2022年 · 第102卷第15期

Patients with locally advanced non-small cell lung cancer are at high risk of recurrence after resection. Although platinum-based adjuvant chemotherapy has become standard treatment, the role of postoperative radiotherapy (PORT) has been controversial for many years. For patients with incomplete resection, despite the lack of randomized evidence, postoperative radiotherapy should be strongly recommended on a consensus basis. In patients with fully resected (R0) NSCLC, a meta-analysis showed a poorer prognosis for PORT in the absence of mediastinal involvement (pN0 and pN1). In pN2 patients, the role of PORT is unknown and needs further investigation. But this meta-analysis included trials with older radiological techniques and poorer surgical quality compared to today's standards, and patient selection was not based on positron emission tomography. Updated retrospective and non-randomized studies, as well as subgroup analyses of randomized trials evaluating adjuvant chemotherapy, suggest that PORT can provide survival benefits for PN2R0 patients. Two recent randomized trials (Lung ART and PORT-C) evaluated the advantage of conformal PORT versus non-PORT for disease-free survival in stage IIIA-N2 patients, although PORT significantly reduced mediastinal recurrence rates. PORT had no effect on survival, probably due to the high rate of distant recurrence and the additional risk of cardiopulmonary toxicity. Ongoing and future analyses are planned in Lung ART to identify patients for whom PORT can be recommended. In neoadjuvant and/or adjuvant therapy settings, new systemic therapies (immune checkpoint inhibitors or targeted therapies for oncogene-dependent patients) are being incorporated. In future studies, it is necessary to better identify patients at high risk of disease recurrence by analyzing circulating tumor cell DNA on the basis of detecting minimal (or molecular) residual disease after surgery.