Should salvage surgery be considered for local recurrence after definitive chemoradiation in locally advanced non-small cell lung cancer?

Rescue surgery in palliative indication as last therapeutic option for complicated advanced stage lung cancer

OBJECTIVE

To evaluate the role of rescue surgery in complicated initially not operatively intended advanced stage lung cancer.

MATERIALS AND METHODS

Retrospective analysis of 30 patients with advanced lung cancer who underwent rescue surgery for control of life-threatening, non-conservatively manageable tumor related complications like post-obstructive pneumonia, super-infected tumor necrosis or active bleeding. Study parameters included tumor stage, histology, type of resection, and patients' characteristics as well as postoperative outcomes.

RESULTS

The study cohort consisted of 12 female and 18 male patients, among those 29 were diagnosed with Non-Small Cell Lung Cancer (NSCLC) and one with Small Cell Lung Cancer (SCLC). On initial tumor-diagnosis 20 patients had been classified as stage IV and 9 with stage III; 1 patient had not yet been completely staged at time of surgery for active tumor bleeding. In all patients, the indication for rescue surgery was not oncologic-therapeutic but to control non-conservatively manageable complications which either contradicted any tumor-specific systemic therapy or acutely threatened life. Types of resections included pneumonectomy, bi-lobectomy, lobectomy and segmentectomy. The mean overall survival was 13.3 (median 11.2) months, the 1-year-survival-probability of the cohort was 45,2%. The 30- and 90-day mortality was 13,3 and 30%, respectively. The reasons for early postoperative mortality were ARDS, multiorgan failure and bronchial-stump insufficiency.

CONCLUSIONS

Rescue surgery for tumor- or therapy-induced life-threatening complications in patients with advanced stage lung cancer is associated with high morbidity and mortality. However, if all other treatment options have failed it nevertheless may be indicated as the last therapeutic chance and if surgery succeeds in controlling the acute event it may also set the condition for subsequent tumor-specific therapies. Future research should focus on elaborating effective criteria regarding patient selection and timing of surgery in order to restrict these high-risk-operations to only those patients, who most likely will benefit.

The Role of Salvage Resection After Definitive Radiation Therapy for Non-small Cell Lung Cancer

BACKGROUND

This study evaluated outcomes of patients who undergo extended delay to resection after definitive radiation therapy for non-small cell lung cancer (NSCLC).

METHODS

Perioperative outcomes and 5-year overall survival of patients with NSCLC who underwent definitive radiation therapy, followed by resection, from 2004 to 2020 in the National Cancer Database were evaluated. Patients who underwent resection >180 days after the initiation of radiation therapy (including any external beam therapy at a total dose of >60 Gy) were included in the analysis. Subgroup analyses were conducted by operation type and pathologic nodal status.

RESULTS

From 2004 to 2020, 293 patients had an extended delay to resection after definitive radiation therapy. The clinical stage distribution was stage I to II in 53 patients (18.1%), stage IIIA in 111 (37.9%), stage IIIB in 106 (36.2%), stage IIIC in 13 (4.4%), and stage IV in 10 (3.4%). Median dose of radiation therapy received was 64.8 Gy (interquartile range, 60.0-66.6 Gy). Median days from radiation therapy to resection were 221.0 (interquartile range, 193.0-287.0) days. Lobectomy (64.5%) was the most common operation, followed by pneumonectomy (17.1%) and wedge resection (7.5%). For wedge resection, lobectomy, and pneumonectomy, the 30-day readmission rate was 4.8%, 4.8%, and 8.3%, the 30-day mortality rate was 0%, 3.4%, and 6.4%, and the 90-day mortality rate was 0%, 6.2%, and 12.8%, respectively. Overall survival at 5 years for patients with pN0, pN1, and pN2 disease was 38.6% (95% CI, 30.0-47.2), 43.3% (95% CI, 16.3-67.9), and 24.0% (95% CI, 9.8-41.7), respectively.

CONCLUSIONS

In this national analysis, extended delay to resection after definitive radiation therapy was associated with acceptable perioperative outcomes among a highly selected patient cohort.

