1
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Eisenberg M, Deboever N, Antonoff MB. Salvage surgery in lung cancer following definitive therapies. J Surg Oncol 2023; 127:319-328. [PMID: 36630094 DOI: 10.1002/jso.27155] [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: 10/29/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023]
Abstract
Salvage surgery refers to operative resection of persistent or recurrent disease in patients initially treated with intention-to-cure nonoperative management. In non-small-cell lung cancer, salvage surgery may be effective in treating selected patients with locally progressive tumors, recurrent local or locoregional disease, or local complications after nonoperative therapy. Importantly, those patients who may be candidates for salvage surgery are evolving, in terms of disease stage as well as the types of attempted definitive therapy received.
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Affiliation(s)
- Michael Eisenberg
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nathaniel Deboever
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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2
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Zhang R, Cai L, Wang G, Wen Y, Wang F, Zhou N, Zhang X, Huang Z, Yu X, Xi K, Yang L, Zhao D, Lin Y, Zhang L. Resection of Early-Stage Second Primary Non-small Cell Lung Cancer After Small Cell Lung Cancer: A Population-Based Study. Front Oncol 2020; 9:1552. [PMID: 32117785 PMCID: PMC7013095 DOI: 10.3389/fonc.2019.01552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/23/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction: A certain number of small cell lung cancer (SCLC) patients become long-term survivors after treatment, and they are at high risk to develop a second primary malignancy, including non-small cell lung cancer. However, the optimal management of early-stage second primary non-small cell lung cancer (SPLC) after SCLC remains unknown. This study aims to evaluate the survival benefits of surgery in these patients. Methods: Patients with early-stage SPLC after SCLC were identified from the Surveillance, Epidemiology, and End Results database. Patients were balanced with propensity score matching (PSM). Overall survival (OS) and lung cancer-specific survival (CSS) were compared between non-surgery group and surgery group with the Kaplan–Meier method and Cox multivariate regressions. Results: A total of 228 patients with early-stage SPLC after SCLC were identified. Surgery was associated with significantly improved OS and CSS in the multivariate Cox regression analysis (OS, 5-year survival: 41.2 vs. 11.6%, HR: 0.42, 95% CI: 0.31–0.59, P < 0.01; CSS, 5-year survival: 46.8 vs. 24.3%, HR: 0.53, 95% CI: 0.37–0.75, P < 0.01). However, no statistically significant survival difference was found between sublobar resection and lobectomy (OS, 5-year survival: 41.0 vs. 45.3%, P = 0.73; CSS, 5-year survival: 43.5 vs. 54.1%, P = 0.49). After 1:1 PSM, 162 patients were selected for further analysis, and surgery continued to demonstrate superior survival (OS, 5-year survival: 44.2 vs. 7.2%, HR: 0.48, 95% CI: 0.33–0.70, P < 0.01; CSS, 5-year survival: 48.0 vs. 20.6%, HR: 0.44, 95% CI: 0.42–0.97, P = 0.03). Conclusion: The resection of early-stage SPLC after SCLC led to significantly improved OS and CSS and therefore should be considered whenever possible. Nevertheless, further randomized controlled trials are warranted to investigate the safety and effect of surgery in these patients.
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Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Ling Cai
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Gongming Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yingsheng Wen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fang Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Molecular Pathology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ningning Zhou
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xuewen Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Anesthesiology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zirui Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiangyang Yu
- Department of Thoracic Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kexing Xi
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Longjun Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Dechang Zhao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yongbin Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
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3
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Brooks ED, Verma V, Senan S, De Baere T, Lu S, Brunelli A, Chang JY. Salvage Therapy for Locoregional Recurrence After Stereotactic Ablative Radiotherapy for Early-Stage NSCLC. J Thorac Oncol 2020; 15:176-189. [PMID: 31712134 PMCID: PMC7058490 DOI: 10.1016/j.jtho.2019.10.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 09/20/2019] [Accepted: 10/21/2019] [Indexed: 12/25/2022]
Abstract
Although isolated local (LRs) and regional recurrences (RRs) constitute a minority of post-stereotactic ablative radiotherapy (SABR) relapses, their management is becoming increasingly important as the use of SABR continues to expand. However, few evidence-based strategies are available to guide treatment of these potentially curable recurrences. On behalf of the Advanced Radiation Technology Committee of the International Association for the Study of Lung Cancer, this article was written to address management of recurrent disease. Topics discussed include diagnosis and workup, including the roles of volumetric and functional imaging as well as histopathologic methods; clinical outcomes after salvage therapy; patterns of recurrence after salvage therapy; and management options. Our main conclusions are that survival for patients with adequately salvaged LRs is similar to that for patients after primary SABR without recurrence, and survival for those with salvaged RRs (regardless of nodal burden or location) is similar to that of patients with de novo stage III disease. Although more than half of patients who undergo salvage do not develop a second relapse, the predominant pattern of second failure is distant, especially for RRs. Management requires rigorous multidisciplinary coordination. Isolated LRs can be managed with resection and nodal dissection, repeat SABR, thermal ablation, or systemic therapies. RRs can be treated with combined chemoradiotherapy, radiation or chemotherapy alone, or supportive services. Finally, regular and structured follow-up is recommended after post-SABR salvage therapy.
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Affiliation(s)
- Eric D Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Thierry De Baere
- Département d'imagerie, Institut de Cancérologie Gustave Roussy, Villejuif, France
| | - Shun Lu
- Department of Medical Oncology, Shanghai Chest Hospital, Shanghai Jiao University, Shanghai, China
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St. James's University Hospital, Leeds, United Kingdom
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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4
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A Prospective Study of Magnetic Resonance Imaging Assessment of Post-radiation Changes Following Stereotactic Body Radiation Therapy for Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2019; 31:720-727. [DOI: 10.1016/j.clon.2019.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 04/09/2019] [Accepted: 04/18/2019] [Indexed: 12/25/2022]
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5
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Kumar SS, McGarry RC. Management of local recurrences and regional failure in early stage non-small cell lung cancer after stereotactic body radiation therapy. Transl Lung Cancer Res 2019; 8:S213-S221. [PMID: 31673526 DOI: 10.21037/tlcr.2019.09.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiation therapy (SBRT) is a very effective way to treat early stage non-small cell lung cancer (NSCLC) and small oligometastatic lung lesions with consistently high rates of local control, but both local and regional/distant recurrences still occur. The management of recurrences remains unsettled and may entail repeat SBRT, conventionally fractionated external beam RT (EF-EBRT), chemotherapy or surgery. Most patients with local recurrences [within the initial planning target volume (PTV)] can be salvaged successfully with good cancer specific survival. Nonetheless, proximity of the initial SBRT delivery to organs at risk (ribs, blood vessels, airways) may make retreatment more difficult. With attention to detail and careful patient selection, both surgery and reirradiation can be performed safely and effectively. Strategies for management of regional (nodal) recurrences may require conventional therapies tailored to the patterns of failure. The role of immunotherapy in salvage has not been elucidated as yet. We review here data on the available literature concerning salvage of SBRT lung patients.
