Postoperative radiotherapy in resected non-small cell lung cancer: The never-ending story

Table 1 Recommendations for postoperative radiotherapy according to the main international guidelines

Guidelines	Clinical scenario	Recommendation for PORT
NCCN[9]	Stage pN0-1	Not recommended
	Stage pN2, negative surgical margins (R0)	Sequential
	Microscopic or macroscopic surgical margins (R1-R2)	Concomitant (selected cases) or sequential
ASTRO[10]	Stage pN2	Sequential
	Microscopic or macroscopic surgical margins (R1-R2)	Concomitant (selected cases) or sequential
	ESTRO-ASTRO[11]
	Multiple nodal stations involved	Sequential
	Extracapsular nodal extension	Sequential
ESMO[12]	Early stage (I-II) disease (R0)	Not recommended
	Positive margins or chest wall involvement (R1-R2)	Sequential
	Stage pN2	Only in selected cases
ASCO[13]	Early stage (I-II) disease (R0)	Not recommended
	Stage pN2	Only in selected cases

NCCN: National Comprehensive Cancer Network; ASTRO: American Sociedad of Radiation Oncology; ESTRO: European Society for Radiotherapy & Oncology; ESMO: European Society for Medical Oncology; ASCO: American Society of Clinical Oncology; PORT: Postoperative radiotherapy.

Table 2 Proposed predictive model for locoregional recurrence in stage IIIA N2 non-small cell lung cancer[41]

Risk model for LRR in stage pIIIA-N2 NSCLC
Factor	Category	Score
EGFR status	Wild- type	4
LMR	LMR < 4.69	2
Type of surgery	Thoracotomy	3
LNR	LNR ≥ 38.9	4
Risk group	Score	3-yr LRFS
Low risk	0-2	71.4%
Medium risk	3-5	57.3%
High risk	6-13	13.6%

LRFS: Locoregional recurrence-free survival; LRR: Locoregional recurrence; NSCLC: Non-small cell lung cancer; LNR: Lymph node ratio; LMR: Lymphocyte-to-monocyte ratio.

Table 3 Registered active studies related to postoperative radiotherapy

NCT	Title	Study type
NCT02977169	To Evaluate the Role of Postoperative Radiotherapy in Patients With IIIA(N2) Non-Small Cell Lung Cancer	Interventional
NCT02974426	To Evaluate the Optimal Timing of Postoperative Radiotherapy in Patients With IIIA(N2) Non-Small Cell Lung Cancer	Interventional
NCT04073745	Single Fraction Stereotactic Body Radiation Therapy After Surgery in Treating Patients with Non-small Cell Lung Cancer	Interventional
NCT03006575	Study of Split-course Chemoradiotherapy for Postoperative Locoregional Recurrence of Non-small Cell Lung Cancer	Interventional
NCT02555592	Strategy of Surgical Resection with Adjuvant Therapy for IIIA NSCLC and N2 Disease Only in Subaortic or Paraaortic Level	Observational
NCT02189967	Postoperative Radiotherapy of Non-small Cell Lung Cancer: Accelerated vs Conventional Fractionation	Interventional
NCT00880971	Postoperative Radiotherapy for Patients with IIIA (N2) Non-small Cell Lung Cancer	Interventional
NCT01112631	Prospective Study of Quality of Life in Non-small Cell Lung Cancer (NSCLC) Patients Treated With/Without Postoperative Radiotherapy	Observational