Reduction of Blood Loss by Means of the Cavitron Ultrasonic Surgical Aspirator for Thoracoscopic Salvage Anatomic Lung Resections

In centrally located lung tumors, salvage pulmonary resections pose challenges due to adhesions between the pulmonary parenchyma, chest wall, and hilum. This study aimed to investigate the surgical outcomes associated with Cavitron Ultrasonic Surgical Aspirator (CUSA) usage in thoracoscopic salvage pulmonary resections. Patients with centrally located advanced-stage lung tumors who underwent salvage anatomic resections following systemic or radiotherapy were included. They were categorized into CUSA and non-CUSA groups, and perioperative parameters and surgical outcomes were analyzed. Results: The study included 7 patients in the CUSA group and 15 in the non-CUSA group. Despite a longer median surgical time in the CUSA group (3.8 h vs. 6.0 h, p = 0.021), there was a significant reduction in blood loss (100 mL vs. 250 mL, p = 0.014). Multivariate analyses revealed that the use of CUSA and radiotherapy had opposing effects on blood loss (β: -296.7, 95% CI: -24.8 to -568.6, p = 0.034 and β: 282.9, 95% CI: 19.7 to 546.3, p = 0.037, respectively). In conclusion, while using CUSA in the salvage anatomic resection of centrally located lung cancer may result in a longer surgical time, it is crucial in minimizing blood loss during the procedure.

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.

Salvage surgery after definitive chemoradiotherapy through VATS for an initial unresectable locally advanced lung cancer: an alternative consolidative modality to radiotherapy?

Background

Definitive chemoradiotherapy (dCRT) is the first choice treatment for patients with locally advanced non-small cell lung cancer (NSCLC), but up to 35% of dCRT-treated tumors may have persistent or recurrent disease. Since the last decades, multimodality therapy showing potential for cure has become the mainstream for treatment of locally advanced NSCLCs, even some that were initially inoperable. Although salvage lung resection after dCRT has been reported with acceptable survivals, experiences in this respect are still limited. Other concerns remain debatable and inconclusive, such as dosage of radiation exposure, long interval between dCRT and surgery, and surgical comorbidity.

Case presentation

A 73-year-old male former smoker with diagnosis of right lower lobe of lung squamous cell carcinoma (SqCC) with multiple mediastinal lymphadenopathy, cT4N2M0, stage IIIB, received salvage right lower lobe + right middle lobe bilobectomy through video-assisted thoracoscopic surgery (VATS) after dCRT and adjuvant CRT to a total of 9000 cGy dosage of radiation. The interval from the 1st and 2nd ends of radiation to the salvage surgery was 980 and 164 days, respectively. The pre-operative forced expiratory volume in the first second was 2.33 L (101% predicted) and the diffusing capacity of the lungs for carbon monoxide was 56% predicted. The operating time was 6.5 h, and the total estimated blood loss was 50 ml. The patient was discharged on the 7th postoperative day without major complications or bronchopleural fistulas. The patient was still alive 42 months after the initial diagnosis of advanced N2 lung SqCC, and kept progression-free for 7 months after salvage lung resection.

Conclusions

Salvage lung resection performed long after high-dose radiation therapy of dCRT is technically feasible through VATS approach in a patient with initially inoperable cT4N2M0 stage IIIB NSCLC, and can be an alternative consolidative treatment for locally advanced NSCLC.

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 after chemotherapy and/or radiotherapy including SBRT and proton therapy: A consecutive analysis of 38 patients

BACKGROUND

Local recurrence after definitive chemoradiation therapy, chemotherapy or radiotherapy with curative intent is often seen in patients with advanced non-small cell lung cancer. We evaluated the feasibility of salvage pulmonary resection after definitive non-surgical treatments and the postoperative morbidity and mortality rates.

METHODS

We retrospectively analyzed the characteristics and medical courses of patients who had undergone salvage pulmonary resections after local relapse or progression between January 2000 and March 2018 at the National Cancer Centre Hospital, Tokyo, Japan. All the candidates were evaluated, and curability by surgical resection was assessed by a multidisciplinary tumor board.