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Affiliation(s)
- Sameera S Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Ronald C McGarry
- Department of Radiation Oncology, University of Kentucky, Lexington, KY, USA
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6
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Seo YS, Kim HJ, Wu HG, Choi SM, Park S. Lobectomy versus stereotactic ablative radiotherapy for medically operable patients with stage IA non-small cell lung cancer: A virtual randomized phase III trial stratified by age. Thorac Cancer 2019; 10:1489-1499. [PMID: 31124275 PMCID: PMC6558457 DOI: 10.1111/1759-7714.13103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although the choice between stereotactic ablative radiotherapy (SABR) and lobectomy for early-stage non-small cell lung cancer (NSCLC) has been debated for years, the two procedures have not yet been directly compared in a randomized trial. We conducted a virtual randomized phase III trial stratified by age to compare the effectiveness of lobectomy and SABR for medically operable patients with stage IA (AJCC eighth) NSCLC using the Markov model analysis. METHODS A Markov model was developed to simulate a cohort of patients aged 45-85 years with stage IA NSCLC who had undergone either lobectomy or SABR and were followed up for their remaining lifetime. Each virtual patient was randomly assigned to undergo lobectomy or SABR, and 10 000 patients were allocated to each group. All estimates of the variables were obtained by a systematic review of published articles. RESULTS The lobectomy group showed a better life expectancy than the SABR group, in patients under 75 years of age. However, no statistically significant difference was seen in patients 75 years or older. The predicted life expectancy was 9.43 and 8.70 years in 75-year-old patients in the lobectomy and SABR groups, respectively. However, the 95%CI for the difference in life expectancy between the two groups was - 0.06-1.50 years (P = 0.0689). CONCLUSIONS The Markov model showed no statistically significant difference in the expected overall survival in stage IA NSCLC patients who were older than 75 years and had undergone SABR or lobectomy.
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Affiliation(s)
- Young-Seok Seo
- Department of Radiation Oncology, ChungBuk National University Hospital, Chungcheongbuk-do, Republic of Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Radiation Oncology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong Gyun Wu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Radiation Oncology, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
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7
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Matsuo Y. A Systematic Literature Review on Salvage Radiotherapy for Local or Regional Recurrence After Previous Stereotactic Body Radiotherapy for Lung Cancer. Technol Cancer Res Treat 2019; 17:1533033818798633. [PMID: 30198413 PMCID: PMC6131295 DOI: 10.1177/1533033818798633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: The purpose of this review article was to summarize available data on the efficacy and safety of salvage radiotherapy for isolated local or regional recurrence after prior stereotactic body radiotherapy for lung cancer. Methods: Studies were systematically searched on PubMed, following which suitable papers were selected. Reported outcomes and toxicities were qualitatively reviewed. Results: Nineteen papers, which were retrospective studies based on single institution experiences, were selected. Sixteen papers were on salvage radiotherapy for local tumor recurrence, and the remaining 3 papers evaluated radiotherapy for regional failures after stereotactic body radiotherapy for lung cancer. Patient cohorts in the selected papers seemed very frail with 2-year survival of 30% to 40% after the salvage. Local control was reported to be approximately 60% to 70%, which is worse than that after primary stereotactic body radiotherapy. Reported rates of toxicity grade 3 or worse were considered acceptable. Larger target volume and central tumor localization were suggested as risk factors for severe toxicities. Dosimetric data on patients having toxicities were found to help with considering dose constraints for organs at risk. Conclusion: Based on data from a limited number of articles, salvage radiotherapy is a reasonable treatment option for select patients with local or regional tumor recurrence after prior stereotactic body radiotherapy for lung cancer. Optimal patient selection and dose prescription can be clarified with a larger study that include more data on experiences with salvage radiotherapy.
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Affiliation(s)
- Yukinori Matsuo
- 1 Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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8
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Kalman NS, Hugo GD, Kahn JM, Zhao SS, Jan N, Mahon RN, Weiss E. Interobserver reliability in describing radiographic lung changes after stereotactic body radiation therapy. Adv Radiat Oncol 2018; 3:655-661. [PMID: 30370367 PMCID: PMC6200874 DOI: 10.1016/j.adro.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/03/2018] [Accepted: 05/09/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Radiographic lung changes after stereotactic body radiation therapy (SBRT) vary widely between patients. Standardized descriptions of acute (≤6 months after treatment) and late (>6 months after treatment) benign lung changes have been proposed but the reliable application of these classification systems has not been demonstrated. Herein, we examine the interobserver reliability of classifying acute and late lung changes after SBRT. METHODS AND MATERIALS A total of 280 follow-up computed tomography scans at 3, 6, and 12 months post-treatment were analyzed in 100 patients undergoing thoracic SBRT. Standardized descriptions of acute lung changes (3- and 6-month scans) include diffuse consolidation, patchy consolidation and ground glass opacity (GGO), diffuse GGO, patchy GGO, and no change. Late lung change classifications (12-month scans) include modified conventional pattern, mass-like pattern, scar-like pattern, and no change. Five physicians scored the images independently in a blinded fashion. Fleiss' kappa scores quantified the interobserver agreement. RESULTS The Kappa scores were 0.30 at 3 months, 0.20 at 6 months, and 0.25 at 12 months. The proportion of patients in each category at 3 and 6 months was as follows: Diffuse consolidation 11% and 21%; patchy consolidation and GGO 15% and 28%; diffuse GGO 10% and 11%; patchy GGO 15% and 15%; and no change 49% and 25%, respectively. The percentage of patients in each category at 12 months was as follows: Modified conventional 46%; mass-like 16%; scar-like 26%; and no change 12%. Uniform scoring between the observers occurred in 26, 8, and 14 cases at 3, 6, and 12 months, respectively. CONCLUSIONS Interobserver reliability scores indicate a fair agreement to classify radiographic lung changes after SBRT. Qualitative descriptions are insufficient to categorize these findings because most patient scans do not fit clearly into a single classification. Categorization at 6 months may be the most difficult because late and acute lung changes can arise at that time.
