Long-Term Survival after Salvage Surgery for Local Failure after Definitive Chemoradiation Therapy for Locally Advanced Non-small Cell Lung Cancer

Resection of Contralateral Scapular Oligometastasis in Non-small Cell Lung Cancer Post Right Salvage Pneumonectomy

A 74-year-old male was diagnosed with right hilar T4N1M0 squamous cell carcinoma of the lung. Radical oncological treatment was initiated with curative intent. Despite this, a post-operative computed tomography scan showed residual disease. Therefore, right thoracotomy and salvage pneumonectomy were performed. The patient recovered well post-operatively. Unfortunately, seven months later, he re-presented with a left scapula subcutaneous mass, with a biopsy confirming metastatic lung squamous cell carcinoma. Radiotherapy was not possible as it would have irradiated the remaining lung, and therefore, surgical resection and chest wall reconstruction were undertaken. The patient remains free of disease at 6 months follow-up. We present an interesting case of surgical management of oligometastatic lung cancer.

Advances in Surgical Techniques for Lung Cancer

Thoracic surgery for non-small cell lung cancer has evolved tremendously in the past two decades. Improvements have come on multiples fronts and include a transition to minimally invasive techniques, an incorporation of neoadjuvant treatment, and a greater utilization of sublobar resection. These advances have reduced the morbidity of thoracic surgery, while maintaining or improving long-term survival. This review highlights major advances in the surgical techniques of lung cancer and the keys to optimizing outcomes from a surgical perspective.

The oncologic efficacy of extended resections for lung cancer

Extended lung resections for T3-T4 non-small-cell lung cancer remain challenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.

Results of emergency salvage lung resection after chemo- and/or radiotherapy among patients with lung cancer

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.

Salvage Surgery Compared to Surgery After Induction Chemoradiation Therapy for Advanced Lung Cancer

BACKGROUND

Salvage surgery is performed for selected patients with relapses of locally advanced lung cancer after definitive chemoradiation therapy (CRT), and seems to be effective. To date, the feasibility of such salvage surgery, particularly anatomical pulmonary resection, has not been fully evaluated. To assess the feasibility of salvage surgery after definitive CRT, we compared clinical outcomes of surgery after definitive CRT to those of surgery after induction CRT.

METHODS

Medical records of patients who underwent surgery from January 2000 to January 2018 were reviewed. We compared patients with salvage anatomical pulmonary resection after definitive CRT to patients with surgery after induction CRT in terms of perioperative and long-term outcomes.

RESULTS

Twenty-three patients underwent salvage surgery after definitive CRT for locally advanced lung cancer (salvage group) and 36 underwent surgery after induction CRT for cN2-stage III non-small cell lung cancer (induction CRT group). The surgical procedures in the salvage group were 2 segmentectomies, 13 lobectomies, 1 bi-lobectomy and 7 pneumonectomies, and those in the induction CRT group were 34 lobectomies and 2 bi-lobectomies. There was no 30-day or 90-day mortality in either group. The 5-year overall survival was 44.7% for the salvage group and 58.6% for the induction CRT group. The 5-year progression-free interval was 42.2% for the salvage group and 47.7% for the induction CRT group.

CONCLUSIONS

Salvage anatomical pulmonary resection after definitive CRT for locally advanced lung cancer is feasible with acceptable morbidity and prognosis in highly selected patients.

CT-guided palladium-103 seed brachytherapy for metastatic adenoid cystic carcinoma: a retrospective study to assess initial safety and effectiveness of percutaneous CT fluoroscopy-guided permanent seed brachytherapy

Purpose

Multiple pulmonary metastases present treatment difficulties in available treatment techniques, which are inconvenient or may damage sufficient pulmonary tissue to cause pulmonary crippling. This retrospective study of a single-community practice evaluated responses to computed tomography (CT)-guided ¹⁰³Pd permanent seed brachytherapy (CTGPSB) in adenoid cystic carcinoma (ACC) synchronous pulmonary metastases. The purpose of the current study was to document that metastatic pulmonary ACC lesions can be controlled with CTGPSB.

