Current Topics on Salvage Thoracic Surgery in Patients with Primary Lung Cancer

Thoracic Reirradiation with Stereotactic Body Radiation Therapy (SBRT) for Recurrent Advanced Non-Small Cell Lung Cancer (NSCLC)

PURPOSE

Non-small cell lung cancer (NSCLC) local control remains suboptimal with rates around 75%. Stereotactic body radiation therapy (SBRT) is an option for isolated local recurrences of small-volume recurrences. This study investigates the safety and efficacy of 60 Gy in 8 fractions in large-volume local recurrences.

METHODS AND MATERIALS

We conducted a retrospective chart review of patients treated with salvage SBRT for NSCLC lung parenchymal recurrence between July 2013 and February 2020. Reirradiation prescribed dose was 60 Gy in 8 fractions using the SBRT technique. The primary endpoint was local control at most recent follow-up or death. Secondary endpoints included overall survival, disease-free interval, cancer-specific survival, and treatment related toxicities.

RESULTS

Seven patients met inclusion criteria. Median follow up time was 38 months (18.1-72.4). Median age was 67 years (63-80). Median time to reirradiation was 18.2 months (7.3-28.6). Retreatment median ITV was 57.9 cc (15.8-344.6), and PTV median was 113.6 cc (38.3-506.9). Local control was maintained in 4 of 7 patients (57.1%). Two of the 7 patients (28.6%) remained alive. Median disease-free interval was 22.5 months (11-65). Three of 7 patients (42.9%) had grade 2 toxicities. One patient (14.3%) had a grade 3 rib/chest wall toxicity with concurrent disease recurrence invading the chest wall.

CONCLUSION

This study reports that SBRT of 60 Gy in 8 fractions was delivered safely and effectively to large volume recurrent NSCLC previously treated with radiation therapy. The disease-free interval of nearly 2 years is meaningful for patients' quality of life and duration of time off systemic therapy.

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.

Salvage surgery for advanced non-small cell lung cancer following previous immunotherapy: a retrospective study

BACKGROUND

The development of systemic chemotherapy including immune checkpoint inhibitors (ICIs) has provided patients with unresectable advanced non-small cell lung cancer (NSCLC) an opportunity to undergo surgical intervention after initial treatment. However, no consensus regarding the indication for salvage surgery in these patients has been reached.

METHODS

We conducted a retrospective study of patients who underwent salvage surgery for advanced NSCLC (cStage IIIA-IVB) after treatment with ICIs from January 2018 to December 2022 at Aizu Medical Center and Fukushima Medical University Hospital. We evaluated the patients' clinical data, calculated disease-free survival (DFS) and overall survival (OS), and assessed the survival benefit using the Kaplan-Meier method.

RESULTS

Thirteen patients underwent salvage surgery after immunotherapy. All patients achieved downstaging after initial chemotherapy. Eleven patients underwent lobectomy, and one patient underwent extirpation of intra-abdominal lymph nodes. The mean surgery time and intraoperative blood loss were 242.2 min and 415.1 g, respectively. The mean drainage period was 4.2 days (range, 2-9 days). Grade ≥ 3 postoperative complications were confirmed in three patients. The 2-year DFS rate was 71.2%, and the 2-year OS rate was 76.2%. A pathological complete response compatible with ypStage 0 was achieved in four (30.8%) patients. Patients with ypStage 0 and I achieved significantly better OS than those with ypStage ≥ II (p = 0.044), and patients without severe complications achieved significantly better DFS and OS than those with severe complications (p = 0.001 and p < 0.001, respectively).

CONCLUSIONS

Salvage surgery after chemotherapy including ICIs is a feasible and effective treatment option for patients with advanced NSCLC, especially those who acquire downstaging to pathological stage 0 or I. However, severe perioperative complications might affect patient survival. A prospective study is urgently needed to evaluate the efficacy of salvage surgery.

