Thoracoscopic lobectomy as salvage surgery for local recurrence of non-small cell lung cancer after carbon ion radiotherapy in an initially operable patient

Salvage surgery for local recurrence after carbon ion radiotherapy for lung cancer: A case report

Background

The good local control rate of radiation therapy has been reported due to recent advances in irradiation technology. Carbon ion radiation therapy (CIRT) has been shown to be effective for early lung cancer. We report a case of performing salvage surgery on the local recurrence of lung cancer after CIRT.

Case presentation

A 79-year-old man was referred to our hospital for treatment of local recurrence of left lung cancer at fifty nine months after CIRT. We performed wedge resection for diagnostic purposes. It was diagnosed as squamous cell carcinoma and was regarded as local recurrence. Subsequently, we performed left upper lobectomy and mediastinal lymph node dissection. The patient had recurrent lesions at 4 months after surgery and died 10 months after surgery.

Conclusions

Surgery was safe even after CIRT. We considered that salvage surgery after CIRT may be one of the options of local control therapy for lung cancer.

Is salvage surgery for patients with lung cancer after carbon ion radiotherapy easy or difficult?

Carbon ion radiotherapy (CIRT) shows higher local control rates and minimal damage to normal lung parenchyma compared with conventional radiotherapy; however, some patients experience local recurrence. The efficacy and safety of salvage surgery after CIRT for non-small-cell lung cancer are unclear. We reviewed clinical, surgical, pathological and prognostic data of 6 patients who underwent salvage surgery after CIRT between 2010 and 2015. All patients were men with a smoking history, and their median age was 67 years. The time from CIRT to surgery was 18 (range 12-24) months. All patients underwent at least lobectomy with mediastinal node dissection. Viable tumour cells were confirmed pathologically in all cases. Five patients required combined resection or extra procedure because of strong adhesions and the possibility of tumour extension; however, none of the patients had a tumour invasion to the adjacent organ. None of the patients had severe complications, perioperative death and local recurrence, and 3 patients are alive without recurrence (range 28-84 months). Salvage surgery appears to be safe and effective. Even though the tumours did not invade the adjacent organs, combined resection was required because of severe adhesion.

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.

Salvage surgery for local recurrence after carbon ion radiotherapy for patients with lung cancer

OBJECTIVES

Carbon ion radiotherapy (CIRT) has been expected to be an alternative for surgery for early-stage non-small-cell lung cancer (NSCLC) and adopted as the second-best choice even in operable patients although local recurrence after CIRT is sometimes experienced. The purpose of this study was to investigate the demographic data, perioperative courses and therapeutic outcomes of patients who underwent salvage resection for local recurrence after CIRT.

METHODS

From November 1994 to February 2012, CIRT was applied for 602 c-T1/T2/T3N0M0 NSCLC lesions of 599 patients at the National Institute of Radiological Science. A total of 95 (16%) patients were diagnosed as having local recurrence, of whom 12 underwent salvage surgeries. The medical records were retrospectively reviewed.

RESULTS

There were 7 men and 5 women (mean age, 63 ± 7.4 years). The clinical stages upon initial presentation with NSCLC were as follows: 4 IA, 7 IB and 1 IIB. All the patients were operable, but refused surgery and underwent CIRT. The median progression-free survival time after CIRT was 20 months (range, 7.1-77 months), and salvage surgery was performed at a median of 24 months (range, 9-78 months) after CIRT. All surgeries were successfully performed without any significant CIRT-related adhesions during the surgery, resulting in no mortality or Clavien-Dindo grade 3-4 postoperative complications. However, the distribution of pathological stages was as follows: 4 IA, 3 IB, 2 IIB, 2 IIIA and 1 IV, which included 6 upstages from the clinical stages before CIRT. The Kaplan-Meier estimate of overall survival after the salvage surgery showed that the 3-year survival rate was 82%.

CONCLUSIONS

The dose intensity of CIRT spared the hilum of the lungs and parietal pleura, none of the patients developed adhesions outside of the radiation field, such that the salvage surgeries for local recurrence after CIRT were safe and feasible.