A 50 year old patient with adenocarcinoma of the right upper lobe has microscopically positive contralateral (4L) lymph nodes (American Thoracic Society staging criteria) at mediastinoscopy. The best management plan is

A. induction chemotherapy with cis-platinum and vinblastine followed by thoracotomy and lobectomy. 
B. radiation therapy to 69.6 Gy given in a twice daily fractionation regimen.
C. standard fractionation radiation therapy given concurrently with vinblastine and cis-platinum.
D. standard fractionation radiation therapy given concurrently with vinblastine and cis-platinum followed by thoracotomy and pulmonary resection. 
E. thoracotomy with lobectomy and complete mediastinal lymph node dissection..

Answer C

While neoadjuvant chemotherapy with cisplatinum and vinblastine and subsequent lobectomy would be appropriate for N2 or stage IIIA disease, this patient has N3 or stage IIIB disease. Disease of this extent (contralateral nodal involvement) cannot be cured with surgery and patients with IIIB disease are usually not treated with operation even when combined with multimodality therapy. Concurrent chemoradiation is an appropriate recommendation for vigorous patients. A "curative" dose of radiation therapy would be a reasonable treatment option for an older patient who is deemed not to be a candidate for chemotherapy or combined chemotherapy/radiation therapy. Distant failure is the major problem in treating patients with stage IIIB disease.