Material and methods

Twenty-nine discrete lesions in 14 patients were evaluated with serial CT scans. All were treated with CTGPSB. Lesions were tracked over serial CT scans and volumes measured. Primary endpoint was a reduction in tumor volume on subsequent CT scan. Secondary endpoint was occurrence of CTCAE grades 2-5.

Results

There was a 100% measured reduction in tumor volume (n = 29) at follow-up. Follow-up was a mean of 3.13 years. Baseline tumor volume was a mean of 1.85 ml (range, 0.69-9.15 ml). There were two grade 1 and one grade 2 adverse events, which did not require hospitalization.

Conclusions

CTGPSB for the treatment of multiple ACC pulmonary metastases is effective, with minimal acute complications, as shown in small cohort of subjects of the present study. Further studies evaluating specific dosimetry parameters in this free-hand technique are needed to specify minimal and maximal dose constraints.

Outcomes of salvage lung resections in advanced EGFR-mutant lung adenocarcinomas under EGFR TKIs

Background

Studies regarding the outcomes of salvage lung resections of epidermal growth factor receptor (EGFR)‐mutant advanced lung adenocarcinomas (ALAs) following treatment with EGFR tyrosine kinase inhibitors (TKIs) are limited, hence the objective of this study was to investigate such outcomes.

Methods

A total of 29 patients with EGFR‐mutant ALA who underwent salvage surgery after EGFR‐TKI treatment from October 2013 through January 2019 were enrolled. The patients were divided into two groups according to the surgical indications. Their perioperative parameters and surgical outcomes, including progression‐free survival (PFS) and overall survival (OS), were then analyzed.

Results

The initial stages of the patients were stage IIIB (seven patients), IVA (17 patients), and IVB (five patients). Their surgical indications included residual tumor (25 patients) and progressive disease (PD) (four patients). They all underwent surgery via minimally invasive approaches and the median follow‐up was 33.9 months. Within that follow‐up duration, the median PFS after surgery was 36.4 months, and the median OS was still not reached. There were no significant differences in PFS or OS according to the different EGFR‐TKIs used, the different durations of EGFR‐TKI treatment before surgery, or the different surgical indications. However, the patients presenting with pleural seeding before EGFR‐TKI treatment had significantly poorer PFS and OS than the other patients (P < 0.001).

Conclusions

Salvage surgery following EGFR‐TKI treatment of ALAs is a safe procedure with acceptable intra‐ and postoperative results. However, studies involving more cases and longer follow‐up periods are needed to clarify its benefits.

Key points

Salvage surgery following EGFR‐TKI treatment of ALAs is a safe procedure with acceptable intra‐ and postoperative results.

Our results support the use of surgery following treatment with EGFR‐TKIs such as afatinib in advanced lung cancer.

Salvage surgery after definitive chemoradiotherapy for patients with non-small cell lung cancer

Definitive chemoradiotherapy (CRT) has been a standard of care for patients with unresectable stage III non-small cell lung cancer (NSCLC). However, locoregional recurrence occurs in about 30% of patients after definitive CRT. Recently, the addition of durvalumab as maintenance therapy has shown to improve the outcome of these patients. However, locoregional recurrence will still remain. “Salvage surgery” has been performed to achieve local control in clinical practice, although its clinical significance is unclear. In this review, we define salvage surgery as lung resection for local control of the tumor which was not planned initially, after failure or insufficient treatment effect of the initial CRT for locally advanced cancer and evaluated nine studies to gain some insights on its role in the treatment of lung cancer. The time from radiotherapy (RT) to salvage surgery varied considerably (range, 3 to 282 weeks). Salvage surgery was performed for persistent disease (47%) and locoregional recurrence (52%). Lobectomy (63%) and mediastinal lymph node dissections (90%) were the most common procedures. However, the rate of pneumonectomy was higher in salvage surgery (28%) compared to that in lung resection in general. The median morbidity was 41% (range, 15% to 62%) and the mortality was 4% (range, 0 to 11%) which appeared acceptable. The median recurrence-free survival and overall survival (OS) after salvage surgery ranged from 10 to 22 months and 13 to 76 months, respectively. Favorable prognostic factors of salvage surgery were longer period from RT to salvage surgery and radiological downstaging. The pathological response was also prognostic, although this information cannot be obtained preoperatively. We conclude that salvage surgery can be considered especially for those with late local recurrence or those with the metabolic response. Given the condition where phase III trials are difficult, the accumulation of real-world evidence in a prospective fashion will be necessary.

