with an emphasis on
phase III randomized control trials. Selected key
references are included in the bibliography.
*From the Mayo Clinic (Dr. Jett), Rochester, MN; Section of
Thoracic Surgical Oncology, Fox Chase Cancer Center (Dr.
Scott), Philadelphia, PA; University of North Carolina (Dr.
Rivera), Chapel Hill, NC; LDS Hospital, University of Utah
(Dr. Sause), Salt Lake City, UT.
Correspondence to: James R. Jett, MD, FCCP, Mayo Clinic, 200
First Street Southwest, Rochester, MN 55905; e-mail: jett.james@
mayo.edu
Limited Role of Surgery
The 5-year survival of patients with clinically
staged IIIB non-small cell lung cancer (NSCLC) is
3 to 7%.1 Data on pathologically staged IIIB disease
was not available in the new Mountain International
Classification. Stage IIIB disease includes T4N0 –
3M0 and T1– 4N3M0. This section will not address
treatment of patients with T4 disease due to malig-
nant pleural or pericardial effusions or IIIB Pancoast
tumors. Malignant effusions will be addressed in the
section on stage IV disease, and Pancoast tumors will
be discussed in the chapter on special treatment
issues.
Surgery may be indicated for stage IIIB disease
only in carefully selected situations.2 Patients who
are T4N0 –1 due solely to a satellite tumor nodule(s)
within the primary tumor lobe have a 5-year survival
of approximately 20% with surgery alone.3,4 Individ-
uals with T4N0 –1 disease due to main carinal in-
volvement have been treated with carinal resection
with or without pulmonary resection. Carinal resec-
tion carries an appreciable mortality of 10 to 15%,
with an increased risk of local recurrence.5,6 The
5-year survival in these carefully selected series is
approximately 20%.
Neoadjuvant chemotherapy, or chemoradiother-
apy followed by surgical resection, has been used in
patients with N2 (IIIA) disease. However, few phase
II series have included carefully selected patients

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© 2003 American College of Chest Physicians
with T4 primary lesions or N3 nodes. A study by the
Southwestern Oncology Group employed concur-
rent chemoradiotherapy in 51 patients with IIIB
disease that excluded superior vena cava syndrome
and malignant effusions. That study observed a
resectability rate of 80%, with a median survival time
of 17 months and a 3-year survival rate of 24%.7
These results were similar to those observed in
patients with IIIA disease reported in that same trial.
To date, however, there are no phase III trial data
that demonstrate that neoadjuvant treatment fol-
lowed by surgery in patients with IIIB disease results
in prolonged survival compared with treatment with
combination chemoradiotherapy.
Recommendations
1. Patients with clinical T4N0 NSCLC due to
either satellite tumor nodule(s) in the same
lobe or carinal involvement should be evaluated
by a thoracic surgeon for possible resection.
Level of evidence: fair; benefit: substantial;
grade of recommendation: B.
2. For patients with stage IIIB NSCLC due to T4
(excluding Pancoast tumors) or N3 disease,
treatment with neoadjuvant chemotherapy or
chemoradiotherapy followed by surgery has
been explored in limited phase II trials. At this
time, there are no phase III trial data available
to document that surgery adds to survival;
therefore, this approach should not be consid-
ered as standard therapy. Level of evidence:
poor; benefit: small/weak; grade of recommen-
dation: I.
