Indications and Parameters Around Postoperative Radiation Therapy for Lung Cancer

Abstract

Patients with locally advanced resected non–small-cell lung cancer present a high risk of relapse. Although adjuvant platinum–based chemotherapy has become the standard of care, the role of postoperative radiation therapy (PORT) has been controversial for years. In patients with incomplete resection, PORT should be proposed, on the basis of a strong consensus, despite the absence of randomized evidence. In patients with completely resected (R0) non–small-cell lung cancer, a meta-analysis showed poorer outcomes after PORT in the absence of mediastinal involvement (pN0 and pN1). In patients with pN2, the role of PORT was less clear and required further research. The meta-analysis included trials using older radiation techniques and poorer quality of surgery according to today's standards, and selection of patients was not positron emission tomography–based. Newer retrospective and nonrandomized studies and subgroup analyses of randomized trials evaluating adjuvant chemotherapy suggested a survival benefit of PORT in patients with pN2 R0. Two recent randomized trials (Lung ART and PORT-C) evaluating conformal PORT versus no PORT retrieved no disease-free survival advantage for stage IIIA-N2 patients, even if mediastinal relapse was significantly decreased with PORT. PORT had no effect on survival, possibly given the high rate of distant relapse and risk of additional cardiopulmonary toxicity. Ongoing and future analyses are planned in Lung ART to identify patients for whom PORT could be recommended. Incorporation of newer systemic treatments (immune checkpoint inhibitors or targeted therapy in oncogene-addicted patients) is underway in the neoadjuvant and/or adjuvant setting. Better identification of patients at a high risk of disease recurrence, with analysis of circulating tumor DNA, on the basis of the detection of postsurgical minimal (or molecular) residual disease is warranted in future studies.

Progress on neoadjuvant immunotherapy in resectable non-small cell lung cancer and potential biomarkers

“…Current data shows that neoadjuvant chemotherapy improved the OS by around 5% in OS and time to recurrence in patients with resectable NSCLC ( 3 ). The addition of radiation to neoadjuvant chemotherapy did not seem to further improve the survival benefit ( 4 ). Radiation gives help to control locoregional disease, but the PFS extension fails to translate into a long-term survival benefit ( 5 – 7 ).…”

Higher Lung and Heart Doses Decrease Early and Long-Term Survival, Respectively, in Patients With Non-Small Cell Lung Cancer Undergoing Postoperative Radiation

“…Postoperative radiation therapy (PORT) for non-small cell lung cancer (NSCLC) is controversial. 1 Many retrospective and large public database studies have suggested that PORT confers survival benefits for patients with pathologic N2 NSCLC 2 , 3 ; however, 2 recent randomized controlled trials showed that PORT does not improve progression-free survival (PFS) or overall survival (OS) in these patients. 4 , 5 Cardiopulmonary toxic effects may diminish the benefit of PORT.…”

Role of prognostic nutritional index in postoperative radiotherapy for non‐small cell lung cancer

“…Radiotherapy can have detrimental effects on immunonutritional status in two ways: (1) radiation damage to lymphocytes and hematopoietic organs, and (2) radiationinduced fatigue, poor oral intake, and anorexia. The aim of our study was to determine the value of PNI in the prognosis of NSCLC patients with PORT.…”