Phase III Randomized Trial of Preoperative Chemotherapy Versus Preoperative Concurrent Chemotherapy and Thoracic Radiotherapy Followed by Surgical Resection and Consolidation Chemotherapy in Favorable Prognosis Patients With Stage IIIA (N2) Non-Small Cell Lung Cancer

Inclusion Criteria

DISEASE CHARACTERISTICS:

- Histologically or cytologically confirmed primary non-small cell lung cancer
(NSCLC)*, including any of the following cellular types:

- Adenocarcinoma

- Squamous cell carcinoma

- Large cell carcinoma

- Non-lobar and non-diffuse bronchoalveolar cell carcinoma

- NSCLC not otherwise specified NOTE: *Diagnosed within the past 3 months;
diagnosis by mediastinal nodal biopsy or needle aspiration allowed provided a
distinct lung primary (separate from the nodes) is clearly evident on CT scan

- Stage IIIA disease

- T1-T3 disease

- If pleural effusion is present, must meet ≥ 1 of the following criteria to
exclude T4 disease:

- Pleural effusion cytologically negative by thoracentesis

- Documented absence of pleural metastases and pleural effusion
cytologically negative by thoracoscopy (for patients with pleural
effusion on CT scan [but not on chest x-ray] that is deemed too small
to tap safely under either CT scan or ultrasound guidance)

- Confirmed positive ipsilateral mediastinal lymph node(s) (N2 disease)**, with or
without positive ipsilateral hilar nodes, by mediastinoscopy, mediastinotomy,
endoscopic ultrasound-guided transesophageal biopsy, thoracotomy, video-assisted
thoracoscopy, Wang needles, or fine needle aspiration under bronchoscopic or CT
guidance

- N2 nodes must be separate from primary tumor by CT scan or surgical
exploration AND maximum diameter ≤ 3.0 cm

- Mediastinoscopy OR other means of mediastinal lymph node biopsy required
(regardless of the primary tumor site) for patients with subcarinal
lymphadenopathy by size criteria or by positron emission tomography (PET)
scan

- If the lymph nodes in the contralateral mediastinum and neck are visible by
contrast CT scan of the chest AND are ≥ 1.0 cm OR if contralateral
involvement is suggested by PET scan, lymph nodes must be confirmed
negative by one of the above diagnostic procedures AND N3 status must be
confirmed negative by histology or cytology

- No palpable lymph nodes in the supraclavicular areas or higher in the neck
unless proven benign by excisional biopsy

- A nodal biopsy or needle aspiration may be omitted provided all of the
following criteria are true:

- Paralyzed left true vocal cord by bronchoscopy or indirect
laryngoscopy

- Nodes visible in the aortopulmonary window (level 5) region on CT scan

- Distinct primary tumor (separate from the nodes) is visible by CT scan

- No evidence of subcarinal nodal involvement by CT scan NOTE: **PET
scan positivity is not sufficient to establish N2 nodal status

- Measurable disease by chest x-ray and/or contrast-enhanced CT scan

- Candidate for surgery

- Resectable disease

- No distant metastases, including other ipsilateral or contralateral parenchymal
lesions or liver or adrenal metastases, by history or physical examination,
fludeoxyglucose F 18 PET scan, MRI or CT scan of the brain, chest x-ray and/or CT
scan of the lungs and upper abdomen

PATIENT CHARACTERISTICS:

Age

- 18 and over

Performance status

- Zubrod 0-1

Life expectancy

- Not specified

Hematopoietic

- Absolute neutrophil count ≥ 1,800/mm^3

- Platelet count ≥ 100,000/mm^3

- Hemoglobin ≥ 10.0 g/dL (transfusion or other intervention allowed)

Hepatic

- ALT and AST ≤ 2.5 times upper limit of normal (ULN)

- Alkaline phosphatase ≤ 2.5 times ULN

- Bilirubin ≤ 1.5 times ULN

- No hepatic insufficiency resulting in clinical jaundice or coagulation defects

Renal

- Creatinine clearance ≥ 60 mL/min

Cardiovascular

- No unstable angina or congestive heart failure requiring hospitalization within the
past 6 months

- No transmural myocardial infarction within the past 6 months

Pulmonary

- FEV_1 ≥ 2.0 L OR

- Predicted post-resection FEV_1 ≥ 0.8 L

- DLCO ≥ 50% of predicted

- No chronic obstructive pulmonary disease exacerbation

- No other respiratory illness requiring hospitalization or that would preclude study
therapy

Immunologic

- No AIDS

- No prior allergic reaction to the study drugs

- No history of severe hypersensitivity to other drugs formulated with polysorbate 80

- No acute bacterial or fungal infection requiring IV antibiotics

Other

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use effective contraception

- No unintentional weight loss > 5% of body weight within the past 6 months

- No pre-existing peripheral neuropathy ≥ grade 2

- No other invasive malignancy within the past 3 years except nonmelanoma skin cancer
or carcinoma in situ of the breast, oral cavity, or cervix

- No other severe active comorbidity

PRIOR CONCURRENT THERAPY:

Biologic therapy

- No prior biological agent for this cancer

- No concurrent filgrastim (G-CSF), sargramostim (GM-CSF), or pegfilgrastim during
study induction therapy (for patients randomized to the chemoradiotherapy arm)

Chemotherapy

- No prior systemic chemotherapy for this cancer

- Prior chemotherapy for a different cancer allowed

Endocrine therapy

- Not specified

Radiotherapy

- No prior radiotherapy to the region of this cancer that would result in overlap of
radiotherapy fields

- No routine post-operative radiotherapy

- No concurrent intensity modulated radiotherapy

Surgery

- See Disease Characteristics

Other

- No prior gefitinib for this cancer

- No concurrent amifostine