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Patella M, Brunelli A, Adams L, Cafarotti S, Costardi L, De Leyn P, Decaluwé H, Franks KN, Fuentes M, Jimenez MF, Karri S, Moons J, Novellis P, Ruffini E, Veronesi G, Voulaz E, Shargall Y. A risk model to predict the delivery of adjuvant chemotherapy following lung resection in patients with pathologically positive lymph nodes. Semin Thorac Cardiovasc Surg 2022; 35:387-398. [PMID: 35272025 DOI: 10.1053/j.semtcvs.2021.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 12/02/2021] [Indexed: 01/20/2023]
Abstract
To investigate factors associated with the ability to receive adjuvant chemotherapy in patients with pathological N1 and N2 stage after anatomic lung resections for non-small cell lung cancer (NSCLC). Multicenter retrospective analysis on 707 consecutive patients found pathologic N1 (pN1) or N2 (pN2) disease following anatomic lung resections for NSCLC (2014-2019). Multiple imputation logistic regression was used to identify factors associated with adjuvant chemotherapy and to develop a model to predict the probability of starting this treatment. The model was externally validated in a population of 253 patients. In the derivation set, 442 patients were pN1 and 265 pN2. 58% received at least one cycle of adjuvant chemotherapy. The variables significantly associated with the probability of starting chemotherapy after multivariable regression analysis were: younger age (p<0.0001), Body Mass Index (BMI) (p=0.031), Forced Expiratory Volume in 1 second (FEV1) (p=0.037), better performance status (PS) (p<0.0001), absence of chronic kidney disease (CKD) (p=0.016), resection lesser than pneumonectomy (p=0.010). The logit of the prediction model was: 6.58 -0.112 x age +0.039 x BMI +0.009 x FEV1 -0.650 x PS -1.388 x CKD -0.550 x pneumonectomy. The predicted rate of adjuvant chemotherapy in the validation set was 59.2 and similar to the observed one (59%, p=0.87) confirming the model performance in external setting. This study identified several factors associated with the probability of initiating adjuvant chemotherapy after lung resection in node-positive patients. This information can be used during preoperative multidisciplinary meetings and patients counseling to support decision-making process regarding the timing of systemic treatment.
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Affiliation(s)
- Miriam Patella
- Department of Thoracic Surgery, San Giovanni Hospital, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St James's University Hospital, Leeds Teaching Hospital NHS Trust, Beckett St, Harehills, Leeds LS9 7TF, Leeds, United Kingdom
| | - Laura Adams
- Department of Clinical Oncology, St James's Institute of Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett St, Harehills, Leeds LS9 7TF, Leeds, UK
| | - Stefano Cafarotti
- Department of Thoracic Surgery, San Giovanni Hospital, Via Ospedale, 6500, Bellinzona, Switzerland
| | - Lorena Costardi
- Department of Thoracic Surgery, University Hospital of Torino, Città della Salute e della Scienza, Corso Bramante, 88, 10126, Torino, Italy
| | - Paul De Leyn
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Herbert Decaluwé
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Kevin N Franks
- Department of Clinical Oncology, St James's Institute of Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett St, Harehills, Leeds LS9 7TF, Leeds, UK
| | - Marta Fuentes
- Service of Thoracic Surgery, Salamanca University Hospital, IBSAL, Paseo de San Vicente, 58-182, 37007, Salamanca, Spain
| | - Marcelo F Jimenez
- Service of Thoracic Surgery, Salamanca University Hospital, IBSAL, Paseo de San Vicente, 58-182, 37007, Salamanca, Spain
| | - Sunanda Karri
- Division of Thoracic Surgery, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Ave E., Hamilton, ON L8N 4A6, Canada
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pierluigi Novellis
- Division of Thoracic and General Surgery, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089, Rozzano (MI), Italy; Present address: Division of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy Via Olgettina 58, 20132 Milano
| | - Enrico Ruffini
- Department of Thoracic Surgery, University Hospital of Torino, Città della Salute e della Scienza, Corso Bramante, 88, 10126, Torino, Italy
| | - Giulia Veronesi
- Division of Thoracic and General Surgery, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089, Rozzano (MI), Italy; Present address: Division of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy Via Olgettina 58, 20132 Milano
| | - Emanuele Voulaz
- Division of Thoracic and General Surgery, Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089, Rozzano (MI), Italy
| | - Yaron Shargall
- Division of Thoracic Surgery, McMaster University, St. Joseph's Healthcare Hamilton, 50 Charlton Ave E., Hamilton, ON L8N 4A6, Canada
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Early postoperative radiotherapy is associated with improved outcomes over late postoperative radiotherapy in the management of completely resected (R0) Stage IIIA-N2 non-small cell lung cancer. Oncotarget 2017; 8:62998-63013. [PMID: 28968966 PMCID: PMC5609898 DOI: 10.18632/oncotarget.18071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 04/24/2017] [Indexed: 02/05/2023] Open
Abstract
Aims The aim of this study was to evaluate the ideal timing of PORT in the management of completely resected (R0) Stage IIIA-N2 NSCLC. Patients and Methods Between January 2008 and December 2015, patients with known histologies of pathologic Stage IIIA-N2 NSCLC who underwent R0 resection and received PORT concurrent with or prior to two sequential cycles of chemotherapy (“early PORT”) or with PORT administered after two cycles of chemotherapy (“late PORT”) at multiple hospitals. The primary endpoint was OS; secondary end points included pattern of the first failure, LRRFS, and DMFS. Kaplan–Meier OS, LRRFS, and DMFS curves were compared with the log-rank test. Cox regression analysis was used to determine prognosticators for OS, LRRFS, and DMFS. Results Of 112 included patients, 41 (36.6%) and 71 (63.4%) patients received early PORT and late PORT, respectively. The median OS, LRRFS, and DMFS were longer for those who received early PORT than for those who received late PORT at the median follow-up of 29.6 months (all p < 0.05). Uni- and multi-variate analyses showed that number of POCT cycles and the combination schedule of PORT and POCT were independent prognostic factors for OS, LRRFS, and DMFS. Conclusions Early PORT is associated with improved outcomes in pathologic Stage IIIA-N2 R0 NSCLC patients.