Radiotherapy Alone vs Combination
Chemotherapy and Radiotherapy
The vast majority of patients with IIIB disease do
not benefit from surgery and are best managed with
chemotherapy plus radiotherapy or with radiother-
apy alone, depending on sites of tumor involvement
and performance score status. A trial by the Cancer
and Acute Leukemia Group B randomly assigned
patients with good performance score (PS 0, 1),
minimal weight loss (ⱕ 5%), and stage IIIA or IIIB
disease to treatment with thoracic radiotherapy alone
(60 Gy/30 Fx) or to treatment with identical radio-
therapy plus cisplatin and vinblastine chemother-
apy.8 After more than 7 years of follow-up, the
median survival time was 13.7 months for combined
modality therapy and 9.6 months for radiotherapy
alone. The 5-year survival rates were 17% and 6%,
respectively (p ⫽ 0.01).9 Multiple randomized trials
of radiotherapy alone vs combined chemotherapy
and radiotherapy have included patients with inop-
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© 2003 American College of Chest Physicians
erable IIIA and IIIB disease. Results of just the IIIB
patients are not independently available. At least 3
meta-analyses have been performed on the random-
ized trials.10 –12 The non-small cell lung cancer col-
laborative group meta-analysis evaluated 11 trials
with cisplatin-based chemotherapy regimens.10 The
results showed a significant overall benefit of che-
moradiotherapy. There was a 13% reduction in the
risk of death (hazard ratio of 0.87) and an absolute
benefit of 4% at 2 years and 2% at 5 years
(p ⫽ 0.005). Trials using noncisplatin chemotherapy
were marginally, but not statistically, significant in
favor of chemoradiotherapy. Results of two separate
meta-analyses were similarly in favor of combination
chemotherapy and radiotherapy.11,12
Clinical practice guidelines issued by the Ameri-
can Society of Clinical Oncology in 199713 recom-
mend the addition of a platinum-based regimen to
thoracic radiotherapy in patients with unresectable
IIIA/IIIB disease with a good performance score and
minimal weight loss. The National Comprehensive
Cancer Network practice guidelines and the Cancer
Care Ontario Practice Guidelines (No. 7-3) agree
with the American Society of Clinical Oncology
recommendations. Accordingly, patients with unre-
sectable stage IIIB NSCLC who have a good perfor-
mance score and minimal weight loss (ⱕ 5%) should
be treated with cisplatin-based chemotherapy in
combination with thoracic radiotherapy. With com-
bined modality therapy, the expected 5-year survival
is 10 to 15%.
Recommendations
3. For patients with stage IIIB disease without
malignant effusions, PS 0 or 1, and minimal
weight loss (ⱕ 5%), combined chemoradiother-
apy should be the standard of care. Level of
evidence: good; benefit: substantial; grade of
recommendation: A.
4. In patients with stage IIIB NSCLC and PS 2 or
those with substantial weight loss (ⱖ 10%),
combined modality treatment could be used
after careful consideration. Level of evidence:
poor; benefit: moderate; grade of recommen-
dation: C.
Altered Fractions of Radiotherapy
It appears from studies in several epithelial tumor
systems that the clinical effectiveness of radiation is
the total dose per unit time. The clinical advantage of
multiple daily fractions is a reduction in late tissue
damage. In a virulent tumor such as lung cancer, it is
unclear whether substantial clinical benefit can be
derived from radiation optimization.14
Lung Cancer Guidelines
 There has been interest in altered fractionation
radiotherapy to increase control of the primary tu-
mor and decrease the toxicity to normal tissue.
Hyperfractionation is defined as the use of two or
more fractions daily of smaller-than-conventional
fraction size. The Radiation Therapy Oncology
Group (RTOG) conducted a three-arm randomized
control trial of standard once daily radiotherapy,
combination chemotherapy, and standard once daily
radiotherapy or hyperfractionated radiotherapy
given twice daily without chemotherapy.15 Ninety-
five percent of patients had stage IIIA or IIIB
disease. The overall survival was statistically superior
for the combined chemotherapy and once daily
thoracic radiotherapy arm. Survival for patients re-
ceiving twice daily radiotherapy was not statistically
superior. The median survival for the standard radi-
ation was 11.4 months, 13.2 months for the com-
bined modality arm, and 12 months for the hyper-
fractionated irradiation treatment. The 5-year
survival rates for these groups were 5%, 8%, and 6%,
respectively.
Meta-analysis of this trial and two other smaller
trials was performed, and it reported improved
survival for hyperfractionated radiotherapy over
standard radiotherapy (odds ratio 0.69; 95% confi-
dence interval 0.51– 0.95; p ⫽ 0.02).16 However, a
second meta-analysis of these same three studies,
conducted at Cancer Care Ontario Practice Guide-
lines Initiation Resource Group and based on 2-year
survival and a fixed effort model, did not demon-
strate a significant benefit of hyperfractionated ra-
diotherapy over standard radiotherapy (odds ratio
0.67; 95% confidence interval 0.42–1.07; p ⫽ 0.09).17
Recently, a phase III trial by the North Central
Cancer Treatment Group evaluated concurrent
combined treatment with etoposide/cisplatin chemo-
therapy (both arms) and once daily or twice daily
split course thoracic radiotherapy. There was no
significant difference in survival or toxicity for the
two arms. The median survival time was 14 vs 15
months, and the 2-year survival rates were 37% and
40%, respectively (p ⫽ 0.6).18 Accordingly, there is
absence of convincing data that hyperfractionated
(twice daily) thoracic radiotherapy is superior to
standard once daily radiotherapy.
