Skip to main content
SpringerLink
Log in

Role of Postoperative Radiation Therapy in Non-Small Cell Lung Cancer

  • Chapter
  • First Online:
Advances in Radiation Oncology in Lung Cancer

Part of the book series: Medical Radiology ((Med Radiol Radiat Oncol))

  • 320 Accesses

Abstract

Patients who undergo surgery for non-small cell lung cancer are at relatively high risk of local/regional recurrence, especially those with involved mediastinal lymph nodes. Postoperative radiation therapy (PORT) has been shown to decrease the risk of local/regional recurrence but its effect on overall survival remains unclear due to the competing risks of distant metastases and treatment-related morbidity and mortality. The randomized LungART study sought to examine the benefit of PORT, using modern techniques and doses, in patients with mediastinal lymph node involvement (N2) receiving adjuvant chemotherapy. Preliminary results show an improvement in local/regional control but no improvement in overall survival. While many guidelines continue to recommend PORT in the setting of positive margins or mediastinal lymph node involvement, these recommendations may change based on the final results of the LungART trial.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Annon (1998) Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. PORT Meta-analysis Trialists Group. Lancet 352(9124):257–263

    Google Scholar 

  • Anon (1986) Effects of postoperative mediastinal radiation on completely resected stage II and stage III epidermoid cancer of the lung. N Engl J Med 315(22):1377–1381

    Google Scholar 

  • Anon (2004) Cisplatin-based adjuvant chemotherapy in patients with completely resected non–small-cell lung cancer. N Engl J Med 350(4):351–360

    Google Scholar 

  • Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T (1999) Lobe-specific extent of systematic lymph node dissection for non–small cell lung carcinomas according to a retrospective study of metastasis and prognosis. J Thorac Cardiovasc Surg 117(6):1102–1111

    Google Scholar 

  • Betticher DC, Hsu Schmitz S-F, Tötsch M, Hansen E, Joss C, von Briel C et al (2006) Prognostic factors affecting long-term outcomes in patients with resected stage IIIA pN2 non-small-cell lung cancer: 5-year follow-up of a phase II study. Br J Cancer 94(8):1099–1106

    Google Scholar 

  • Billiet C, De Ruysscher D, Peeters S, Decaluwé H, Vansteenkiste J, Dooms C et al (2016) Patterns of locoregional relapses in patients with contemporarily staged stage III-N2 NSCLC treated with induction chemotherapy and resection: implications for postoperative radiotherapy target volumes. J Thorac Oncol 11(9):1538–1549

    Google Scholar 

  • Burdett S, Stewart L (2005) PORT meta-analysis group. Postoperative radiotherapy in non-small-cell lung cancer: update of an individual patient data meta-analysis. Lung Cancer 47(1):81–83

    Google Scholar 

  • Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Brønnum D et al (2013) Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 368(11):987–998

    Google Scholar 

  • Darling GE, Allen MS, Decker PA, Ballman K, Malthaner RA, Inculet RI et al (2011) Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non–small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial [Internet]. J Thorac Cardiovasc Surg 141:662–670. https://doi.org/10.1016/j.jtcvs.2010.11.008

    Article  Google Scholar 

  • Dautzenberg B, Arriagada R, Boyer Chammard A, Jarema A, Mezzetti M, Mattson K et al (1999) A controlled study of postoperative radiotherapy for patients with completely resected nonsmall cell lung carcinoma. Cancer 86(2):265–273

    Google Scholar 

  • Debevec M, Bitenc M, Vidmar S, Rott T, Orel J, Strojan P et al (1996) Postoperative radiotherapy for radically resected N2 non-small-cell lung cancer (NSCLC): randomised clinical study 1988–1992. Lung Cancer 14(1):99–107

    Google Scholar 

  • Douillard J-Y, Rosell R, De Lena M, Carpagnano F, Ramlau R, Gonzáles-Larriba JL et al (2006) Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB--IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol 7(9):719–727

    Google Scholar 

  • Douillard J-Y, Rosell R, De Lena M, Riggi M, Hurteloup P, Mahe M-A et al (2008) Impact of postoperative radiation therapy on survival in patients with complete resection and stage I, II, or IIIA non-small-cell lung cancer treated with adjuvant chemotherapy: the adjuvant Navelbine International Trialist Association (ANITA) Randomized Trial. Int J Radiat Oncol Biol Phys 72(3):695–701

    Google Scholar 

  • Feng QF, Wang M, Wang LJ, Yang ZY, Zhang YG, Zhang DW et al (2000) A study of postoperative radiotherapy in patients with non–small-cell lung cancer: a randomized trial. Int J Radiat Oncol Biol Phys 47(4):925–929

