Updated December 2013

Recommendation: Post-operative adjuvant radiotherapy should not be used after complete resection of Stage I or II NSCLC, due to an increased risk of non-cancer deaths. There is lower-level evidence that adjuvant post-operative radiotherapy may confer some survival benefit to patients with Stage III NSCLC after complete resection. Radiotherapy after complete resection decreases local recurrence in all stages.

Amongst patients with positive bronchial resection margins, postoperative adjuvant radiotherapy will decrease the chance of local recurrence. Those with macroscopically positive resection margins are less apt to benefit from adjuvant radiotherapy because of generally poorer results for these patients.

Discussion:

For patients with complete resection of Stage I or II lung cancers post-operative radiation is not recommended due to a suggestion of non-cancer deaths. Many studies show lower recurrence rates yet no effect or a detrimental effect of radiation on overall survival. More recent studies of smaller field radiation and modern radiation planning techniques have demonstrated small gains in overall survival yet these series are limited.

In the case of positive resection margins in early stage lung cancer, patients should be referred for a discussion regarding the merits of radiation. Factors to consider include the stage of the disease, the location of the margin, the patients overall health and respiratory status.

There is evidence from randomized controlled trials that post-operative radiotherapy (PORT) reduces local recurrence by 11% to 18% (or 1.6-19 fold) in patients with completely resected, pathologic stage II and IIIA NSCLC. Data from several RCT and the PORT meta-analysis show that non-cancer deaths are increased in those treated with PORT after complete resection of Stage I and II NSCLC. This increase in non-cancer deaths was not seen amongst Stage III NSCLC patients who had complete resection, and some studies showed a trend towards a survival advantage to PORT in those patients. There is a suggestion that older radiation therapy techniques may have impacted the benefits of PORT. A recent review of the SEER database and ANITA trial suggest that patients with N2 disease are most likely to benefit from PORT. Thus treatment may be considered in the following circumstances:

1. Microscopic involvement of the resection margin, including bronchial resection margin.
2. Limited involvement of completely resected N2 nodal stations, particularly in a young, fit patient with significant extra nodal extension.
3. Infiltration of the chest wall in a patient who did not receive pre-operative radiotherapy.

Discussion with the Radiation Oncology service is recommended in patients with Stage III NSCLC, or incompletely resected Stage I or II NSCLC patients.

Key References:

1. Logan DM, Lochrin CA, Darling G et al. Adjuvant radiotherapy and chemotherapy for stage II or IIIA non-small-cell lung cancer after complete resection. Provincial Lung Cancer Disease Site Group. Cancer Prevention & Control,1997;1(5):366-78.

2. PORT meta-analysis. 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 1998; 352; 257-63

3. Cochrane Review. The Cochrane Library 2000, Issue 2

4. Burdett S, Stewart L; PORT Meta-analysis Group. Postoperative radiotherapy in non-small-cell lung cancer: update of an individual patient data meta-analysis. Lung Cancer 2005; 47, 81-83

5. Dautzenberg B Arriagada R, Chammard AB et al, A controlled study of postoperative radiotherapy for patients with completely resected non-small cell lung carcinoma. Groupe d'Etude et de Traitement des Cancers Bronchiques. Cancer 1999 ; 86; 265-273

6. Trodella L, Granone P, Valente S et al, Adjuvant radiotherapy in non-small cell lung cancer with pathological stage I: definitive results of a phase III randomized trial. Radiother Oncol 2002; 62:11-19

7. Feng QF, Wang M, Wang LJ et al. A study of postoperative radiotherapy in patients with non-small-cell lung cancer: a randomized trial. Int J Radiat Oncol Biol Phys. 2000 Jul 1;47(4):925-9.

8. Lally BE, Zelterman D, Colasanto JM et al. Postoperative radiotherapy for stage II or III non-small-cell lung cancer using the surveillance, epidemiology, and end results database. J Clin Oncol. 2006;24(19):2998.

9. Douillard JY, Rosell R, De Lena M et al. 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. 2008;72(3):695.