Patients with stage IIIA non-small cell lung cancer, determined based on involvement of ipsilateral mediastinal lymph nodes, represent the most challenging management problem in this disease. Patients with this stage disease may have very different degrees of lymph node involvement.

The pathologic confirmation of this involvement is a key step in the therapeutic decision. The difference in the degree of lymph node compromise has prognostic and treatment implications. Based on multiple considerations, patients can be treated with induction chemotherapy, chemoradiotherapy followed by surgery, or definitive chemoradiotherapy without surgery. Data derived from clinical trials have provided incomplete guidance for physicians and their patients.

The best therapeutic plan is achieved through the multidisciplinary cooperation of a team specialized in lung cancer.

Bone metastases are often asymptomatic and are not diagnosed until after the onset of bone pain. However, bone structural integrity may have diminished considerably before pain onset, resulting in increased risk of skeletal-related events. Therefore, we evaluated whether bisphosphonate therapy was differentially beneficial depending on initiation before or after the onset of bone pain.

METHODS: Exploratory analyses were performed in patients with bone metastases from breast cancer or lung cancer/other solid tumors enrolled in two randomized trials comparing monthly zoledronic acid versus pamidronate (breast cancer) or placebo (lung cancer/other solid tumors). Analyses included proportion of patients with one or more skeletal-related events, time to first skeletal-related event, and skeletal morbidity rate in patients with and without baseline pain.

RESULTS: Approximately 80 % of patients reported baseline pain. Similar to overall trial results, zoledronic acid reduced the skeletal morbidity rate in all groups. Although some subsets lacked statistical power, benefits were generally greater in patients without baseline pain. For example, in breast cancer, zoledronic acid increased the 25th quartile of time to first skeletal-related event versus pamidronate by 522 days in patients with no baseline pain (median not reached for either group), but by only 10 days in patients with baseline pain. Similar trends were observed in lung cancer.

CONCLUSIONS: Benefits from zoledronic acid appeared to be greater if introduced before bone pain onset. Early diagnosis and treatment of bone metastases may delay onset of skeletal-related events.

Particle irradiation started to draw attention in the past decade and has now become a hotspot in the radiation oncology community.

This article reviews the most advanced developments in particle irradiation, focusing on the characteristics of proton and carbon ions in radiation physics and radiobiology. The Bragg peak of physical dose distribution causes proton and carbon beams to optimally meet the requirement for cancer irradiation because the Bragg peak permits the accurate concentration of the dose on the tumor, thus sparing the adjacent normal tissues. Moreover, carbon ion has more radiobiological benefits than photon and proton beams. These benefits include stronger sterilization effects on intrinsic radio-resistant tumors and more effective killing of hypoxic, G0, and S phase cells.

Compared with the most advanced radiation techniques using photon, such as three-dimensional conformal radiation therapy and intensity-modulated radiation therapy, proton therapy has yielded more promising outcomes in local control and survival for head and neck cancers, prostate carcinoma, and pediatric cancers. Carbon therapy in Japan showed even more promising results than proton therapy. The local controls and overall survivals were as good as that treated by surgery in early stages of non-small cell lung cancer, hepatocellular carcinoma, prostate carcinoma, and head and neck cancers, especially for such highly resistant tumors as melanoma. The non-invasive nature of particle therapy affords more patients with chances to receive and benefit from treatment.

Particle therapy is gradually getting attention from the oncology community. However, the cost of particle therapy facilities has limited the worldwide use of this technology.