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Affiliation(s)
- Noah S. Kalman
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Geoffrey D. Hugo
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Jenna M. Kahn
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Sherry S. Zhao
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Nuzhat Jan
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Rebecca N. Mahon
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
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9
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Brooks ED, Sun B, Feng L, Verma V, Zhao L, Gomez DR, Liao Z, Jeter M, O’Reilly M, Welsh JW, Nguyen QN, Erasmus JJ, Eapen G, Ahrar K, Antonoff MB, Hahn SM, Heymach JV, Rice DC, Chang JY. Association of Long-term Outcomes and Survival With Multidisciplinary Salvage Treatment for Local and Regional Recurrence After Stereotactic Ablative Radiotherapy for Early-Stage Lung Cancer. JAMA Netw Open 2018; 1:e181390. [PMID: 30646121 PMCID: PMC6324276 DOI: 10.1001/jamanetworkopen.2018.1390] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/26/2018] [Indexed: 12/19/2022] Open
Abstract
Importance Stereotactic ablative radiotherapy (SABR) is first-line treatment for patients with early-stage non-small cell lung cancer (NSCLC) who cannot undergo surgery. However, up to 1 in 6 such patients will develop isolated local recurrence (iLR) or isolated regional recurrence (iRR). Little is known about outcomes when disease recurs after SABR, or about optimal management strategies for such recurrences. Objective To characterize long-term outcomes for patients with iLR or iRR after SABR for early-stage NSCLC with the aim of informing treatment decision making for these patients with potentially curable disease. Design, Setting, and Participants In this cohort study, a retrospective review was conducted of 912 patients prospectively enrolled in an institutional database at a tertiary cancer center from January 1, 2004, through December 31, 2014. Main Outcomes and Measures Overall survival, progression-free survival, recurrence patterns, demographics, salvage techniques, patterns of salvage failure, and toxic effects. Results Of the 912 patients in the study (456 women and 456 men; median age, 72 years [range, 46-91 years]), 756 (82.9%) had T1 tumors at initial diagnosis; 502 tumors (55.0%) were adenocarcinomas and 309 tumors (33.9%) were squamous cell carcinomas. Of 912 patients with early-stage I to II NSCLC who received definitive SABR (50 Gy in 4 fractions or 70 Gy in 10 fractions), 102 developed isolated recurrence (49 with iLR and 53 with iRR), and 658 had no recurrence. Median times to recurrence after SABR were 14.5 months (range, 1.5-60.8 months) for iLR and 9.0 months (range, 1.9-70.7 months) for iRR; 39 of 49 patients (79.6%) with iLR and 48 of 53 patients (90.6%) with iRR underwent salvage with reirradiation, surgery, thermal ablation, or chemotherapy. Median follow-up times for patients with iLR or iRR were 57.2 months (interquartile range, 37.7-87.6 months) from initial SABR and 38.5 months (interquartile range, 19.9-69.3 months) from recurrence. Rates of overall survival at 5 years from initial SABR were no different between patients with iLR and salvage treatment (57.9%) and patients with no recurrence (54.9%; hazard ratio, 0.89; 95% CI, 0.56-1.43; P = .65) but were lower for patients with iRR and salvage treatment (31.1%; hazard ratio, 1.43; 95% CI, 1.00-2.34; P = .049). Patients receiving salvage treatment had longer overall survival than patients who did not (median, 37 vs 7 months after recurrence; hazard ratio, 0.40; 95% CI, 0.09-0.66; P = .006). Twenty-four of 87 patients (27.6%) who received salvage treatment for iLR or iRR subsequently developed distant metastases. No patient experienced grade 5 toxic effects after salvage treatment. Conclusions and Relevance Life expectancy after salvage treatment for iLR was similar to that for patients without recurrence, but survival after salvage treatment for iRR was similar to that of patients with stage III NSCLC. Patients who received salvage treatment had significantly improved survival. Because salvage treatment for iLR or iRR was based on a consistent multidisciplinary approach, this may help in clinical decision making.
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Affiliation(s)
- Eric D. Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Bing Sun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha
| | - Lina Zhao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Daniel R. Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Melenda Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Michael O’Reilly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - James W. Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jeremy J. Erasmus
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston
| | - George Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Stephen M. Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - John V. Heymach
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - David C. Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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10
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Dickhoff C, Rodriguez Schaap PM, Otten RHJ, Heymans MW, Heineman DJ, Dahele M. Salvage surgery for local recurrence after stereotactic body radiotherapy for early stage non-small cell lung cancer: a systematic review. Ther Adv Med Oncol 2018; 10:1758835918787989. [PMID: 30023008 PMCID: PMC6047243 DOI: 10.1177/1758835918787989] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/19/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction: Stereotactic body (or ablative) radiotherapy (SBRT/SABR) is now a
guideline-recommended treatment for medically inoperable patients with
peripherally-located, stage I non-small cell lung cancer (NSCLC), and for
medically operable patients who decline surgery. The 5-year local failure
rate after SBRT is about 10% and in highly selected patients, surgery has
been used as a salvage therapy. We performed a systematic review to address
the feasibility, safety, and outcome of salvage surgery for locally
recurrent early stage NSCLC after SBRT. Methods: A systematic literature search was performed according to Preferred Reporting
Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
PubMed, Embase and Cochrane databases
were searched and two authors independently assessed the articles. A total
of seven eligible articles were identified. Results: All seven articles were retrospective case series, representing a total of 47
patients. Surgery was completed in all patients. Where reported in
sufficient detail, morbidity (four studies) was between 29 and 50% (series
of two patients) and 90-day mortality (six studies) was between 0% (four
studies) and 11% (n = 1, disease progression). Median
(n = 5)/mean (n = 1) reported or
calculated follow ups were 7–54.5/17.3 months. Median overall survival was
reported in three studies and ranged between 13.6–82.7 months. Crude
survival in three others was 2–35 months. Conclusion: Limited, low-level evidence prevents firm conclusions, but based on the
existing data, salvage surgery after local recurrence of NSCLC following
SBRT appears technically feasible, with acceptable morbidity and mortality
in appropriately selected and counselled patients who are fit enough and who
accept the risks (level of evidence 4, strength of recommendation C).