Bronchoplastic Procedure Versus Pneumonectomy After High-dose Radiation for Non-small Cell Lung Cancer

BACKGROUND

Studies have revealed that salvage surgery after definitive chemoradiotherapy (CRT) for unresectable advanced non-small cell lung cancer improves survival with acceptable surgical adverse events. Few reports exist regarding pneumonectomy or the bronchoplastic procedure in this setting.

METHODS

Between 2008 and 2018, 27 patients (21 men; median age, 61 years) underwent salvage surgery after definitive CRT for non-small cell lung cancer. We investigated postoperative short- and long-term outcomes of salvage surgery and aimed to elucidate the feasibility of pneumonectomy or the bronchoplastic procedure.

RESULTS

The median radiation dose was 60 Gy. The median period from the last day for irradiation to the operative day was 8.5 months. Pneumonectomy was performed in 9 patients, including 2 carinal resections; lobectomy was performed in 18 patients, including 5 bronchoplasties. Bronchial wrapping was performed in 9 cases (33%), R0 resection was achieved in 24 (89%), and postoperative complications were detected in 16 (59%). Although bronchopleural fistulas were found in only 2 patients who underwent pneumonectomy, arrhythmia was observed more frequently in patients who underwent the bronchoplastic procedure (P = .05). Regarding major complications, no relationship with any factors were found. The 90-day mortality was 0%. The 5-year overall and recurrence-free survival were 63% and 27%, respectively. R0 resection was a good prognostic factor for recurrence-free survival (P = .001).

CONCLUSIONS

Perioperative short- and long-term outcomes of salvage surgery after definitive CRT for non-small cell lung cancer were acceptable. Complete resection offered a better recurrence-free survival. The bronchoplastic procedure or pneumonectomy should be considered as an option even after administration of high-dose CRT.

Salvage Surgery for Non-Small Cell Lung Cancer After Definitive Radiotherapy

BACKGROUND

The aim of this study was to describe the characteristics and outcomes of patients with non-small cell lung cancer undergoing salvage surgery after chemoradiotherapy, conventional external beam, stereotactic body radiotherapy, and ion beam radiotherapy.

METHODS

We retrospectively evaluated patients who underwent salvage surgery between 2010 and 2016. Data on perioperative morbidity and mortality and patient outcomes were analyzed.

RESULTS

In total, 156 patients were included; of those, 110 were categorized into category 1, chemoradiotherapy or conventional external beam; and 46 into category 2, stereotactic body radiotherapy or ion beam radiotherapy. Three-year overall survival (OS) and recurrence-free survival (RFS) in category 1 were 67.3% and 49.8%, respectively. In category 1, pathological nodal stage was an independent prognosticator of both OS (hazard ratio [HR] = 3.53, 95% confidence interval [CI], 1.05-11.83) and RFS (HR = 4.32, 95% CI, 1.32-14.14). In category 2, 3-year OS and RFS were 57.7% and 46.4%, respectively. Age 70 years and greater at initial treatment was the only independent prognosticator of OS (HR = 5.61; 95% CI, 1.44-21.87), whereas age at initial treatment (HR = 6.13; 95% CI, 1.38-27.12) and pathological nodal metastasis (HR = 3.84; 95% CI, 1.40-10.57) were independent prognosticators for RFS. Overall 30- and 90-day mortality were 0% and 0.9% in category 1 and 0% and 4.3% in category 2, respectively.

CONCLUSIONS

Patients who undergo salvage surgery can have reasonable outcomes, and salvage surgery can be considered in selected patients.

Is pneumonectomy justifiable for patients with a locoregional recurrence or persistent disease after curative intent chemoradiotherapy for locally advanced non-small cell lung cancer?

OBJECTIVES

Locoregional recurrence and persistent/progressive disease after curative-intent definitive chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) is challenging to manage, as salvage options are limited. Selected patients might be candidates for resection. This study evaluated the outcomes of patients after salvage surgery for locoregional recurrence, focusing specifically on morbidity and mortality after salvage pneumonectomy.

