Is brachytherapy effective for local recurrence control in sublobar resections for non-small-cell lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: in high-risk patients undergoing sublobar resection for non-small-cell lung cancer, is brachytherapy effective in reducing local recurrence? Altogether, 60 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three papers are prospective non-randomized studies, two are retrospective and one is a prospective randomized clinical trial. The first prospective non-randomized study included 14 patients treated with sublobar resection plus brachytherapy. No local recurrence was observed. In the second study, 33 patients underwent sublobar resection plus brachytherapy for non-small-cell lung cancer (NSCLC), of which 10 patients had recurrences. In the third study, 110 patients with Stage IA and IB NSCLC underwent sublobar resection and brachytherapy, of which 3 local recurrences and 1 combined local and regional recurrence were observed. Two retrospective studies were considered. The first study compared 102 patients undergoing sublobar resection with 101 patients undergoing surgery and brachytherapy. There were 19 recurrences in the surgical resection group (18.6%) and 2 recurrences in the adjuvant brachytherapy arm (2%). In the second study, 214 patients undergoing segmentectomy for Stage I NSCLC, were compared with 155 patients undergoing segmentectomy plus brachytherapy. Adding brachytherapy did not appear to have an effect on local recurrence in patients undergoing anatomical segmentectomy (4.6 vs 6.4%). In the prospective randomized trial, 108 patients with Stage I NSCLC were randomized to sublobar resection, and 104 to sublobar resection and brachytherapy. No statistical difference between the two groups was observed in terms of local recurrence. However, in the latter group, 14 patients had a positive staple line, and this group represented the strongest evidence that brachytherapy effectively reduced local recurrence. There may be a role for adjuvant brachytherapy in reducing the local recurrence when sublobar non-anatomical resections are performed and in cases where the surgical margins are compromised. Brachytherapy appears not to affect local control when an anatomical resection is performed with adequate margins.