Sequencing postoperative radiotherapy and adjuvant chemotherapy in non-small cell lung cancer: unanswered questions on the not evidence-based approach

Abstract

This editorial comments on the study by Lee et al. which reported on the use of postoperative radiotherapy (PORT) as first strategy after resection of stage IIIA-pN2 non-small cell lung cancer (NSCLC).After completion of PORT, 41% of patients received postoperative chemotherapy (POCT). The five-year overall survival (OS) was significantly higher in patients treated with PORT and POCT than in patients treated with PORT alone. Authors concluded that PORT used as first postoperative strategy does not compromise a benefit of POCT and its implementation should be further studied. We discuss the pros and cons of using PORT before POCT for stage IIIA-pN2 NSCLC. Some radiobiological data support earlier use of PORT, however, caution should be paid to not to unnecessarily delay or omit POCT because of its demonstrated survival benefit. Concurrent postoperative radio-chemotherapy could be an attractive approach, but we still have very limited clinical data on its use in this indication. after surgical resection (44-45 Gy for a bronchial stump, involved mediastinal nodal stations, and its next draining stations and a boost up to 50.4-60 Gy for a bronchial stump and involved nodal stations). POCT (4-6 cycles of platinum-based chemotherapy administered 3 to 4 weeks after the completion of PORT) was given for 43 patients (41%). Thirty patients (48.4%) did not receive POCT because of comorbidities, 23 patients (37.1%) because of institutional policy, 8 patients (12.9%) because of refusal of treatment, and one patient (1.6%) because of old age. There were no significant differences in loco-regional and distant failure between the groups with and without POCT. The 5-year OS was significantly higher in the group with POCT than in group without POCT: 61.3% vs. 29.2%, respectively, P<0.001. There was no significant difference in the loco-regional recurrence free survival between the groups. The authors concluded that the PORT-first strategy after surgery for stage IIIA (pN2) NSCLC patients did not compromise the clinical outcomes, and that the OS benefit of POCT given after PORT was observed. Since the OS was superior to that obtained in the historical series in which PORT was applied after POCT (3,9,12), the authors suggested that the use of PORT before rather than after POCT may have contributed to this improvement. Such conclusions obviously have their limitations, also acknowledged by the authors. The main limitation of the presented study is its retrospective nature and-in consequence-an imbalance in the main prognostic factors between the presented groups. Patients in the POCT arm were younger, showed significantly better performance status and had lower comorbidity index, which could impact the obtained result. Homogenous treatment protocol was probably provided for all cases, but the total radiation dose actually administered in the POCT group was higher. PORT was probably interrupted in some no-POCT patients due to clinically important reasons. One may presume that the patients who died or progressed during PORT ...

Early postoperative radiotherapy is associated with improved outcomes over late postoperative radiotherapy in the management of completely resected (R0) Stage IIIA-N2 non-small cell lung cancer

“…There has been no study comparing the optimal sequencing of POCT and PORT among patients with pathologic Stage IIIA-N2 R0 NSCLC [ 8 ]. In the absence of randomized data, we sought to answer this question in a multi-institutional retrospective study of high-quality data to provide insight into the relationship between the PORT and POCT combination schedule and survival.…”

Conventional CT and PET/CT imaging in the evaluation and management of subsolid pulmonary nodules: an overview of the literature and author recommendations

“…In the authors' experience, in SSNs with 18 F-FDG-positive findings, it is worthwhile considering a pre-emptive approach to treatment with conventional radiotherapy, focal stereotactic ablative radiotherapy (SABR), or surgery (depending on fitness), rather than proceed to biopsy given the high rate of negative biopsies and the additional morbidity [35,36].…”