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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe treatment of non-small cell lung cancer (NSCLC) presents several challenges. Practice guidelines are based on limited evidence, and are often unclear and subject to multiple interpretations. Determining when mediastinal lymph nodes should be sampled, and how to best treat stage III disease, presents a particular challenge. Better treatment outcomes are needed.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECancer\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERespiratory Cancers\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EOncology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EFeatured Meeting - Specialty page\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPulmonary \u0026amp; Critical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECancer\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERespiratory Cancers\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThe treatment of non-small cell lung cancer (NSCLC) presents several challenges. Practice guidelines are based on limited evidence, and are often unclear and subject to multiple interpretations. Determining when mediastinal lymph nodes should be sampled, and how to best treat stage III disease, presents a particular challenge. Better treatment outcomes are needed.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMEDIASTINAL SAMPLING\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EAnil Vachani, MD, Abramson Cancer Center, Philadelphia, Pennsylvania, USA indicated that positron emission tomography (PET) is the preferred imaging method for mediastinal staging since it provides more accuracy than computed tomography (CT). However, a biopsy is still needed to confirm PET findings. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique for obtaining tissue for staging, with results equivalent to those for surgical staging. The 3rd edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on Lung Cancer (LCIII guidelines) indicate that surgical biopsy should be done if the findings of a needle biopsy are negative [Silvestri GA et al. \u003Cem\u003EChest\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EDue to variation in the patterns of lymph node involvement, it is difficult to know when mediastinal sampling is necessary. There are four main patterns of mediastinal lymph node involvement (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E):\u003C\/p\u003E\n         \u003Cp\u003E\n            \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-6\u0022\u003E\u25aa Massive mediastinal infiltration\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \u003Cp id=\u0022p-7\u0022\u003E\u25aa Discrete node involvement\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-8\u0022\u003E\u25aa Central tumor with enlarged N1 lymph nodes\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                  \u003Cp id=\u0022p-9\u0022\u003E\u25aa Peripheral tumor with no mediastinal or hilar node enlargement\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe risk of node involvement is high in the first two patterns, so the LCIII guidelines recommend that the nodes be sampled using the easiest method available (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). Dr. Vachani added that the EBUS-TBNA technique allows for the assessment of contralateral hilar disease.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe last two patterns are often classified as a \u201cnormal mediastinum\u201d and present greater challenges in staging. For a central lung cancer with enlarged N1 lymph nodes, the risk of mediastinal node involvement is estimated to be 20% to 25%. Dr. Vachani noted that even if PET findings are negative, that risk is high enough to warrant sampling. However, PET is still useful, as it provides a \u201croadmap\u201d for sampling.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/32\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Four Main Patterns of Node Involvement\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1437465700\u0022 data-figure-caption=\u0022Four Main Patterns of Node Involvement\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/32\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/32\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/4\/32\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13127\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003EFour Main Patterns of Node Involvement\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003E(A) massive mediastinal Infiltration, (B) discrete node involvement, (C) central tumor with enlarged N1 lymph nodes, and (D) peripheral tumor with no mediastinal or hilar node enlargement.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Silvestri GA et al. Methods for Staging Non-small Cell Lung Cancer. \u003Cem\u003EChest\u003C\/em\u003E 2013;145(5)Suppl. With permission from the American College of Chest Physicians.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EFor a peripheral tumor with radiographic evidence of mediastinal or hilar node enlargement, the percentage of N2 or N3 disease ranges from 2% to 9%. When the findings of both CT and PET are negative, the prevalence of N2 or N3 disease decreases to \u223c4%. The prevalence of node involvement increases with the size of the tumor; the prevalence of N2 or N3 disease increases to 13% for T2 lesions.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EDr. Vachani also noted that the LCIII recommendation addresses lesions that are either T1a or T1b, and does not provide specific guidance for larger primary lesions with a normal mediastinum. He added that mediastinal sampling should be considered when the prevalence of mediastinal disease is \u0026gt;10%.