Multimodality Treatment and Salvage Surgery for the Treatment of Lung Cancer

Lung cancer remains the leading cause of cancer deaths in the United Kingdom. For locally advanced disease, multimodality treatment is recommended, which includes a combination of chemotherapy, radiotherapy, surgery and, more recently immunotherapy. Options depend on the resectability of the cancer and there has been debate about the optimal treatment strategy: surgery may be planned to follow chemoradiotherapy (CRT), be offered for residual disease after CRT, or given as salvage therapy for patients treated with CRT who have later relapse of their disease. We conducted a retrospective analysis of all patients who underwent CRT and surgical resection under a single surgical team and performed a descriptive study after dividing the patients into these three groups. For the planned trimodality group, 30-day mortality this was 7% (n = 1) and 1-year survival was 78.6%; the residual disease group had a 30-day mortality rate of 0% and 1-year survival of 81.3%; for the salvage group, the figures were 0% and 62.5%, respectively. The median overall survival of the study population was 35.8 months. Median overall survival in the trimodality group was 35.4 months (20.1-51.7 interquartile range IQR), for the residual group was 34.2 months (18.5-61.0 IQR). and for the salvage group was 35.8 months (32.4-52.7 IQR).).

Salvage Surgery for Small-Cell Lung Cancer-A Literature Review

(1) Background: Salvation surgery for small-cell lung cancer (SCLC) is exceptionally performed, and only a few cases are published. (2) Methods: There are 6 publications that present 17 cases of salvation surgery for SCLC-the salvation surgery was performed in the context of modern clearly established protocols for SCLC and after including SCLC in the TNM (tumor, node, metastasis) staging in 2010. (3) Results: After a median follow-up of 29 months, the estimated overall survival (OS) was 86 months. The median estimated 2-year survival was 92%, and the median estimated 5-year survival was 66%. (4) Conclusion: Salvage surgery for SCLC is a relatively new and extremely uncommon concept and represents an alternative to second-line chemotherapy. It is valuable because it may offer a reasonable treatment for selected patients, good local control, and a favorable survival outcome.

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.

Treatment of a Double Cancer Patient With Primary Inferior Vena Cava Sarcoma and Lung Adenocarcinoma: A Case Report and Literature Review

Background

Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignancy. Here, we present the case of a 38-year-old woman with a primary IVC leiomyosarcoma and lung adenocarcinoma.

Case Report

The patient, a 38-year-old Chinese female, presented to the general surgical outpatients clinic with a 18-month history of intermittent right upper abdominal pain. Contrast-enhanced computed tomography (CT) showed a tumor of IVC (3.4^*2.7 cm) extending to the renal veins. In addition, chest CT revealed a mass lesion in the upper left lung lobe. Then, the patient underwent resection of the IVC tumor and wedge resection of the upper lobe of the left lung. The patient then received gefitinib (250 mg/day) as a maintenance therapy until the tumor recurrence or metastasis in the follow-up period. Pulmonary metastasis of the sarcoma were first diagnosed 20 month after the resection of the IVC leiomyosarcoma. So the patient again received thoracoscopic wedge pneumonectomy, and it was confirmed to be metastasis of IVC leiomyosarcoma. The patient received oral anlotinib treatment (12 mg once daily) after the last operation. During on-going regular follow-up visits no evidence of recurrence or metastasis was observed from December 2020 to October 2021.

Conclusions

The patient with a primary IVC leiomyosarcoma and lung adenocarcinoma is extremely rare. Surgery is still an effective treatment for patients with a primary IVC leiomyosarcoma and lung adenocarcinoma at present.

Role of Surgical Intervention in Unresectable Non-Small Cell Lung Cancer

With the development of systemic treatments with high response rates, including tyrosine kinase inhibitors and immune checkpoint inhibitors, some patients with unresectable lung cancer now have a chance to undergo radical resection after primary treatment. Although there is no general consensus regarding the definition of “unresectable” in lung cancer, the term “resectable” refers to technically resectable and indicates that resection can provide a favorable prognosis to some extent. Unresectable lung cancer is typically represented by stage III and IV disease. Stage III lung cancer is a heterogeneous disease, and in some patients with technically resectable non-small cell lung cancer (NSCLC), multimodality treatments, including induction chemoradiotherapy followed by surgery, are the treatments of choice. The representative surgical intervention for unresectable stage III/IV NSCLC is salvage surgery, which refers to surgical treatment for local residual/recurrent lesions after definitive non-surgical treatment. Surgical intervention is also used for an oligometastatic stage IV NSCLC. In this review, we highlight the role of surgical intervention in patients with unresectable NSCLC, for whom an initial complete resection is technically difficult. We further describe the history of and new findings on salvage surgery for unresectable NSCLC and surgery for oligometastatic NSCLC.