Accelerated radiotherapy is defined as the use of
two or more fractions of standard fraction size daily
to the same conventional total dose as standard
radiotherapy, but increasing the number of fractions
per week and shortening the overall treatment time.
Hyperfractionated accelerated radiotherapy com-
bines the features of accelerated and hyperfraction-
ated regimen. It uses two or three fractions of
smaller fraction size daily, delivered over a shorter
period of time than conventional therapy. The goal is
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© 2003 American College of Chest Physicians
to reduce long-term normal tissue toxicity by smaller
fraction size and to reduce repopulation in rapidly
proliferating tumors. One randomized phase III trial
in England19,20 compared continuous hyperfraction-
ated accelerated radiotherapy (CHART) to standard
radiotherapy (60 Gy/30 Fx). CHART consisted of
three treatments per day (1.5 Gy/Fx), at least 6 h
apart, for 12 days without a break (54 Gy). Sixty-one
percent of patients were IIIA or IIIB. The 1- and
2-year survival rates for the CHART arm were 63%
and 29%, respectively, vs 55% and 20% for standard
radiotherapy. Overall, there was a 22% reduction in
the relative risk of death (p ⫽ 0.008). Acute esoph-
agitis was more severe for patients receiving
CHART, but the incidence at 3 months was similar
to patients receiving standard radiotherapy, and
there was no difference in late morbidity. Recently,
a phase III trial of HART (same as CHART except
for no treatments on weekends) vs standard radio-
therapy after induction chemotherapy had to be
closed due to poor accrual in the Eastern Coopera-
tive Oncology Group.
Accordingly, at this time we have one phase III
trial of CHART that showed superior survival over
standard radiotherapy, but it had only 61% of pa-
tients with stage IIIA and IIIB disease, and no data
are available concerning the combination of CHART
and chemotherapy. Additionally, the schedule of
radiotherapy 3 times per day seems to have been
rejected by radiotherapists in North America. There-
fore, at this time, neither CHART nor HART can be
recommended as standard therapy. Optional dose,
volume, and fractionation schedules are evolving. An
RTOG randomized phase III trial in the 1980s21
demonstrated that 60 Gy produced a nonstatistically
significant survival improvement compared with 50
Gy or two different schedules of 40 Gy. Accordingly,
the dose of 60 Gy in 6 weeks has been widely used
for 20 years. However, this dose and fractionation
schedule results in local control rates of 15 to
30%.15,22 Therefore, higher doses may yield better
results. Guidelines of the American Society of Clin-
ical Oncology advise that definitive dose thoracic
radiotherapy should be at least 60 Gy in 1.8 to 2.0 Gy
fractions.13
Recommendation
5. For stage IIIB NSCLC patients, there are no
convincing data that hyperfractionated (two or
more fractions daily) radiotherapy is superior to
standard once daily treatment. Continuous
hyperfractionated accelerated radiotherapy
(CHART) was demonstrated in one small trial
to be superior to standard once daily therapy,
CHEST / 123 / 1 / JANUARY, 2003 SUPPLEMENT 223S
 but the logistics of three treatments daily have
not proven to be acceptable in a North Amer-
ican trial. No data are available in combining
CHART with chemotherapy. Level of Evi-
dence: poor; benefit: small/weak; grade of rec-
ommendation: I.
Concurrent vs Sequential
Chemoradiotherapy
Concurrent treatment with chemoradiotherapy
has become the standard in treatment of limited
stage small cell lung cancer. There is less information
available on treatment of NSCLC. The West Japan
Lung Cancer Group conducted a randomized phase
III trial of concurrent vs sequential thoracic radio-
therapy in combination with mitomycin, vindesine,
and cisplatin, with over 150 patients participating in
each arm.23 Seventy-two percent had stage IIIB
disease. Radiation was begun on day 2 at a dose of
28 Gy (2 Gy/Fx ⫻ 14), followed by a rest of 10 days
and then repeated for a total dose of 56Gy. In the
sequential arm, the same chemotherapy was given,
but radiotherapy was initiated after completing che-
motherapy and consisted of 56 Gy (2 Gy/Fx ⫻ 28)
without a break. The median survival time was
superior for patients in the concurrent therapy arm
(16.5 vs 13.3 months), and the 5-year survival differ-
ence was 15.8% vs 8.9% (p ⫽ 0.039). The RTOG
conducted a phase III trial of concurrent vs sequen-
tial chemoradiotherapy. The chemotherapy was vin-
blastine and cisplatin. Radiotherapy was begun on
day 1 of chemotherapy or on day 50 after chemo-
therapy, and the total dose was 63 Gy. The median
survival time was 17 months with concurrent therapy
and 14.6 months with sequential treatment.24 This
difference was significant at the time of a follow-up
report in the fall of 2000.
