Salvage Surgery Feasible, Safe After Radiation for Lung canc

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Salvage Surgery Feasible, Safe After Radiation for Lung Cancer: Presented at STS

By Ed Susman

FORT LAUDERDALE, FL -- February 4, 2008 -- Salvage surgery after radiation in patients with recurrent non-small-cell lung cancer is feasible, safe and appears to have a relatively good long-term outcome.

"Median overall survival for our cohort is 30 months and 3-year overall survival is 47%," said Julie Bauman, MD, Associate Medical Oncologist, Geisinger Health Care in Wilkes-Barre, Pennsylvania, United States. She conducted her retrospective study of postradiation salvage surgery at the University of Washington, Seattle, United States.

Although her study included 24 patients, it was the largest series of its type, Dr. Bauman said during an oral presentation here on January 29 at the Society of Thoracic Surgeons 44th Annual Meeting (STS).

Dr. Bauman and her colleagues reviewed cases between 1997 and 2005 in which patients with stage 3 non-small-lung cancer had been treated with chemoradiation and then had been referred for surgery when the cancer returned.

"The optimal management for resectable stage 3a non-small-cell lung cancer remains controversial," Dr. Bauman said. National guidelines recommend two treatment standards: induction therapy followed by resection or definitive concurrent chemoradiation. In the U.S. chemoradiation appears to be the dominant treatment approach. Among patients with stage-3 disease treated with multimodal therapy in 2001 approximately three quarters received chemoradiation alone and one quarter received surgery. About one third of patients have isolated local relapse after definitive chemoradiation. "However, the safety and efficacy of salvage lung resection remain undefined," Dr. Bauman noted.

Dr. Bauman said surgeons are concerned about lung resection because often the surgery is suggested long after chemoradiation and when fibrosis in the lungs makes surgery difficult and dangerous. "The golden window for surgery following radiation is between 4 and 8 weeks because radiation fibrosis matures over time. In practice the surgeon operating late after radiation will encounter brittle, devascularised tissue and obliterated planes. This complicates dissection and ultimately impairs wound healing."

In her series 1, Dr. Bauman reported that the median time to surgery following last radiation was about 5 months. In these patients, there had been no plans to consider surgery -- in fact, in half the patients, doctors had considered the patients inoperable before giving chemoradiation.

She noted that seven of the patients were selected for salvage surgery because radiologists found growths on followup computer-assisted tomography scans or pathologists found evidence of cancer in a biopsy; 12 patients underwent salvage for a persistent abnormal positron emission tomography scan following completion of radiation therapy; four patients were converted to trimodality therapy when subspecialty doctors concluded that surgery had been inappropriately excluded from primary therapy; one patient had surgery for a chronic bronchopleural fistula.

The 24 patients underwent 25 salvage lung resections with one patient having two operations for recurrence. Nineteen resections were paired with a vascularised flap to buttress the bronchial stump, Dr. Bauman said. Median operative time was 5.5 hours; median hospital stay was 8 days.

She said there was one postoperative death in the series, a patient who succumbed to adult respiratory distress syndrome following left pneumonectomy. Fourteen of the patients experienced perioperative morbidity, notably two patients sustained major vessel injury and one suffered thoracic duct injury. "In all three operative reports, dense fibrosis is described," Dr. Bauman said. Pathological examination found 13 specimens with N0 disease; N1 disease was described in six cases and N2 in five.

She noted that in the preparation for initial treatment, four of the patients received upfront surgical consultation.

"Salvage lung resection is technically feasible with acceptable morbidity and mortality," Dr. Bauman said. "In this high-risk population we observed encouraging survival, but prospective trials are warranted. Consultation with a surgical oncologist is paramount in multimodality management of non-small-cell lung cancer," she concluded.

[Presentation title: Salvage Lung Resection Following Definitive Radiation (>59 Gy) for Non-Small Cell Lung Cancer: Surgical and Oncological Outcomes. Abstract 43]