Elsevier

The Annals of Thoracic Surgery

Volume 86, Issue 5, November 2008, Pages 1632-1639
The Annals of Thoracic Surgery

Original article
General thoracic
Salvage Lung Resection After Definitive Radiation (>59 Gy) for Non-Small Cell Lung Cancer: Surgical and Oncologic Outcomes

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.
https://doi.org/10.1016/j.athoracsur.2008.07.042Get rights and content

Background

Isolated local relapse occurs in 24% to 35% of patients after definitive chemoradiation for locally advanced non-small cell lung cancer. Although originally considered inoperable, select patients are referred for surgical salvage. We describe a series of salvage lung resection after curative-intent radiation.

Methods

Twenty-four consecutive patients from 1997 to 2005 were identified retrospectively. Medical records reviewed. Patients were grouped by surgical indication: A, obvious relapse by computed tomography (CT), 7 patients; B, abnormal fluorodeoxyglucose-positron emission tomography (FDG-PET), 12; C, delayed conversion to trimodality, 4; and D, chronic bronchopleural fistula, 1.

Results

All patients received definitive radiation (median, 63.9 Gray), 22 with concurrent chemotherapy. Original staging included cardiothoracic surgical consultation in 4. Median time from radiation to resection was 21 weeks. Twenty-four patients underwent 25 resections: one wedge, 10 lobectomies, 4 bilobectomies, and 10 pneumonectomies. Nineteen flaps were performed, 16 omental. Fourteen had complications, including one death from adult respiratory distress syndrome. Viable tumor was found in 19 patients. Median overall survival was 30 months (12 months, group A; 43 months, group B). Estimated 3-year survival was 47%. The Kaplan-Meier survival curve for group B was superior to that for group A (p = 0.019).

Conclusions

Salvage lung resection after definitive chemoradiation is feasible, with encouraging survival. Surgical indication is predictive, with higher survival among patients undergoing resection for abnormal FDG-PET than for obvious relapse by CT. FDG-PET should be studied prospectively in selecting patients for salvage lung resection. Systematic staging may have increased primary incorporation of surgery, minimizing the need for late salvage.

Section snippets

Data Collection

Institutional Review Board approval was granted by the University of Washington (UW) in December 2005, with waiver of individual consent. Potential cases were identified from the 1997 to 2005 case log of the Thoracic Surgical Division. The first consultation note by a thoracic surgeon was reviewed for all cases of pulmonary wedge resection, lobectomy, or pneumonectomy. Entry criteria included (1) histologic or cytologic diagnosis of NSCLC; (2) prior treatment of NSCLC with curative-intent

Patient Characteristics

The characteristics of the 24 patients are detailed in Table 1. In 23 of 24 patients, the initial staging and treatment occurred at another institution, and they were referred for consideration of salvage lung resection. Specifics of initial staging procedures were known in 23 of 24 patients. A surgeon participated in 9 of 23 (39%) staging evaluations, and in 4 patients the surgeon was certified by the American Board of Thoracic Surgery or its equivalent (44% of surgical evaluations and 17% of

Comment

Intergroup 0139, a randomized phase III comparison of definitive chemoradiation vs induction chemoradiation followed by operation, did not demonstrate a survival benefit to trimodality therapy in patients with resectable stage IIIA NSCLC [9]. Although planned trimodality therapy remains an accepted standard in certain cases, the optimal therapy for patients with N2 disease remains controversial. National guidelines recommend that patients with resectable, locally advanced NSCLC be treated with

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