Surgery After Induction Chemotherapy or Chemoradiotherapy for Locally Advanced Lung Cancer: A Technical Challenge

Abstract

The optimal management of the patients with clinical stage IIIA disease (especially IIIA-N2 disease) has not been clearly defined. Those who have had questionable lymph nodes for metastasis by chest computed tomography or positron emission tomography scan should undergo a mediastinal evaluation via endobronchial ultrasound bronchoscopy or cervical mediastinoscopy for the cytologic/histologic confirmation of clinical N2 disease. Although it has been widely accepted that the upfront surgery for patients with a proven N2 disease does not improve their survival and the concurrent chemoradiotherapy is respected as the standard management for these patients, the significance of the surgical intervention of this scenario has not been well established.1,2 In the present issue of Journal of Thoracic Oncology, important results on the outcome of surgical interventions after induction chemotherapy or chemoradiotherapy for non-small cell lung cancer (NSCLC) have been reported from the Memorial SloanKettering Cancer Center in New York. 3 This retrospective analysis is the largest singleinstitution experience in the literature with 549 patients who underwent surgical resection after chemotherapy alone (83%) or chemoradiotherapy (17%). The in-hospital mortality was 1.8% (10 of 549), and the predicted postoperative (PPO) pulmonary function was associated with postoperative morbidity. The authors concluded that that the resection of NSCLC after induction therapy is feasible with low mortality and that PPO pulmonary function should be used in selecting the candidates for surgery. This important report provides us with benchmark data regarding the postoperative morbidity/mortality of surgery after induction treatment. The outcome clearly shows that this especially challenging surgery can be performed safely at an experienced center. However, we must consider two issues that are relevant to the nature of the combined modality treatment approach with surgery after induction treatment. They are the objective risk of pneumonectomy and the influence of the inclusion of radiotherapy in the induction treatment on the development of postoperative complications. In our previous retrospective study on the incidence, risk factors, and management of the bronchopleural fistula (BPF), prior radiation treatment was one of the significant risk factors for BPF together with pneumonectomy, R1 operation, and diabetes. 4 Therefore, the addition of radiation to the systemic chemotherapy in the induction treatment is reasonably expected to increase the risk after operation. Cerfolio et al. 5 retrospectively studied 104 patients who had the pulmonary resection following low-dose (50 patients) and high-dose radiation (54 patients). They reported that mortality rate for the low-dose radiation group and high-dose radiation group were 2% and 3.7%, respectively. However, for the 12 patients undergoing pneumonectomy, the mortality rate was 16.7%. Daly et al. 6 also reported the similar mortality rate of 13.3% after pneumonectomy following highdose radiation therapy. Although they concluded that pneumonectomy should continue