3
Figure 1A. Management of Stage IVA & IVB Disease
• RT
b
(if no previous RT)
• Surgery
• Chemotherapy/Clinical trial
• Hospice
Surgery
a
Stage IVA or IVB
Tumor Resectable
RT
b
± Chemotherapy
No Evidence
of Disease
• Observe
• Adjuvant
therapy
• Palliative RT
b
• Chemotherapy
• Clinical trial
• Hospice
Stage IVA or IVB
Unresectable
• RT
b
(if no previous RT)
• Surgery
• Chemotherapy/Clinical trial
• Hospice
? Surgery
RT
b
± Chemotherapy
No Evidence
of Disease
• Observe
• Adjuvant
therapy
• Palliative RT
b
• Chemotherapy
• Clinical trial
• Palliative surgery
• Hospice
a
Neoadjuvant RT ± chemotherapy may precede surgery.
b
Intensity-modulated radiation therapy (IMRT) is preferred if possible.
Initial
Therapy
Follow-Up
Local Recurrence
Systemic Disease
Initial
Therapy
Follow-Up
Local Recurrence
Systemic Disease
Treatment
