Postoperative radiotherapy in stage III non-small cell lung cancer: Is a reassessment necessary in modern times?

Background: The role of postoperative radiation therapy (PORT) in patients with completely resected non-small cell lung cancer (NSCLC) with pathologically involved mediastinal lymph nodes (N2) remains unclear. Despite a reduction of local recurrence (LR), its effect on overall survival (OS) remains unproven. Therefore \nwe conducted a review of the current literature. \nMethods: To investigate the benefit and safety of modern PORT, we identified published phase III trials for PORT. We investigated modern PORT in low-risk (ypN0/1 and R0) and high-risk (ypN2 and/or R1/2) patients with stage III-N2 NSCLC treated with induction chemotherapy and resection. \nResults: Seventeen phase III trials using PORT were selected. Of all PORT N2 studies, 4 were eligible for evaluation of LR, all in high-risk patients only. In these highrisk patients receiving PORT, the mean LR rate at 5 years was 20.9% (95% CI 16–24). Two trials were suitable to assess LR rates after chemotherapy and \nsurgery without PORT. In these low-risk patients, the mean 5-year LR was 33.1% (95% CI 27–39). No significant difference in non-cancer deaths between PORT vs. non-PORT patients was observed in N2 NSCLC. \nConclusion: PORT is worth the controversy because data illustrate that PORT may increase the OS. However, prospective randomized trials are needed to verify this.