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Affiliation(s)
- Chris Dickhoff
- Department of Surgery and Cardiothoracic Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | | | - Rene H J Otten
- Medical Library, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - David J Heineman
- Department of Surgery and Cardiothoracic Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Max Dahele
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
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11
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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 2018; 8:78-87. [PMID: 30788237 DOI: 10.21037/tlcr.2018.08.15] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Treatment options for thoracic recurrences of non-small cell lung cancer (NSCLC) are limited. Stereotactic body radiation therapy (SBRT) is an emerging, potentially effective technology to manage recurrent NSCLC, although with limited prospective studies. This work reviews the outcomes of patients undergoing salvage SBRT for pulmonary recurrences after prior resection or prior radiotherapy for NSCLC. Following salvage SBRT, after prior external beam radiation (SBRT or conventionally fractionated), the 2-year overall survival (OS) ranged from 37% to 79% in 11 of the studies (397 patients) reviewed here, while the 2-year local control (LC) ranged from 37% to 90% in 6 studies that reported that outcome. Toxicity risks are acceptable albeit with appreciable risks of severe to potentially fatal toxicity, necessitating the need to weigh risks vs. benefits in the re-irradiation setting. There were fewer studies on the use of SBRT after prior resection. Following salvage SBRT, after prior resection, the 2-year OS ranged from 56% to 68% in 4 studies (131 patients) reviewed here, while the 2-year LC ranged from 83% to 100% in 3 of these studies. SBRT in the salvage setting after prior resection appeared to be well-tolerated, with toxicity risks comparable to historical patients treated with SBRT alone (i.e., SBRT without prior resection, which is not reviewed here). The data are limited due to the retrospective nature of published studies (all but 4 with <40 patients), with various clinical scenarios (i.e., original NSCLC stage, prior treatment, location of target amenable to salvage SBRT) and a range of SBRT dosing and techniques. More studies are needed to better understand the tumor control, survival and toxicity of SBRT for salvage therapy of NSCLC patients, as well as the potentially prognostic factors that could affect these outcomes.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Cancer Institute at Henry Ford Health System, Detroit, MI, USA
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12
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Postmus PE, Kerr KM, Oudkerk M, Senan S, Waller DA, Vansteenkiste J, Escriu C, Peters S. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28:iv1-iv21. [PMID: 28881918 DOI: 10.1093/annonc/mdx222] [Citation(s) in RCA: 1146] [Impact Index Per Article: 163.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- P E Postmus
- The Clatterbridge Cancer Centre and Liverpool Heart and Chest Hospital, Liverpool
| | - K M Kerr
- University of Aberdeen, Aberdeen, UK
| | - M Oudkerk
- Center for Medical Imaging, University of Groningen, Groningen
| | - S Senan
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - D A Waller
- Department of Thoracic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - C Escriu
- The Clatterbridge Cancer Centre and Liverpool Heart and Chest Hospital, Liverpool
| | - S Peters
- Oncology Department, Service d'Oncologie Médicale, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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13
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Hamaji M, Chen-Yoshikawa TF, Matsuo Y, Motoyama H, Hijiya K, Menju T, Aoyama A, Sato T, Sonobe M, Date H. Salvage video-assisted thoracoscopic lobectomy for isolated local relapse after stereotactic body radiotherapy for early stage non-small cell lung cancer: technical aspects and perioperative management. J Vis Surg 2017; 3:86. [PMID: 29302412 DOI: 10.21037/jovs.2017.04.02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 04/06/2017] [Indexed: 11/06/2022]
Abstract
Limited data is available on salvage surgery for local relapse (LR) after stereotactic body radiotherapy (SBRT) for non-small cell lung cancer (NSCLC). We aimed to characterize treatment options and clarify long-term outcomes of isolated LR after SBRT for patients with clinical stage I NSCLC. Herein, we discuss technical aspects, perioperative management, and postoperative follow-up of two patients of the 12 patients undergoing salvage surgery for LR after SBRT at Kyoto University between 1999 and 2013. A 76-year-old male, 15 months after SBRT, underwent a salvage right upper lobectomy combined with adjacent right lower lobe wedge resection via video-assisted thoracoscopic surgery (VATS) for a 5.0-cm mass. Local recurrence was found 5 years after salvage surgery and treated with repeat SBRT, however he died from multiple distant metastases. An 85-year-old male, 14 months after SBRT, underwent a salvage left upper lobectomy via VATS for a 3.5-cm mass. Moderate intrapleural adhesion was noted and required careful dissection on the mediastinum. He is alive with no recurrence at 2 years from salvage surgery. Salvage VATS lobectomy was feasible after SBRT in two patients. Long-term follow-up and continued discussions at multidisciplinary conferences are required.
