Skip to main content

Advertisement

SpringerLink
Log in

Radiotherapy in the management of non-small-cell lung cancer

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Radiation plays an important role in the management of patients with non-small-cell carcinoma of the lung. Understanding the impact of radiation on this tumor and on normal tissues requires a knowledge of the natural history of the tumor, and of basic sciences, including radiation physics and biology. This review gives a brief outline of the scientific basis of radiotherapy, followed by a discussion of some practical issues concerning radiation tolerances of tissues within the thorax, the acute and late sequelae of radiation, and the treatment planning process. The role of radiotherapy is explored in the following settings: Radical radiation with curative intent for early stage disease, adjuvant mediastinal irradiation for completely resected tumors, radiation of known residual disease after surgical resection, preoperative radiation, prophylactic cranial radiation, radiation of locally advanced unresectable disease, and, finally, radiation with palliative intent in patients with metastatic disease. Pertinent studies, with the emphasis on randomized trials, are outlined to document the present state of understanding with respect to the impact of radiation in each of these situations. Several of the controversies in this area are addressed, with particular emphasis on selection of patients for high-dose radiation and recent results of combined modality treatment with radiation and chemotherapy.

Résumé

La radiothérapie a un rôle important dans le traitement des cancers pulmonaires (tous les cancers en dehors de ceux à petites cellules). Comprendre l'impact de la radiothérapie sur de telles tumeurs et sur les tissus avoisinants normaux nécessite la connaisance de l'histoire naturelle de la tumeur et des sciences fondamentales touchant à la physique et à la biologie des rayons. Cette revue donne un bref apercu des bases scientifiques de la radiothérapie, suivi de quelques notions pratiques sur la tolérance des tissus à l'intérieur du thorax, les séquelles aiguës et tardives des rayons et les différérents schémas thérapeutiques qu'on peut proposer. Le rôle de la radiothérapie est expliqué dans les situations suivantes: irradiation radicale avec intention curative en cas de tumeur au début, radiothérapie adjuvante du médiastin après résection complète des tumeurs, irradiation de tissus tumoraux après résection incomplète, radiothérapie préopératoire, irradiation prophylactique du crâne, irradiation des tissus non résecables, ainsi que irradiation avec intention palliative chez de patients ayant des métastases. Des études pertinentes, et surtout des études randomisées, sont soulignées pour comprendre le rôle des irradiations dans chacune de ces situations. Plusieurs controverses sont exposées, en insistant sur la sélection des patients pouvant recevoir de hautes doses de radiothérapie et les résultats de la radiothérapie combinée avec la chimiothérapie.

Resumen

La irradiación ocupa un lugar importante en el manejo de los pacientes con carcinoma pulmonar de células no pequenas. Se requière un buen conocimiento de la historia natural del tumor y de las ciencias básicas, incluso de la física de la radiación y de la biología, para la debida comprensión de los efectos de la radiación sobre tumores y sobre tejidos normales. La presente revisión incluye un bosquejo de las bases científicas de la radioterapia, y a continuación se discuten algunos aspectos prácticos de la tolerancia a la irradiación por parte de los tejidos intratorácicos, las secuelas agudas y a largo término de la irradiación y, por último, el proceso de planeación de la terapia. Se analiza el papel de la radioterapia en diversas situaciones clínicas: radioterapia radical con propósito de curación para tumores en estadios tempranos, radioterapia mediastinal coadyuvante en casos de resección compléta del tumor, irradiación de enfermedad residual luego de la resección quirúrgica, irradiación preoperatoria, irradiacción profiláctica del cráneo, irradiación de enfermedad local avanzada y no resecable y, finalmente, irradiación palíativa en pacientes con metástasis. Se resumen los estudios clínicos pertinentes, con énfasis en los ensayos randomizados, con el objeto de documentar el estado actual del conocimiento sobre el impacto de la radioterapia en cada una de tales situaciones clínicas, enfocando los aspectos que son motivo de controversia, especialmente en cuanto a la seleccíon de pacientes para irradiación de alta dosis y a los resultados con la modalidad de radio y quimioterapias combinadas.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hall, E.: Radiobiology for the Radiologist, 3rd edition. Philadelphia, Lippincott, 1988

    Google Scholar 

  2. Greenberg, D., Sawicka, J., Eisenthal, S., Ross, D.: Fatigue syndrome due to localized radiation. J. Pain Sympt. Manage.7:38, 1992

    Google Scholar 

  3. Maasilta, P.: Radiation-induced lung injury. From the chest physician's point of view. Lung Cancer7:367, 1991

    Google Scholar 

  4. Morrison, R., Deeley, T., Cleland, W.: The treatment of carcinoma of the bronchus. A clinical trial to compare surgery and supervoltage radiotherapy. Lancet1:683, 1963

