What is the role of radiotherapy after surgery in the treatment of operable stage I NSCLC?

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What is the role of radiotherapy after surgery in the treatment of operable stage I NSCLC?

Introduction

Radiotherapy either to the tumour bed or the regional lymph nodes may be employed after surgery to reduce local recurrence, and possibly improve survival. The role of external beam radiotherapy following complete resection of NSCLC has been extensively investigated, but there is less information on the role of radiotherapy following incomplete removal of the tumour. In addition to external beam radiotherapy, brachytherapy using iodine-125 seeds applied to the tumour bed following sublobar resection has been investigated in a randomised trial.[1][2]

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Postoperative external beam radiotherapy (PORT) versus no radiotherapy

There is strong evidence, based on an individual patient data meta-analysis and recently updated, that the use of postoperative radiotherapy following complete resection of stage I NSCLC is detrimental, and is associated with worse survival.[3]

In 665 patients with stage I disease randomised to PORT or no PORT, there was an increased risk of death with a hazard ratio of 1.42 (95% C.I.: 1.16, 1.75) in patients randomised to PORT.

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Brachytherapy in addition to sublobar resection

Since local recurrence is more frequent after sublobar resection compared with lobectomy,[4] the American College of Surgeons Oncology Group (ACOSOG) conducted a randomised trial of sublobar resection with and without I-125 seed brachytherapy in patients with high risk stage I NSCLC. The addition of brachytherapy did not affect local recurrence, morbidity or survival.[1][2]

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Evidence summary and recommendations

Evidence summary Level References
Following complete resection of stage I NSCLC, the addition of adjuvant external beam radiotherapy decreases survival. I [3]
The use of I-125 seed brachytherapy applied to the tumour bed after sublobar resection for high risk stage I NSCLC does not improve local recurrence rates or survival. II [2]
Evidence-based recommendationQuestion mark transparent.png Grade
In patients who have had complete resection of stage I NSCLC, postoperative radiotherapy is not recommended.
A
Evidence-based recommendationQuestion mark transparent.png Grade
I-125 seed brachytherapy to the tumour bed is not recommended after sublobar resection for stage I NSCLC.
B


Practice pointQuestion mark transparent.png

In the absence of any evidence regarding the treatment of incompletely resected stage I disease (positive margins) unsuitable for further surgery, expert consensus opinion recommends that radiotherapy be given to the site of residual disease using the same dose and technique as if no resection had been performed.

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References

  1. 1.0 1.1 Fernando HC, Landreneau RJ, Mandrekar SJ, Hillman SL, Nichols FC, Meyers B, et al. Thirty- and ninety-day outcomes after sublobar resection with and without brachytherapy for non-small cell lung cancer: results from a multicenter phase III study. J Thorac Cardiovasc Surg 2011 Nov;142(5):1143-51 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21872277].
  2. 2.0 2.1 2.2 Fernando HC, Landreneau RJ, Mandrekar SJ, Nichols FC, Hillman SL, Heron DE, et al. Impact of Brachytherapy on Local Recurrence Rates After Sublobar Resection: Results From ACOSOG Z4032 (Alliance), a Phase III Randomized Trial for High-Risk Operable Non-Small-Cell Lung Cancer. J Clin Oncol 2014 Jun 30 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24982457].
  3. 3.0 3.1 PORT Meta-analysis Trialists Group. Postoperative radiotherapy for non-small cell lung cancer. Cochrane Database Syst Rev 2005 Apr 18;(2):CD002142 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15846628].
  4. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995 Sep;60(3):615-22; discussion 622-3 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7677489].


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Appendices

Further resources

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