Pneumonectomy for Lung Cancer After Preoperative Concurrent Chemotherapy and High-Dose Radiation

Prophylactic Bronchial Stump Support With Intrathoracic Muscle Flap Transposition

BACKGROUND

Bronchopleural fistula (BPF) is a dreaded complication of pulmonary resection. For high-risk patients, bronchial stump coverage with vascularized tissue has been recommended. The goal of this study was to report our experience with intrathoracic muscle transposition for bronchial stump coverage.

METHODS

A retrospective review of all patients who underwent intrathoracic muscle flap transposition as a prophylactic measure at our institution between 1990 and 2010 was conducted. Demographics, surgical characteristics, and complication rates were abstracted and analyzed.

RESULTS

A total of 160 patients were identified. The most common lung resections performed were pneumonectomy (n = 69, 43%) and lobectomy (n = 60, 38%). A total of 168 flaps were used where serratus anterior was the most common flap (n = 136, 81%), followed by intercostal (n = 14, 8%), and latissimus dorsi (n = 12, 7%). Ten patients (6%) developed BPF, and empyema occurred in 13 patients (8%). Median survival was 20 months, and operative mortality occurred in 7 patients (4%).

CONCLUSIONS

Reinforcement of the bronchial closure with vascularized muscle is a viable option for potentially decreasing the incidence of BPF in high-risk patients. Further randomized studies are needed to determine the efficacy of this technique for BPF prevention.

Resection following concurrent chemotherapy and high-dose radiation for stage IIIA non-small cell lung cancer

OBJECTIVE

Concern exists regarding surgery after thoracic radiation. We aimed to assess early results of anatomic resection following induction therapy with platinum-based chemotherapy and full-dose thoracic radiation for resectable N2+ stage IIIA non-small cell lung cancer.

METHODS

Two prospective trials were recently conducted by NRG Oncology in patients with resectable N2+ stage IIIA non-small cell lung cancer with the primary end point of mediastinal node sterilization following concurrent full-dose chemoradiotherapy (Radiation Therapy Oncology Group trials 0229 and 0839). All surgeons demonstrated postinduction resection expertise. Induction consisted of weekly carboplatin (area under the curve, 2.0) and paclitaxel (50 mg/m2) and concurrent thoracic radiation 60 Gy (0839)/61.2 Gy (0229) in 30 fractions. Patients in study 0839 were randomized 2:1 to weekly panitumumab + chemoradiotherapy or chemoradiotherapy alone during induction. Primary results were similar in all treatment arms and reported previously. Short-term surgical outcomes are reported here.

RESULTS

One hundred twenty-six patients enrolled; 93 (74%) had anatomic resection, 77 underwent lobectomy, and 16 underwent extended resection. Microscopically margin-negative resections occurred in 85 (91%). Fourteen (15%) resections were attempted minimally invasively, including 2 converted without event. Grade 3 or 4 surgical adverse events were reported in 26 (28%), 30-day mortality in 4 (4%) and 90-day mortality in 5 (5%). Patients undergoing extended resection experienced similar rates of grade 3 or 4 adverse events (odds ratio, 0.95; 95% confidence interval, 0.42-3.8) but higher 30-day (1.3% vs 18.8%) (odds ratio, 17.54; 95% confidence interval, 1.75-181.8) and 90-day mortality (2.6% vs 18.8%) (odds ratio, 8.65; 95% confidence interval, 1.3-56.9).

CONCLUSIONS

Lobectomy was performed safely following full-dose concurrent chemoradiotherapy in these multi-institutional prospective trials; however, increased mortality was noted with extended resections.

The analysis of prognosis factor in patients with non-small cell lung cancer receiving pneumonectomy

Background

Pneumonectomy is a procedure that possesses several side effects, but is sometimes necessary in the management of non-small cell lung cancer (NSCLC). The benefits of pneumonectomy have yet to be clearly outlined.

