What is the stage and treatment for a patient with a 7cm left upper lobe lung mass, right hilar node, and supraclavicular lymph node (LN), diagnosed with adenocarcinoma, and negative molecular markers?

Staging and Treatment for Left Upper Lobe Lung Mass with Adenocarcinoma

The patient with a 7cm left upper lobe lung mass, right hilar node, and supraclavicular lymph node involvement has stage IIIC (T4N3M0) non-small cell lung adenocarcinoma and should receive concurrent chemoradiation therapy as primary treatment.

Staging Assessment

T Classification

• The 7cm left upper lobe mass is classified as T4 due to size >7cm 1
• T4 tumors are defined as those >7cm or those that invade the carina, diaphragm, vertebral bodies, or mediastinal structures 1

N Classification

• The presence of right hilar lymph node involvement indicates contralateral hilar disease (N3) 1
• Supraclavicular lymph node involvement on either side is also classified as N3 disease 1
• N3 includes contralateral mediastinal or hilar lymph node(s) and any supraclavicular or scalene node on either side 1

M Classification

• No evidence of distant metastases is mentioned, so M0 classification applies 1

Overall Stage

• T4N3M0 corresponds to stage IIIC non-small cell lung cancer 1

Treatment Recommendations

Primary Treatment Approach

• For stage IIIC (T4N3M0) NSCLC, definitive concurrent chemoradiation therapy is the standard of care 1
• Surgery is not indicated for patients with N3 disease as this is considered unresectable 1
• N3 disease (including supraclavicular lymph node involvement) is a major negative prognostic factor and generally considered a contraindication to surgery 1

Chemotherapy Regimen

• Platinum-based combination chemotherapy should be used concurrently with radiation 1
• Cisplatin-based combinations have shown superior overall survival compared to carboplatin combinations, particularly in non-squamous tumors 1

Radiation Approach

• Radiation should encompass the primary tumor and involved lymph node stations 1
• The presence of contralateral hilar and supraclavicular nodes requires careful radiation planning to cover all disease sites 1

Molecular Testing Considerations

• Despite negative molecular markers, comprehensive molecular testing should be performed to confirm the absence of actionable mutations 1, 2
• For adenocarcinoma, testing for EGFR mutations and ALK rearrangements is standard, even though these were reported as negative 1, 2

Prognosis and Follow-up

• The 5-year overall survival for stage IIIC NSCLC is approximately 7% 1
• The presence of N3 disease significantly worsens prognosis compared to earlier stages 1
• After completion of concurrent chemoradiation, regular surveillance with imaging is recommended to monitor for recurrence 1

Important Considerations and Pitfalls

• Thorough mediastinal staging with mediastinoscopy or EBUS is essential before initiating definitive therapy, even though clinical staging already indicates advanced disease 1, 3
• Avoid the pitfall of considering surgical resection in patients with N3 disease, as this does not improve outcomes and may delay appropriate therapy 1
• Be aware that some institutions may offer enrollment in clinical trials for stage IIIC disease, which could provide access to novel therapeutic approaches 1
• Ensure that adequate tissue was obtained during biopsy to allow for comprehensive molecular testing, even though initial results were negative 1, 2