A 59 year-old woman who is a lifelong non-smoker presents with a 3.4 cm right middle lobe squamous cell carcinoma. PET scan and subsequent mediastinoscopy demonstrate involved ipsilateral N2 lymph nodes. MRI brain is negative. Pulmonary function tests are normal. The patient's case is presented at tumor board and the thoracic surgeon recommends pre-operative chemoradiation. What is the standard pre-operative radiation therapy dose?
Locally Advanced Non-Small Cell Lung Cancer
The standard pre-operative radiation dose is 45 Gy in 1.8 Gy per fraction (INT 0139 Albain et al. Lancet 2009). Some institutions are treating to a higher pre-operative dose (~60 Gy) with good outcomes (Shaikh et al. UChicago AJCO 2007. Seder et al. MDACC Ann Thorac Surg 2013). The potential advantage of this higher dose is increased sterilization pre-operatively. Practically, it also simplifies radiation treatment delivery as a definitive dose is administered prior to the patient being re-evaluated by the surgeon for resection. Should the surgeon or patient choose not to proceed, definitive treatment has already been delivered. However, the thoracic surgeon must be in agreement and comfortable with operating after 60 Gy of neoadjuvant radiotherapy.