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Chapter 115: Treatment of Non–Small-Cell Lung Cancer: Radiation Therapy

Tithi Biswas; Mitchell Machtay

Introduction

Lung cancer is the second most common malignancy in the United States, after prostate cancer among men and breast cancer among women, but the number one cause of cancer-related mortality in both genders. Non–small-cell lung cancer (NSCLC) accounts for 80% to 85% of all lung cancers.1 Most patients with NSCLC receive radiotherapy as part of their treatment, either as initial management or later in the course of their disease. This may include thoracic radiotherapy and/or irradiation of sites of metastatic disease.

Thoracic radiotherapy for NSCLC can be categorized as follows:

  • Neoadjuvant = preoperative

  • Adjuvant = postoperative

  • Definitive = cure without surgery as treatment goal; with or without chemotherapy

  • Palliative = directed at relief of thoracic symptoms

There is some overlap in these categories with respect to the goals of treatment. For example, most patients treated with definitive intent are not cured but do achieve palliation of thoracic symptoms. Similarly, a few patients originally considered to be technically unresectable may have a dramatic response to irradiation and/or chemotherapy, and the goal of treatment may then change from palliative to neoadjuvant or definitive intent.

The size of the primary lesion, stage, and total dose of radiation are important factors in determining the likelihood of achieving local control. A summary of radiotherapy for lung cancer is provided in Table 115-1.

Table 115-1Summary of Radiotherapy for Lung Cancer: Indications and Treatment
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Table 115-1Summary of Radiotherapy for Lung Cancer: Indications and Treatment
Type Indication(s) Dosea
Preoperative (with chemotherapy) Pancoast tumor; clinical N2 45–50 Gy
Postoperative N2 disease; T4 tumors; selected T3 and/or N1 disease; incomplete resection 50–66 Gy (depends on surgical pathology findings)
Definitive medically inoperable T1–2N0–1 not surgical candidate or refuses surgery 60–74 Gy (conventional fractionation) or 40–60 Gy (accelerated hypofractionation with stereotactic techniques)
Definitive unresectable (with chemotherapy) Selected stage III patients; performance status high 56–74 Gy
Palliative unresectable Other stage III and IV patients with local symptoms 20–50 Gy with accelerated hypofractionation (2.5–4 Gy fraction size)
Small cell (with chemotherapy) Limited stage with good performance status 45–55 Gy or in 1.5 Gy bid fractionation

a1.8–2 Gy once daily fractionation unless otherwise indicated.

The decision to utilize thoracic radiotherapy as part of the therapeutic regimen, and the treatment goals of such therapy, depend not only on tumor-related factors such as stage but also on patient-related factors such as pulmonary reserve and performance status. All these factors need to be considered when deciding whether to irradiate. Although radiotherapy might be appropriate for a patient with a postoperative forced expiratory volume (FEV1) of 2 L and pathologic stage T2N2M0 disease, the same treatment would be problematic in a patient with a postlobectomy FEV1 of 1.1 L who has had a series of postoperative complications. Of course, such clear-cut cases usually are ...

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