    Google Scholar 

  5. Holmes, E.: Surgical adjuvant therapy of non-small-cell lung cancer. Lung Cancer7:71, 1991

    Google Scholar 

  6. Mathews, M., Kanhousa, W., Pickren, J., Robinette, D.: Frequency of residual and metastatic tumor in patients undergoing curative surgical resection for lung cancer. Cancer Chem. Rep.4:63, 1973

    Google Scholar 

  7. Israel, L., Bonadonna, G., Sylvester, R., European Lung Cancer Group: Controlled study with adjuvant radiotherapy, chemotherapy, immunotherapy, and chemoimmunotherapy in operable squamous carcinoma of the lung. In Lung Cancer: Progress in Therapeutic Research, F. Muggia, M. Rosencweig, editor, New York, Raven Press, 1979, pp. 443–452

    Google Scholar 

  8. Van Houtte, P., Rocmans, P., Smets, P., Goffin, J.-C., Lustman-Marechal, J., Vanderhoeft, P., Henry, J.: Post-operative radiation therapy in lung cancer: a controlled trial after resection of curative design. Int. J. Radiat. Oncol. Biol. Phys.6:983, 1980

    Google Scholar 

  9. Weisenburger, T., Gail, M., Lung Cancer Study Group: 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, 1986

    Google Scholar 

  10. Van Houtte, P.: Postoperative radiotherapy for lung cancer. Lung Cancer7:57, 1991

    Google Scholar 

  11. Grover, F., Komaki, R.: Superior sulcus tumors. In Thoracic Oncology, J. Roth, J. Ruckdeschel, T. Weisenburger, editors. Philadelphia, W.B. Saunders, 1989, pp. 263–279

    Google Scholar 

  12. Anderson, T.M., May, P.M., Holmes, E.C.: Factors affecting survival in superior sulcus tumors. J. Clin. Oncol.4(11): 1598, 1986

    Google Scholar 

  13. Komaki, R., Mountain, C., Holbert, J., Garden, A., Shallenberger, R., Cox, J., Maor, M., Guinee, V., Samuels, B.: Superior Sulcus tumors: treatment selection and results for 85 patients without metastasis (MO) at presentation. Int. J. Radiat. Oncol. Biol. Phys.19(1):31, 1990

    Google Scholar 

  14. National Cancer Institute.: Preoperative irradiation of cancer of the lung. Final report of a therapeutic trial. Cancer36:914, 1975

    Google Scholar 

  15. Shields, T.: Preoperative radiation therapy in the treatment of bronchial carcinoma. Cancer30:1388, 1972

    Google Scholar 

  16. Kazem, I., Jongerius, C.M., Lacquet, L.K., Kramer, G.: Evaluation of short-course preoperative irradiation in the treatment of resectable bronchus carcinoma: long-term analysis of a randomized pilot-study. Int. J. Radiat. Oncol. Biol. Phys.10:981, 1984

    Google Scholar 

  17. Payne, D.: Pre-operative radiation therapy in non-small cell cancer of the lung. Lung Cancer7:1, 1991

    Google Scholar 

  18. Figlin, R., Piantadosi, S., Feld, R., Lung Cancer Study Group: Intracranial recurrence after complete surgical resection of Stage I, II, and III non-small cell lung cancer. New Engl. J. Med.318:1300, 1988

    Google Scholar 

  19. Cox, J., Stanley, K., Petrovich, Z., Paig, C., Yesner, R.: Cranial irradiation in cancer of the lung of all cell types. J.A.M.A.245:469, 1981

    Google Scholar 

  20. Perez, C.A., Bauer, M., Edelstein, S., Gillespie, B.W., Birch, R.: Impact of tumor control on survival in carcinoma of the lung treated with irradiation. Int. J. Radiat. Oncol. Biol. Phys.12:539, 1986

    Google Scholar 

  21. Payne, D.: Non-small-cell lung cancer: should unresectable stage III patients routinely receive high-dose radiation therapy? J. Clin. Oncol.6:552, 1988

    Google Scholar 

  22. Perez, C.A., Pajak, T.F., Rubin, P., Simpson, J.R., Mohiuddin, M., Brady, L.W., Perez-Tamayo, R., Rotman, M.: Long-term observations of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Cancer 59:1874, 1987

    Google Scholar 

  23. Durrant, K., Ellis, F., Black, J., Berry, R., Ridehalgh, F., Hamilton, W.: Comparison of treatment policies in inoperable bronchial carcinoma. Lancet4:715, 1971

    Google Scholar 

  24. Medical Research Council Lung Cancer Working Party: Inoperable non-small cell lung cancer (NSCLC): a Medical Research Council randomized trial of palliative radiotherapy with two fractions or ten fractions. Br. J. Cancer63:265, 1991