Successful salvage surgery following multimodal therapy in a patient who harboured ALK-rearranged advanced lung adenocarcinoma with multiple organ metastases

The prognosis of stage IVb non-small cell lung cancer (NSCLC) patients with multiple distant metastases or involvement of different extra-thoracic sites is poor. The prognosis following salvage surgery for patients with more than five metastases has been reported as most unfavourable. The following case is of a 71-year-old man with a 9-year survival duration after being diagnosed with stage IVb ALK-rearranged lung adenocarcinoma, who was treated for 6 years with whole-brain radiotherapy, pemetrexed-based chemotherapy, ALK-tyrosine kinase inhibitors (TKIs) including ceritinib and alectinib, and salvage sublobar resection of the primary lung cancer and who obtained treatment-free remission (TFR) for more than 3 years following surgery.

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.

The impact of PRDX4 and the EGFR mutation status on cellular proliferation in lung adenocarcinoma

Background: Oxidative stress plays key roles in the progression of lung adenocarcinoma. Recently, we reported that peroxiredoxin 4 (PRDX4), an antioxidant enzyme, can be a prognostic marker of lung adenocarcinoma (LUAD). In the present study, we aimed to further investigate the relationship among the PRDX4 expression, epidermal growth factor receptor (EGFR) mutations and cell proliferation in LUAD. Methods: The expression of PRDX4 was immunohistochemically analyzed and the EGFR mutation status was examined in 127 paraffin-embedded human surgical specimens from patients with stage I LUAD. The PRDX4 expression was considered to be high when >40% of the adenocarcinoma cells were positively stained. In vitro, using plasmid transfection methods, PRDX4 plasmid DNAs were transfected into human lung adenocarcinoma cell lines, A549 (EGFR-wild) or PC-9 (EGFR mutant). The viability of these cells was analyzed using a Cell Counting Kit-8 kit. Results: The number of cases with high PRDX4 expression levels among patients with LUAD with EGFR mutations was significantly larger than that in patients with EGFR wild-type. The combination of the PRDX4 expression level with the EGFR mutation status was closely associated with the prognosis of patients with stage I LUAD. Viability assays showed that the proliferation of A549 cells was significantly suppressed after PRDX4 plasmid transfection, while the overexpression of PRDX4 had no effect on the proliferation of EGFR-mutant PC-9 cells. Conclusions: The PRDX4 expression and EGFR mutation status were significantly associated with the prognosis of patients with stage I LUAD, and EGFR mutations affected the role of PRDX4 in the proliferation of LUAD cells.

The Combination Of Weak Expression Of PRDX4 And Very High MIB-1 Labelling Index Independently Predicts Shorter Disease-free Survival In Stage I Lung Adenocarcinoma

Background: Oxidative stress plays pivotal roles in the progression of lung adenocarcinoma (LUAD) through cell signaling related closely to cancer growth. We previously reported that peroxiredoxin 4 (PRDX4), a secretory-type antioxidant enzyme, can protect against the development of various diseases, including potential malignancies. Since many patients with early-stage LUAD develop recurrence, even after curative complete resection, we investigated the association of the PRDX4 expression with the clinicopathological features and recurrence/prognosis using post-surgical samples of stage I-LUAD. Methods: The expression of PRDX4 and MIB-1, a widely accepted Ki67 protein, was immunohistochemically analysed in 206 paraffin-embedded tumour specimens of patients with stage I-LUAD. The PRDX4 expression was considered to be weak when less than 25% of the adenocarcinoma cells showed positive staining. Results: A weak PRDX4+ expression demonstrated a significantly close relationship with pathologically poor differentiation, highly invasive characteristics and recurrence. The decrease in PRDX4-positivity potentially induced cell growth in LUAD, which was correlated significantly with a very high MIB-1 labelling index (≥17.3%). Univariate/multivariate analyses revealed that the subjects with both weak PRDX4+ expression and a very high MIB-1 index had significantly worse disease-free survival rates than other subjects. Conclusions: The combination of weak PRDX4 expression and a very high MIB-1 index can predict high proliferating activity and recurrence with a potential poor prognosis, especially in post-operative stage I-LUAD patients.