    Google Scholar 

  • Früh M, Betticher DC, Stupp R, Xyrafas A, Peters S, Ris HB et al (2019) Multimodal treatment in operable stage III NSCLC: a pooled analysis on long-term results of three SAKK trials (SAKK 16/96, 16/00, and 16/01). J Thorac Oncol 14(1):115–123

    Google Scholar 

  • Fujimoto T, Cassivi SD, Yang P, Barnes SA, Nichols FC, Deschamps C et al (2006) Completely resected N1 non–small cell lung cancer: factors affecting recurrence and long-term survival. J Thorac Cardiovasc Surg 132(3):499–506

    Google Scholar 

  • Ginsberg RJ, Rubinstein LV (1995) Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Ann Thorac Surg 60(3):615–623

    Google Scholar 

  • Group N-SCLCC, Non-small Cell Lung Cancer Collaborative Group (1995) Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials [Internet]. BMJ 311:899–909. https://doi.org/10.1136/bmj.311.7010.899

    Article  Google Scholar 

  • Guerra JLL, Lopez Guerra JL, Gomez DR, Lin SH, Levy LB, Zhuang Y et al (2013) Risk factors for local and regional recurrence in patients with resected N0–N1 non-small-cell lung cancer, with implications for patient selection for adjuvant radiation therapy [Internet]. Ann Oncol 24:67–74. https://doi.org/10.1093/annonc/mds274

    Article  Google Scholar 

  • Harpole DH Jr, Hemdon JE II, Young WG Jr, Wolfe WG, Sabiston DC Jr (1996) Stage I nonsmall cell lung cancer: A multivariate analysis of treatment methods and patterns of recurrencee. Division of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. Cancer 1995;76:787–796. Lung Cancer 14(1):165

    Google Scholar 

  • Hata E (1990) Rationale for extended lymphadenectomy for lung cancer. Theor Surg 5:19–25

    Google Scholar 

  • Hsu H-C, Wang C-J, Huang E-Y, Sun L-M (2004) Post-operative adjuvant thoracic radiotherapy for patients with completely resected non-small cell lung cancer with nodal involvement: outcome and prognostic factors. Br J Radiol 77(913):43–48

    Google Scholar 

  • Hung J-J, Jeng W-J, Hsu W-H, Chou T-Y, Huang B-S, Wu Y-C (2012) Predictors of death, local recurrence, and distant metastasis in completely resected pathological stage-I non–small-cell lung cancer. J Thorac Oncol 7(7):1115–1123

    Google Scholar 

  • Ishida T, Yano T, Maeda K, Kaneko S, Tateishi M, Sugimachi K (1990) Strategy for lymphadenectomy in lung cancer three centimeters or less in diameter. Ann Thorac Surg 50(5):708–713

    Google Scholar 

  • Izbicki JR, Passlick B, Pantel K, Pichlmeier U, Hosch SB, Karg O et al (1998) Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non-small cell lung cancer: results of a prospective randomized trial. Ann Surg 227(1):138–144

    Google Scholar 

  • Kelsey CR, Light KL, Marks LB (2006) Patterns of failure after resection of non–small-cell lung cancer: Implications for postoperative radiation therapy volumes. Int J Radiat Oncol Biol Phys 65(4):1097–1105

    Google Scholar 

  • Kelsey CR, Marks LB, Hollis D, Hubbs JL, Ready NE, D’Amico TA et al (2009) Local recurrence after surgery for early stage lung cancer: an 11-year experience with 975 patients. Cancer 115(22):5218–5227

    Google Scholar 

  • Kelsey CR, Higgins KA, Peterson BL, Chino JP, Marks LB, D’Amico TA et al (2013) Local recurrence after surgery for non–small cell lung cancer: a recursive partitioning analysis of multi-institutional data. J Thorac Cardiovasc Surg 146(4):768–73.e1

    Google Scholar 

  • Kepka L, Bujko K, Orlowski TM, Jagiello R, Salata A, Matecka-Nowak M et al (2011) Cardiopulmonary morbidity and quality of life in non-small cell lung cancer patients treated with or without postoperative radiotherapy. Radiother Oncol 98(2):238–243

    Google Scholar 

  • Lafitte JJ, Ribet ME, Prévost BM, Gosselin BH, Copin M-C, Brichet AH (1996) Postresection irradiation for T2 N0 M0 non–small cell carcinoma: a prospective, randomized study. Ann Thorac Surg 62(3):830–834

    Google Scholar 

  • Lally BE, Zelterman D, Colasanto JM, Haffty BG, Detterbeck FC, Wilson LD (2006) Postoperative radiotherapy for stage II or III non-small-cell lung cancer using the surveillance, epidemiology, and end results database. J Clin Oncol 24(19):2998–3006

