Postoperative radiotherapy is effective in improving survival of patients with stage pIII-N2 non-small-cell lung Cancer after pneumonectomy

Abstract

Background There were few reports of postoperative radiotherapy (PORT) in stage pIII-N2 Non-small-cell Lung Cancer (NSCLC) patients receiving pneumonectomy followed by adjuvant chemotherapy. This study aims to evaluate safety and efficacy of PORT among these patients. Methods Between Jan. 2004 and Dec. 2015, stage pIII-N2 NSCLC patients receiving pneumonectomy and adjuvant chemotherapy with or without PORT in our institution were retrospectively reviewed. Results Totally 119 patients were included, 32 patients receiving adjuvant chemotherapy and PORT (PORT group) and 87 receiving adjuvant chemotherapy alone (Control group). There were more patients with non-R0 resection in PORT group than Control group (25% vs. 8%, p = 0.031). In PORT group, ≥Grade 2 radiation-induced pneumonitis was 2/32. No severe radiation-related heart injury was observed. There was no PORT-related death. Of all patients, median follow-up time was 25 months. Median overall survival time (mOS) and median disease-free survival time (mDFS) were 46 months and 15 months, respectively. The PORT group had significantly better OS (not reached vs. 34 months, p = 0.003), DFS (19 months vs. 13 months, p = 0.024), local recurrence free survival (LRFS, p = 0.012), and distant metastasis free survival (DMFS, p = 0.047) than the Control group. As for failure pattern, PORT significantly reduced local regional failure rate (39.1% vs. 15.6%, p = 0.016). In subgroup analysis, patients with R0 resection ( n = 104), OS and LRFS in PORT group were significantly longer, and PORT tended to increase DFS and DMFS. Conclusion For patients with stage pIII-N2 NSCLC after pneumonectomy and adjuvant chemotherapy, PORT can improve OS, DFS, LRFS and DMFS with tolerable toxicity.

Supraclavicular Recurrence in Completely Resected (y)pN2 Non-Small Cell Lung Cancer: Implications for Postoperative Radiotherapy

“…Although there was limited historical data published that could be directly compared, the incidence of SCR in our study was reliable, since the overall recurrence rate and the percentage of SCR among patients with recurrent disease were in accordance with previous findings. The cumulative incidence of postoperative recurrence in the PORT group and non-PORT group, were generally comparable with recent studies (7,9,17,23). Furthermore, studies from our institution (7) and others (16,24) had reported a similar percentage of SCR among patients with recurrent disease (7.7-11.6% in the literature, 13.3% in our study).…”

“…The clinical value of PORT in completely resected (y)pN2 NSCLC was demonstrated again in our study, but the delineation of CTV remain controversial. In the current study, PORT significantly reduced LRR and improved OS1, which have been demonstrated in various studies ( 5 , 6 , 8 – 11 , 16 , 17 , 23 ). However, since ESRT was not routinely performed in our cancer institution ( 7 ), PORT failed to reduce SCR, indicating that the majority of SCRs represented the outgrowth of subclinical tumor lesions already in the supraclavicular region and were not originated from the loco-regional recurrent disease through lymphatic metastasis.…”

“…Compared with their counterpart, patients staged cN2 or ypN2 generally had a more advanced and aggressive disease, and thus it was reasonable for them to have a higher risk developing disease recurrence, including SCR ( 17 , 25 – 27 ). Compared with those receiving lobectomy, patients receiving pneumonectomy generally had a higher tumor burden and those receiving sublobectomy commonly had unfavorable prognostic factors, such as more comorbidities and poorer preoperative lung functions, that made them unsuitable for lobectomy ( 23 , 28 ). Therefore, patients who didn't receive lobectomy were also at a higher risk developing postoperative recurrence, which is generally consistent with a recent retrospective study using the SEER database ( 29 ).…”

Clinicopathological Characteristics and Survival Outcomes for Pneumonectomy: a Population-Based Study

“…Martin et al [13] had a total mortality rate of 3.8% after PN (18/470), with an overall incidence of PN of 38.1% (179/470). Ludwig et al [14] reported that the 5-year overall survival rate after PN was 27%, while Wang et al [15] reported a post-PN 5-year survival rate of 46.3% in patients with pIII-N2 NSCLC. In this study, 1-, 3-, and 5-year OS rates after PN were 76.7%, 53.5%, and 44.7% before PSM, and OS was worse after right PN vs left PN (HR: 1.303; 95% CI 1.133-1.498; P<0.001).…”

Resectable IIIA-N2 Non-Small-Cell Lung Cancer (NSCLC): In Search for the Proper Treatment

“…Another recent study [147] evaluated the safety and efficacy of PORT plus POCT after pneumonectomy for 119 patients with stage IIIA(N2) NSCLC, demonstrating that PORT is feasible and safe in this subset. When comparing the PORT with the non-PORT group, the median OS and DFS significantly improved in the first subset of patients, as well as locoregional failure significantly decreased in PORT group; moreover, no treatment-related complication was registered.…”