What is the role of radiotherapy after surgery in the treatment of operable stage I NSCLC?
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 but until the results are released its use remains investigational.
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. 
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.
Evidence summary and recommendations
|Following complete resection of stage I NSCLC, the addition of adjuvant external beam radiotherapy decreases survival.||I|||
|In patients who have had complete resection of stage I NSCLC, postoperative radiotherapy is not recommended.||A|
In the absence of any evidence regarding the treatment of incompletely resected stage I disease 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.
- Fernando HC, Landreneau RJ, Mandrekar SJ, Hillman SL, Nichols FC, Meyers B, et al. The impact of adjuvant brachytherapy with sublobar resection on pulmonary function and dyspnea in high-risk patients with operable disease: preliminary results from the American College of Surgeons Oncology Group Z4032 trial. J Thorac Cardiovasc Surg 2011 Sep;142(3):554-62 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21724195].
- 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].