The Role of Postoperative Radiation Therapy for pN2 Non–small-cell Lung Cancer

Nikhil P. Mankuzhy, Oakland University William Beaumont School of Medicine
Muayad F. Almahariq
Zaid A. Siddiqui
Andrew B. Thompson
Inga S. Grills
Thomas M. Guerrero
Kuei C. Lee
Craig W. Stevens
Thomas J. Quinn


© 2020 Elsevier Inc. Background: The role for postoperative radiation therapy (PORT) for patients with non–small-cell lung cancer (NSCLC) with mediastinal lymph node (LN) involvement (pN2 disease) is controversial. We compared surgery alone with PORT among patients with pN2 NSCLC. We then performed subset analyses to better delineate patients that might benefit from PORT. Patients and Methods: We conducted a propensity score (PS)-matched, inverse probability of treatment weighting (IPTW) Surveillance, Epidemiology, and End Results (SEER) analysis of patients with pN2 disease from 1989 to 2016 with surgery alone or PORT. Multiple imputation with chained equations was used for missing LN data. Results: A total of 8631 patients were included in this analysis; 4579 underwent surgery alone, and 4052 underwent PORT. Following PS matching and IPTW, there was no difference in overall survival (OS) (hazard ratio [HR], 0.99; P =.76). However, PORT improved OS among a subset of patients with a LN positive to sampled ratio ≥ 50% (HR, 0.90; P =.01). Moreover, there was a trend towards improved OS among this subset, even with chemotherapy (HR, 0.91; P =.09). Conclusion: PORT is not associated with an improvement or detriment in OS for all patients with pN2 NSCLC. However, patients with a positive to sampled LN ratio ≥ 50% may benefit, regardless of chemotherapy status. Nevertheless, PORT will remain the standard of care as we await the results of the ongoing LUNG ART trial.