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.

A recurrence-free survivor with chemotherapy-refractory small cell lung cancer after pneumonectomy: A case report and review of the literature

RATIONALE

The optimal therapeutic regimen for chemotherapy-refractory and node-positive small-cell lung cancer (SCLC) is criticizable for the lack of evidence.

PATIENT CONCERNS

A patient with locally advanced SCLC was insensitive to the first-line chemotherapy of etoposide, irinotecan, and cisplatin.

DIAGNOSES

The patient was diagnosed as SCLC with mediastinal lymph node metastasis by pathological staining.

INTERVENTIONS

Salvage pneumonectomy and systematic lymph node dissection combined with oral apatinib and mediastinal radiotherapy were performed for him.

OUTCOMES

The patient survived for more than 2 years without recurrence after the operation and adjuvant therapy.

LESSONS

For patients with chemotherapy-resistant but resectable SCLC, a timely resection combined with postoperative radiotherapy and apatinib might be effective.

Surgical Management of Stage IIIA Non-Small Cell Lung Cancer

According to the eighth edition of the tumor–node–metastasis classification, stage III non-small cell lung cancer is subdivided into stages IIIA, IIIB, and IIIC. They represent a heterogeneous group of bronchogenic carcinomas with locoregional involvement by extension of the primary tumor and/or ipsilateral or contralateral lymph node involvement. Surgical indications have not been definitely established but, in general, long-term survival is only obtained in those patients in whom a complete resection is obtained. This mini-review mainly focusses on stage IIIA disease comprising patients with locoregionally advanced lung cancers. Different subcategories of N2 involvement exist, which range from unexpected N2 disease after thorough preoperative staging or “surprise” N2, to bulky N2 involvement, mostly treated by chemoradiation, and finally, the intermediate category of potentially resectable N2 disease treated with a combined modality regimen. After induction therapy for preoperative N2 involvement, best surgical results are obtained with proven mediastinal downstaging when a lobectomy is feasible to obtain a microscopic complete resection. However, no definite, universally accepted guidelines exist. A relatively new entity is salvage surgery applied for recurrent disease after full-dose chemoradiation when no other therapeutic options exist. Equally, only a small subset of patients with T4N0-1 disease qualify for surgical resection after thorough discussion within a multidisciplinary tumor board on the condition that a complete resection is feasible. Targeted therapies and immunotherapy have recently become part of our therapeutic armamentarium, and it might be expected that they will be incorporated in current regimens after careful evaluation in randomized clinical trials.

Advances in the use of surgery and multimodality treatment for N2 non-small cell lung cancer

INTRODUCTION

Stage IIIA-N2 non-small cell lung cancer (NSCLC) represents a heterogeneous group of bronchogenic carcinomas with locoregional involvement. Different categories of N2 disease exist, ranging from unexpectedly encountered N2 involvement after detailed preoperative staging or 'surprise' N2, to potentially resectable disease treated within a combined modality setting, and finally, bulky N2 involvement treated by chemoradiation. Areas covered: Large randomised controlled trials and meta-analyses on stage IIIA-N2 NSCLC have been published but their implications for treatment remain a matter of debate. No definite recommendations can be provided as diagnostic and therapeutic algorithms vary according to local, national or international guidelines. Expert commentary: From the literature, it is clear that patients with stage IIIA-N2 NSCLC should be treated by combined modality therapy including chemotherapy, radiotherapy and surgery. The relative contribution of each modality has not been firmly established. For patients undergoing induction therapy, adequate restaging is important as only down-staged patients will clearly benefit from surgical resection. Each patient should be discussed within a multidisciplinary team to determine the best diagnostic and therapeutic approach according to the specific local expertise. In the near future, it might be expected that targeted therapies and immunotherapy will be incorporated as possible therapeutic options.

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.