Higher Versus Standard Preoperative Radiation in the Trimodality Treatment of Stage IIIa Lung Cancer

The management of potentially resectable stage III non-small cell lung carcinoma (NSCLC) is controversial. Options include induction chemotherapy or induction chemoradiation followed by resection, or chemoradiation without surgery. No trial has compared the outcomes of induction chemoradiation using different radiation doses. We reviewed our experience involving patients with clinical stage III disease treated with trimodality therapy involving two radiation strategies to determine the response rates, operative results, recurrence patterns, and long-term survival.

A retrospective review was made of consecutive stage III NSCLC patients treated from 2004 to 2011.

Fifty-two patients with clinical stage IIIa NSCLC were treated with trimodality therapy. Eighteen patients were treated to doses of 60 Gy or higher, and 34 to lower doses (45, 50, or 54 Gy). There were significantly more postoperative complications in the higher radiation group (p < 0.001). Pathologic complete response (50% versus 15%, p = 0.016) and mediastinal nodal clearance (75% versus 42%, p = 0.254) rates were also higher in the high-dose group. That did not, however, translate into better disease-free and overall survival rates. Importantly, long-term noncancer mortality was significantly higher after higher dose preoperative radiation therapy.

In this series of patients with clinical stage IIIa NSCLC treated with trimodality therapy, a higher dose of preoperative radiation therapy resulted in better response rates but that did not translate to better cancer-specific survival. Of significance, we observed a notably higher delayed noncancer mortality in the high-dose group.