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOPTIMAL TREATMENT OF STAGE III DISEASE\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EOne of the greatest challenges in determining the best treatment for stage III NSCLC is that the population of patients is highly heterogeneous, said Douglas Arenberg, MD, University of Michigan, Ann Arbor, Michigan, USA. Stage III NSCLC represents the largest proportion of available stages, with 25 TNM combinations being classified as stage III in the 7th edition of the American Joint Committee on Cancer Staging Manual.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EFocusing on identifiable stage III NSCLC at the time of diagnosis (excluding clinically occult N2 disease), Dr. Arenberg noted that the goal of treatment is to eradicate gross chest disease and prevent distant metastasis, which is a common cause of death. Due to poor survival rates, radiation therapy or surgery alone are no longer considered first-line treatment options. Poor surgical outcomes are primarily related to a high proportion of incomplete resections, even among patients treated by experienced teams. However, pooled data have shown that (for patients with unexpected stage III disease discovered at the time of surgery, after thorough preoperative staging) cisplatin-based adjuvant chemotherapy is associated with a benefit in overall survival (compared with surgery alone) for stage I-III NSCLC, and the benefit is greatest for people with stage III disease [Pignon JP et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EChemoradiation therapy as definitive treatment or as induction treatment (followed by planned surgery) has also led to slightly higher 5-year survival rates, especially when chemotherapy and radiation therapy are given concurrently. Studies have shown that both preoperative chemoradiation and definitive chemoradiation therapy lead to similar outcomes, with average 5-year survival rates of 19% and 22%. These findings led to the LCIII recommendation of either definitive chemoradiation therapy or induction therapy followed by surgery for patients with stage III NSCLC (\u003Ca id=\u0022xref-table-wrap-1-2\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Ramnath N et al. \u003Cem\u003EChest\u003C\/em\u003E 2013]. Patients in whom complete resection is not feasible should be treated with chemoradiation therapy.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13129\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13129\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13129\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-18\u0022 class=\u0022first-child\u0022\u003ELCIII Recommendations for Mediastinal Sampling of Early-Stage NSCLC and Treatment of Stage III NSCLC\u003Csup\u003E\u003Csup\u003Ea\u003C\/sup\u003E\u003C\/sup\u003E\n               \u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EDr. Arenberg also emphasized that it is not possible to identify patients who are more likely to benefit from surgical resection after induction therapy based on pretreatment characteristics. He emphasized several points:\u003C\/p\u003E\n         \u003Cp\u003E\n            \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                  \u003Cp id=\u0022p-22\u0022\u003E\u25aa All treatment recommendations are based on the assumption that staging has been thoroughly carried out and is unequivocal.\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n                  \u003Cp id=\u0022p-23\u0022\u003E\u25aa It is essential to plan all treatments upfront rather than to \u201csee what happens with chemotherapy and radiation therapy first.\u201d\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n                  \u003Cp id=\u0022p-24\u0022\u003E\u25aa Treatment must be planned by a multidisciplinary team; this team should also track relevant clinical outcomes.\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                  \u003Cp id=\u0022p-25\u0022\u003E\u25aa Patient preferences are paramount in decision-making.\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n                  \u003Cp id=\u0022p-26\u0022\u003E\u25aa Toxicity and complications should be minimized and well-managed.\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EROLE OF TARGETED THERAPY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-27\u0022\u003EWith metastasis as the most common cause of systemic failure, is there a role for targeted therapy in adjuvant treatment? Gregory J. Riely, MD, Memorial Sloan-Kettering Cancer Center, New York, New York, USA, discussed the ongoing trials that are addressing this question. The tyrosine kinase inhibitors (TKI) erlotinib and gefitinib have been evaluated as targeted therapy for NSCLC that tests positively for the EGFR mutation (EGFR+).\u003C\/p\u003E\n         \u003Cp id=\u0022p-28\u0022\u003EStudies have shown that these targeted agents extend progression-free survival (compared with chemotherapy alone) for patients with metastatic EGFR+ NSCLC [Maemondo M et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010; Rosell R et al. \u003Cem\u003ELancet Oncol\u003C\/em\u003E 2012]. Erlotinib and gefitinib are now being evaluated in the adjuvant setting. One Phase 2 trial indicated that adjuvant erlotinib for early-stage EGFR+ NSCLC is feasible and is associated with disease-free survival at 2 years (94%) [Neal JW et al. \u003Cem\u003EJ Clin Oncol\u003C\/em\u003E 2012]. In another retrospective study, D\u0027Angelo and colleagues show that the two targeted therapy agents led to longer disease-free and overall survival among patients with early-stage, resected EGFR+ NSCLC [\u003Cem\u003EJ Thorac Oncol\u003C\/em\u003E 2013]. Further studies are needed to determine whether an EGFR TKI has a role as part of adjuvant treatment of early-stage EGFR+ NSCLC.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/4\/32.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzny02\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}