Intrathoracic Recurrence Research Articles

Pleural drop-metastasis five years post-thymectomy manifesting with myasthenia gravis

Introduction: Thymomas are the most common tumors in the anterior mediastinum. Intrathoracic recurrence of thymomas after initial resection is common and mostly seen in patients with advanced Masaoka stage. A number of paraneoplastic syndromes can be associated with thymoma, but myasthenia gravis (MG) is the most common. A total radical thymectomy often leads to a resolution of MG in a considerable number of patients. However, MG relapse post-thymectomy can occur whether there is a recurrence of the thymoma or not. In this case report, a patient presented with MG five years after radical removal of a thymoma which was not associated with MG before his surgery.

A surveillance method-oriented detection of post-operative spatial-temporal recurrence for non-small cell lung cancer.

This study evaluated spatial-temporal recurrence patterns after curative resection for non-small cell lung cancer (NSCLC) to clarify and recommend appropriate post-operative surveillance. A total of 2,486 consecutive patients between January 2005 and December 2012 with NSCLC (stage I-IIIA) who underwent definitive surgical resection were retrospectively analyzed. We used a hazard rate curve to evaluate event dynamics. Disease-free survival (DFS) was evaluated by the Kaplan-Meier method. Univariate and multivariate analyses with Cox proportional hazards regression identified risk factors that predicted DFS. The median follow-up was 50.1 months. Recurrences were diagnosed in 852 (34.3%) patients. Four hundred eighty-nine events first occurred in the chest, 177 in the brain, 117 in the bone, and 71 in the abdomen. Of all recurrences, 78.5% occurred in the first 3 years. Univariate and multivariate analyses identified the age at diagnosis (P<0.001), histology (P=0.023), tumor size (P<0.001), pathologic N stage (P<0.001), and grade (P=0.043) as independent risk factors for intra-thoracic recurrences. Histology (P<0.001), tumor size (P<0.001), surgical method (P=0.021), pathologic N stage (P<0.001), and grade (P=0.005) were independent to predict extra-thoracic recurrences. The hazard rate curve displayed an initial surge of time to any treatment failure during 12 months after surgery. Based on sub-group analysis, both intra- and extra-recurrences increased with stage and brain recurrences in stage IIIA occurred earlier than stage II. Hazard rate curve of brain recurrences in squamous cell carcinoma showed a moderate peak during 9-15 months. Hazard rate curves of brain and bone recurrences in adenocarcinoma displayed clear peaks at 9-27 and 15-30 months, respectively. Intra- and extra-thoracic recurrences correlate with different clinicopathological factors. Brain MRI and bone ECT were recommended for selected patients in particular time to early detect extra-thoracic recurrences.

P1.16-64 The Histological Predominant Pattern Could Predict Site of Recurrence and Metastasis in Surgically Treated Stage I Adenocarcinoma of the Lung

Pattern-based subtyping of adenocarcinoma of the lung is currently recommended due to prognostic implications. We aimed to evaluate whether predominant pattern subtype in surgically treated stage I adenocarcinoma of the lung can predict first site of recurrence or metastasis. We retrospectively reviewed clinical information, radiological findings, PET/CT-records, and pathological features (classified by IASLC/ATS/ERS subtyping criteria) of 906 Stage-I adenocarcinoma of the lung, who underwent surgery in 7 Centers. Patients were classified by histologic grade according to the IASLC/ATS/ERS classification as follow: intermediate grade (Invasive Lepidic, Acinar, Papillary) vs. high grade (Micropapillary, Solid) vs. NOS. The date of recurrence or metastases was defined as the first radiographic evidence of cancer relapse upon imaging or pathological tumour evidence from a biopsy. Univariate and multivariate logistic analysis were used to identify predictors of first site of recurrence or metastasis. A total of 248 (27%) patients developed recurrence or distant metastasis. The most commonly observed first location of recurrence was ipsilateral thorax (133 cases, 44%), followed by brain (27, 11%), contralateral lung (24, 10%), bones (11, 4%), liver and adrenal gland (10, 4%). Forty-three patients (17%) presented recurrence or metastasis in multiple sites simultaneously at the time of diagnosis. At multivariate analysis, patients with intermediate-grade histology developed intra-thoracic recurrence more frequently compared to the remainder of the cohort (odds ratio (OR) 1.85, 95% confidence interval (CI): 1.1– 3.18, P=0.038). Patients with high-grade histology developed contralateral lung metastasis (OR 2.1, 95%CI 1.1-4.2, P= 0.044) and brain metastasis (OR 2.5, 95%CI 1.3-5.1, P<0.01) more frequently compared to the low-grade ones. Predominant pattern subtype seems to predict site-specific recurrence and metastasis in surgically treated Stage I adenocarcinoma of the lung.