MATERIALS AND METHODS

This retrospective study included patients from 2 tertiary referral hospitals who underwent salvage pulmonary resection for locoregional recurrence or disease persistence/progression >12 weeks after completion of curative intent high dose (>60 Gy) CRT. Disease-free (DFS) and overall survival (OS) were estimated and the influence of patient and treatment characteristics on these endpoints was assessed.

RESULTS

A total of 30 patients treated between 2015-2017 were identified with a median age of 60 years (range 42-72 years), 67 % were male. Median follow-up was 47 months (95 % CI 46-NR). Pneumonectomy was performed in 13/30 (43 %) patients and lobectomy in 17/30 (57 %). Median DFS and OS after pneumonectomy/lobectomy were 14/6 and NR/17 months, respectively. 30 and 90-day mortality for pneumonectomy/lobectomy were 0/12 % and 0/24 % respectively. More favorable survival was seen after pathologically radical resection, i.e. R0, and when surgery was performed more than 12 months after completion of CRT.

CONCLUSION

Salvage surgery, including pneumonectomy is associated with acceptable outcomes in selected patients with recurrent or persistent/progressive NSCLC after curative-intent high dose CRT. Patients should be assessed for the probability of an R0 resection, and patients with a locoregional recurrence more than 12 months after treatment with CRT may benefit most from salvage surgery.

Survival Outcomes of Salvage Therapy for Local and Regionally Recurrent NSCLC

Introduction

The treatment of locally recurrent NSCLC after initial curative therapy is variable. We sought to perform a real-world analysis of curative and palliative therapeutic strategies used in locally recurrent NSCLC and explore the impact of baseline factors and the previous and recurrent treatment on outcomes.

Methods

A retrospective cohort study was done including all patients with stage I to III NSCLC who were referred to BC Cancer and received curative-intent therapy between 2005 and 2012. Patients were followed up to determine whether they developed locoregional recurrence. Two cohorts were created: curative-intent treatment at recurrence (surgery, radiotherapy with ≥50Gy ± chemotherapy, stereotactic radiosurgery) and palliative treatment. The primary outcome was overall survival (OS).

Results

A total of 1571 patients received curative-intent therapy during the study period. Of these, 179 (11%) developed a local and regional recurrence. A total of 51 patients (28%) were treated with curative intent at recurrence (12 surgery, 39 radiotherapy ± chemotherapy), and 128 (72%) received palliative treatment only. Patients receiving curative-intent therapy were more likely to have an Eastern Cooperative Oncology Group performance status of 0 to 1 (90% versus 58%), earlier stage at diagnosis (51% stage I) and receive more aggressive staging investigations at recurrence, pathologic confirmation (75% versus 27%) and positron emission tomography (77% versus 27%). OS was longer in the cohort receiving curative-intent therapy, with an OS of 34.3 months versus 9.8 months (p < 0.001) in palliative treatment.

Conclusions

In this real-world population, isolated locoregional recurrences occurred in 11% of patients. Curative-intent treatment at recurrence is associated with a reasonable chance of long-term survival, making aggressive therapy of locoregional recurrences an important treatment consideration.

Pattern-of-failure and salvage treatment analysis after chemoradiotherapy for inoperable stage III non-small cell lung cancer

Background

Loco-regional and distant failure are common in inoperable stage III non small-cell lung cancer (NSCLC) after chemoradiotherapy (CRT). However, there is limited real-world data on failure pattern, patient prognosis and salvage options.

Methods

We analysed 99 consecutive patients with inoperable stage III NSCLC treated with CRT between 2011 and 2016. Follow up CT scans from date of the first-site failure were matched with the delivered radiation treatment plans. Intra-thoracic loco-regional relapse was defined as in-field (IFR) vs. out-of-field recurrence (OFR) [in- vs. outside 50Gy isodose line in the involved lung], respectively. Extracranial distant (DMs) and brain metastases (BMs) as first site of recurrence were also evaluated. Using the Kaplan-Meier method, impact of salvage surgery (sS), radiotherapy (sRT), chemotherapy (sCT) and immunotherapy (sIO) on patient survival was assessed.