    Google Scholar 

  25. Medical Research Council Lung Cancer Working Party: A Medical Research Council (MRC) randomised trial of palliative radiotherapy with two fractions or a single fraction in patients with inoperable non-small-cell lung cancer (NSCLC) and poor performance status. Br. J. Cancer65:934, 1992

    Google Scholar 

  26. Cox, J.D., Azarnia, N., Byhardt, R.W., Shin, K.H., Emami, B., Pajak, T.F.: A randomized phase I/II trial of hyperfractionated radiation therapy with total doses of 60.0 Gy to 79.2 Gy: possible survival benefit with ≥69.6 Gy in favorable patients with Radiation Therapy Oncology Group stage III non-small-cell lung carcinoma: report of Radiation Therapy Oncology Group 83-11. J. Clin. Oncol.8(9): 1543, 1990

    Google Scholar 

  27. Saunders, M., Dische, S.: Continuous hyperfractionated accelerated radiotherapy (CHART). Semin. Radiat. Oncol.2;41, 1992

    Google Scholar 

  28. Burt, P.A., Hancock, B.M., Stout, R.: Radical radiotherapy for carcinoma of the bronchus: an equal alternative to radical surgery? Clin. Oncol.1:86, 1989

    Google Scholar 

  29. Cooper, J., Pearson, F., Todd, T., Patterson, G.A., Ginsberg, R.J., Basiuk, J., Blair, V., Cass, W.: Radiotherapy alone for patients with operable carcinoma of the lung. Chest87:289, 1985

    Google Scholar 

  30. Dosoretz, D., Katin, M., Blitzer, P., Rubenstein, J.H., Salenius, S., Rashid, M., Dosani, R.A., Mestas, G., Siegel, A.D., Chadha, T.T., Chandrahasa, T., Hannan, S.E., Bhat, S.G., Metke, M.P.: Radiation therapy in the management of medically inoperable carcinoma of the lung: results and implications for future treatment strategies. Int. J. Radiat. Oncol. Biol. Phys.24:3, 1992

    Google Scholar 

  31. Haffty, B.G.: Can lung cancer be cured by irradiation alone? Int. J. Radiat. Oncol. Biol. Phys.24:181, 1992

    Google Scholar 

  32. Noordijk, E.M., Clement, E., Hermans, J., Wever, A.M.J., Leer, J.W.H.: Radiotherapy as an alternative to surgery in elderly patients with resectable lung cancer. Radiother. Oncol.13:83, 1988

    Google Scholar 

  33. Sandler, H.O.M., Curran, W.J., Turrisi, A.T.: The influence of tumor size and pre-treatment staging on outcome following radiation therapy alone for Stage I non-small cell lung cancer. Internat. J. Radiat. Oncol. Biol. Phys.19(1):9, 1990

    Google Scholar 

  34. Smart, J., Hilton, G.: Radiotherapy of cancer of the lung. Lancet6:880, 1956

    Google Scholar 

  35. Talton, B.M., Constable, W.C., Kersh, C.R.: Curative radiotherapy in non-small cell carcinoma of the lung. Int. J. Radiat. Oncol. Biol. Phys.19(1):15, 1990

    Google Scholar 

  36. Zhang, H., Yin, W., Zhang, L., Yang, Z.Y., Zhang, Z.X., Wang, M., Chen, D.F., Gu, X.Z.: Curative radiotherapy of early operable non-small cell lung cancer. Radiother. Oncol.14:89, 1989

    Google Scholar 

  37. Bangma, P.: Post-operative radiotherapy. In Carcinoma of the Bronchus: Modern Radiotherapy. T. Deeley, editor, New York, Appleton-Century-Crofts, 1972, pp. 163

    Google Scholar 

  38. Paterson, R., Russell, M.: Clinical trials in malignant disease, part IV—lung cancer. Value of post-operative radiotherapy. Clin. Radi.13:141, 1962

    Google Scholar 

  39. Eichhorn, H., Eule, H., Lessel, A., Menne, W.: Results of a controlled clinical trial for evaluation of intensive preoperative irradiation in operable bronchial cancer. Archiv Geschwulstforschung45(4):376, 1975

    Google Scholar 

  40. Tildon, T.T., Hughes, R.K.: Complications from preoperative irradiation therapy for lung cancer. Am. Thorac. Surg.3:307, 1967

    Google Scholar 

  41. Dillman, R.O., Seagren, S.L., Propert, K.J., Guerra, J., Eaton, W.L., Carey, R.W., Frei, E.F. III, Green, M.R.: A randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer. N. Eng. J. Med.323:940, 1990