Methods

Data of 100 cases were extracted from the medical records of patients that underwent a pneumonectomy for NSCLC from January 2007 to December 2016. Primary outcomes were 5-year overall survival (OS) and 30-day mortality. Statistical comparisons were performed using the Chi-Square test. Kaplan-Meier curves were utilized to evaluate the 5-year OS which were compared using the log-rank test. Multivariable analysis of survival data was done using risk proportional model.

Results

The 5-year OS of NSCLC after pneumonectomy is 32.3%. Squamous cell carcinomas had a better prognosis than adenocarcinomas (P=0.039). Patients with higher N stage had a worse prognosis. Among patients undergoing pneumonectomy with N2 lymphatic metastasis, those who also underwent neoadjuvant therapy achieved a better 5-year OS (P=0.042). The 30-day mortality was 4.0%.

Conclusions

Pneumonectomy sometimes is inevitable and necessary in certain subtypes of NSCLC with acceptable perioperative mortality and long-term survival. For patients with NSCLC undergoing pneumonectomy, pathological diagnosis and nodal stage were independent predictors of OS. When pneumonectomy was done in patients with NSCLC and N2 lymphatic metastasis, a better long-term OS could be achieved amongst patients receiving neoadjuvant therapy compared to those without neoadjuvant therapy.

Bronchus Anastomosis Healing Depending on Type of Neoadjuvant Therapy

BACKGROUND

Preoperative radiotherapy and/or chemotherapy of lung cancer in patients with locally advanced disease is an option in multimodal treatment. Sleeve lobectomy has an important part in decreasing complications and sparing lung function. We present our experience in a large cohort of patients after sleeve lobectomy with or without neoadjuvant treatment and standardized assessment of bronchial anastomotic healing.

METHODS

The data used for this study were collected in a prospective database in our hospital. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day and thereafter only when necessary, using a standardized scoring system. From 2006 to 2017, we performed 501 sleeve lobectomies representing 19% of all lung cancer resections. A total of 365 of patients had no preoperative treatment (73%), 41 had neoadjuvant chemotherapy (8%), and 95 had radiochemotherapy (19%).

RESULTS

Using our scoring system of the bronchial anastomosis from 1 (excellent) to 5 (insufficient), we found the anastomosis was worse than grade 2 after no treatment, chemotherapy, or radiochemotherapy in 17%, 10%, and 30%, respectively (P = .002). The rate of anastomotic insufficiency was equally low after no pretreatment and chemotherapy (2.7% and 2.4%) and rose to 10.4% after radiotherapy (P = .002). Similarly, the risk for pulmonary complications was higher after radiochemotherapy (39%) compared with no pretreatment (29%) or chemotherapy (27%), respectively (P = .382).

CONCLUSIONS

Neoadjuvant radiotherapy is associated with worse wound healing of the anastomosis after sleeve lobectomy in lung cancer. There seems to be a higher risk for anastomotic insufficiency and complications.

Salvage surgery after definitive chemo-radiotherapy for patients with Non-Small Cell Lung Cancer

INTRODUCTION

Despite all treatment advances, lung cancer is still the main cause of death worldwide. Treatment for resectable stage IIIA remains controversial including definitive chemoradiotherapy and induction treatment followed by surgery. After definitive chemoradiation up to 35% of patients will relapse locally. Experience with salvage resection after definitive chemoradiotherapy in lung cancer is limited. We present our experience in 27 patients who underwent surgical resection after definitive treatment.

PATIENTS AND METHODS

Between January 2007 and December 2016, 27 patients were evaluated in our department for surgical resection after receiving definitive chemoradiation treatment in different institutions. We conducted a retrospective study gathering the following data: age, gender, clinical and pathologic stage, histology, chemotherapy treatment regimen, radiotherapy dosage, surgical procedure and complications. Time between surgical resection and last follow-up was used to calculate Overall Survival (OS). Disease-Free Survival (DFS) was calculated from surgical resection to diagnosis of relapse.