Failure patterns of radical surgery in patients with T1-4N0-1M0 thoracic esophageal squamous cell carcinoma: implications for the target area design of postoperative therapy

Objective To analyze the failure patterns and prognostic factors of radical surgery in patients with T1-4N0-1M0 thoracic esophageal squamous cell carcinoma (TESCC), and the implications for the target area design of postoperative therapy. Methods We retrospectively analyzed 1 191 patients with TESCC who underwent radical surgery at our institution. The failure patterns, the prognostic factors, as well as the effects of lesion locations and N stage on the failure patterns were analyzed. Results The thoracic-region recurrence rate and the distant metastasis rate was 31.7% and 16.4% in all patients. The multivariate analysis showed that the lesion locations, the degree of inflammatory adhesion, T staging, N staging and the rate of lymph nodes metastasis were independent factors affecting the regional recurrence (P<0.05). Gender, tumor differentiation and the rate of lymph nodes metastasis were independent factors affecting distant metastasis (P<0.05). The intrathoracic lymph nodes recurrence rate of upper/middle TESCC was significantly higher than that of the lower TESCC (χ2=6.179, P=0.046), while the abdomen lymph nodes recurrence rate of the lower was significantly higher than that of upper/middle TESCC (χ2=15.853, P<0.05). The recurrence rate and distant metastasis rate of stage N1 patients were significantly higher than that of N0 patients (χ2=7.764-56.495, P<0.05). The abdomen lymph nodes recurrence rate of stage N1 patients was significantly higher than that of N0 in upper TESCC (χ2=7.905, P<0.05). The supraclavicular and intrathoracic lymph nodes recurrence rates of stage N1 patients were significantly higher than that of N0 patients in middle TESCC (χ2=12.506, 18.436, P<0.05). The supraclavicular lymph nodes, anastomosis and abdomen lymph node recurrence rates of stage N1 were significantly higher than that of N0 patients in lower TESCC (χ2=5.272, 4.878, 18.006, P<0.05). The anastomotic recurrence rate of stage T3+ 4 was higher than that of T1+ 2 in middle/lower TESCC (χ2=4.341, 7.154, P<0.05), and the abdominal lymph nodes recurrence rate of stage T3+ 4 was higher than that of T1+ 2 in lower TESCC(χ2=5.366, P<0.05). Conclusions The lymphatic drainage regions for postoperative radiotherapy (PORT) are selective. We suggest that abdominal lymph nodes drainage area should be noted for the stage N1 patients with upper TESCC, and the supraclavicular lymph nodes drainage area should be noted for the N1 patients with lower TESCC. In addition, the anastomosis is suggested to be included in PORT target area for stage T3/T4 middle/lower TESCC patients. Key words: Esophageal neoplasms; Failure mode; Target area

Feasibility of carbon-ion radiotherapy for re-irradiation of locoregionally recurrent, metastatic, or secondary lung tumors.

