Post-operative radiation therapy in locally advanced non-small cell lung cancer and the impact of sequential versus concurrent chemotherapy

Lung cancer is the second most common cancer and the leading cause of death from cancer in the United States (1). Despite the adoption of lung cancer screening, most patients present with locally advanced or advanced disease which is associated with poor survival (1). In an attempt to improve survival multimodality therapy including surgery, chemotherapy, and/or radiation therapy is commonly utilized in locally advanced non-small cell lung cancer (NSCLC). For patients who are surgical candidates and have T1–3 disease (tumors ≤7 cm that do not invade the mediastinum, diaphragm, heart, great vessels, carina, trachea, esophagus, recurrent laryngeal nerve, or spine) and have only ipsilateral pulmonary or hilar nodes (N1) the optimal treatment is surgery followed by chemotherapy (2). However, patients found to have pathologically involved ipsilateral mediastinal lymph nodes (pN2) at the time of surgery, or have microscopically (R1) or grossly (R2) positive margins, have unacceptably high rates of local-regional recurrence at 40–60% (3). Although the optimal adjuvant treatment for these patients is uncertain, post-operative radiation therapy (PORT) with either concurrent or sequentially chemotherapy is typically recommended