Thoracic Postoperative Radiation Therapy: To Treat or Not to Treat?

  • Muneeb Z. Niazi
    Affiliations
    Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois
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  • Daniel W. Golden
    Correspondence
    Reprint requests to: Daniel W. Golden, MD, MHPE, Department of Radiation and Cellular Oncology, Pritzker School of Medicine, University of Chicago, 5758 South Maryland Avenue Mail Code 9006, Chicago, IL 60637. Tel: (773) 702-6870
    Affiliations
    Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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      A 41-year-old woman with a 5 pack-year smoking history presented with abdominal pain. Computed tomography (CT) of the abdomen incidentally revealed a left lower lobe lung nodule. Positron emission tomography/CT showed a 1.7-cm spiculated nodule in the left lower lobe of the lung, maximum standardized uptake value 4.9, 2 hypermetabolic station 10L lymph nodes measuring 1.3 cm, maximum standardized uptake value 5.6, and no evidence of metastatic disease. Follow-up CT scan without contrast re-demonstrated the spiculated nodule with no visible lymphadenopathy, although the lack of contrast limited nodal assessment.
      The patient underwent left lower lobectomy and mediastinal node dissection. Pathology showed a primary infiltrating poorly differentiated adenocarcinoma, anaplastic lymphoma kinase (ALK)+, with invasion of the visceral pleura. Of 18 lymph nodes, 11 (8 hilar, 2 inferior pulmonary ligament, and 1 anterior mediastinal) were positive for metastatic adenocarcinoma. Two of the hilar lymph nodes were positive for extracapsular extension. The final stage classification was pT2aN2M0, IIIA. The patient received adjuvant chemotherapy at an outside institution. She then presented to our institution to discuss radiation therapy in the management of pN2 disease after lobectomy for non-small cell lung cancer.

      Questions

      • 1.
        Per American Society of Clinical Oncology guidelines,
        • Kris M.G.
        • Gaspar L.E.
        • Chaft J.E.
        • et al.
        Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario clinical practice guideline update.
        adjuvant radiation therapy is no longer routinely recommended for pN2 disease. Would an expert treat given the pN2 disease and nodes with extracapsular extension?
      • 2.
        Would consideration be given for concurrent chemoradiation in the setting of pN2 disease?
      • 3.
        What mediastinal volume would be covered given the unimpressive positron emission tomography result (2 nodes) and extensive pathologic nodal involvement (11 nodes)? Would consideration be given to cover the contralateral mediastinum?

      Reference

        • Kris M.G.
        • Gaspar L.E.
        • Chaft J.E.
        • et al.
        Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario clinical practice guideline update.
        J Clin Oncol. 2017; 35: 2960-2974

      Linked Article

      • Check the Reports and Check the Brain
        International Journal of Radiation Oncology • Biology • PhysicsVol. 104Issue 4
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          There has been no recent randomized evidence justifying postoperative radiation therapy (PORT) in patients with non-small cell lung cancer who have undergone complete resection; it is not recommended for routine use, even in patients with mediastinal involvement (pN2).1,2 Adjuvant treatments such as chemotherapy and PORT should be discussed at a multidisciplinary board with complete surgical and pathologic reports, checking whether the nodal exploration was appropriate, the location and number of mediastinal nodes and hilar/intrapulmonary nodes that were resected, and whether resection was complete.
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      • Early Bird Catches the Worm: PORT—A Compelling Treatment Strategy
        International Journal of Radiation Oncology • Biology • PhysicsVol. 104Issue 4
        • Preview
          This patient is a candidate for aggressive postoperative therapy.1 We recommend sequential postoperative radiation therapy (PORT) after chemotherapy given the patient's young age, the multilevel mediastinal (pN2) lymph node involvement (anterior and inferior mediastinum), and the presence of extracapsular extension. Although routine use of PORT for pN2 disease has been controversial, the aforementioned factors portend a high risk of local recurrence and therefore a potential benefit of consolidative radiation therapy.
        • Full-Text
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      • The Role of Adjuvant Radiotherapy for Resected Non-Small Cell Lung Cancer in the Modern Era
        International Journal of Radiation Oncology • Biology • PhysicsVol. 104Issue 4
        • Preview
          The role of adjuvant therapy in resected non-small cell lung cancer has been a contentious issue for decades. The current standard of adjuvant chemotherapy1 was only proven by the completion of a series of modern international trials when a first set of older trials failed to demonstrate significant benefit.2 The Lung Adjuvant Cisplatin Evaluation meta-analysis of modern trials demonstrated a significant overall survival improvement of ∼5%.3 This does not seem to extend to molecular targeted therapies for resected Epidermal Growth Factor Receptor or ALK+ non-small cell lung cancer because improvement is seen only for progression-free survival, not for overall survival.
        • Full-Text
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