    Google Scholar 

  • Lally BE, Detterbeck FC, Geiger AM, Thomas CR Jr, Machtay M, Miller AA et al (2007) The risk of death from heart disease in patients with nonsmall cell lung cancer who receive postoperative radiotherapy: analysis of the surveillance, epidemiology, and end results database. Cancer 110(4):911–917

    Google Scholar 

  • Lardinois D, Suter H, Hakki H, Rousson V, Betticher D, Ris H-B (2005) Morbidity, survival, and site of recurrence after mediastinal lymph-node dissection versus systematic sampling after complete resection for non-small cell lung cancer. Ann Thorac Surg 80(1):268–275

    Google Scholar 

  • Lee JH, Machtay M, Kaiser LR, Friedberg JS, Hahn SM, McKenna MG et al (1999) Non-small cell lung cancer: prognostic factors in patients treated with surgery and postoperative radiation therapy. Radiology 213(3):845–852

    Google Scholar 

  • Libshitz HI, McKenna RJ Jr, Mountain CF (1986) Patterns of mediastinal metastases in bronchogenic carcinoma. Chest 90(2):229–232

    Google Scholar 

  • Martini N (1995) Mediastinal lymph node dissection for lung cancer. The memorial experience. Chest Surg Clin N Am 5(2):189–203

    Google Scholar 

  • Martini N, Bains MS, Burt ME, Zakowski MF, McCormack P, Rusch VW et al (1995) Incidence of local recurrence and second primary tumors in resected stage I lung cancer. J Thorac Cardiovasc Surg 109(1):120–129

    Google Scholar 

  • Mayer R, Smolle-Juettner FM, Szolar D, Stuecklschweiger GF, Quehenberger F, Friehs G et al (1997) Postoperative radiotherapy in radically resected non-small cell lung cancer. Chest 112(4):954–959

    Google Scholar 

  • Mikell JL, Gillespie TW, Hall WA, Nickleach DC, Liu Y, Lipscomb J et al (2015) Postoperative radiotherapy is associated with better survival in non–small cell lung cancer with involved N2 lymph nodes: results of an analysis of the National Cancer Data Base. J Thorac Oncol 10(3):462–471

    Google Scholar 

  • National Comprehensive Cancer Network (2020) NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer. Report No.: Version 2.2021

    Google Scholar 

  • Nohl-Oser HC (1972) An investigation of the anatomy of the lymphatic drainage of the lungs as shown by the lymphatic spread of bronchial carcinoma. Ann R Coll Surg Engl 51(3):157–176

    Google Scholar 

  • NSCLC Meta-analyses Collaborative Group, Arriagada R, Auperin A, Burdett S, Higgins JP, Johnson DH et al (2010) Adjuvant chemotherapy, with or without postoperative radiotherapy, in operable non-small-cell lung cancer: two meta-analyses of individual patient data. Lancet 375(9722):1267–1277

    Google Scholar 

  • Pass HI, Pogrebniak HW, Steinberg SM, Mulshine J, Minna J (1992) Randomized trial of neoadjuvant therapy for lung cancer: interim analysis. Ann Thorac Surg 53(6):992–998

    Google Scholar 

  • Pechoux CL, Le Pechoux C, Pourel N, Barlesi F, Faivre-Finn C, Lerouge D et al (2020) LBA3_PR An international randomized trial, comparing post-operative conformal radiotherapy (PORT) to no PORT, in patients with completely resected non-small cell lung cancer (NSCLC) and mediastinal N2 involvement: primary end-point analysis of LungART (IFCT-0503, UK NCRI, SAKK) NCT00410683 [Internet]. Ann Oncol 31:S1178. https://doi.org/10.1016/j.annonc.2020.08.2280

    Article  Google Scholar 

  • Postmus PE, Kerr KM, Oudkerk M, Senan S, Waller DA, Vansteenkiste J et al (2017) Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 28(suppl_4):iv1–i21

    Google Scholar 

  • Riquet M, Hidden G, Debesse B (1989) Direct lymphatic drainage of lung segments to the mediastinal nodes. An anatomic study on 260 adults. J Thorac Cardiovasc Surg 97(4):623–632

    Google Scholar 

  • Rodrigues G, Choy H, Bradley J, Rosenzweig KE, Bogart J, Curran WJ et al (2015) Adjuvant radiation therapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline [Internet]. Pract Radiat Oncol 5:149–155. https://doi.org/10.1016/j.prro.2015.02.013

    Article  Google Scholar 

  • Sawyer TE, Bonner JA, Gould PM, Foote RL, Deschamps C, Trastek VF et al (1997a) Effectiveness of postoperative irradiation in stage IIIA non–small cell lung cancer according to regression tree analyses of recurrence risks. Ann Thorac Surg 64(5):1402–1407