RESULTS

Most of the patients were men with a median age of 56.09 years. Median follow-up time was 46.94 months. All patients received platinum-based chemotherapy regimen and high-dose radiotherapy, except for one patient who received 45 Gy. Lobectomy and bilobectomy was performed in 7 patients each, and pneumonectomy in 13. Complications appeared in 5 patients. Bronchopleural fistula appeared in two patients, and only one death in the early postoperative period. The analysis showed an OS of 75.56 months, with 1-year, 3-year and 5-year survival of 74.1%, 57.8% and 53.3% respectively.

CONCLUSION

Salvage surgery in selected patients is technically feasible, with low morbidity and mortality rates and good long-term outcomes.

Salvage surgery for recurrent or persistent tumour after radical (chemo)radiotherapy for locally advanced non-small cell lung cancer: a systematic review

Background:

Once recurrent or persistent locoregional tumour after radical chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) is identified, few curative-intent treatment options are available. Selected patients might benefit from surgical salvage. We performed a systematic review of the available literature for this emerging treatment option.

Methods:

A systematic literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Publications about persistent or (locoregional) recurrent disease after radical/definitive CRT for locally advanced non-small cell lung cancer were identified.

Results:

Eight full papers were found, representing 158 patients. All were retrospective series and data were heterogeneous: definition and indication for salvage surgery varied and the median time from radiotherapy to surgery was 4.1–33 months. Complete resection (R0) was achieved in 85–100%, with vital tumour in 61–100%. A large number of pneumonectomies were performed, and additional structures were often resected. Where reported, 90-day mortality was 0–11.4%. Reported survival metrics varied but included median overall survival 9–46 months and 5-year survival 20–75%.

Conclusion:

There are limited, low-level, heterogeneous data in support of salvage surgery after radical CRT. Based on this, perioperative mortality appears acceptable and long-term survival is possible in (highly) selected patients. In suitable patients (fit, no distant metastases, tumour appears completely resectable and preferably with confirmed viable tumour), this treatment option should be discussed in an experienced multidisciplinary lung cancer team.

Pneumonectomy for Non-Small Cell Lung Cancer

Lung cancer is the leading cause of cancer deaths and its incidence continues to increase. Emerging therapies as part of a multimodal approach are making more patients eligible for surgical resection. As more surgeons are treating locally advanced non-small cell lung cancer they find themselves recommending pneumonectomy as the surgical component of the multidisciplinary plan. Performing a pneumonectomy is technically demanding and is associated with many potential perioperative comorbidities. With the proper preparation, experience, and attention to perioperative care, pneumonectomy can be carried out safely with excellent outcomes and a good quality of life.

Pneumonectomy is safe and effective for non-small cell lung cancer following induction therapy

BACKGROUND

Uncertainty surrounds the safety and efficacy of pneumonectomy in the setting of induction chemoradiation for non-small cell lung cancer (NSCLC). We sought to evaluate fifteen years of experience with pneumonectomy with and without induction therapy.

METHODS

Over a 15-year period [1999-2014], data were extracted from medical records of patients undergoing pneumonectomy for NSCLC. Primary outcomes were 5-year overall survival and mortality at 30, 60 and 90 days following operation. Morbidity data was also reviewed. Statistical comparisons were performed using the Chi-Square test. Kaplan-Meier curves were compared using the log rank test. Significance was defined as a P value less than 0.05. Patients with a prior cancer history, bilateral lung nodules and oligometastatic disease at presentation were excluded.

RESULTS

After exclusion criteria were applied, 240 patients were analyzed and 137 (57%) underwent induction therapy prior to pneumonectomy. Five-year overall survival was 38.5%. Mortality at 90 days was 7.94%. There was no statistically significant difference in perioperative mortality with the addition of induction therapy. In fact, in the subset of patients with N2 disease (n=65), induction therapy was associated with improved 5-year overall survival (10.7% vs. 32.7%, P=0.014). Thirty-five percent of patients with N2 disease exhibited a complete response in the nodal basin following induction therapy; however, this did not confer a statistically significant overall or disease-free survival benefit.

