Optimising treatment for post-operative lung cancer recurrence

Abstract

@ERSpublicationsThe second lung resection is a valuable option for post-operative lung cancer recurrence http://ow.ly/U8z3cSurgical treatment offers the best chances for long-term survival in patients with primary nonsmall cell lung cancer (NSCLC). However, long-term survival after surgery remains less than 50%, mostly due to a 30-77% rate of tumour recurrence. Unlike the distant type of recurrence that is treated nonsurgically in the vast majority of patients, local or loco-regional recurrence, which occurs in 4.6-24% of patients after complete resection (∼80% of cases in the first 2 years) [1], raises several concerns related to the optimal therapeutic approach.Unfortunately, literature data are not always helpful in practice. For example, 5-year loco-regional recurrence rates are between 15 and 38.5% [2], and the incidence of local recurrence in early-stage lung cancer of 10-15% [3], or a mean disease-free interval of 14.1-19.8 months, that is similar to distant recurrent disease [4]. Failure to demonstrate the advantage of complete lymphadenectomy over nodal sampling in terms of local recurrence or survival in patients operated for T1-2, N0 or T1-2, N1 disease, makes the clinical approach more complex [5]. Moreover, the impact of intensified follow-up on overall survival or local recurrence detection could not be clearly demonstrated. In ∼50-67% of patients, recurrence will appear before a scheduled control because of the onset of symptoms [6].Finally, switching to seventh edition of the TNM (tumour, node, metastasis) staging system automatically led to the stage migration, reaching 21% in some studies. The only study of the role of computed tomography (CT) in post-operative recurrence detection demonstrated a high negative predictive value of 95%, but a positive predictive value of only 53% (94% sensitivity and 87% specificity) [7]. For positron emission tomography, although it is more sensitive than CT in detecting recurrent tumours (97-100%), variations of the cut-off values for the standardised uptake value (⩾4.5-⩾10) make its clinical application difficult, together with its specificity (62-100%) that is lower than for CT.The role of prognostic factors after surgery is more evidence-based, owing to awareness of the poor 5-year survival of patients in stages IA and IB (73% and 58%, respectively). This also applies to the high recurrence rate in patients with stage I after complete resection (25-50%) [8]. The results of these studies really helped to identify patients who would probably benefit from adjuvant therapy.Among tumour markers, although increased serum concentrations of carcinoembryonic antigen (CEA) are rare (17%), persistently high post-operative CEA levels were found to be a strong indicator of poor prognosis. In 55-70% of patients with CEA values of 5-10 ng·mL , an early recurrence will develop [9].Of the many analysed clinical and pathological prognostic factors, vascular invasion, lymphatic vessel and visceral pleural invasion have been identified as clearly unfavourable in terms of surviv...

A rare case of squamous cell carcinoma lung with multiple locoregional recurrences and histological transformation

“…Surgery, potentially curative treatment for early-stage NSCLC has a tumor recurrence rate of 30%–77% with a long-term survival of <50%. [ 4 ] Management of recurrent lung cancer is challenging due to limited treatment options being available and poor performance status of the patient. In the present case, despite lobectomy and adjuvant chemotherapy, the patient had locoregional recurrence with the mass invading into SVC, closely abutting right pulmonary artery and azygous vein.…”

Radiation therapy for post-operative recurrence: yes, but only for limited indications

“…In the January edition of the European Respiratory Journal, we read with interest the paper by HARTL et al [1], which evaluated, from the European COPD Audit, patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and the mortality risk during hospitalisation and in the post-discharge period of 90 days. Moreover, the authors evaluate the risk of readmission in a period of 90 days from discharge.…”

“…Although the study by HARTL et al [1] focuses on a period of 90 days from discharge and the causes of readmission are not exclusively respiratory related, our recently published long-term observational study [8]…”

“…Radiation therapy, either alone or in combination with chemotherapy, is a widely accepted treatment modality for post-operative lung cancer relapse. The focus of our editorial was to increase the awareness of possible repeat intervention in this quite limited patient group with generally poor prognosis [1]. Although the overall message of this correspondence is not debatable, the statement that "the available evidence shows that patients with post-resection recurrent nonsmall cell lung cancer (NSCLC) can achieve excellent results when treated with radiation therapy alone, or with radio-chemotherapy" is somewhat misleading as we have several concerns related to the evidence supporting the above statement.…”

Treatment options for isolated locoregional recurrences of nonsmall cell lung cancer after surgery: yes, radiation therapy too!

“…In a recent article, SUBOTIC et al [1] summarised the importance of salvage surgery in treating local or loco-regional, post-surgical recurrences in patients with, mostly, early stage nonsmall cell lung cancer (NSCLC). While the feasibility of such an approach is indisputable, we believe that the readership of the European Respiratory Journal should be made aware of another treatment option already successfully used in this setting, namely, radiation therapy.…”