Multidisciplinary management of N2 stage III non-small cell lung cancer: opportunities and challenges for radiation oncology

Stage III non-small cell lung cancer (NSCLC) constitutes a heterogeneous ailment, with optimal treatment evolving. This is especially true in N2 disease, where definitive treatment is often a discussion of surgery versus definitive chemoradiotherapy (CRT). New developments in neoadjuvant and adjuvant systemic therapeutics have shifted treatment paradigms, emphasizing the importance of multidisciplinary team discussions. The recent revisions to the ninth edition of the American Joint Commission on Cancer (AJCC) staging system have prompted a realignment in nodal stage categorization, introducing refined subcategories of N2 disease (N2a and N2b), which enhance prognostic accuracy. Critical questions including defining resectability and operability, feasibility of definitive CRT for operable patients, radiotherapy in operative and non-operative disease, and advanced radiation technology for definitive CRT are needed to be considered and answered in clinical practice. The current review aims to present a comprehensive overview of radiation oncology in management of N2 stage NSCLC by summarizing key clinical trials as well as most advanced evidence, including defining resectability and operability, feasibility of definitive CRT for operable patients, radiotherapy in operative and non-operative disease, and advanced radiation technology for definitive CRT. The review summarizes the most recent evidence and insights for radiation oncologists and other specialists involved in the multidisciplinary thoracic oncology team, to provide a better understanding of the opportunities and challenges for radiotherapy in the management of N2 stage III NSCLC.