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Affiliation(s)
- Masatsugu Hamaji
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideki Motoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kyoko Hijiya
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshi Menju
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshihiko Sato
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Makoto Sonobe
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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14
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Antonoff MB, Correa AM, Sepesi B, Nguyen QN, Walsh GL, Swisher SG, Vaporciyan AA, Mehran RJ, Hofstetter WL, Rice DC. Salvage pulmonary resection after stereotactic body radiotherapy: A feasible and safe option for local failure in selected patients. J Thorac Cardiovasc Surg 2017; 154:689-699. [PMID: 28495066 DOI: 10.1016/j.jtcvs.2017.03.142] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 02/23/2017] [Accepted: 03/25/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE For inoperable patients with pulmonary malignancy, stereotactic body radiotherapy is a reasonable therapeutic option. Despite good early tumor control, local failure occurs in up to 10% of patients by 3 years. Because management of local recurrence after stereotactic body radiotherapy is unclear, we evaluated use of surgery as a salvage option. METHODS A retrospective review was conducted of consecutive patients from a single institution who underwent salvage resection of primary and metastatic pulmonary malignancies previously treated with stereotactic body radiotherapy. In addition, a literature search was conducted to identify previous reports of pulmonary resection for local stereotactic body radiotherapy failures, to allow cumulative analyses with previously published cases. RESULTS A total of 21 patients met inclusion criteria. The median time between stereotactic body radiotherapy and salvage surgery was 16.2 months (range, 6.4-71.5). Postoperative complications occurred in 7 patients (18.9%), in whom atrial arrhythmias and prolonged air leaks (>5 days) were most frequent (n = 2 each, 5.4%). There was no local recurrence after salvage surgery. Distant failure occurred in 5 of 21 patients (23.8%) at a median of 36.2 months, and median disease-free survival was 19.2 months. The 30- and 90-day mortality was 4.8% (1 patient). Cumulative analysis included 37 patients from 4 institutions and comprised 26 (78.8%) primary non-small cell lung cancers and 11 (29.7%) lung metastases. Median overall survival after salvage surgery was 46.9 months, and 3-year survival was 71.8%. CONCLUSIONS After local failure of stereotactic body radiotherapy, salvage resection remains a viable option for operable patients, with acceptable morbidity and survival. As use of stereotactic body radiotherapy continues to expand, further studies to evaluate the optimal management for local failure are needed.
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Affiliation(s)
- Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex.
| | - Arlene M Correa
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Quynh-Nhu Nguyen
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex
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15
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Van Breussegem A, Hendriks JM, Lauwers P, Van Schil PE. Salvage surgery after high-dose radiotherapy. J Thorac Dis 2017; 9:S193-S200. [PMID: 28446984 DOI: 10.21037/jtd.2017.03.88] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Salvage surgery is a relatively new entity in thoracic surgery and oncology. Salvage resection after radiotherapy refers to surgery as only remaining therapeutic option in patients who were treated with high-dose stereotactic radiotherapy (SRT) for early-stage lung cancer or full-dose chemoradiation for locally advanced lung cancer. Indications include locally progressive tumors, recurrent local or locoregional disease, or specific complications after radiotherapy such as lung abscesses or infected, necrotic cavities. Small, retrospective series demonstrate that salvage surgery after high-dose radiotherapy is feasible and may yield good long-term results. A clear distinction should be made between salvage surgery after SRT for early-stage lung cancer and salvage procedures after full-dose chemoradiation for lung cancers with locoregional extension into the mediastinum. Salvage surgery after SRT may be rather straightforward and in specific cases even feasible by a minimally invasive approach. In contrast, surgery after a full dose of chemoradiation delivered several months or years earlier, can be quite challenging and the dissection of the pulmonary artery and mediastinal lymph nodes technically demanding. Due to the more central irradiation an intrapericardial dissection is often required. To prevent a bronchopleural fistula protection of the bronchial stump with well-vascularized flaps is recommended. Each individual patient in whom salvage surgery is considered, should be discussed thoroughly within a multidisciplinary board, detailed cardiopulmonary functional evaluation is required, and the operation should be performed by an experienced team including a thoracic surgeon, anaesthesiologist and intensive care physician. At the present time only retrospective series are available. Carefully designed prospective studies are necessary to more precisely define indications and results of salvage surgery not only after SRT for peripherally localized lesions but also following full-dose chemoradiation for locoregionally advanced disease.
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Affiliation(s)
- Annemie Van Breussegem
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Jeroen M Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Patrick Lauwers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Paul E Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium
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16
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Giuliani M, Bezjak A. Rebuttal from Dr. Bezjak and Dr. Giuliani. Transl Lung Cancer Res 2017; 5:658-659. [PMID: 28151537 DOI: 10.21037/tlcr.2016.12.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Meredith Giuliani
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Andrea Bezjak
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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17
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Palma DA, Nguyen TK, Kwan K, Gaede S, Landis M, Malthaner R, Fortin D, Louie AV, Frechette E, Rodrigues GB, Yaremko B, Yu E, Dar AR, Lee TY, Gratton A, Warner A, Ward A, Inculet R. Short report: interim safety results for a phase II trial measuring the integration of stereotactic ablative radiotherapy (SABR) plus surgery for early stage non-small cell lung cancer (MISSILE-NSCLC). Radiat Oncol 2017; 12:30. [PMID: 28129789 PMCID: PMC5270342 DOI: 10.1186/s13014-017-0770-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/18/2017] [Indexed: 02/11/2023] Open
Abstract
Abstract A phase II trial was launched to evaluate if neoadjuvant stereotactic ablative radiotherapy (SABR) before surgery improves oncologic outcomes in patients with stage I non-small cell lung cancer (NSCLC). We report a mandated interim safety analysis for the first 10 patients who completed protocol treatment. Operable patients with biopsy-proven T1-2 N0 NSCLC were eligible. SABR was delivered using a risk-adapted fractionation (54Gy/3 fractions, 55/5 or 60/8). Surgical resection was planned 10 weeks later at a high-volume center (>200 lung cancer resections annually). Patients were imaged with dynamic positron emission tomography-computed tomography scans using 18F-fludeoxyglucose (18F-FDG-PET CT) and dynamic contrast-enhanced CT before SABR and again before surgery. Toxicity was recorded using CTCAE version 4.0. Twelve patients were enrolled between 09/2014 and 09/2015. Two did not undergo surgery, due to patient or surgeon preference; neither patient has developed toxicity or recurrence. For the 10 patients completing both treatments, median age was 70 (range: 54–76), 60% had T1 disease, and 60% had adenocarcinoma. Median FEV1 was 73% predicted (range: 54–87%). Median time to surgery post-SABR was 10.1 weeks (range: 9.3–15.6 weeks). Surgery consisted of lobectomy (n = 8) or wedge resection (n = 2). Median follow-up post-SABR was 6.3 months. After combined treatment, the rate of acute grade 3–4 toxicity was 10%. There was no post-operative mortality at 90 days. The small sample size included herein precludes any definitive conclusions regarding overall toxicity rates until larger datasets are available. However, these data may inform others who are designing or conducting similar trials. Trial registration NCT02136355. Registered 8 May 2014.