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Gao SJ, Corso CD, Blasberg JD, Detterbeck FC, Boffa DJ, Decker RH, Kim AW. Role of Adjuvant Therapy for Node-Negative Lung Cancer Invading the Chest Wall. Clin Lung Cancer 2016; 18:169-177.e4. [PMID: 27890561 DOI: 10.1016/j.cllc.2016.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/19/2016] [Accepted: 08/23/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The present study investigated the effect of adjuvant chemotherapy and radiation on survival among patients undergoing chest wall resection for T3N0 non-small cell lung cancer (NSCLC). MATERIALS AND METHODS Patients with T3N0 NSCLC who underwent chest wall resection were identified in the National Cancer Data Base in 2004 to 2012. The cohort was divided into patients who had received adjuvant chemotherapy, radiation therapy, chemoradiation therapy, or no adjuvant treatment. Kaplan-Meier and log-rank tests were used to compare overall survival, and a bootstrapped Cox proportional hazards model was used to determine the significant contributors to survival. A subset analysis was performed with stratification by margin status and tumor size. RESULTS Of 759 patients identified, 42.0% underwent surgery alone, 23.3% underwent surgery followed by chemotherapy, 22.3% underwent surgery followed by chemoradiation therapy, and 12.3% underwent surgery followed by radiotherapy alone. Tumors > 4 cm benefited from adjuvant chemotherapy and radiation therapy in the multivariable analysis, and those ≤ 4 cm benefited only from adjuvant chemotherapy. The subgroup analysis by margin status identified that margin-positive patients with tumors > 4 cm benefited significantly from either adjuvant chemoradiation therapy or radiation therapy alone. CONCLUSION T3N0 NSCLC with chest wall invasion requires unique management compared with other stage IIB tumors. An important determinant of management is tumor size, with tumors ≤ 4 cm benefiting from adjuvant chemotherapy and tumors > 4 cm benefiting from adjuvant chemotherapy if margin negative and adjuvant chemoradiation therapy or radiotherapy if margin positive.
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Affiliation(s)
- Sarah J Gao
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Christopher D Corso
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Justin D Blasberg
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Frank C Detterbeck
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Daniel J Boffa
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Anthony W Kim
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
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Dupic G, Bellière-Calandry A. [Postoperative radiotherapy for non-small cell lung cancer: Efficacy, target volume, dose]. Cancer Radiother 2016; 20:151-9. [PMID: 26996789 DOI: 10.1016/j.canrad.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 09/29/2015] [Accepted: 10/14/2015] [Indexed: 11/30/2022]
Abstract
The rate of local failure of stage IIIA-N2 non-small cell lung cancer is 20 to 40%, even if they are managed with surgery and adjuvant chemotherapy. Postoperative radiotherapy improves local control, but its benefit on global survival remains to be demonstrated. Considered for many years as an adjuvant treatment option for pN2 cancers, it continues nevertheless to be deemed too toxic. What is the current status of postoperative radiotherapy? The Lung Adjuvant Radiotherapy Trial (Lung ART) phase III trial should give us a definitive, objective response on global survival, but inclusion of patients is difficult. The results are consequently delayed. The aim of this review is to show all the results about efficacy and tolerance of postoperative radiotherapy and to define the target volume and dose to prescribe.