RESULTS

A total of 38 patient received salvage surgery: 26 of the patients were men, and the median age was 64.5 years (range, 20-78 years). Among these 38 patients, salvage lung resection was performed after chemoradiotherapy in 23 patients, after chemotherapy in 9 patients, and after radiotherapy with curative intent in 6 patients. The surgical resection methods were as follows: 26 lobectomies (2 bilobectomy, 15 right upper, 5 right lower, 1 right middle, 2 left lower and 1 left upper), 8 pneumonectomies (5 left and 3 right), and 4 segmentectomies. A complete resection (R0 resection) was achieved in 35 cases (92.1 %). Postoperative complications were observed in 3 patients (prolonged air leakage, bronchopleural fistula and surgical site infection in 1 patient each). No postoperative deaths occurred within 30 days after surgery.

CONCLUSION

Along with better outcomes after definitive chemoradiotherapy, chemotherapy, and radiotherapy, the frequency of salvage surgery has been increasing in recent years. Salvage pulmonary resections after definitive non-surgical treatments with curative intent are feasible with an acceptable morbidity rate and oncological outcomes in thoroughly assessed patients.

Salvage surgery combined with descending aorta resection for lung cancer

Background

Recent retrospective studies have shown that salvage surgery can improve survival with acceptable adverse events, and this procedure has been adapted for lung cancer. However, there are no reports demonstrating the efficacy of salvage surgery combined with aortic resection.

Case presentation

A 73-year-old man had received definitive concurrent chemoradiotherapy (carboplatin/paclitaxel, 70 Gy) for lung cancer originated from the left upper lobe and infiltrating the thoracic aorta (cT4N1M0 stage IIIA). Although the tumor has shrunk significantly (ycT4N0M0 stage IIIA), radiation pneumonitis occurred. Due to the steroid therapy, radiation pneumonitis was relieved; however, re-enlargement of the primary tumor was observed during steroid tapering. Nonetheless, the lymphatic and distant metastases were controlled. Moreover, aortic invasion was localized to the periphery of the third branch, and the tumor was considered to be resectable. Intraoperatively, we observed macroscopic evidence of aortic invasion in the periphery of the third branch; thus, left upper lobectomy combined with descending aorta resection was performed under partial extracorporeal circulation. The patient is currently active without any recurrence 21 months post-surgery.

Conclusions

No clear consensus exists regarding salvage surgery combined with aortic resection for primary lung cancer. However, we believe that this surgery may improve the survival of carefully selected patients.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Salvage thoracic surgery in patients with lung cancer: potential indications and benefits

Background

To investigate the feasibility and efficacy of salvage lung resection and describe the possible indications and contraindications in patients with primary lung cancer.

Methods

Thirty patients undergoing anatomical salvage lung resection were classified into three groups: GI, patients with progressive lung tumor despite definitive chemo- and/or radiotherapy; GII, patients who underwent emergency resection; and GIII, patients in whom neoadjuvant or definitive chemo- and/or radiotherapy was contraindicated because of severe comorbidities. The groups were compared based on, peri- and postoperative factors, and survival rates.

Results

The morbidity rate was 70%. Revision surgery was required in 23% of patients. Morbidity was affected by lower hematocrit and hemoglobin levels (P = 0.05). Mean hospital stay was 11 ± 4 days, which was longer in patients in whom complications developed (P = 0.0003). The in-hospital or 30-day mortality rate was 3%. Mean relapse-free survival and overall survivals were 14 ± 12 and 19 ± 13 months.

Conclusion

Patients with progression of the persistent primary tumor after definitive chemo- and/or radiotherapy can undergo salvage lung resection with acceptable mortality and high morbidity rates, if the tumor is considered resectable. Other indications may be considered for salvage lung resection based on each patient’s specific evaluation.

Salvage surgery after high-dose radiotherapy

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.

