Vol 26, No 6 (2021)
Research paper
Published online: 2021-08-13

open access

Page views 6025
Article views/downloads 335
Get Citation

Connect on Social Media

Connect on Social Media

Target volume definition for staple line recurrences of non-small cell lung cancer

Jan Nuzhat1, Nitai D. Mukhopadhyay1, Elisabeth Weiss2
Rep Pract Oncol Radiother 2021;26(6):861-868.


Background: Staple line (SL) recurrences of non-small cell lung cancer (NSCLC) are commonly treated with radiotherapy (RT), but the target volume definition — whole SL versus focused on recurrence — is unclear.

The aim of the study was to determine the appropriate target volume for RT of SL recurrences.

Materials and methods: Twenty-two consecutive patients (20 stage I, 2 stage II) treated with salvage RT for SL recurrences were retrospectively analyzed. Imaging features at the time of SL recurrence were evaluated to guide target volume definition.


Surgery: All patients had complete tumor resection (wedge resection in 10 (45%) and lobectomy in 12 (55%) patients). 14 (64%) patients had risk factors for recurrence, including surgical margins ≤ 2 cm, angiolymphatic and visceral pleural invasion. 

Salvage RT: After a median 26 months (9–67), all 22 patients developed SL recurrence which was metabolically active on PET in all and biopsy-confirmed in 18/22 (82%) patients. All patients underwent RT targeting the location of the SL recurrence only. 13/22 (59%) patients had additional PET-negative nodular or linear SL changes that were not included in the irradiated volume.

Recurrence after RT: After a median 17 months (9–34) 10/22 (45%) patients recurred either regionally 6/10 (60%), in the lungs 4/10 (40%) or distally 3/10 (30%). No patient recurred at the SL. Two-year overall and disease-free survival rates after RT were 71% and 65%, respectively. 

Conclusion: RT to SL recurrences alone results in excellent local control. Additional treatment to reduce regional and distant recurrences should be considered. 