Intrathoracic recurrence after carbon‐ion radiotherapy for primary or metastatic lung tumors remains a major cause of cancer‐related deaths. However, treatment options are limited. Herein, we report on the toxicity and efficacy of re‐irradiation with carbon‐ion radiotherapy for locoregionally recurrent, metastatic, or secondary lung tumors. Data of 95 patients with prior intrathoracic carbon‐ion radiotherapy who were treated with re‐irradiation with carbon‐ion radiotherapy at our institution between 2006 and 2016 were retrospectively analyzed. Seventy‐three patients (76.8%) had primary lung tumors and 22 patients (23.2%) had metastatic lung tumors. The median dose of initial carbon‐ion radiotherapy was 52.8 Gy (relative biological effectiveness) and the median dose of re‐irradiation was 66.0 Gy (relative biological effectiveness). None of the patients received concurrent chemotherapy. The median follow‐up period after re‐irradiation was 18 months. In terms of grade ≥3 toxicities, one patient experienced each of the following: grade 5 bronchopleural fistula, grade 4 radiation pneumonitis, grade 3 chest pain, and grade 3 radiation pneumonitis. The 2‐year local control and overall survival rates were 54.0% and 61.9%, respectively. In conclusion, re‐irradiation with carbon‐ion radiotherapy was associated with relatively low toxicity and moderate efficacy. Re‐irradiation with carbon‐ion radiotherapy might be an effective treatment option for patients with locoregionally recurrent, metastatic, or secondary lung tumors.

P1.16-021 Midterm Oncologic Outcomes of Single Port Thoracoscopic Lobectomy for Lung Cancer by Propensity Matched Analysis

Current evidence is still weak to establish the oncologic equivalence of single port thoracoscopic approach compared to conventional multiport thoracoscopic surgery as one of minimally invasive approach for lung cancer surgery. The purpose of this study is to evaluate the midterm surgical outcomes of single port approach compared to conventional multiport approach in thoracoscopic lobectomy for lung cancer. A total of 228 patients in propensity matched group (both 114 patients with pathologic stage I who underwent lobectomy by conventional multiport or single port VATS) were compared the operative outcomes and we analyzed midterm survival and recurrence to evaluate the feasibility of single port VATS lobectomy for lung cancer. Both propensity matched groups showed comparable preoperative variables (age, gender, FEV1, and tumor size) (Table 1). The mean operation time, the number of resected lymph node, and conversion to open thoracotomy or multiport VATS in both group did not show differences (respectively, P=0.076, P=0.291, P=0.253). There was no difference in postoperative major morbidity (P=0.807) and 30-day mortality (p=0.247). The duration of chest drain was shorter in single port VATS group (p<0.001) (Table 2). The survival (P=0.258) and freedom from intrathoracic recurrence (p=0.797) for mean 32 (6-62) months follow up in patients with pathological stage I were not statistically different between groups (Fig). Single port thoracoscopic lobectomy in lung cancer showed acceptable oncologic outcomes for midterm follow ups with oncologic equivalence compared to conventional multiport thoracoscopic lobectomy.