Long-Term Outcomes of Salvage Stereotactic Ablative Radiotherapy for Isolated Lung Recurrence of Non-Small Cell Lung Cancer: A Phase II Clinical Trial

OBJECTIVES

Our goal was to evaluate stereotactic ablative radiotherapy (SABR) as a salvage option for isolated recurrence of NSCLC in the lung parenchyma after definitive treatment of stage I to III disease.

METHODS

Patients who had histologically confirmed, positron emission tomography-staged, isolated NSCLC recurring locally or metastasis in the lung parenchyma (≤3 cm, suitable for SABR) after previous definitive treatment were prospectively enrolled in this trial and treated with volumetric, image-guided SABR to 50 Gy in four fractions. Patients were then followed with computed tomography or positron emission tomography/computed tomography. Primary end points included the pattern of failure after salvage SABR, overall survival (OS), and progression-free survival (PFS).

RESULTS

Fifty-nine patients with recurrent disease were treated with salvage SABR. The median age was 70 years (range 45-86 years), and the median follow-up time after salvage SABR was 58.3 months. Re-recurrence after salvage SABR developed in 19 patients (32%). Measuring from the date of salvage SABR, the estimated 5-year rates of local, regional, and distant failure were 5.2%, 10.3%, and 22.4%, respectively; the estimated PFS was 46.2% at 3 years and 41.1% at 5 years; and the OS rates were 63.5% at 3 years and 56.5% at 5 years. A high post-SABR neutrophil-to-lymphocyte ratio was found to predict poor survival. Grade 3 treatment-related adverse events developed in three patients (5%). No patient had a grade 4 or 5 event.

CONCLUSION

Our study showed that salvage SABR provides excellent 5-year OS, local control, and PFS rates with minimal toxicity for patients with isolated NSCLC recurrence in the lung parenchyma. These results are striking and comparable to historically reported outcomes of patients with primary early-stage NSCLC treated with definitive SABR. SABR appears to be a very effective and safe salvage option for patients with isolated lung parenchyma recurrent disease after definitive treatment and should be considered along with surgery as a potential first-line option for patients with local lung parenchymal recurrent disease.

Clinical outcomes of cytoreductive surgery combined with intrapleural perfusion of hyperthermic chemotherapy in advanced lung adenocarcinoma with pleural dissemination

BACKGROUND

This study aimed to investigate the safety and feasibility of intrapleural perfusion hyperthermic chemotherapy (IPHC) followed by cytoreductive surgery as a part of multimodal strategy for the treatment of advanced lung adenocarcinoma.

METHODS

Medical records of advanced lung cancer patients with pleural dissemination who underwent surgical treatment between 2003 and 2013 were reviewed retrospectively. Enrolled patients were divided into a surgery group comprising patients who underwent surgery only and an IPHC group, which consisted of patients who underwent surgery combined with IPHC.

RESULTS

A total of 33 patients were enrolled in this study. Twenty-three patients underwent IPHC after surgical resection, and 10 patients underwent surgical resection only. The complication rate of the IPHC group was estimated to be 34.8% (8 cases), none of which included postoperative mortality. The complication rate of the surgery group was 40.0% (4 cases), which included one postoperative mortality. The 6-month, 1-year, and 3-year overall survival rates for the IPHC group were 95.7%, 91.3% and 38.6%, respectively, while those of the surgery group were 80.0%, 80.0% and 37.5%. The 6-month, 1-year and 3-year progression-free survival rates for the IPHC group were 87.0%, 47.8% and 24.3%, while those of surgery group were 44.4%, 33.3% and 0.0%, respectively. There were significant differences in overall survival rates between two groups (P=0.045); however, progression-free survival was not different between the two groups.

CONCLUSIONS

IPHC combined with cytoreductive surgery for advanced lung adenocarcinoma associated with pleural seeding could be performed safely and feasible. It would be part of multimodality therapy for certain category of advanced lung adenocarcinoma. However, the long-term benefits for survival is uncertain. More extensive and precisely designed studies are warranted to further evaluate the effectiveness of IPHC.