Combined modality treatment in “clinical stage IIIA” non small cell lung cancer: when, how, whom.

Since about the last twenty years the therapeutical approach to locally advanced non small cell lung carcinoma has been characterized by the efforts to ameliorate overall prognosis by integrating medical and radiation therapeutical resources. The specific features of the two modalities motivated this choice: radiation exerts its action locally, while chemotherapy acts systemically, so realizing both the spatial and temporal therapeutical cooperation and optimizing the reciprocal synergy. This conceptual strategy gives the best chance of obtaining a tumoral response, but also determines a higher and sometimes unacceptable rate of toxic side effects. This evidence has conducted to the development of two basic schema, simultaneous and sequential, of chemotherapy and radiotherapy combination, so delineating the so-called “bimodality” approach. In case of optimal tumour control after any form of chemo-radiotherapy combination, the surgical option remains for fit patients an eventual adjunctive chance, so delineating the so called “trimodality” approach. The optimal strategic choices will certainly find a crucial help and will be radically conditioned by the recent introduced technology and staging modalities such as the PET scan, the transbronchial needle aspiration (TBNA), endoscopic ultrasound, etc. These various therapeutical approaches are discussed in this paper, referring to the recent literature reports of the most accreditated research groups in the world.