Surgical treatment of locally recurrent lung cancer   E. Fadel,  M.D., PhD Department of Thoracic Surgery Marie Lannelongu...
Definition of local recurrent LC <ul><li>Second malignant tumor with the same cell type occurring in the same anatomic sit...
Incidence of LC local recurrence <ul><li>increased incidence of lung cancer </li></ul><ul><li>increased rate of patients w...
Rationales (I) <ul><li>Surgery remains the treatment of choice for patients with NSCLC but still debated when recurrence o...
<ul><li>Chemotherapy and radiation therapy are commonly accepted treatment options for recurrent LC, whereas surgical rese...
Lobectomy  vs.  Wedge (T1) <ul><li>A prospective, multiinstitutional randomized trial was published in 1995, comparing lim...
Purpose <ul><li>To review our experience with  surgical treatment of local recurrence of resected NSCLC  during the last d...
Methods <ul><li>Retrospective review over a  10-year period of patients with resected local recurrent NSCLC in Marie Lanne...
Demographics Jan 1996-Dec 2005 <ul><li>22 patients (14 men, 8 women) </li></ul><ul><li>Median age: 63 years (range, 40 - 8...
82 years old W Adenocarcinoma T2N0M0 Middle Lobectomy + UL Wedge resection+ LN dissection No adjuvant treatment
2 years later UL recurrence
Previous stage Previous surgery Median interval between the first resection and local recurrence:  17 months (range, 3 to ...
Operative procedure 1 3 17 1 R0: 100%
Pathologic stage
Postoperative complications Morbidity Mortality Bronchopleural fistula 1 Pneumonia 6 1 Pulmonary embolism 1 Empyema 1 Aryt...
Factors affecting early mortality Hypertension 0.05 COPD 0.02 Renal failure 0.001 0.02 Multivariate  analysis Univariate  ...
Overall survival 0 .2 .4 .6 .8 1 0 12 24 36 48 60 months Pts at risk 22 6 8 13 17 3 50% 77% Median survival 48 months 9 de...
Survival according N status 0 .2 .4 .6 .8 1 0 12 24 36 48 60 months N0 N1/2 p=NS 66% 43%
Results of LC local recurrence surgery # LC recurrence + SPLC associated 15 8 33 12 2000 Voltolini 50 9 45 22 2007 Current...
Operative morbidity and mortality <ul><li>Higher than standard resection </li></ul><ul><li>Particularly in irradiated pati...
To improve postoperative results <ul><li>Better selection of patients: a careful workup to rule out operative contraindica...
Long-term survival after surgery <ul><li>Good long term survival rates  (5-year survival rates: 25 – 50% ) </li></ul><ul><...
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  1. 2. Surgical treatment of locally recurrent lung cancer E. Fadel, M.D., PhD Department of Thoracic Surgery Marie Lannelongue Hospital Paris- Sud University
  2. 3. Definition of local recurrent LC <ul><li>Second malignant tumor with the same cell type occurring in the same anatomic site ( bronchial stump, hilar or mediastinal lymph-nodes, or in the mediastinal fat ) within 2 years of the first operation Martini and Melamed JTCVS 1975 </li></ul><ul><li>SPLC: different cell type developed in lung parenchyma or same cell type in a different anatomic site > 2 years after the first operation </li></ul><ul><li>Distant recurrence: all other sites of recurrence </li></ul><ul><li>Residual tumor: after incomplete resection </li></ul>≠
  3. 4. Incidence of LC local recurrence <ul><li>increased incidence of lung cancer </li></ul><ul><li>increased rate of patients who survive a first pulmonary resection for lung cancer </li></ul><ul><li>improvement of radiographic techniques </li></ul>indications for LC local recurrence surgery continue to expand
  4. 5. Rationales (I) <ul><li>Surgery remains the treatment of choice for patients with NSCLC but still debated when recurrence or second primary lung cancer (SPLC) is detected. </li></ul><ul><li>It is very important to distinguish between a SPLC and a recurrence of the first tumor. </li></ul><ul><li>The majority of recurrences are distant, and more than 80% of recurrences occur within the first 2 years. </li></ul>
  5. 6. <ul><li>Chemotherapy and radiation therapy are commonly accepted treatment options for recurrent LC, whereas surgical resection is limited to a relatively few patients. </li></ul><ul><li>This surgical procedure ( standard lobectomy, completion pneumonectomy or carinal resection) is associated to higher mortality and morbidity rates </li></ul><ul><li>Very few studies on surgical treatment of locally recurrent LC </li></ul>Rationales (II)