Article available in PDF format

View PDF Download PDF file


  1. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 Suppl): e278S–e313S.
  2. Billè A, Ahmad U, Woo KM, et al. Detection of Recurrence Patterns After Wedge Resection for Early Stage Lung Cancer: Rationale for Radiologic Follow-Up. Ann Thorac Surg. 2016; 102(4): 1067–1073.
  3. Fedor D, Johnson WR, Singhal S. Local recurrence following lung cancer surgery: incidence, risk factors, and outcomes. Surg Oncol. 2013; 22(3): 156–161.
  4. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995; 60(3): 615–22; discussion 622.
  5. Sittenfeld SMC, Juloori A, Reddy CA, et al. Salvage Stereotactic Body Radiation Therapy for Isolated Local Recurrence After Primary Surgical Resection of Non-small-cell Lung Cancer. Clin Lung Cancer. 2021; 22(3): e360–e365.
  6. Su S, Scott WJ, Allen MS, et al. Patterns of survival and recurrence after surgical treatment of early stage non-small cell lung carcinoma in the ACOSOG Z0030 (ALLIANCE) trial. J Thorac Cardiovasc Surg. 2014; 147(2): 747–52: Discussion 752.
  7. Varlotto JM, Yao AN, DeCamp MM, et al. Nodal stage of surgically resected non-small cell lung cancer and its effect on recurrence patterns and overall survival. Int J Radiat Oncol Biol Phys. 2015; 91(4): 765–773.
  8. Kelsey CR, Marks LB, Hollis D, et al. Local recurrence after surgery for early stage lung cancer: an 11-year experience with 975 patients. Cancer. 2009; 115(22): 5218–5227.
  9. Razi SS, Daskalaki D, Burack J. Current trends in lung resection for T1a non-small cell lung cancer: is lobectomy still the answer? J Thorac Dis. 2017; 9(2): E164–E165.
  10. Saynak M, Veeramachaneni NK, Hubbs JL, et al. Local failure after complete resection of N0-1 non-small cell lung cancer. Lung Cancer. 2011; 71(2): 156–165.
  11. Taylor MD, Nagji AS, Bhamidipati CM, et al. Tumor recurrence after complete resection for non-small cell lung cancer. Ann Thorac Surg. 2012; 93(6): 1813–20; discussion 1820.
  12. Hung JJ, Yeh YC, Hsu WH, et al. Prognostic Factors of Survival after Recurrence in Patients with Resected Lung Adenocarcinoma. J Thorac Oncol. 2015; 10(9): 1328–1336.
  13. Kelsey CR, Clough RW, Marks LB. Local recurrence following initial resection of NSCLC: salvage is possible with radiation therapy. Cancer J. 2006; 12(4): 283–288.
  14. Aoki S, Yamashita H, Takahashi W, et al. Salvage stereotactic body radiotherapy for post-operative oligo-recurrence of non-small cell lung cancer: A single-institution analysis of 59 patients. Oncol Lett. 2020; 19(4): 2695–2704.
  15. Sun B, Brooks ED, Komaki R, et al. Long-Term Outcomes of Salvage Stereotactic Ablative Radiotherapy for Isolated Lung Recurrence of Non-Small Cell Lung Cancer: A Phase II Clinical Trial. J Thorac Oncol. 2017; 12(6): 983–992.
  16. Agolli L, Valeriani M, Carnevale A, et al. Role of salvage stereotactic body radiation therapy in post-surgical loco-regional recurrence in a selected population of non-small cell lung cancer patients. Anticancer Res. 2015; 35(3): 1783–9.
  17. Emami B, Graham MV, Deedy M, et al. Radiation therapy for intrathoracic recurrence of non-small cell lung cancer. Am J Clin Oncol. 1997; 20(1): 46–50.
  18. Jeremic B, Shibamoto Y, Milicic B, et al. External beam radiation therapy alone for loco-regional recurrence of non-small-cell lung cancer after complete resection. Lung Cancer. 1999; 23(2): 135–142.
  19. Sun B, Kamel MK, Nasar A, et al. Staple Line Thickening After Sublobar Resection: Reaction or Recurrence? Ann Thorac Surg. 2020; 109(6): 1670–1676.
  20. Milano MT, Kong FMS, Movsas B. Stereotactic body radiotherapy as salvage treatment for recurrence of non-small cell lung cancer after prior surgery or radiotherapy. Transl Lung Cancer Res. 2019; 8(1): 78–87.
  21. Hou Y, Hermann G, Lewis JH, et al. Clinical Outcomes After Lung Stereotactic Body Radiation Therapy in Patients With or Without a Prior Lung Resection. Am J Clin Oncol. 2018; 41(7): 695–701.
  22. Timmerman R, Paulus R, Galvin J, et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA. 2010; 303(11): 1070–1076.
  23. Videtic GM, Paulus R, Singh AK, et al. Long-term follow-up on NRG Oncology RTOG 0915 (NCCTG N0927): a randomized phase 2 study comparing 2 stereotactic body radiation therapy schedules for medically inoperable patients with stage I peripheral non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2019; 103(5): 1077–1084.
  24. Zhao L, Zhou S, Balter P, et al. Planning Target Volume D95 and Mean Dose Should Be Considered for Optimal Local Control for Stereotactic Ablative Radiation Therapy. Int J Radiat Oncol Biol Phys. 2016; 95(4): 1226–1235.
  25. Takeda A, Sanuki N, Eriguchi T, et al. Salvage stereotactic ablative irradiation for isolated postsurgical local recurrence of lung cancer. Ann Thorac Surg. 2013; 96(5): 1776–1782.
  26. Xiong W, Xu Q, Xu Y, et al. Stereotactic body radiation therapy for post-pulmonary lobectomy isolated lung metastasis of thoracic tumor: survival and side effects. BMC Cancer. 2014; 14: 719.
  27. Giuliani ME, Hope A, Mangona V, et al. Predictors and Patterns of Regional Recurrence Following Lung SBRT: A Report From the Elekta Lung Research Group. Clin Lung Cancer. 2017; 18(2): 162–168.
  28. Videtic GMM, Hu C, Singh AK, et al. A Randomized Phase 2 Study Comparing 2 Stereotactic Body Radiation Therapy Schedules for Medically Inoperable Patients With Stage I Peripheral Non-Small Cell Lung Cancer: NRG Oncology RTOG 0915 (NCCTG N0927). Int J Radiat Oncol Biol Phys. 2015; 93(4): 757–764.
  29. Chaudhuri AA, Chabon JJ, Lovejoy AF, et al. Early Detection of Molecular Residual Disease in Localized Lung Cancer by Circulating Tumor DNA Profiling. Cancer Discov. 2017; 7(12): 1394–1403.

Reports of Practical Oncology and Radiotherapy