    Google Scholar 

  42. Gregor, A., Macbeth, F., Paul, J., Cram, L., Hansen, H.: Radical radiotherapy and chemotherapy in localized inoperable non-small cell lung cancer: a randomized trial. J. Nat. Cancer Inst.85:997, 1993

    Google Scholar 

  43. Johnson, D.H., Einhorn, L.H., Bartolucci, A., Birch, R., Omura, G., Perez, C.A., Greco, A.: Thoracic radiotherapy does not prolong survival in patients with locally advanced, unresectable non-small cell lung cancer. Ann. Intern. Med.113:23, 1990

    Google Scholar 

  44. Le Chevalier, T., Arriagada, R., Quoix, E., Martin, M., Ruffié, P., Tarayre, M., Douillard, J., Laplanche, A.: Radiotherapy alone versus combined chemotherapy and radiotherapy in nonresectable non-small cell lung cancer: first analysis of a randomized trial in 353 patients. J. Natl. Cancer Inst.83:417, 1991

    Google Scholar 

  45. Le Chevalier, T., Arriagada, R., Quoix, E., Ruffié, P., Martin, M., Tarayre, M., Lacombe-Terrier, M.J., Douillard, J., Laplanche, A.: Impact of chemotherapy (CT) on survival of locally advanced non-small cell lung carcinoma (NSCLC): Results of a randomized study of 353 patients. (Abstract) Lung Cancer7(Suppl):159, 1991

    Google Scholar 

  46. Mattson, K., Holsti, L.R., Holsti, P., Jakobsson, M., Kajanti, M., Liipo, K., Mäntylä, M., Niitamo Korhonen, S., Nikkanen, V., Nordman, E., Platin, L.-H., Pyrhönen, S., Romppanen, M.-L., Salmi, R., Tammilhehto, L., Taskinen, P.J.: Inoperable non-small cell lung cancer: radiation with or without chemotherapy. Eur. J. Cancer. Clin. Oncol.24(3):477, 1988

    Google Scholar 

  47. Morton, R.F., Jett, J.R., McGinnis, W.L., Earle, J.D., Therneau, T.M., Krook, J.E., Elliott, T.E., Mailliard, J.A., Nelimark, R.A., Maksymiuk, A.W., Drummond, R.G., Laurie, J.A., Kugler, J.W., Anderson, R.T.: Thoracic radiation therapy alone compared with combined chemoradiotherapy for locally unresectable non-small cell lung cancer. Ann Intern Med115:681, 1991

    Google Scholar 

  48. Schaake-Koning, C., Van Den Bogaert, W., Dalesio, O., Festen, J., Hoogenhout, J., Van Houtte, P., Kirkpatrick, A., Koolen, M., Maat, B., Nijs, A., Renaud, A., Rodrigus, P., Schuster-Uitterhoeve, L., Sculier, J.-P., Van Zandwijk, N., Bartelink, H.: Effects of concomitant cisplatin and radiotherapy on inoperable non-small-cell lung cancer. N. Engl. J. Med.326(8):524, 1992

    Google Scholar 

  49. Slawson, R., Salazar, O.M., Poussin-Rosillo, H., Amin, P.P., Strohl, R., Sewchand, W.: Once-a-week vs conventional daily radiation treatment for lung cancer: final report. Int. J. Radiat. Oncol. Biol. Phys.15:66, 1988

    Google Scholar 

  50. Trovó, M., Minatel, E., Veronesi, A., Roncadin, M., De Paoli, A., Franchin, G., Magri, D.A., Tirelli, L., Carbone, A., Grigoletto, E.: Combined radiotherapy and chemotherapy versus radiotherapy alone in locally advanced epidermoid bronchogenic carcinoma—a randomized study. Cancer65:400, 1990

    Google Scholar 

  51. Trovó, M., Minatel, E., Franchin, G., Boccieri, M.G., Nascimben, O., Bolzicco, G., Pizzi, C., Torretta, A., Veronesi, A., Gobitti, C., Zanelli, D.J., Monfardini, S.: Radiotherapy versus radiotherapy enhanced by cisplatin in stage III non-small cell lung cancer. Int. J. Radiat. Oncol. Biol. Phys.24:11, 1992

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, University of Toronto and Princess Margaret Hospital, Toronto, Ontario, Canada

    Andrea Bezjak M.D., F.R.C.P.C. & David Payne M.D., F.R.C.P.C.

Authors
  1. Andrea Bezjak M.D., F.R.C.P.C.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David Payne M.D., F.R.C.P.C.
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bezjak, A., Payne, D. Radiotherapy in the management of non-small-cell lung cancer. World J. Surg. 17, 741–750 (1993). https://doi.org/10.1007/BF01659084

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01659084

Keywords

Search

Navigation