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Affiliation(s)
- David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada. .,Department of Oncology, Western University, London, Canada.
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Keith Kwan
- Department of Pathology, Western University, London, Canada
| | - Stewart Gaede
- Department of Oncology, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada.,Department of Physics and Engineering, London Health Sciences Centre, London, Canada
| | - Mark Landis
- Department of Radiology, Western University, London, Canada
| | - Richard Malthaner
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
| | - Dalilah Fortin
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Eric Frechette
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
| | - George B Rodrigues
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Brian Yaremko
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Edward Yu
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - A Rashid Dar
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada.,Department of Oncology, Western University, London, Canada
| | - Ting-Yim Lee
- Department of Medical Biophysics, Western University, London, Canada.,Imaging Program, Lawson Health Research Institute, London, Canada
| | - Al Gratton
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - Aaron Ward
- Department of Oncology, Western University, London, Canada.,Department of Medical Biophysics, Western University, London, Canada
| | - Richard Inculet
- Department of Surgery, Division of Thoracic Surgery, Western University, London, Canada
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18
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Nguyen TK, Palma DA. Pros: After stereotactic ablative radiotherapy for a peripheral early-stage non-small cell lung cancer, radiological suspicion of a local recurrence can be sufficient indication to proceed to salvage therapy. Transl Lung Cancer Res 2016; 5:647-650. [PMID: 28151535 DOI: 10.21037/tlcr.2016.12.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Canada
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19
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Verstegen NE, Maat APWM, Lagerwaard FJ, Paul MA, Versteegh MI, Joosten JJ, Lastdrager W, Smit EF, Slotman BJ, Nuyttens JJME, Senan S. Salvage surgery for local failures after stereotactic ablative radiotherapy for early stage non-small cell lung cancer. Radiat Oncol 2016; 11:131. [PMID: 27716240 PMCID: PMC5048455 DOI: 10.1186/s13014-016-0706-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 09/20/2016] [Indexed: 12/17/2022] Open
Abstract
Introduction The literature on surgical salvage, i.e. lung resections in patients who develop a local recurrence following stereotactic ablative radiotherapy (SABR), is limited. We describe our experience with salvage surgery in nine patients who developed a local recurrence following SABR for early stage non-small cell lung cancer (NSCLC). Methods Patients who underwent surgical salvage for a local recurrence following SABR for NSCLC were identified from two Dutch institutional databases. Complications were scored using the Dindo-Clavien-classification. Results Nine patients who underwent surgery for a local recurrence were identified. Median time to local recurrence was 22 months. Recurrences were diagnosed with CT- and/or 18FDG-PET-imaging, with four patients also having a pre-surgical pathological diagnosis. Extensive adhesions were observed during two resections, requiring conversion from a thoracoscopic procedure to thoracotomy during one of these procedures. Three patients experienced complications post-surgery; grade 2 (N = 2) and grade 3a (N = 1), respectively. All resection specimens showed viable tumor cells. Median length of hospital stay was 8 days (range 5–15 days) and 30-day mortality was 0 %. Lymph node dissection revealed mediastinal metastases in 3 patients, all of whom received adjuvant therapy. Conclusions Our experience with nine surgical procedures for local recurrences post-SABR revealed two grade IIIa complications, and a 30-day mortality of 0 %, suggesting that salvage surgery can be safely performed after SABR.
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Affiliation(s)
- Naomi E Verstegen
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
| | - Alexander P W M Maat
- Department of Cardiothoracic Surgery, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frank J Lagerwaard
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Marinus A Paul
- Department of Cardiothoracic Surgery, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Michel I Versteegh
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris J Joosten
- Department of Surgery, Westfriesgasthuis Hoorn, Hoorn, The Netherlands
| | - Willem Lastdrager
- Department of Surgery, Gelre Hospital Apeldoorn, Apeldoorn, The Netherlands
| | - Egbert F Smit
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, VU University Medical Center Amsterdam, De Boelelaan 1117, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
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20
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Peulen H, Mantel F, Guckenberger M, Belderbos J, Werner-Wasik M, Hope A, Giuliani M, Grills I, Sonke JJ. Validation of High-Risk Computed Tomography Features for Detection of Local Recurrence After Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2016; 96:134-41. [DOI: 10.1016/j.ijrobp.2016.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/16/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
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21
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Brown LM, Louie BE, Jackson N, Farivar AS, Aye RW, Vallières E. Recurrence and Survival After Segmentectomy in Patients With Prior Lung Resection for Early-Stage Non-Small Cell Lung Cancer. Ann Thorac Surg 2016; 102:1110-8. [PMID: 27350237 DOI: 10.1016/j.athoracsur.2016.04.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 03/12/2016] [Accepted: 04/11/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lobectomy is the standard of care for patients with early-stage non-small cell lung cancer (NSCLC). However, the treatment of choice for patients with prior lung resection and a second primary NSCLC has not been established. We compared rates and patterns of recurrence and survival in patients with and without prior lung resection treated by segmentectomy and determined predictors of recurrence. METHODS This was a retrospective cohort study of 90 patients who underwent 91 consecutive segmentectomies for early-stage NSCLC between April 2004 and December 2014. Logistic regression was used to determine predictors of recurrence, and Kaplan-Meier curves were used to determine survival. RESULTS Of the 91 segmentectomies, 21 (23%) had a prior lung cancer resection and 70 (77%) were primary resections. There were 18 recurrences (20%): 9 of 21 (43%) in those with prior lung resection and 9 of 70 (13%) in those without. The 90-day mortality was 0%. The recurrence-free survival and 5-year survival were 61% and 55% in those with prior lung resection (p = 0.09) and 84% and 65% in those without (p = 0.4). Close parenchymal margin and number of lymph nodes examined were significant modifiable predictors of recurrence. CONCLUSIONS Segmentectomy is a reasonable option for patients with early-stage NSCLC who have had a prior lung resection. It results in similar survival but trends toward lower recurrence-free survival compared with patients undergoing primary resection.