CONCLUSIONS

Pneumonectomy can safely be performed in the setting of induction chemoradiation. In patients with N2 disease, induction therapy may confer a survival benefit when the surgery can be done with limited morbidity and mortality.

Induction chemoradiotherapy using docetaxel and cisplatin with definitive-dose radiation followed by surgery for locally advanced non-small cell lung cancer

Background

Induction chemoradiotherapy (CRT) followed by surgery is a therapeutic option for locally advanced non-small cell lung cancer (LA-NSCLC). Typically, around 40-50 Gy of radiation is applied as the induction-dose; however, a definitive-dose (DD) of radiation (60 Gy or higher) is occasionally applied to increase local control. We investigated the impact of induction CRT with DD radiation in LA-NSCLC patients treated with a single regimen of docetaxel and cisplatin.

Methods

We reviewed 110 patients with LA-NSCLC who underwent induction CRT followed by surgery using a single regimen (docetaxel and cisplatin) between January 1999 and December 2014 at our hospital. The clinical outcomes of a DD group (60 Gy or higher, n=11) and a non-DD group (less than 60 Gy, n=99) were investigated using a propensity score (PS)-matched analysis.

Results

An advanced clinical stage was significantly more common in the DD group than in the non-DD group (P=0.033). Before and after the PS-matching based on seven factors including clinical stage, there was no significant difference in the rates of postoperative (PO) complication, mortality, 5-year overall survival (OS), or 5-year recurrence-free survival (RFS) between the two groups. After the PS-matching, the pathological complete response (CR) rate was significantly higher in the DD group than in the non-DD group [50% (n=5/10) vs. 0% (n=0/10), P=0.033].

Conclusions

Induction CRT followed by surgery using docetaxel and cisplatin with DD radiation can be performed safely and is associated with a higher pathological CR rate than that attained using non-DD radiation in LA-NSCLC patients.

Salvage Surgery After Definitive Chemoradiotherapy for Non-small Cell Lung Cancer

Following definitive chemoradiation therapy, 24%-35% of patients with locally advanced non-small cell lung cancer have recurrence. We aimed to evaluate the feasibility of salvage surgery after definitive chemoradiotherapy and perioperative morbidity and mortality rates to determine long-term survival. From June 2003 to June 2013, 35 patients were eligible for lung cancer resection owing to relapse after definitive chemoradiation therapy. All patients received cisplatin-based chemotherapy and definitive radiotherapy (mean Gy: 58) with curative intent and all underwent total body computed tomography scan and 18-fluoro-deoxyglucose positron emission tomography scan after the end of medical treatment and before surgery. Cyto-histologic confirmation was attempted in 20 (57%) patients. Six patients had exploratory thoracotomies. Twenty-nine patients underwent lung cancer resection: 11 lobectomies, 1 bilobectomy, and 17 pneumonectomies (7 right, 10 left). Complete resection was obtained in 27 of 35 (77%) patients. Thirteen (45%) patients underwent extended resection: intrapericardial pneumonectomy in 5 patients, vascular or bronchial sleeve resection in 2, atrial resection in 1, tracheal sleeve in 1, superior vena cava resection and reconstruction in 2 (1 with tracheal-sleeve resection), and chest wall resection in 2. Median time from chemoradiation therapy to resection was 7 months (range: 1-39). Viable tumor was found in 26 of 29 (89.6%) patients. Major complications occurred in 9 patients (25.7%). There were 2 (5.7%) perioperative deaths within 30 days. With a median follow-up of 13 months, postoperative 2- and 3-year survival rates after complete resection were 46% and 37%, respectively. Salvage lung resection after definitive chemoradiation therapy is feasible, with acceptable postoperative survival and complication rates.