MTE 04.01 Role of Radiotherapy in Multimodality Treatment for SCLC

Major advances in SCLC include improvements in RT techniques, the use of prophylactic cranial irradiation (PCI) for all stages of SCLC and the improved combination of chemotherapy and RT (Califano). The role of thoracic radiotherapy is well established in the management of stage I-III SCLC (Pignon). There is increasing evidence in the literature in favor of early concurrent chemo-radiotherapy, and a standard of care for patients with a good performance status is twice-daily thoracic radiotherapy (45 Gy in 3 weeks) with concurrent cisplatin and etoposide (Turrisi). Although current clinical trials are exploring the efficacy of new chemotherapeutic strategies, essential questions related to the optimization of thoracic radiotherapy and the benefit of chemo-radiotherapy in sub-groups of patients remain unanswered, e.g. the elderly (Blackhall). The CONVERT trial (twice-daily (BD) versus once daily (OD) radiotherapy given concurrently with chemotherapy in stage I-III SCLC) was reported at ASCO 2016 (Faivre-Finn). OD RT did not result in a superior survival or worse toxicity than BD RT (two-year survival was 56% (95% CI 50-61) vs 51% (95% CI 45-57), p= 0.14). The survival for both regimens was higher than previously reported and using modern RT techniques radiation toxicities were lower than expected. In the stage IV setting the CREST trial as shown that the addition on thoracic RT to chemotherapy and PCI leads to a significant reduction in intrathoracic recurrence and, despite the lack of a significant benefit in overall survival at 1 year, there were significant improvements in overall survival at 2 years (Slotman). It is crucial that patients with SCLC are given the opportunity to participate in clinical research in order to continue to improve the survival of this disease. Molecular studies are ongoing aiming to gain improved insight into the molecular biology of SCLC, discover and/or validate candidate biomarkers for response, resistance to or toxicity of systemic treatment and radiation. It is expected that this understanding will lead to the development of targeted therapies that will not only prove efficacious but also less toxic than more conventional chemotherapy treatments. In combination with advanced RT techniques and better imaging, it is hoped that the rates of long term survivors will increase significantly in the future. We will address the following controversial questions: 1) Should BDRT be considered standard of care in stage I-III SCLC? 2) Role of CTRT in stage I-II SCLC 3) Role of CTRT in elderly patients with LS-SCLC 4) Should thoracic RT be given to all patients with stage IV SCLC? 1. Califano R, et al. Management of small cell lung cancer: recent developments for optimal care. Drugs. 2012 5;72(4):471-90. 2. Pignon JP, et al. A meta-analysis of thoracic radiotherapy for small-cell lung cancer. N Engl J Med 1992; 327:1618-1622. 3. Turrisi AT, et al. Twice daily compared to once-daily thoracic radiotherapy in limited-stage small-cell lung cancer treated concurrently with cisplatin and etoposide. N Engl J Med 1999; 340: 265-271. 4. Auperin A, et al. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J Med 1999;341(7):476-84. 5. Blanchard P, et al. Prophylactic cranial irradiation in lung cancer. Curr Opin Oncol. 2010; 22(2):94-101. 6. Blackhall F et al. Treatment of limited small cell lung cancer: an old or new challenge? Curr Opin Oncol. 2011; 23(2):158-62. 7. Faivre-Finn C, et al. Concurrent once-daily versus twice-daily chemoradiotherapy in patients with limited-stage small-cell lung cancer (CONVERT): an open-label, phase 3, randomised, superiority trial. Lancet Oncol. 2017;18(8):1116-1125. 8. Slotman BJ, et al. Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial. Lancet. 2015 3;385(9962):36-42. 9. Slotman BJ, et al. Which patients with ES-SCLC are most likely to benefit from more aggressive radiotherapy: A secondary analysis of the Phase III CREST trial. Lung Cancer. 2017; 108:150-153. small-cell, radiotherapy, thoracic

PS03.03 Salvage Therapy for Relapse after Stereotactic Body Radiation for Stage I Lung Cancer: Topic: Radiation Oncology

To evaluate treatment outcomes of recurrent non-small cell lung cancer (NSCLC) following initial SBRT for stage I disease. Retrospective review of patients treated with SBRT for stage I NSCLC from 2007-2017 who were found to have relapsed. Recurrences were classified as local (initial treated lesion), lobar (outside the treated lesion but confined to one lobe), nodal (hilum or mediastinum), or distant. Out of 297 treated with SBRT, 61 patients were found to have recurrence including 5 local, 14 lobar, 18 nodal, and 24 distant. Local recurrences developed at a median 21.2 months (range 11.6-63.4) from SBRT, and salvage treatment included radiation with concurrent chemotherapy (2 patients), lobectomy (2 patients), or radiofrequency ablation (1 patient). Lobar recurrences developed in a median 12 months (1.3 to 44.2), and nodal recurrences developed with median 11.3 months (1.8 to 34.5). Of 7 patients treated definitively after lobar relapse, 6 patients developed subsequent distant or regional relapse. Four of 11 patients treated for nodal relapse were salvaged without subsequent relapse. Approximately 40% of patients with lobar or nodal relapse did not undergo salvage therapy often due to poor functional status. Treatment related grade 3 + toxicity was not reported for patients treated with definitive salvage therapy. Median overall survival was 51 months after local relapse, 16 months after lobar relapse, and 13.7 months after nodal relapse. Median survival was 46 months for patients receiving definitive salvage therapy for intrathoracic recurrence compared with 9.7 months for patients not treated definitively. Distant recurrences occurred with a median of 10.9 months (range 2.0-55.9) after SBRT, and median survival was only 6.2 months after distant relapse in this group. Salvage therapy is feasible in the majority of patients with local or locoregional relapse after SBRT for stage I NSCLC. The success of salvage therapy appears to correlate with site of relapse with an unexpected high rate of subsequent relapse in patients treated for lobar recurrence. Novel approaches should be considered for addressing systemic disease in this poor risk population of patients.

