Completion pneumonectomy is safe and effective in select patients with recurrent non-small cell lung cancer

Abstract

Background: Locoregional recurrence rates for non-small cell lung cancer (NSCLC) remain high, even following curative surgical resection. While national guidelines advocate surgical resection for locoregional recurrence, it is rarely offered when resection would require completion pneumonectomy, which available literature associates with a 12-36% perioperative mortality and 40-80% morbidity. Additionally, survival advantages to radical surgery in this scenario are largely unknown, particularly because available series often include patients undergoing completion pneumonectomy for benign indications or metastatic disease from other primary sites, making extrapolation to primary lung cancer patients challenging. As systemic therapy options continue to evolve, particularly as it relates to immunotherapy, we expect that there will be more and more opportunities for locoregional surgical control. The aim of this study was to evaluate outcomes following completion pneumonectomy for recurrent NSCLC. Methods: We retrospectively reviewed all patients who underwent completion pneumonectomy for recurrent NSCLC at our institution between 2000 and 2015. Factors affecting perioperative morbidity and mortality, as well as overall survival, were analyzed. Results: Between 2000 and 2015, 28 patients underwent completion pneumonectomy for recurrent lung cancer (14 female, 14 male). The median age was 64.2 years (range, 36.7-84.0). There were 11 left-sided and 17 right-sided operations. Fourteen patients (50.0%) underwent chemotherapy or chemoradiotherapy prior to surgery. Perioperative morbidity was seen in 13 of 28 (46.4%) patients, and atrial fibrillation was the most common complication. Mortality at 30-and 90-day intervals was 3.6%, and 14.3% respectively. Five-year overall survival was 43.1% and was not associated with preoperative chemotherapy or chemoradiotherapy use. Patients over 70 years old (n=5) experienced a statistically higher rate of postoperative complications (100.0% vs. 34.8%, P=0.013), and this translated into a higher mortality rate at 60 and 90 days. Left-sided resections were associated with increased risk of recurrent laryngeal nerve injury (RLN) compared to rightsided resections (36.4% vs. 0%, P=0.016), and those patients with RLN injury were more likely to be reintubated (50.0% vs. 4.2%, P=0.04). Bronchopleural fistula occurred in 1 patient (3.6%). Conclusions: Completion pneumonectomy is a viable treatment option for patients with recurrent NSCLC. We attribute our low risks of major morbidity, such as bronchopleural fistula, to careful patient selection and technique. In patients over 70 years, morbidity is higher which should inform discussion regarding surgical options.

Clinical Outcomes and Prognostic Factors of Salvage Stereotactic Body Radiotherapy for Post-Surgical Thoracic Oligo-Recurrence/Metastasis of Non-Small-Cell Lung Cancer

“…The median post recurrence survival (PRS) was 46.4 months, and the 5-year PRS rates were 67% in the operative. White et al 21 retrospectively reviewed all patients who underwent completion pneumonectomy for recurrent NSCLC. Overall survival at 5 years was 43.1%.…”

Completion Pneumonectomy for Non-Small-Cell Lung Cancer: Does Induction Treatment Influence Postoperative Outcomes?

“…BPF occurred in two (2.9%) patients, both on the right side, one of which occurred with preoperative radiation. This rate is slightly lower than the majority of previous reports (2.7-13.3%) [3,5,7,12,16,17]. The following factors are considered the key factors impacting the outcomes of patients undergoing CP: surgical technique, the development of BPF, and the resulting morbidity and mortality [5,15].…”

“…In our experience, we encountered increased difficulties in the surgical procedure in the IT group, but there was no difference between the two groups (IT versus no-IT). In terms of long-term results, in the study by White, 50% of patients received chemotherapy or chemoradiotherapy prior to CP [ 16 ]. With the constraints of small sample size, this does not appear to confer a survival advantage.…”

Salvage surgery for local recurrence after sublobar surgery in Stages I and II non‐small cell lung cancer

“…This is provided that the disease is deemed resectable 5 . Our study is one of the few to look at salvage surgery below the extent of completion pneumonectomy; this has been studied before by the authors 6 . In 2009 Takahashi et al studied outcomes following completion lobectomy after segmentectomy 4 .…”

“…5 Our study is one of the few to look at salvage surgery below the extent of completion pneumonectomy; this has been studied before by the authors. 6 In 2009 Takahashi et al studied outcomes following completion lobectomy after segmentectomy. 4 It is telling that only 4% of segmentectomy patients were eligible for additional surgery.…”