Results

Median follow-up was 60.0 months. Median PFS from the end of CRT for the entire cohort was 7.5 (95% CI: 6.0–9.0 months) months. Twenty-six (26%) and 25 (25%) patients developed IFR and OFR. Median time to diagnosis of IFR and OFR was 7.2 and 6.2 months. In the entire cohort, onset of IFR and OFR did not influence patient outcome. However, in 73 (74%) patients who survived longer than 12 months after initial diagnosis, IFR was a significant negative prognostic factor with a median survival of 19.3 vs 40.0 months (p < 0.001). No patients with IFR underwent sS and/or sRT. 18 (70%) and 5 (19%) patients with IFR underwent sCT and sIO. Three (12%) patients with OFR underwent sS and are still alive with 3-year survival rate of 100%. 5 (20%) patients with OFR underwent sRT with a median survival of 71.2 vs 19.1 months (p = 0.014). Four (16%) patients with OFR received sIO with a numerical survival benefit (64.6 vs. 26.4 months, p = 0.222).

DMs and BMs were detected in 27 (27%) and 16 (16%) patients after median time of 5.8 and 5.13 months. Both had no impact on patient outcome in the entire cohort. However, patients with more than three BMs showed significantly poor OS (9.3 vs 26.0 months; p = 0.012).

Conclusions

After completion of CRT, IFR was a negative prognostic factor in those patients, who survived longer than 12 months after initial diagnosis. Patients with OFR benefit significantly from salvage local treatment. Patients with more than three BMs as first site of failure had a significantly inferior outcome.

Salvage surgery for advanced non-small cell lung cancer after targeted therapy: A case series

Background

Tumor recurrence or residual tumor after targeted therapy is common in patients with advanced non‐small cell lung cancer (NSCLC). There is a lack of high‐level evidence on which type of treatment should be employed for these patients and the role of salvage surgery has not been well reported in the literature.

Methods

A retrospective analysis of patients who underwent salvage surgery in our center between January 2016 and June 2019 for advanced NSCLC after targeted therapy was performed.

Results

A total number of nine patients were identified, including five males and four females, with a median age of 56 years (range, 40–65 years), all diagnosed with lung adenocarcinoma stage IIIa–IVb. All patients had received targeted therapy according to individual positive mutation of driver gene(s). Salvage surgery was performed for tumor recurrence or residual tumor after a duration of 2–46 months of targeted therapy. A negative surgical margin was achieved in all cases. Postoperative complication rate was 11.1% (1/9). All patients were alive at the time of this analysis and two patients had disease progression. After a median follow‐up of 17 months (range: 5–44 months), the median event‐free survival and postoperative survival was 14 months (range: 2–44 months) and 17 months (range: 5–44 months) respectively.

Conclusions

Salvage surgery may be a feasible and promising therapeutic option for tumor recurrence or residual tumor in advanced NSCLC in selective patients after targeted therapy.

Key points

Salvage surgery is feasible in selected patients with advanced NSCLC and provides promising survival outcomes after targeted therapy failure.

Salvage surgery provides precise molecular and pathological information which is most important for subsequent therapy.

Differential Expression And Effects Of Peroxiredoxin-6 On Drug Resistance And Cancer Stem Cell-Like Properties In Non-Small Cell Lung Cancer

Objective

Cancer stem-like cells (CSC) are thought to be involved in the cisplatin resistance of tumors. This study was designed to investigate the effect of PRDX6 on CSCs present in cisplatin-resistant non-small cell lung cancer (NSCLC) tumors.

Materials and methods

CD133+/ABCG2+ H1299 CSCs and A549 CSCs were isolated. The IC₅₀ values for cisplatin in treatment of CSCs were detected using the CCK8 assay. Then the isolated cells were identified using CD133. Wnt/β-catenin expression was evaluated by Western blot assays. Specimens of tumor and adjacent para-carcinoma tissue were collected from 30 NSCLC patients and examined by immunohistochemistry (IHC), qRT-PCR, and Western blotting to determine and compare their levels of PRDX6 and CD133 expression. Finally, siRNA-mediated silencing of PRDX6 was employed with both types of CSCs to determine the impact of PRDX6 on CD133 enrichment by flow cytometry, cell viability, and sphere formation ability.