  6. 7. Lobectomy vs. Wedge (T1) <ul><li>A prospective, multiinstitutional randomized trial was published in 1995, comparing limited resection with lobectomy for patients with peripheral T1 N0 NSCLC </li></ul><ul><li>75% increase in recurrence rates ( p = 0.02) attributable to an observed tripling of the local recurrence rate ( p = 0.008) </li></ul><ul><li>Because of the higher death rate and locoregional recurrence rate associated with limited resection, lobectomy still must be considered the surgical procedure of choice for patients with peripheral T1 N0 NSCLC </li></ul><ul><li>Ginsberg RJ. Rubinstein LV. Annals of Thoracic Surgery 1995 </li></ul>Wedge resection avoided
  7. 8. Purpose <ul><li>To review our experience with surgical treatment of local recurrence of resected NSCLC during the last decade in order to identify factors that could affect post operative mortality and morbidity and long term survival. </li></ul>
  8. 9. Methods <ul><li>Retrospective review over a 10-year period of patients with resected local recurrent NSCLC in Marie Lannelongue Hospital </li></ul><ul><li>LC resection: 2317 procedures </li></ul><ul><li>Resection of local recurrent LC: 22 pts (1%) </li></ul>Sleeve pneumonectomy: 71 Pneumonectomy: 420 Sleeve lobectomy :159 Lobectomy: 1651 Segmentectomy: 7 Wedge resection: 9
  9. 10. Demographics Jan 1996-Dec 2005 <ul><li>22 patients (14 men, 8 women) </li></ul><ul><li>Median age: 63 years (range, 40 - 83 years) </li></ul><ul><li>Histology: Squamous 10 / Non squamous 12 </li></ul><ul><li>Previous Radiation therapy: 2 </li></ul><ul><li>Associated comorbidities: 14 pts (64%) </li></ul>COPD 8 Hypertension 8 Coronary disease 5 Renal failure 2
  10. 11. 82 years old W Adenocarcinoma T2N0M0 Middle Lobectomy + UL Wedge resection+ LN dissection No adjuvant treatment
  11. 12. 2 years later UL recurrence
  12. 13. Previous stage Previous surgery Median interval between the first resection and local recurrence: 17 months (range, 3 to 25 months)
  13. 14. Operative procedure 1 3 17 1 R0: 100%
  14. 15. Pathologic stage
  15. 16. Postoperative complications Morbidity Mortality Bronchopleural fistula 1 Pneumonia 6 1 Pulmonary embolism 1 Empyema 1 Arythmia 2 Total 10 (45%) 2 (9%)
  16. 17. Factors affecting early mortality Hypertension 0.05 COPD 0.02 Renal failure 0.001 0.02 Multivariate analysis Univariate analysis
  17. 18. Overall survival 0 .2 .4 .6 .8 1 0 12 24 36 48 60 months Pts at risk 22 6 8 13 17 3 50% 77% Median survival 48 months 9 deaths: Local recurrence: 2 Systemic recurrence: 2
  18. 19. Survival according N status 0 .2 .4 .6 .8 1 0 12 24 36 48 60 months N0 N1/2 p=NS 66% 43%
  19. 20. Results of LC local recurrence surgery # LC recurrence + SPLC associated 15 8 33 12 2000 Voltolini 50 9 45 22 2007 Current series 45# 11# 24# 32# 1995 Massard 32# 14# 42# 76# 1998 Muysoms 15 9 38 1988 McGovern 24 12 21 28 1993 Grégoire 27 11 28 36 1999 Tronc 60 7 47 14 2001 Fujimoto 26 - - 8 2002 Terzi 29 13 - 6 2004 Guggino 23 10 39 26 2004 Jungraithmayr 5-year survival (%) Mortality (%) Morbidity (%) Patients ( n ) Year Series
  20. 21. Operative morbidity and mortality <ul><li>Higher than standard resection </li></ul><ul><li>Particularly in irradiated patients </li></ul><ul><li>Pleural adhesions and difficulties to obtain a vascular control: bleeding+++ and large vessels injuries challenging procedure </li></ul><ul><li>Patients with associated comorbidities that often precluded a pneumonectomy during the first procedure </li></ul>
  21. 22. To improve postoperative results <ul><li>Better selection of patients: a careful workup to rule out operative contraindication </li></ul><ul><li>Skilled thoracic surgeon </li></ul><ul><li>Read the first surgical report (if has been done extrapleurally+++) </li></ul><ul><li>Intrapericardial surgery </li></ul><ul><li>Avoid radiation therapy in low stage cancers </li></ul>
  22. 23. Long-term survival after surgery <ul><li>Good long term survival rates (5-year survival rates: 25 – 50% ) </li></ul><ul><li>Better when the operation is done for a SPLC than for a local recurrence </li></ul><ul><li>All patients with resected NSCLC should be followed carefully. If a local recurrence or a second cancer is diagnosed, providing precluding comorbidities ruled out, a surgical resection should be discussed because it offers a second chance for cure </li></ul>This surgery is justified

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