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Affiliation(s)
- G Dupic
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - A Bellière-Calandry
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63000 Clermont-Ferrand, France
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Rieber J, Deeg A, Ullrich E, Foerster R, Bischof M, Warth A, Schnabel PA, Muley T, Kappes J, Heussel CP, Welzel T, Thomas M, Steins M, Dienemann H, Debus J, Hoffmann H, Rieken S. Outcome and prognostic factors of postoperative radiation therapy (PORT) after incomplete resection of non-small cell lung cancer (NSCLC). Lung Cancer 2015; 91:41-7. [PMID: 26711933 DOI: 10.1016/j.lungcan.2015.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/12/2015] [Accepted: 11/21/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE Current guidelines recommend postoperative radiation therapy (PORT) for incompletely resected non-small cell lung cancer (NSCLC). However, there is still a paucity of evidence for this approach. Hence, we analyzed survival in 78 patients following radiotherapy for incompletely resected NSCLC (R1) and investigated prognostic factors. PATIENTS AND METHODS All 78 patients with incompletely resected NSCLC (R1) received PORT between December 2001 and September 2014. The median total dose for PORT was 60 Gy (range 44-68 Gy). The majority of patients had locally advanced tumor stages (stage IIA (2.6%), stage IIB (19.2%), stage IIIA (57.7%) and stage IIIB (20.5%)). 21 patients (25%) received postoperative chemotherapy. RESULTS Median follow-up after radiotherapy was 17.7 months. Three-year overall (OS), progression-free (PFS), local (LPFS) and distant progression-free survival (DPFS) rates were 34.1, 29.1, 44.9 and 51.9%, respectively. OS was significantly prolonged at lower nodal status (pN0/1) and following dose-escalated PORT with total radiation doses >54 Gy (p=0.012, p=0.013). Furthermore, radiation doses >54 Gy significantly improved PFS, LPFS and DPFS (p=0.005; p=0.050, p=0.022). Interestingly, survival was neither significantly influenced by R1 localization nor by extent (localized vs. diffuse). Multivariate analyses revealed lower nodal status and radiation doses >54.0 Gy as the only independent prognostic factors for OS (p=0.021, p=0.036). CONCLUSION For incompletely resected NSCLC, PORT is used for improving local tumor control. Local progression is still the major pattern of failure. Radiation doses >54 Gy seem to support improved local control and were associated with better OS in this retrospective study.
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Affiliation(s)
- Juliane Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Germany
| | - Alexander Deeg
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Germany
| | - Elena Ullrich
- Translational Research Unit, Thoraxklinik, Heidelberg University, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Robert Foerster
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Germany
| | - Marc Bischof
- Department of Radiation Oncology, Klinikum am Gesundbrunnen, SLK-Kliniken Heilbronn GmbH, Germany
| | - Arne Warth
- Department of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Thomas Muley
- Translational Research Unit, Thoraxklinik, Heidelberg University, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Jutta Kappes
- Translational Research Unit, Thoraxklinik, Heidelberg University, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Pneumology, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Claus Peter Heussel
- Translational Research Unit, Thoraxklinik, Heidelberg University, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik gGmbH, University Hospital Heidelberg, Heidelberg, Germany; Department of Diagnostic and Interventional Radiology, University-HospitalHeidelberg, Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Heidelberg, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Martin Steins
- Department of Thoracic Oncology, Thoraxklinik, Heidelberg University, Heidelberg, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Hendrik Dienemann
- Translational Research Unit, Thoraxklinik, Heidelberg University, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Germany
| | - Hans Hoffmann
- Translational Research Unit, Thoraxklinik, Heidelberg University, Germany Translational Lung Research Centre Heidelberg (TLRC-H), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany; Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology, Germany.
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Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e278S-e313S. [PMID: 23649443 DOI: 10.1378/chest.12-2359] [Citation(s) in RCA: 883] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. METHODS The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. RESULTS Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
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Affiliation(s)
- John A Howington
- NorthShore HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL.
| | - Matthew G Blum
- Penrose Cardiothoracic Surgery, Memorial Hospital, University of Colorado Health, Colorado Springs, CO
| | | | - Alex A Balekian
- Division of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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Gomez DR, Komaki R. Postoperative radiation therapy for non-small cell lung cancer and thymic malignancies. Cancers (Basel) 2012; 4:307-22. [PMID: 24213242 PMCID: PMC3712677 DOI: 10.3390/cancers4010307] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 02/21/2012] [Accepted: 03/06/2012] [Indexed: 12/25/2022] Open
Abstract
For many thoracic malignancies, surgery, when feasible, is the preferred upfront modality for local control. However, adjuvant radiation plays an important role in minimizing the risk of locoregional recurrence. Tumors in the thoracic category include certain subgroups of non-small cell lung cancer (NSCLC) as well as thymic malignancies. The indications, radiation doses, and treatment fields vary amongst subtypes of thoracic tumors, as does the level of data supporting the use of radiation. For example, in the setting of NSCLC, postoperative radiation is typically reserved for close/positive margins or N2/N3 disease, although such diseases as superior sulcus tumors present unique cases in which the role of neoadjuvant vs. adjuvant treatment is still being elucidated. In contrast, for thymic malignancies, postoperative radiation therapy is often used for initially resected Masaoka stage III or higher disease, with its use for stage II disease remaining controversial. This review provides an overview of postoperative radiation therapy for thoracic tumors, with a separate focus on superior sulcus tumors and thymoma, including a discussion of acceptable radiation approaches and an assessment of the current controversies involved in its use.
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Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1840 Old Spanish Trail, Houston, TX 77054, USA.
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