Results

High levels of PRDX6 and CD133 expression were detected in samples of tumor tissue from NSCLC patients, and expression of PRDX6 and CD13 presented a positive relationship. Increasing levels of cisplatin resistance and upregulated levels of PRDX6, ABCG2, Wnt, and β-catenin expression were detected in CD133+/ABCG2+ H1299 and A549 CSCs. Transfection with siRNA targeting PRDX6 changed these cellular characteristics by decreasing the levels of PRDX6, ABCG2, Wnt, and β-catenin expression. We further demonstrated that exogenous silencing of PRDX6 effectively inhibited the sphere formation ability of CSCs and re-sensitized them to cisplatin.

Conclusion

Our results strongly suggest that PRDX6 promotes cisplatin resistance in human lung cancer cells by promoting the stem-like properties of cancer cells. Our findings also suggest PRDX6 as a target for treating cisplatin resistant NSCLC.

Impact of histology on patterns of failure and clinical outcomes in patients treated with definitive chemoradiotherapy for locally advanced non-small cell lung cancer

BACKGROUND

Chemoradiotherapy is the standard treatment for locally advanced non-small cell lung cancer. Unlike metastatic disease, histological differences are usually not considered while planning chemoradiotherapy. This study aimed to compare clinical outcomes and relapse patterns between squamous cell carcinomas and adenocarcinomas, and investigated possible histology-specific approaches for chemoradiotherapy in locally advanced non-small cell lung cancer.

METHODS

We retrospectively analyzed the outcomes and relapse patterns in patients who received definitive chemoradiotherapy for locally advanced non-small cell lung cancer in Katsura hospital between 2003 and 2012.

RESULTS

A total of 68 and 33 patients with squamous cell carcinomas and adenocarcinomas, respectively, were enrolled. Patients with adenocarcinoma had less advanced T stages, and a larger proportion of female patients. Other factors were not different between the two groups. The median follow-up duration in all patients and survivors was 21.3 months and 91.4 months, respectively. Median survival and relapse-free survival were not significantly different between the two groups. In contrast, the failure patterns and incidences of distant failure were significantly different. Patients with squamous cell carcinomas had predominantly locoregional disease features and a shorter duration from relapse to death compared to patients with adenocarcinoma.

CONCLUSION

Failure pattern was significantly different between the two histologies. Among relapsed patients, the prognosis was poorer in those with squamous cell carcinomas than those with adenocarcinomas. Further studies, to evaluate histology-specific approaches in chemoradiotherapy, are warranted.

Salvage Surgery After Chemotherapy or Chemoradiotherapy for Initially Unresectable Lung Carcinoma

BACKGROUND

Salvage surgery is used for resection of locoregionally recurrent or regrowing lesions after treatment for unresectable non-small cell lung cancer. It is also used to resect lesions that have regressed after treatment and that had not initially been indicated for resection. Relationships between salvage surgery, safety, and prognosis, however, have remained unclear.

METHODS

Between 2006 and 2017, 29 patients received salvage resection (median age, 60 years; 25 men and 4 women). Safety and prognosis were analyzed.

RESULTS

Tumor grade at the time of initial treatment was stage III or IV in 23 and 6 patients, respectively. Twenty-two patients received chemoradiotherapy (radiation, 40-66 Gy) and 7 received chemotherapy. Time from initial treatment to surgery ranged from 2 to 60 months. Segmentectomy, lobectomy, bilobectomy and pneumonectomy were performed in 1, 25, 2, and 1 patients, respectively. Combined resections were needed in 17 patients; this included 10 bronchoplasties, 9 pulmonary arterioplasties, 4 chest wall resections, and 1 great vessel resection. There was no 30-day postoperative mortality. Grade 3 or higher-grade postoperative complications (mostly cardiopulmonary) were observed in 11 patients. Five-year overall survival after initial treatment was 61%; after surgery it was 51%. Five-year relapse-free survival after surgery was 49%. On recurrent-free survival patients with clinical stage III at the initial treatment, pathologic stage 0-II, or a good response to initial treatment showed a favorable prognosis.

CONCLUSIONS

Although cardiopulmonary complications can accompany salvage surgery, the procedure is generally safe. Survival outcome is encouraging, especially in cases with good response to initial treatment.

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.