Updated Feb. 2008

Guideline: Post-operative adjuvant radiotherapy should not be used after complete resection of Stage I or II NSCLC, due to an increased risk of non-cancer deaths. There is lower-level evidence that adjuvant post-operative radiotherapy may confer some survival benefit to patients with Stage III NSCLC after complete resection. Radiotherapy after complete resection decreases local recurrence in all stages.

Amongst patients with positive bronchial resection margins, postoperative adjuvant radiotherapy will decrease the chance of local recurrence. Those with macroscopically positive resection margins are less apt to benefit from adjuvant radiotherapy because of generally poorer results for these patients.

Level of Evidence: I-III

Grade of Recommendation: A-B

There is evidence from randomised controlled trials that post-operative radiotherapy (PORT) reduces local recurrence by 11% to 18% (or 1.6-19 fold) in patients with completely resected, pathologic stage II and IIIA NSCLC. Data from several RCT and the PORT meta-analysis show that non-cancer deaths are increased in those treated with PORT after complete resection of Stage I and II NSCLC. This increase in non-cancer deaths was not seen amongst Stage III NSCLC patients who had complete resection, and some studies showed a trend towards a survival advantage to PORT in those patients. Therefore, radical radiotherapy after surgical resection is not routinely recommended. Treatment may be considered in the following circumstances:

1. Microscopic involvement of the resection margin, including bronchial resection margin.
2. Limited involvement of completely resected N2 nodal stations, particularly in a young, fit patient with significant extra nodal extension.
3. Infiltration of the chest wall in a patient who did not receive pre-operative radiotherapy.

Discussion with the Radiation Oncology service is recommended in patients with Stage III NSCLC, or incompletely resected Stage I or II NSCLC patients.

Key References:

1. Logan DM, Lochrin CA, Darling G et al. Adjuvant radiotherapy and chemotherapy for stage II or IIIA non-small-cell lung cancer after complete resection. Provincial Lung Cancer Disease Site Group. Cancer Prevention & Control,1997;1(5):366-78.
2. PORT metaanalysis. Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. PORT Meta-analysis Trialists Group. Lancet 1998; 352; 257-63
3. Cochrane Review. The Cochrane Library 2000, Issue 2
4. Burdett S, Stewart L; PORT Meta-analysis Group. Postoperative radiotherapy in non-small-cell lung cancer: update of an individual patient data meta-analysis.Lung Cancer 2005; 47, 81-83
5. Dautzenberg B Arriagada R, Chammard AB et al, A controlled study of postoperative radiotherapy for patients with completely resected nonsmall cell lung carcinoma. Groupe d'Etude et de Traitement des Cancers Bronchiques.Cancer 1999 ; 86; 265-273

6. Trodella L, Granone P, Valente S et al, Adjuvant radiotherapy in non-small cell lung cancer with pathological stage I: definitive results of a phase III randomized trial. Radiother Oncol 2002; 62:11-19
7. Feng QF, Wang M, Wang LJ et al. A study of postoperative radiotherapy in patients with non-small-cell lung cancer: a randomized trial. Int J Radiat Oncol Biol Phys. 2000 Jul 1;47(4):925-9.