Local-Regional Failure After Surgery for Node-Negative Stage I and II NSCLC: Survival After Salvage Treatment

Abstract

Local control rates are excellent after surgical resection for patients diagnosed with early stage non-small cell lung cancer (NSCLC), but data is sparse on outcomes after salvage for local-regional recurrence (LRR). We hypothesized that aggressive local treatment for LRR after surgical resection would yield similar survival outcomes as in the up-front setting. The purpose of this study was to estimate the incidence of isolated LRR and to determine overall survival after local-regional recurrence (SALR), potentially providing information on the role of radiation in the salvage setting. We identified 1203 patients treated at a single institution with curative resection for early stage (I-II) NSCLC from 2004 – 2014, who met the following criteria 1) pathologically confirmed NSCLC; 2) no history of induction chemotherapy at diagnosis, 3) surgical resection as primary treatment, 4) pathologic N0 disease at initial diagnosis, 5) no history of preoperative or postoperative radiation. Of the initial 1203 patients, 24 (2.0%) met further inclusion criteria including 6) local-regional recurrence, defined as at the staple line, ipsilateral hilum, or mediastinum (as reviewed by thoracic surgeon and radiation oncologist), and 7) follow-up of at least 3 months after a diagnosis of LRR. Patients were not excluded based on type of salvage treatment received. Our primary outcome was SALR, measured from the time of diagnosis of LRR. We also evaluated patterns of failure after salvage treatment. Median survivals were determined using the Kaplan-Meier method. Median age was 70.5 years at time of recurrence and median follow up was 23.5 months (range: 6 – 96 months). Salvage treatment consisted of: (chemo)radiation for 21 patients, surgery for 2 patients, and chemotherapy for 1 patient. Radiation techniques varied depending on the location of recurrence and included intensity modulated radiation, volumetric arc therapy, proton beam radiation, and stereotactic body radiation. The median SALR was 30 months (95% CI, 18 – 42 months). The median progression free survival after recurrence was 15 months (95% CI, 12 – 18 months). Ten patients had recurrent disease after upfront salvage. Neither patient salvaged with surgery experienced further recurrence, with SALR times of 6 and 74 months. The patient salvaged with chemotherapy failed distantly within 5 months. In the 21 patients who received radiation, four patients (19%) experienced failure within the radiation field, at a median time of 22.5 months (range: 14 – 42 months). The rate of isolated LRR after surgery for early stage, node-negative, NSCLC is very low, and these recurrences are salvageable in some patients. The most common form of salvage treatment in this setting involved radiation. SALR is comparable to that in upfront stage III patients, and thus an aggressive approach is warranted for these patients with LRR after surgery