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Affiliation(s)
- Lisa M Brown
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Washington.
| | - Nicole Jackson
- Department of Cardiothoracic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Ralph W Aye
- Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Washington
| | - Eric Vallières
- Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Washington
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22
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Mattonen SA, Ward AD, Palma DA. Pulmonary imaging after stereotactic radiotherapy-does RECIST still apply? Br J Radiol 2016; 89:20160113. [PMID: 27245137 DOI: 10.1259/bjr.20160113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The use of stereotactic ablative radiotherapy (SABR) for the treatment of primary lung cancer and metastatic disease is rapidly increasing. However, the presence of benign fibrotic changes on CT imaging makes response assessment following SABR a challenge, as these changes develop with an appearance similar to tumour recurrence. Misclassification of benign fibrosis as local recurrence has resulted in unnecessary interventions, including biopsy and surgical resection. Response evaluation criteria in solid tumours (RECIST) are widely used as a universal set of guidelines to assess tumour response following treatment. However, in the context of non-spherical and irregular post-SABR fibrotic changes, the RECIST criteria can have several limitations. Positron emission tomography can also play a role in response assessment following SABR; however, false-positive results in regions of inflammatory lung post-SABR can be a major clinical issue and optimal standardized uptake values to distinguish fibrosis and recurrence have not been determined. Although validated CT high-risk features show a high sensitivity and specificity for predicting recurrence, most recurrences are not detected until more than 1-year post-treatment. Advanced quantitative radiomic analysis on CT imaging has demonstrated promise in distinguishing benign fibrotic changes from local recurrence at earlier time points, and more accurately, than physician assessment. Overall, the use of RECIST alone may prove inferior to novel metrics of assessing response.
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Affiliation(s)
- Sarah A Mattonen
- 1 Department of Medical Biophysics, The University of Western Ontario, London, ON, Canada
| | - Aaron D Ward
- 1 Department of Medical Biophysics, The University of Western Ontario, London, ON, Canada.,2 Department of Oncology, The University of Western Ontario, London, ON, Canada
| | - David A Palma
- 2 Department of Oncology, The University of Western Ontario, London, ON, Canada.,3 Division of Radiation Oncology, London Health Sciences Centre, London, ON, Canada
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23
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Detection of Local Cancer Recurrence After Stereotactic Ablative Radiation Therapy for Lung Cancer: Physician Performance Versus Radiomic Assessment. Int J Radiat Oncol Biol Phys 2016; 94:1121-8. [DOI: 10.1016/j.ijrobp.2015.12.369] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 12/11/2015] [Accepted: 12/21/2015] [Indexed: 12/25/2022]
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24
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Follow-up of patients after stereotactic radiation for lung cancer: a primer for the nonradiation oncologist. J Thorac Oncol 2016; 10:412-9. [PMID: 25695219 DOI: 10.1097/jto.0000000000000435] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The use of stereotactic ablative radiotherapy (SABR) as primary treatment for early stage non-small-cell lung cancer, or for ablation of metastases, has increased rapidly in the past decade. With local recurrence rates reported at approximately 10%, and a patient population that is becoming increasingly fit and amenable to salvage treatment, appropriate multidisciplinary follow-up care is critical. Appropriate follow-up will allow for detection and management of radiation-related toxicity, early detection of recurrent disease and differentiation of recurrence from radiation-induced lung injury. METHODS This narrative review summarizes issues surrounding follow-up of patients treated with SABR in the context of a multidisciplinary perspective. We summarize treatment-related toxicities including radiation pneumonitis, chest wall pain, rib fracture, and fatal toxicity, and highlight the challenges of early and accurate detection of local recurrence, while avoiding unnecessary biopsy or treatment of benign radiation-induced fibrotic lung damage. RESULTS Follow-up recommendations based on the current evidence and available guidelines are summarized. Imaging follow-up recommendations include serial computed tomography (CT) imaging at 3-6 months posttreatment for the initial year, then every 6-12 months for an additional 3 years, and annually thereafter. With suspicion of progressive disease, recommendations include a multidisciplinary team discussion, the use of high-risk CT features for accurate detection of local recurrence, and positron emission tomography/CT SUV max cutoffs to prompt further investigation. Biopsy and/or surgical or nonsurgical salvage therapy can be considered if safe and when investigations are nonreassuring. CONCLUSIONS The appropriate follow-up of patients after SABR requires collaborative input from nearly all members of the thoracic multidisciplinary team, and evidence is available to guide treatment decisions. Further research is required to develop better predictors of toxicity and recurrence.
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Uramoto H. Current Topics on Salvage Thoracic Surgery in Patients with Primary Lung Cancer. Ann Thorac Cardiovasc Surg 2016; 22:65-8. [PMID: 26948299 DOI: 10.5761/atcs.ra.16-00019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Salvage primary tumor resection is sometimes considered for isolated local failures after definitive chemoradiation, urgent matters, such as hemoptysis (palliative intent), and in cases judged to be contraindicated for chemotherapy or definite radiation due to severe comorbidities, despite an initial clinical diagnosis of stage III or IV disease. However, salvage surgery is generally considered to be technically more difficult, with a potentially higher morbidity. This review discusses the current topics on salvage thoracic surgery such as the definition of salvage surgery and its outcome, and future perspectives.
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Affiliation(s)
- Hidetaka Uramoto
- Division of Thoracic Surgery, Saitama Cancer Center, Kita-adachi-gun, Saitama, Japan
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Schreiner W, Dudek W, Lettmaier S, Fietkau R, Sirbu H. Should salvage surgery be considered for local recurrence after definitive chemoradiation in locally advanced non-small cell lung cancer? J Cardiothorac Surg 2016; 11:9. [PMID: 26781697 PMCID: PMC4717585 DOI: 10.1186/s13019-016-0396-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 01/10/2016] [Indexed: 12/25/2022] Open
Abstract
Background Incidence of local relapse after definitive chemoradiation (>59 Gy) for locally advanced non-small-cell lung cancer (NSCLC) is high, irrespective of high dose radiation applied. Experience with salvage lung resections in patients with locally relapsed NSCLC after definitive chemoradiation is limited. We present our series of salvage lung resections for local NSCLC relapse after curative–intent chemoradiation for locally advanced tumor. Methods Nine consecutive patients with local tumor recurrence or persistence following definitive chemoradiation were reviewed. Kaplan-Meier analysis was used to assess patient survival. Results All patients received definitive radiation (median dose 66.2 Gy) with concurrent chemotherapy. Tumor stage prior to chemoradiation was IIIA in 8 patients and IV in 1. In 4 patients tumor invaded the chest wall, in 2 the spine and in 1 the aorta. Median interval between chemoradiation and salvage resection was 30.2 weeks. Nine patients underwent 9 resections (6 lobectomies, 1 bilobectomy, 1 pneumonectomy and 1 bi-segmentectomy). One death occurred on the 12th postoperative day. Median overall survival was 23 months; postoperative 3-year survival was 47 %. Median progression-free survival was 21 months. Conclusion Salvage lung resection for locally recurrent or persisted NSCLC in selected patients with locally advanced NSCLC following definitive chemoradiation is a worthwhile treatment option.
