Surgical salvage following stereotactic body radiotherapy for early-stage NSCLC

Salvage surgery after high-dose radiotherapy

“…After a median follow-up of 30 months there was no evidence of disease. Although in the cases of Hamaji, Sugimoto and Neri, only limited pleural adhesions were present after SRT, more extensive adhesions were encountered by Allibhai and also in 2 out of 9 patients published by Verstegen, which led to conversion in one case (34,35). This may be due to a different location of the primary lesion and therefore a low radiation dose to the ipsilateral bronchial tree (33,35).…”

“…There were no technical difficulties and complications consisted of 1 pulmonary fistula and 4 cases of post-radiotherapy pneumonitis. Allibhai et al reported a small but interesting series as detailed pathological examination was available (34). Out of a prospective series of 209 patients who underwent SRT for early-stage NSCLC 4 had salvage surgery consisting of lobectomy and nodal sampling.…”

Cons: After lung stereotactic ablative radiotherapy for a peripheral stage I non-small cell lung carcinoma, radiological suspicion of a local recurrence is not sufficient indication to proceed to salvage therapy

“…A series with 6 biopsy proven local recurrences reported high SUV max , all greater the 5 (19). However, other reports describe cases that exceed that SUV threshold but were proven to be benign changes without any evidence of residual or recurrent tumors (20,21), as illustrated in Figure 1. There are other reports of highly suspicious radiographic findings prompting surgical resection without evidence of disease (8,21), but the true frequency of this phenomenon is unclear.…”

“…Given the challenges of operating once post radiation fibrosis has occurred, and patients' age and comorbidities, salvage surgery for local failure post SBRT is clearly a high-risk option and should only be contemplated after careful consideration of risks and benefits. Small series looking at salvage lobectomy have reported low rates of morbidities in very well selected patients in centers with high surgical volume and expertise (20,21,24).…”

Pros: After stereotactic ablative radiotherapy for a peripheral early-stage non-small cell lung cancer, radiological suspicion of a local recurrence can be sufficient indication to proceed to salvage therapy

“…In radiated lesions, accurate assessment of biopsy specimens may be further obscured by fibrotic and necrotic changes. In one report, a patient required 11 needle passes over 3 different biopsy attempts before a diagnosis of recurrence was made (16).…”