Chest
Volume 112, Issue 4, October 1997, Pages 954-959
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Clinical Investigations: Cancer
Postoperative Radiotherapy in Radically Resected Non-small Cell Lung Cancer

https://doi.org/10.1378/chest.112.4.954Get rights and content

Purpose

To evaluate the value of adjuvant postoperative external-beam radiation (EBR) in patients with radically resected non-small cell lung cancer (NSCLC) pT1–3 pN0–2 compared to patients with resected NSCLC without adjuvant EBR.

Materials and methods

In 155 patients (121 male, 34 female; mean age, 59 years) 105 lobectomies, 12 bilobectomies, and 38 pneumonectomies with radical lymph node dissection of the ipsilateral side were performed. Postoperative staging was done according to the TNM system and was as follows: pT1 (n=38), pT2 (n=89), pT3 (n=28); pNO (n=39), pN1 (n=67) and pN2 (n=49). Histopathologic study revealed 68 squamous cell carcinomas, 53 adenocarcinomas, 21 large cell carcinomas, 6 adenosquamous cell carcinomas, and 7 bronchioloalveolar cell carcinomas. All patients were randomly assigned into two treatment groups: 72 patients with no further treatment (control group), and 83 patients (EBR group) with adjuvant postoperative EBR of the bronchial stump and mediastinum (50 to 56 Gy, 8 or 23 MV photons, 2 Gy/d, 5 d/wk) beginning 4 to 6 weeks after surgery.

Results

The overall 5-year survival rate (median observation time, 43 months) of all patients was 24.1% (EBR group, 29.7%; control group, 20.4%; p>0.05, not significant). The relative risk of the EBR group was 0.85 with a two-sided confidence interval of 0.66 to 1.09. The overall 5-year recurrence-free survival was 20.6% (EBR, 27.1%; control group, 15.6%; p=0.07). The relative risk of the EBR group was 0.80 with a confidence interval of 0.63 to 1.01. The rate of local recurrences at the bronchial stump and/or mediastinum was significantly smaller in the EBR group (n=5) than in the control group (n=17) (p<0.01). Multivariate analysis2 test) demonstrated an independent influence of postoperative EBR on the incidence of local recurrences. The incidence of distant metastases was slightly but not significantly higher in patients without EBR (38 patients) compared to those who had EBR (32 patients).

Conclusion

High-dose postoperative EBR to the mediastinum significantly reduces the risk of local recurrence at the bronchial stump and/or mediastinum. Age, sex, histologic subtype, tumor size, surgical approach, or extent of lymph node involvement had no prognostic value—only postoperative EBR had an independent influence on the risk of local recurrence. The effect of postoperative EBR was on the verge of significance with respect to recurrence-free survival and showed the same tendency in overall survival, however with an attenuated relative risk.

Section snippets

Study Population

All patients eligible for the study had histologic or cytologic evidence of NSCLC. Based on findings from physical examination, laboratory data, abdominal ultrasound, CT, and bone scans, all patients were free of distant metastases (M0). Bronchoscopy and esophagoscopy were performed in each patient. Mediastinoscopy was done only in patients with central tumors and/or enlarged mediastinum as detected on chest radiographs and/or CT. Patients with contralateral or high (above the azygos vein on

Survival Rate

The overall 5-year survival rate (median observation time, 43 months) of all patients was 24.1% (Fig 1). It was slightly better in the EBR group (29.7%) than in the control group (20.4%) (p<0.05, not significant). The relative risk of the EBR group was 0.85 with a two-sided confidence interval of 0.66 to 1.09. pNO patients had an overall survival of 40.9% (EBR group, 60.4%; control group, 32.3%) (p<0.05, not significant), pN1 patients had 26.1% (EBR group, 41.8%; control group, 22.1%) (p<0.05,

Discussion

For many years, postoperative EBR has been used frequently to prevent local failure in patients with breast cancer, rectal cancer, other pelvic malignancies, or soft-tissue sarcomas. Other rationales for using postoperative EBR in resected NSCLC are to prevent local recurrence and to increase long-term survival. A number of studies, both retrospective and prospective, have compared postoperative EBR with no further treatment in patients with resected NSCLC.

Green et al9 (1975) and Kirsh and Sloan

Conclusion

In summary, the current data indicate a significant reduction of local recurrence at the bronchial stump and/or mediastinum in patients with adjuvant postoperative EBR.

In contrast to other studies, there was no difference in the number of local relapses within the different histologic subgroups.10, 22 Neither age, sex, histologic subtype, tumor size, surgical approach, nor extent of lymph node involvement had prognostic value—only EBR had an independent influence on the risk of local

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