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Affiliation(s)
- Waldemar Schreiner
- Department of Thoracic Surgery, University Hospital, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Wojciech Dudek
- Department of Thoracic Surgery, University Hospital, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Sebastian Lettmaier
- Department of Radiation Oncology, University Hospital, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Horia Sirbu
- Department of Thoracic Surgery, University Hospital, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
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Treatment and Prognosis of Isolated Local Relapse after Stereotactic Body Radiotherapy for Clinical Stage I Non-Small-Cell Lung Cancer. J Thorac Oncol 2015; 10:1616-24. [DOI: 10.1097/jto.0000000000000662] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Schreiner W, Dudek W, Sirbu H. Is salvage surgery for recurrent non-small-cell lung cancer after definitive non-operative therapy associated with reasonable survival? Interact Cardiovasc Thorac Surg 2015; 21:682-4. [PMID: 26323288 DOI: 10.1093/icvts/ivv243] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/03/2015] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether salvage pulmonary resection is possible and worthwhile for patients with recurrence of non-small-cell lung cancer (NSCLC) after prior definitive non-operative therapy. A total of nine reports were identified using the reported search, of which four represented the best available evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All studies were retrospective. In total, 48 pulmonary salvage resections were performed in 47 patients after prior definitive radiation, chemoradiation or stereotactic body radiation therapy, of which 28 were lobectomies (including 1 sleeve lobectomy), 12 pneumonectomies, 4 bilobectomies and 4 sublobar resections (2 segmentectomies and 2 wedge resections). Postoperative complications ranged from 0 to 58% (mean from four studies 42.5%). Only one study reported any mortality (4%), the other three had zero mortality. Median postoperative survival was reported in two studies and ranged from 9 to 30 months. Experience with salvage lung resection for locally recurrent NSCLC, after prior definitive non-surgical treatment, remains limited. Therefore, this analysis was based on only 48 resections in 47 patients from four retrospective studies. Nevertheless, the published data suggest that salvage lung surgery for recurrent, previously non-operatively managed non-small-cell lung cancer is a worthwhile treatment option with good survival, acceptable morbidity and low mortality.
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Affiliation(s)
- Waldemar Schreiner
- Department of Thoracic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Wojciech Dudek
- Department of Thoracic Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Horia Sirbu
- Department of Thoracic Surgery, University Hospital Erlangen, Erlangen, Germany
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Patterns of Disease Recurrence after SABR for Early Stage Non–Small-Cell Lung Cancer: Optimizing Follow-Up Schedules for Salvage Therapy. J Thorac Oncol 2015. [DOI: 10.1097/jto.0000000000000576] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Louie AV, Palma DA, Dahele M, Rodrigues GB, Senan S. Management of early-stage non-small cell lung cancer using stereotactic ablative radiotherapy: Controversies, insights, and changing horizons. Radiother Oncol 2015; 114:138-47. [DOI: 10.1016/j.radonc.2014.11.036] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 12/17/2022]
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Faruqi S, Giuliani ME, Raziee H, Yap ML, Roberts H, Le LW, Brade A, Cho J, Sun A, Bezjak A, Hope AJ. Interrater Reliability of the Categorization of Late Radiographic Changes After Lung Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2014; 89:1076-1083. [DOI: 10.1016/j.ijrobp.2014.04.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/17/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
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High-risk CT features for detection of local recurrence after stereotactic ablative radiotherapy for lung cancer. Radiother Oncol 2013; 109:51-7. [DOI: 10.1016/j.radonc.2013.06.047] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 06/20/2013] [Accepted: 06/24/2013] [Indexed: 11/19/2022]
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Stauder MC, Rooney JW, Neben-Wittich MA, Garces YI, Olivier KR. Late tumor pseudoprogression followed by complete remission after lung stereotactic ablative radiotherapy. Radiat Oncol 2013; 8:167. [PMID: 23829565 PMCID: PMC3707780 DOI: 10.1186/1748-717x-8-167] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 06/28/2013] [Indexed: 12/21/2022] Open
Abstract
Lung stereotactic ablative radiotherapy (SABR) has recently become more common in the management of patients with early-stage non-small cell lung cancer (NSCLC) and metastatic lung lesions who are not surgical candidates. By design, SABR is applied to small treatment volumes, using fewer but significantly higher dose fractions, and steep dose gradients. This treatment theoretically maximizes tumor cell death and decreases the risk of damage to the surrounding normal tissues. Local control rates for SABR in early stage lung cancer remain high. Since the numbers of primary tumor recurrences is small, some debate exists as to the appropriate definition of treatment failure. Controversies remain regarding the most appropriate interpretation of imaging tests obtained to evaluate treatment outcomes after lung SABR. Most definitions of progression include an increasing diameter of target lesion which can be problematic given the known mass-like consolidation seen on CT imaging after ablative therapy. Here, we present a case report illustrative of the pitfalls of relying solely on anatomic imaging to determine SABR treatment failure.
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Affiliation(s)
- Michael C Stauder
- Department of Radiation Oncology, MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1202, Houston, TX 77030, USA.
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Treatment of early-stage lung cancer detected by screening: surgery or stereotactic ablative radiotherapy? Lancet Oncol 2013; 14:e270-4. [DOI: 10.1016/s1470-2045(12)70592-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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