Role of surgery in N2 NSCLC: pros

The optimal management of clinical N2 Stage IIIA non-small cell lung cancer is still controversial. For a cure of locally advanced IIIA/N2 non-small cell lung cancer, the control of both local regions and possible distant micrometastases is crucial. Chemotherapy is generally expected to prevent distant recurrence. For local tumor control, radiotherapy or surgery has been adopted singly or in combination. If a complete resection can be safely performed, surgery remains the strongest modality for 'eradicating' local disease. Many retrospective studies have reported a possible survival benefit of induction treatment followed by surgery in selected patients with IIIA/N2 non-small cell lung cancer; however, randomized Phase III trials have failed to demonstrate the superiority of induction treatment followed by surgery over chemoradiotherapy, mainly because of the heterogeneity of the N2 status. IIIA/N2 non-small cell lung cancer consists of a heterogeneous group of disease ranging from microscopically single station to radiologically bulky ipsilateral multi-station mediastinal lymph node involvement. A recent definition proposed by the American College of Chest Physicians classified non-small cell lung cancer based on the N2 status, such as discrete or infiltrative type, and recommendations were made according to this N2 status, with definitive chemoradiotherapy recommended for infiltrative clinical N2 and definitive chemoradiotherapy or induction treatment followed by surgery recommended for other cases. Thus, the introduction of a multimodality treatment strategy seems to be necessary for the improved prognosis of non-small cell lung cancer patients with IIIA/N2 disease. In this review, we discuss the role of surgery and the optimal surgical management for patients with IIIA/N2 non-small cell lung cancer.

Feasibility and efficacy of salvage lung resection after definitive chemoradiation therapy for Stage III non-small-cell lung cancer

OBJECTIVES

For highly selected patients with Stage III non-small-cell lung cancer (NSCLC) who relapse or have residual disease after definitive chemoradiotherapy, salvage lung resection is likely to be one of the options for local control and possible better prognosis. However, the long-term benefit has not been verified.

METHODS

We conducted a retrospective study on salvage surgery on a multicentre basis. Patients included in this study met the following criteria: (i) prior treatment of lung cancer with curative-intent radiotherapy (≥60 Gy); (ii) no a priori plans for induction multimodality therapy; (iii) confirmation of loco-regional recurrence or persistent tumour in the irradiated area; (iv) pretherapeutic pathological results of NSCLC and (v) Stage III disease prior to chemoradiotherapy.

RESULTS

A total of 18 patients were eligible for evaluation (Stage IIIA/IIIB, 14/4). The prior median radiation therapy dose was 60 Gy (60-74 Gy), and the median time between the last day of radiotherapy and resection was 38 weeks. The indications for surgery were primary tumour regrowth (10 patients) or tumour persistence (8 patients). Surgical procedures included lobectomy in 13 patients and pneumonectomy in 5 patients. Postoperative complications occurred in 5 patients (28%) without perioperative death. Complete resection was shown in 16 patients (89%) and a complete pathological response in 5 patients (28%). The median follow-up time was 1405 days, and the 3-year overall survival and recurrence-free survival rates were 78 and 72%, respectively.

CONCLUSIONS

In the highly selected Stage III NSCLC after curative-intent chemoradiation therapy, salvage surgery was safely performed and contributed to satisfactory long-term survival.

Pneumonectomy for node-positive non-small cell lung cancer: can it be a treatment option for N2 disease?

OBJECTIVE

The feasibility of multimodality therapy in patients with node-positive non-small cell lung cancer (NSCLC) requiring pneumonectomy and the role of pneumonectomy in N2 disease remain controversial. This study evaluated outcomes in patients with node-positive NSCLC undergoing pneumonectomy in a community hospital.

METHODS

Perioperative and long-term outcomes of 37 patients with node-positive (pN1-2) NSCLC undergoing pneumonectomy from September 1994 to April 2010 as a clinical practice were retrospectively analyzed.

RESULTS

Twenty patients received induction therapy, and 17 received preoperative chemoradiation (30-40 Gy). Fifteen patients and 22 patients underwent right and left pneumonectomy, respectively. A postoperative complication occurred in 8 patients. In-hospital mortality occurred in 1 patient. Induction therapy did not increase the operative risk including operative time, blood loss and postoperative complications. Nineteen patients were given a diagnosis of pN2. Although 7 bulky N2 patients and 10 multi-station N2 patients were included, 5-year overall survival was 34.3 % in pN1 and 28.0 % in pN2 (p = 0.998), respectively. Twenty-three patients received additional postoperative therapy. Five patients died within 3 months postoperatively due to distant metastases. Induction therapy and laterality did not influence survival. Extended resection, such as vagus nerve or chest wall resection, predicted an unfavorable outcome in multivariate analysis (Hazard ratio 2.81, p = 0.032).

CONCLUSIONS

The safety and acceptable long-term outcome of pneumonectomy as a general clinical practice were shown for both pN1 and pN2 patients with various preoperative or postoperative therapies. Extended resection due to the extrapleural or extranodal involvement of tumor was an unfavorable prognostic factor.

Long-term survival after pneumonectomy for non-small-cell lung cancer

OBJECTIVE

to investigate long-term survival in patients who underwent pneumonectomy for non-small-cell lung cancer at the University of Kentucky Medical Center.

METHODS

we retrospectively reviewed 100 consecutive pneumonectomy cases from 1998 to 2009 at the University of Kentucky. We were able to obtain follow-up data on 99 of 100 patients.

RESULTS

overall 1-, 2-, and 5-year survival was 66%, 48%, and 32%, respectively. The 1-, 2-, and 5- survival for left pneumonectomy was 76%, 55%, and 40%, respectively, compared to 56%, 44%, and 22%, respectively, for right pneumonectomy. The median survival for left pneumonectomy was 2.4 years compared to 1.2 years for right pneumonectomy (p = 0.056). The 5-year survival for patients diagnosed with stage I disease was 34%, compared to 19% for stage II disease, and 38% for stage III disease. The 5-year survival for patients who underwent neoadjuvant therapy was 31% compared to 39% for patients who received adjuvant therapy and 29% for patients who received surgery alone. These results were also not statistically significant.

CONCLUSION

neoadjuvant therapy did not adversely affect long-term survival in our study. When compared to left pneumonectomy, right pneumonectomy for non-small-cell lung cancer is associated with adverse postoperative outcomes as well as poorer long-term survival.

Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy

Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.

Pulmonary resections following prior definitive chemoradiation therapy are associated with acceptable survival

OBJECTIVES

The benefits of salvage resection for lung cancer recurrence following high-dose curative-intent chemoradiation therapy are unclear. We assessed survival after salvage lung resection following definitive chemoradiation.

METHODS

Medical records of patients undergoing lung cancer resections at our institution following definitive chemoradiation therapy were reviewed from June 2006 to August 2012. A multivariate Cox proportional model was used to assess the factors associated with improved survival.

RESULTS

Fourteen patients had chemoradiation therapy before lung resection (pneumonectomy, lobectomy or segmentectomy). Pretherapy cancer stage was Stage III in 11 patients, Stage IV in 2 and Stage II in 1. Postoperative 2-year survival was 49%. Patients had a median disease-free interval before resection of 33 months. No variables were found to be associated with improved post-chemoradiation survival from the time of definitive treatment or postoperative survival. Complications occurred in 6 (43%) patients, with 2 of those complications directly attributable to post-chemoradiation changes. There were no perioperative deaths within 90 days.

CONCLUSIONS

Salvage lung resection for recurrent lung cancer following definitive chemoradiation therapy is feasible and is associated with postoperative survival and complication rates that are reasonable.

[Chemo-radiotherapy before surgery in stage III non-small-cell lung cancer]

Surgery is often performed when N2 non-small-cell lung cancer can be resected by lobectomy since the publication of the "EORTC 08941" and "RTOG 9309" trials (the latter showed high mortality rate after pneumonectomy). The usefulness of adjuvant chemotherapy has been proved, and that of modern adjuvant radiotherapy is suspected, but neoadjuvant chemotherapy is also routinely performed in France. Neoadjuvant chemo-radiotherapy is more accepted in the USA and northern Europe. Four randomized trials have not shown any advantage in comparison with neoadjuvant chemotherapy, due to increased postoperative mortality, but retrospective studies in specialized centers have demonstrated low operative risks, even after high-dose radiation, or pneumonectomy. In the case of invasive apical tumors, neoadjuvant chemo-radiotherapy is recommended. In case of local recurrence without distant recurrence after exclusive chemo-radiotherapy, curative surgery may be envisaged.

Role of surgery following induction therapy for stage III non-small cell lung cancer

Over the last 30 years neoadjuvant treatment of stage IIIA non-small cell lung cancer (NSCLC) followed by surgical resection for stage IIIB disease has significantly improved the overall results of treatment for patients with stage III NSCLC as well as for those with locally invasive tumors. Different chemotherapy regimens have been used, although in most studies some combination of drugs that include cisplatin is the standard. Radiation when given as part of the induction protocol appears to offer a higher rate of resection and complete resection, and higher doses of radiation are associated with better nodal downstaging. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial.

The surgical management of stage I and stage II lung cancer

There have been recent advances in the treatment of non-small cell lung cancer (NSCLC). Surgical resection remains the cornerstone in the treatment of patients with stages I and II NSCLC. Anatomic lobectomy combined with hilar and mediastinal lymphadenectomy constitutes the oncologic basis of surgical resection. The surgical data favor video-assisted thoracic surgery (VATS) lobectomy over open lobectomy and have established VATS lobectomy as a gold standard in the surgical resection of early-stage NSCLC. However, the role of sublobar pulmonary resection, either anatomic segmentectomy or nonanatomic wedge resection, in patients with subcentimeter nodules may become important.

Impact of laterality on early and late survival after pneumonectomy

BACKGROUND

This study evaluated the effect of laterality on survival in patients who underwent pneumonectomy for lung cancer.

METHODS

We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent pneumonectomy for lung cancer from 1988 through 2006. Predictors of survival were determined by univariate and multivariable analysis.

RESULTS

A total of 9746 patients had pneumonectomies. Left pneumonectomies (56%) were more common than right; 67% of patients were men with mean age of 63 years (range, 12 to 92 years). Tumor pathology was squamous cell in 49% and adenocarcinoma in 34%. Stage distribution was stage I, 28%; stage II, 28%; stage IIIA, 19%; stage IIIB, 18%; and stage IV, 6%. Overall survival was 67% and 40%, respectively, at 1 and 3 years; with 63% and 39% for right vs 70% and 41% for left (p<0.001). Mortality at 1 and 3 months was 8% and 16% for right pneumonectomies and 4% and 9% for left (p<0.001). Multivariate predictors of worse survival were right pneumonectomy, age, stage, male sex, tumor size, grade, prior malignancy, not married, number of positive lymph nodes, and fewer lymph nodes evaluated (all p<0.05). The adjusted hazard ratio for right pneumonectomy was 1.12 (95% confidence interval, 1.07 to 1.18; p<0.00001). For 3-month survival, right pneumonectomy had an adjusted odds ratio of 2.01 (95% confidence interval, 1.77 to 2.29; p<0.001). Neoadjuvant radiotherapy did not affect 3-month survival (adjusted odds ratio, 0.88; 95% confidence interval, 0.1 to 7.03, p=0.9).

CONCLUSIONS

A right pneumonectomy is associated with approximately twice the perioperative mortality as a left pneumonectomy. However, neoadjuvant radiotherapy does not appear to add incremental risk, and long-term survival is not affected by laterality.

Role of surgery for stage IIIA-N2 non-small cell lung cancer

Perhaps no topic other than stage IIIA-N2 non-small-cell lung cancer management is as controversial among surgeons, radiologists and medical oncologists. Much of the debate relates to the choice between surgical resection and radiation as the local control modality. Although limited, available evidence from randomized controlled trails raised concerns about the role of surgical resection. However, there is no perfect study, and the results should not be over-interpreted. This mini review will scrutinize these trials, focusing on the study design, results and, most importantly, limitations, and will explore the possible role of surgery for stage IIIA-N2 non-small-cell lung cancer.

Pathologic response rates following definitive dose image-guided chemoradiotherapy and resection for locally advanced non-small cell lung cancer

INTRODUCTION

Treatment of technically operable, medically fit locoregionally advanced non-small cell lung cancer (NSCLC) patients is a controversial therapeutic challenge. Our group routinely uses a trimodality approach. Recent advances in radiotherapy allow for improved tumor targeting and daily patient positioning. We hypothesized that these technologies would improve pathologic response rates. We analyzed consecutively treated stage IIIA/IIIB NSCLC patients undergoing chemoradiotherapy before major lung resection, with particular attention paid to the impact of advanced technologies.

METHODS

Locoregionally advanced NSCLC patients (N2) staged in a multidisciplinary forum with mediastinoscopy were planned to receive platinum-based chemotherapy and 60Gy and major lung resection. Four-dimensional CT (4DCT) and image-guided radiotherapy (IGRT) were used as available. Survival endpoints were estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was performed using Cox proportional hazards models.

RESULTS

We identified 53 patients from 2/1999 to 2/2010. Median RT dose was 59Gy. 68% underwent lobectomy. Forty-three patients were downstaged pathologically (81%), 38 experienced mediastinal sterilization (72%), and 21 (40%) had complete pathologic response (pCR). 1 and 2 year OS were 85.5% and 61.6%. Superior OS and DFS were associated with nodal downstaging and mediastinal sterilization (pN0). Treatment with IGRT/4DCT in 10 patients resulted in high rates of nodal downstaging (100% vs 77%, p=0.0452), mediastinal sterilization (90% vs 67%, p=0.0769), and pCR (60% vs 35%, p=0.0728).

CONCLUSIONS

In selected patients, definitive dose CRT followed by major lung resection results in promising DFS and OS. The use of advanced radiotherapy techniques (4DCT and IGRT) appears to result in promising pathologic response rates.

Survival of patients with clinical stage IIIA non-small cell lung cancer after induction therapy: age, mediastinal downstaging, and extent of pulmonary resection as independent predictors

BACKGROUND

In clinical stage IIIA non-small cell lung cancer, the role of surgical resection, particularly pneumonectomy, after induction therapy remains controversial. Our objective was to determine factors predictive of survival after postinduction surgical resection.

METHODS

We retrospectively reviewed a prospectively collected database of 136 patients who underwent surgical resection after induction chemotherapy (n = 119) or chemoradiation (n = 17) from June 1990 to January 2010.

RESULTS

One hundred five lobectomies or bilobectomies and 31 pneumonectomies were performed. There was 1 perioperative death (pneumonectomy). Seventy-one patients had downstaging to N0 or N1 nodal status (52%). There were 2 complete pathologic responses. Median follow-up was 42 months (range, 0.69-136 months). Overall 5-year survival for entire cohort was 33% (36% lobectomy, 22% pneumonectomy, P = .001). Patients with pathologic downstaging to pN0 or pN1 had improved 5-year survival (45% vs 20%, P = .003). For patients with pN0 or pN1 disease, survival after lobectomy was better than after pneumonectomy (48% vs 27%, P = .011). In patients with residual N2 disease, there was no statistically significant survival difference between lobectomy and pneumonectomy (5-year survival, 21% vs 19%; P = .136). Multivariate analysis showed as independent predictors of survival age (hazard ratio, 1.05; P = .002), extent of resection (hazard ratio, 2.01; P = .026), and presence of residual pN2 (hazard ratio, 1.60; P = .047).

CONCLUSIONS

After induction therapy for patients with clinical stage IIIA disease, both pneumonectomy and lobectomy can be safely performed. Although survival after lobectomy is better, long-term survival can be accomplished after pneumonectomy for appropriately selected patients. Nodal downstaging is important determinant of survival, particularly after lobectomy.