Local Failure after Complete Resection of “Early-Stage” Non–small Cell Lung Cancer: The Potential Role of Postoperative Radiation Therapy

Abstract

Surgery is the standard treatment for early stage non–small cell lung cancer (NSCLC). “Conventional wisdom” is that the rate of local/regional failure (LRF) is low, and that adjuvant postoperative RT is not necessary. We herein quantify the risk of local/regional failure in a large series of resected patients at tertiary referral center. The records of 270 patients undergoing complete resection (lobectomy, or pneumonectomy) for pathological T1–3 N0–1 (UICC 7th edition staging) NSCLC from 1996–2006 were reviewed. (N2 disease, benign diagnosis, or carcinoid tumors were excluded). Median age 66 years. Pathology: Adeno 43%, squamous 43%, other 14%. Adjuvant chemotherapy was given in 11%, but no patient received postoperative RT. Crude and actuarial (Kaplan-Meier) rates of LRF, as the first site of failure, were computed. LRF was considered as the lung, surgical stump, or hilar, mediastinal or supraclavicular nodes. Follow-up duration in the patients without an event was 1–148 (median 39) months; 232 patients had ≥ 6 months of follow-up. The numbers of evaluable surviving patients at ≥1, ≥3, and ≥5 years postresection are 130, 88, and 55, respectively. For the overall group, the crude rate of LRF was 26%; 14% as the sole site of failure, and 12% with concurrent local/regional and distant recurrence. The crude rates of the LRF by pathologic stage are T1N0 20% (n = 94), T1N1 25% (n = 17), T2N0 19% (n = 83), T2N1 33% (n = 24), T3N0 31% (n = 32), T3N1 50% (n = 12), T4N0 67% (n = 6), T4N1 0% (n = 2). For the overall group, the actuarial 5 year LRF rate was 37%. The actuarial 5 years rates of LRF by stage are: T1N0 30%, T1N1 42%, T2N0 31%, T2N1 53%, T3N0 46%, T3N1 100%, T4N0 77%, T4N1 0%. The rate of failure at the different sites was lung (10%), stump (4.8%), hilum (5.2%), mediastinum (12.6%), supraclavicular (1.5%), and chest wall (2.6%); several patients who failed in multiple local/regional sites are counted more than once. LRF rates (by both crude and actuarial measures) are high (≥ 20–30%) following gross total resection of early stage NSCLC. The role of postoperative RT in these patients should be reassessed.