A French cooperative group performed a phase
III randomized trial of sequential vs concurrent
chemoradiotherapy in unresectable IIIA/IIIB pa-
tients.25 The chemotherapy was cisplatin and vi-
norelbine for 3 cycles, followed by thoracic radio-
therapy (66 Gy/33 Fx), or concurrent cisplatin/
etoposide, with thoracic radiotherapy followed by
cisplatin and vinorelbine. Seventy-five percent of
patients had IIIB disease, and over 100 patients
were enrolled in each arm. Incidence of grade 3/4
esophagitis was 26% in patients in the concurrent
therapy arm vs 0% in the sequential arm. The
median survival time was 13.8 months with se-
quential therapy and 15 months with concurrent
therapy. The 2-year survival rates were 23% and
35%, respectively.25 While there was a trend in
favor of concurrent therapy, it was not statistically
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© 2003 American College of Chest Physicians
significant at the time of this preliminary report.
Therefore, based on these three large phase III
randomized trials, concurrent chemoradiotherapy
appears to result in better survival than sequential
therapy. It is associated with some increased tox-
icity, mainly acute esophagitis, and should be
reserved for patients with PS 0 or 1 and minimal
weight loss.
Recommendation
6. For stage IIIB NSCLC patients with PS 0 or 1
and minimal weight loss, concurrent therapy
would be recommended. Concurrent chemora-
diotherapy is associated with an increase rate of
acute esophagitis compared to sequential ther-
apy. Concurrent therapy appears to be associ-
ated with improved survival over that of sequen-
tial therapy. Level of evidence: fair; benefit:
substantial; grade of recommendation: B.
Summary of Recommendations
1. Patients with clinical T4N0 NSCLC due to
either satellite tumor nodule(s) in the same
lobe or carinal involvement should be evalu-
ated by a thoracic surgeon for possible resec-
tion. Level of evidence: fair; benefit: substan-
tial; grade of recommendation: B.
2. For patients with stage IIIB NSCLC due to T4
(excluding Pancoast tumors) or N3 disease,
neoadjuvant chemotherapy or chemoradio-
therapy followed by surgery has been explored
in limited phase II trials. At the time this
article was written, there were no phase III
trial data available to document that surgery
would improve survival rates, so this approach
should not be considered as standard therapy.
Level of evidence: poor; benefit: small/weak;
grade of recommendation: I.
3. For patients with stage IIIB disease without
malignant effusions, PS 0 or 1, and minimal
weight loss (ⱕ 5%), combined chemoradio-
therapy should be the standard of care. Level
of evidence: good; benefit: substantial; grade
of recommendation: A.
4. For patients with stage IIIB NSCLC and PS 2
or those with substantial weight loss (ⱖ 10%),
combined modality treatment could be used
after careful consideration. Level of evidence:
poor; benefit: moderate; grade of recommen-
dation: C.
5. For stage IIIB NSCLC patients, there are no
convincing data that hyperfractionated (two or
Lung Cancer Guidelines
 more fractions daily) radiotherapy is superior
to standard once daily treatment. Continuous
hyperfractionated accelerated radiotherapy
(CHART) was demonstrated in one small trial
to be superior to standard once daily therapy,
but the logistics of three treatments daily have
not proven to be acceptable in a North Amer-
ican trial. No data are available in combining
CHART with chemotherapy. Level of evi-
dence: poor; benefit: small/weak; grade of
recommendation: I.
6. For stage IIIB NSCLC patients with PS 0 or 1
and minimal weight loss, concurrent therapy
would be recommended. Concurrent chemo-
radiotherapy is associated with an increased
rate of acute esophagitis compared to sequen-
tial therapy. Concurrent therapy appears to be
associated with improved survival vs sequential
therapy. Level of evidence: fair; benefit: sub-
stantial; grade of recommendation: B.
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CHEST / 123 / 1 / JANUARY, 2003 SUPPLEMENT 225S
 Guidelines on Treatment of Stage IIIB Non-small Cell Lung Cancer*
James R. Jett, Walter J. Scott, M. Patricia Rivera and William T. Sause
Chest 2003;123; 221S-225S
DOI 10.1378/chest.123.1_suppl.221S
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