    Google Scholar 

  • Sawyer TE, Bonner JA, Gould PM, Foote RL, Deschamps C, Trastek VF et al (1997b) The impact of surgical adjuvant thoracic radiation therapy for patients with nonsmall cell lung carcinoma with ipsilateral mediastinal lymph node involvement. Cancer 80(8):1399–1408

    Google Scholar 

  • Sawyer TE, Bonner JA, Gould PM, Foote RL, Deschamps C, Lange CM et al (1999) Factors predicting patterns of recurrence after resection of N1 non-small cell lung carcinoma. Ann Thorac Surg 68(4):1171–1176

    Google Scholar 

  • Saynak M, Veeramachaneni NK, Hubbs JL, Nam J, Qaqish BF, Bailey JE et al (2011) Local failure after complete resection of N0–1 non-small cell lung cancer. Lung Cancer 71(2):156–165

    Google Scholar 

  • Siegel RL, Miller KD, Jemal A (2020 Jan) Cancer statistics, 2020. CA Cancer J Clin 70(1):7–30

    Google Scholar 

  • Stephens RJ, Girling DJ, Bleehen NM, Moghissi K, Yosef HM, Machin D (1996) The role of post-operative radiotherapy in non-small-cell lung cancer: a multicentre randomised trial in patients with pathologically staged T1-2, N1-2, M0 disease. Medical Research Council lung cancer working party. Br J Cancer 74(4):632–639

    Google Scholar 

  • Sugi K, Nawata K, Fujita N, Ueda K, Tanaka T, Matsuoka T et al (1998) Systematic lymph node dissection for clinically diagnosed peripheral non-small-cell lung cancer less than 2 cm in diameter. World J Surg 22(3):290–294. discussion 294–5

    Google Scholar 

  • Taylor NA, Liao ZX, Stevens C, Walsh G, Roth J, Putnam J et al (2003) Postoperative radiotherapy increases locoregional control of patients with stage IIIA non–small-cell lung cancer treated with induction chemotherapy followed by surgery [Internet]. Int J Radiat Oncol Biol Phys 56:616–625. https://doi.org/10.1016/s0360-3016(03)00063-4

    Article  Google Scholar 

  • Trodella L, Granone P, Valente S, Valentini V, Balducci M, Mantini G et al (2002) Adjuvant radiotherapy in non-small cell lung cancer with pathological stage I: definitive results of a phase III randomized trial. Radiother Oncol 62(1):11–19

    Google Scholar 

  • Van Houtte P, Rocmans P, Smets P, Goffin J-C, Lustman-maréchal J, Vanderhoeft P et al (1980) Postoperative radiation therapy in lung cancer: a controlled trial after resection of curative design. Int J Radiat Oncol Biol Phys 6(8):983–986

    Google Scholar 

  • Varlotto JM, Recht A, Flickinger JC, Medford-Davis LN, Dyer A-M, DeCamp MM (2010) Varying recurrence rates and risk factors associated with different definitions of local recurrence in patients with surgically resected, stage I nonsmall cell lung cancer [Internet]. Cancer 116(10):2390–2400. https://doi.org/10.1002/cncr.25047

    Article  Google Scholar 

  • Warren WH, Faber LP (1994) Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma. Five-year survival and patterns of intrathoracic recurrence. J Thorac Cardiovasc Surg 107(4):1087–1093. discussion 1093–4

    Google Scholar 

  • Winton T, Livingston R, Johnson D, Rigas J, Johnston M, Butts C et al (2005) Vinorelbine plus cisplatin vs. observation in resected non–small-cell lung cancer. N Engl J Med 352(25):2589–2597

    Google Scholar 

  • Wu YL, Huang Z-F, Wang S-Y, Yang X-N, Ou W (2002) A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 36(1):1–6

    Google Scholar 

  • Wu Y-L, Tsuboi M, He J, John T, Grohe C, Majem M et al (2020 Oct 29) Osimertinib in resected EGFR-mutated non-small-cell lung cancer. N Engl J Med 383(18):1711–1723

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Duke University Medical Center, Durham, NC, USA

    Alexander K. Diaz & Chris R. Kelsey

Authors
  1. Alexander K. Diaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chris R. Kelsey
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chris R. Kelsey .

Editor information

Editors and Affiliations

  1. School of Medicine, University of Kragujevac, Kragujevac, Serbia

    Branislav Jeremić

Rights and permissions

Reprints and permissions

Copyright information

© 2021 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Diaz, A.K., Kelsey, C.R. (2021). Role of Postoperative Radiation Therapy in Non-Small Cell Lung Cancer. In: Jeremić, B. (eds) Advances in Radiation Oncology in Lung Cancer. Medical Radiology(). Springer, Cham. https://doi.org/10.1007/174_2021_274

Download citation

  • DOI: https://doi.org/10.1007/174_2021_274

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-34846-4

  • Online ISBN: 978-3-031-34847-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation