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Suzuki S, Asakura K, Okui M, Izawa N, Sawafuji M, Sakamaki H, Shigenobu T, Tajima A, Oka N, Masai K, Kaseda K, Hishida T, Yasuda H, Fukunaga K, Asamura H. Prognostic factors affecting survival in patients with non-small cell lung cancer treated with salvage surgery after drug therapy: a multi-institutional retrospective study. World J Surg Oncol 2023; 21:290. [PMID: 37715273 PMCID: PMC10503184 DOI: 10.1186/s12957-023-03177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/09/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The prevalence of salvage surgeries after drug therapy for non-small cell lung cancer (NSCLC) has risen, mainly due to recent progress in molecular-targeted drugs and immune checkpoint inhibitors for NSCLC. While the safety and effectiveness of salvage surgery after drug therapy for NSCLC have been studied, its indications remain unclear. We aimed to identify the prognostic factors affecting survival in patients with advanced-stage (stages III-IV) NSCLC treated with salvage surgery after drug therapy. METHODS A retrospective investigation was conducted on patients who received salvage surgery after drug therapy at four hospitals between 2007 and 2020. Salvage surgery was defined as surgery after drug therapy for local progression, tumor conversion to resectable status, and discontinuation of prior drug therapy owing to serious complications. RESULTS Thirty-two patients received cytotoxic agents alone (n = 12 [38%]), tyrosine kinase inhibitors (TKIs; n = 16 [50%]), or immune checkpoint inhibitors (n = 4 [13%]) as prior drug therapy. In 11 (34%) and 21 (66%) patients, the clinical stage before treatment was III or IV, respectively. The median initial and preoperative serum carcinoembryonic antigen (CEA) levels were 10.2 (range, 0.5-1024) ng/mL and 4.2 (range, 0.6-92.5) ng/mL, respectively. Among the patients, 28 (88%) underwent lobectomy, 2 (6%) underwent segmentectomy, and 2 (6%) underwent wedge resection. Complete resection of the primary lesion was accomplished in 28 (88%) patients. Postoperative complications were documented in six (19%) patients. Mortality rates were 0% at 30 days and 3% at 90 days post-operation. The 5-year overall survival rate stood at 66%, while the 5-year progression-free survival rate was 21%. Multivariate analyses showed that prior TKI therapy and preoperative serum CEA level < 5 ng/mL were prognostic factors influencing overall survival (hazard ratio [95% confidence interval]: 0.06 [0.006-0.68] and 0.03 [0.002-0.41], respectively). The 5-year overall survival in the 11 patients with both favorable prognosticators was 100%. CONCLUSIONS In this study, prior TKI therapy and preoperative serum CEA level < 5 ng/mL were favorable prognostic factors for overall survival in patients with NSCLC treated with salvage surgery. Patients with these prognostic factors are considered good candidates for salvage surgery after drug therapy.
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Affiliation(s)
- Shigeki Suzuki
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
- Department of General Thoracic Surgery, Sagamihara Kyodo Hospital, Sagamihara, Kanagawa, Japan
| | - Keisuke Asakura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan.
| | - Masayuki Okui
- Department of General Thoracic Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan
| | - Naoko Izawa
- Department of General Thoracic Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan
| | - Makoto Sawafuji
- Department of General Thoracic Surgery, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan
| | - Hiroyuki Sakamaki
- Department of General Thoracic Surgery, Sagamihara Kyodo Hospital, Sagamihara, Kanagawa, Japan
| | - Takao Shigenobu
- Department of General Thoracic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Atsushi Tajima
- Department of General Thoracic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Naoyuki Oka
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Kyohei Masai
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Kaoru Kaseda
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Tomoyuki Hishida
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
| | - Hiroyuki Yasuda
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Shinanomachi, Shinjyuku-ku, Tokyo, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Shinanomachi, Shinjyuku-ku, Tokyo, Japan
| | - Hisao Asamura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjyuku-ku, Tokyo, 160-8582, Japan
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Ren J, Ren J, Wang K, Tan Q. The consideration of surgery on primary lesion of advanced non-small cell lung cancer. BMC Pulm Med 2023; 23:118. [PMID: 37060050 PMCID: PMC10103432 DOI: 10.1186/s12890-023-02411-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/31/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Numerous reports have shown that medical treatment confers excellent survival benefits to patients with advanced stage IV non-small cell lung cancer (NSCLC). However, the implications of surgery for primary lesions as palliative treatment remain inconclusive. METHODS We retrospectively extracted clinical data from the Surveillance, Epidemiology, and End Results Program (SEER) database and selected patients with stage IV NSCLC. Patients were classified into non-surgery and surgery groups, and propensity score matching (PSM) analysis was performed to balance the baseline information. Patients in the surgery group, whose overall survival (OS) was longer than the median survival time of those in the non-surgery group, were deemed to benefit from surgery. We evaluated the efficacy of three surgical techniques, namely, local destruction, sub-lobectomy, and lobectomy, on the primary site in the beneficial population. RESULTS The results of Cox regression analyses revealed that surgery was an independent risk factor for both OS (hazard ratio [HR]: 0.441; confidence interval [CI]: 0.426-0.456; P < 0.001) and cancer-specific survival (CSS) (HR: 0397; CI: 0.380-0.414; P < 0.001). Notably, patients who underwent surgery had a better prognosis than those who did not (OS: P < 0.001; CSS: P < 0.001). Moreover, local destruction and sub-lobectomy significantly compromised survival compared to lobectomy in the beneficial group (P < 0.001). After PSM, patients with stage IV disease who underwent lobectomy needed routine mediastinal lymph node clearing (OS: P = 0.0038; CSS: P = 0.039). CONCLUSION Based on these findings, we recommend that patients with stage IV NSCLC undergo palliative surgery for the primary site and that lobectomy plus lymph node resection should be conventionally performed on those who can tolerate the surgery.
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Affiliation(s)
- Jianghao Ren
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, 241 Huaihai Rd, Shanghai, 200030, China
| | - Jiangbin Ren
- Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Kan Wang
- The 4Th Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qiang Tan
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, 241 Huaihai Rd, Shanghai, 200030, China.
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Hino H, Utsumi T, Maru N, Matsui H, Taniguchi Y, Saito T, Tsuta K, Murakawa T. Results of emergency salvage lung resection after chemo- and/or radiotherapy among patients with lung cancer. Interact Cardiovasc Thorac Surg 2022; 35:ivac043. [PMID: 35253874 PMCID: PMC9714598 DOI: 10.1093/icvts/ivac043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVES This study aimed to elucidate the outcomes of emergency salvage surgery following life-threatening events (serious haemorrhage and/or infections) among patients with lung cancer who had undergone chemo- and/or radiotherapy. MATERIALS AND METHODS We analysed the data of patient from 2015 to 2020, retrospectively. The clinical characteristics, including preoperative treatment, perioperative outcomes and survival time, were analysed. RESULTS Of the 862 patients who underwent primary lung cancer surgeries, 10 (1.2%) underwent emergency surgeries. The preoperative clinical characteristics were: median age, 63.7 years [interquartile range (IQR) 55-70.5]; sex (male/female), 9/1; clinical staging before initial treatment (I/II/III/IV), 1/1/3/5; initial treatment (chemoradiotherapy/chemotherapy/proton beam therapy), 5/4/1; and indications for emergency surgery (lung abscess/lung abscess with haemoptysis/haemoptysis/empyema), 5/3/1/1. The selected procedures and results were as follows: lobectomy/bilobectomy/pneumonectomy, 8/1/1 (all open thoracotomies); median operation time, 191.0 min (IQR 151-279); median blood loss, 1071.5 ml (IQR 540-1691.5); postoperative severe complications, 3 (30%); hospital mortality, none; median postoperative hospital stay, 37 days (12-125); control of infection and/or haemoptysis, all the cases; final outcome (alive/dead), 3/7 (all the cancer deaths); median postoperative survival, 9.4 months (IQR 4.3-20.4); and median survival from initial treatment, 19.4 months (IQR 8.0-66.9). CONCLUSIONS Emergency salvage lung resection is a technically challenging procedure; however, the results were feasible and acceptable when the surgical indication, procedure and optimal timing were considered carefully by a multidisciplinary team. Although the aim was palliation, some patients who received additional chemotherapy afterwards and, thus, had additional survival time.
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Affiliation(s)
- Haruaki Hino
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
| | - Takahiro Utsumi
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
| | - Natsumi Maru
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
| | - Hiroshi Matsui
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
| | - Yohei Taniguchi
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
| | - Tomohito Saito
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
| | - Koji Tsuta
- Department of Pathology, Kansai Medical University, Osaka, Japan
| | - Tomohiro Murakawa
- Department of Thoracic Surgery, Kansai Medical University, Osaka, Japan
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Safety and efficacy of salvage surgery for non-small cell lung cancer: a retrospective study of 46 patients from four Keio-affiliated hospitals. Gan To Kagaku Ryoho 2022; 70:891-899. [PMID: 35344124 DOI: 10.1007/s11748-022-01808-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/12/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Advances in drug therapy and radiotherapy for non-small cell lung cancer resulted in an increased number of salvage surgeries for initially unresectable tumors. This study aimed to evaluate the safety and efficacy of salvage surgery for non-small cell lung cancer. METHODS We defined salvage surgery as (1) surgery for local recurrence/residual tumor after definitive chemoradiotherapy/radiotherapy (salvage surgery in a narrow sense) or (2) conversion surgery after non-surgical treatment. We retrospectively analyzed patients who underwent salvage surgery at four Keio University-affiliated hospitals. RESULTS Forty-six patients were included. The initial clinical stage was I in 4 patients (9%), III in 19 (41%), and IV in 23 (48%). Initial treatment before salvage surgery was chemoradiotherapy in 10 patients (24%), radiotherapy in 4 (9%), and drug therapy in 32 (67%). Pneumonectomy, lobectomy, segmentectomy, and wedge resection were performed in 2 (4%), 37 (80%), 3 (7%), and 4 (9%) patients, respectively. Complete resection was achieved in 41 patients (89%). Postoperative complications occurred in 11 patients (24%). Initial chemoradiotherapy/radiotherapy was an independent predictor of postoperative complications (odds ratio 10, p = 0.03). The 30- and 90-day mortality rates were 0 and 2%, respectively. The 5-year overall and progression-free survival rates were 66 and 30%, respectively. CONCLUSION The safety and efficacy of salvage surgery for non-small cell lung cancer were acceptable. Salvage surgery was a viable treatment option for selected patients with recurrent/residual tumors after non-surgical treatments.
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Patient Selection for Local Aggressive Treatment in Oligometastatic Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13246374. [PMID: 34944994 PMCID: PMC8699700 DOI: 10.3390/cancers13246374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Since the first introduction of the oligometastatic state with a low burden of metastases in non-small cell lung cancer, accumulating evidence from retrospective and prospective studies has shown that a local aggressive, multimodality treatment may significantly improve the prognosis in these patients. Local aggressive treatment includes a systemic therapy of micrometastatic disease, as well as a radical resection of the primary tumor and surgical resection and/or radiation therapy of distant metastases. However, patient selection and treatment allocation remain a central challenge in oligometastatic disease. In this review, we aimed to address the current evidence on criteria for patient selection for local aggressive treatment in non-small cell lung cancer. Abstract One-fourth of all patients with metastatic non-small cell lung cancer presents with a limited number of metastases and relatively low systemic tumor burden. This oligometastatic state with limited systemic tumor burden may be associated with remarkably improved overall and progression-free survival if both primary tumor and metastases are treated radically combined with systemic therapy. This local aggressive therapy (LAT) requires a multidisciplinary approach including medical oncologists, radiation therapists, and thoracic surgeons. A surgical resection of the often advanced primary tumor should be part of the radical treatment whenever feasible. However, patient selection, timing, and a correct treatment allocation for LAT appear to be essential. In this review, we aimed to summarize and discuss the current evidence on patient selection criteria such as characteristics of the primary tumor and metastases, response to neoadjuvant or first-line treatment, molecular characteristics, mediastinal lymph node involvement, and other factors for LAT in oligometastatic NSCLC.
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Hino H, Nakahama K, Ogata M, Kibata K, Miyasaka C, Utsumi T, Maru N, Matsui H, Taniguchi Y, Saito T, Tsuta K, Murakawa T. Emergent salvage surgery for massive hemoptysis after proton beam therapy for lung cancer: a case report. Surg Case Rep 2021; 7:98. [PMID: 33877476 PMCID: PMC8058119 DOI: 10.1186/s40792-021-01177-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022] Open
Abstract
Background Salvage surgery is an effective therapeutic option for patients experiencing relapses after chemoradiotherapy for advanced-stage lung cancer or after high-dose radiotherapy for early-stage lung cancer. We report a case involving an emergent salvage surgery for a patient with massive hemoptysis who developed lung cancer recurrence after undergoing proton beam therapy 7 years prior to presentation. Case presentation A 70-year-old male patient was emergently admitted due to massive hemoptysis. He had undergone proton beam therapy for a stage I adenocarcinoma of the left upper lobe 7 years ago, and was receiving chemotherapy for local recurrence. We performed an emergent salvage pulmonary resection to achieve hemostasis. During the operation, we confirmed the presence of a left broncho-pulmonary arterial fistula, which was considered as the origin of the massive hemoptysis. We repaired the fistula between the pulmonary artery and left upper bronchus without incident; an orifice of the fistula at the left pulmonary artery was sutured using a non-absorbable monofilament, and the central portion of the orifice of the fistula at the left upper bronchus was closed with a mechanical stapling device. The postoperative diagnosis was of an adenocarcinoma—ypT3(pm1) N0M1a (dissemination)-IVA, ef1b. The patient has survived for over a year with the cancer in almost complete remission following the administration of an epidermal growth factor receptor tyrosine kinase inhibitor. Conclusions Emergent salvage surgery demands high skill levels with optimal timing and correct patient selection. Our case suggested that the procedure played an important role in controlling serious bleeding and/or infectious conditions. Consequently, he could receive chemotherapy again and survive for over a year. Supplementary Information The online version contains supplementary material available at 10.1186/s40792-021-01177-9.
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Affiliation(s)
- Haruaki Hino
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan.
| | - Kahori Nakahama
- First Department of Internal Medicine, Division of Thoracic Oncology, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Makoto Ogata
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Kayoko Kibata
- First Department of Internal Medicine, Division of Thoracic Oncology, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Chika Miyasaka
- Department of Pathology and Laboratory Medicine, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Takahiro Utsumi
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Natsumi Maru
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Hiroshi Matsui
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Yohei Taniguchi
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Tomohito Saito
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Koji Tsuta
- First Department of Internal Medicine, Division of Respiratory Medicine, Infectious Disease and Allergology, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
| | - Tomohiro Murakawa
- Department of Thoracic Surgery, Kansai Medical University, 2-3-1 Shinmachi Hirakata-shi, Osaka, 573-1191, Japan
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Role of Surgical Intervention in Unresectable Non-Small Cell Lung Cancer. J Clin Med 2020; 9:jcm9123881. [PMID: 33260352 PMCID: PMC7760873 DOI: 10.3390/jcm9123881] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 12/25/2022] Open
Abstract
With the development of systemic treatments with high response rates, including tyrosine kinase inhibitors and immune checkpoint inhibitors, some patients with unresectable lung cancer now have a chance to undergo radical resection after primary treatment. Although there is no general consensus regarding the definition of “unresectable” in lung cancer, the term “resectable” refers to technically resectable and indicates that resection can provide a favorable prognosis to some extent. Unresectable lung cancer is typically represented by stage III and IV disease. Stage III lung cancer is a heterogeneous disease, and in some patients with technically resectable non-small cell lung cancer (NSCLC), multimodality treatments, including induction chemoradiotherapy followed by surgery, are the treatments of choice. The representative surgical intervention for unresectable stage III/IV NSCLC is salvage surgery, which refers to surgical treatment for local residual/recurrent lesions after definitive non-surgical treatment. Surgical intervention is also used for an oligometastatic stage IV NSCLC. In this review, we highlight the role of surgical intervention in patients with unresectable NSCLC, for whom an initial complete resection is technically difficult. We further describe the history of and new findings on salvage surgery for unresectable NSCLC and surgery for oligometastatic NSCLC.
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