Rôle de la radiothérapie postopératoire des cancers bronchiques non à petites cellules : revue de la littérature actualisée sur de nouvelles données

Abstract

Most non-small-cell lung cancer long-term survivors are patients having had a completely resected tumor. Even in this highly selected group of patients, there is still a high risk of both local and distant failure. In patients with stage II and III, administration of adjuvant platinum-based chemotherapy is now considered the standard of care, based on level 1 evidence. The role of postoperative radiation therapy (PORT) remains controversial, especially in stage III. In the PORT meta-analysis published in 1998, the conclusions were that if PORT was detrimental to completely resected patients with no mediastinal involvement (pN0 and pN1 patients), the role of PORT in the treatment of tumors with N2 involvement was unclear and further research was warranted. Thus at present, after complete resection, adjuvant radiotherapy should not be administered in patients with early lung cancer (pN0 or pN1). Recent retrospective and non-randomized studies as well as subgroup analyses of randomized trials evaluating adjuvant chemotherapy, provide evidence of the possible benefit of PORT in patients with mediastinal nodal involvement. The role of PORT needs to be evaluated also for patients with proven N2 disease who undergo neo-adjuvant chemotherapy followed by surgery. Based on currently available data, PORT should be discussed for fit patients with completely resected non-small-cell lung cancer with N2 nodal involvement, preferably after completion of adjuvant chemotherapy or after surgery if patients have had pre-operative chemotherapy. There is need for new randomized evidence to reassess PORT using modern three-dimensional conformal radiation technique. A new large multi-institutional randomized trial (Lung ART IFCT 0503) evaluating PORT in this patient population is needed and now underway. In patients with R1 or R2 resection, postoperative radiotherapy should be proposed when re-resection cannot be achieved, based on a strong consensus, and despite the absence of randomized trial.