Postoperative radiotherapy in non-small cell lung cancer stage IIIA-N2: Focus and perspectives

Patients with resectable stage IIIA - N2 lung cancer represent a very heterogeneous population with variable risks of postoperative recurrence depending on the type of N2 involvement (unisite N2, multisite N2, bulky N2, extra-capsular rupture, incomplete resection. . .). This heterogeneity associated with the difficulty of carrying out prospective randomized studies with sufficient power in stages IIIA - 2, results in the absence of clear and consensual recommendations (except for stages IIIA- N2 resectable R0, since LungART and PORT-C studies). The objective of this article is to make an update on the place of postoperative radiotherapy in the management of stages IIIA - N2 following the publication of two recent randomized trials (PORT-C and LungART) but also compare them fort a better understanding of the current issues raised by these first published results. Indeed, these two trials do not find any benefit in terms of progression free survival and overall survival of postoperative radiotherapy but exploratory analyzes from these two studies seem to show a potential benefit of postoperative in some pN2 populations at high risk of locoregional recurrence (N2 multisite, N2 bulky. . .). In addition, the advent of immunotherapy (atezolizumab or pembrolizumab) and targeted therapies (osimertinib) in the adjuvant situation are redebating the place of a possible indication for postoperative radiotherapy in stage IIIA - 2.

Automated summary

Patients with resectable stage IIIA - N2 lung cancer are a heterogeneous group, and the risks of postoperative recurrence vary depending on the type of N2 involvement. The lack of clear recommendations is due to the difficulty of conducting prospective randomized studies and the heterogeneity of the population. However, recent trials suggest a potential benefit of postoperative radiotherapy in certain high-risk pN2 subgroups. The emergence of immunotherapy and targeted therapies in the adjuvant setting also raises questions about the role of postoperative radiotherapy in stage IIIA - N2.