Analysis of the causes of failure after radical surgery in patients with PT3N0M0 thoracic esophageal squamous cell carcinoma and consideration of postoperative radiotherapy

BackgroundFive-year overall survival rate of TESCC after surgery is low (approximately 30% to 60%), so it is meaningful to discuss the significance of PORT.MethodsWe retrospectively collected the data of 227 patients with PT3N0M0 esophageal cancer (EC). The failure pattern after surgery was analyzed. Difference of adjuvant PORT in patients with PT3N0M0 TESCC and the appropriate population were explored based on the relevant studies.ResultsThere were 58 cases with intrathoracic locoregional recurrence (LRR) after radical surgery and 27 cases with distant metastasis, including 10 cases of recurrence. The recurrence rate of mediastinal lymph nodes in the thoracic cavity was 50.0%. Univariate analysis revealed that compared with patients with middle and lower thoracic EC, the 3/5-year survival rate of patients with upper thoracic EC was significantly lower, accompanied with remarkably higher thoracic LRR. Compared with those with moderately- and well-differentiated TESCC, the 3/5-year survival rate of patients with poorly differentiated TESCC was significantly lower, whereas the distant metastasis rate was notably higher. Multivariate analysis revealed that different lesion locations and different pathologic differentiation were the independent prognostic factors. The lesion location and degree of differentiation were the independent influencing factors for thoracic LRR and distant metastasis, respectively.ConclusionThe intrathoracic LRR is the major failure pattern for patients with PT3N0M0 TESCC after conventional two-field lymphadenectomy. In addition, recurrence rate of PT3N0M0 TESCC was significantly higher in upper thoracic EC than in middle and lower thoracic EC. PORT is recommended to patients with PT3N0M0 upper TESCC.

Lung Metastasectomy in Pulmonary Metastatic Colorectal Carcinoma

Patients with colorectal cancer are often affected by liver and lung metastases. Besides systemic therapies, lung metastasectomy is a suitable treatment option after complete resection of primary colorectal carcinoma and even concomitant liver metastases. We have performed a systematical literature research of all studies published after 01. 01. 2010. Studies reporting on at least 100 patients undergoing lung metastasectomy after 01. 01. 2000 have been included in our final analysis. Operative data, survival data and prognostic factors have been extracted. Eleven study cohorts reporting on 2,891 patients could be included in the final analysis. Complete resection could be achieved in most cases and thoracic surgeons preferred subsegmental resections. Pathological examination revealed thoracic lymph node involvement in 2.3 to 18.2% of patients. The postoperative mortality varied from 0 to 0.5%. The median follow up ranged between 27.5 and 65.1 months. Pulmonary metastasectomy resulted in 5-year survival rates of 53 to 75.5% and 5-year progression-free survival rates of 33 to 50.9%. Intrathoracic recurrence occurred in 25.2 to 42.9% of patients with complete resection and five-year survival rates ranged from 49 to 75.5% after repeat pulmonary metastasectomy. Analysis of prognostic factors revealed that number, size and distribution of lung metastases are minor important prognostic factors. Moreover, current data suggest disadvantageous post-metastasectomy survival for patients with elevated pre-metastasectomy serum CEA level or intrathoracic lymph node metastases in comparison with the control groups. Nevertheless, even in these patients, lung metastasectomy might be a beneficial procedure. In patients with colorectal cancer and resectable isolated lung or combined liver and lung metastases pulmonary resection should be the treatment of choice. Pulmonary metastasectomy should be combined with thoracic lymph node resection to remove potential lymph node metastases. Repeat metastasectomy should be offered to patients suffering from isolated intrathoracic recurrence.

Video-assisted diaphragmatic resection and reconstruction for intra-thoracic recurrence of hepatocellular carcinoma

Trans-diaphragmatic intra-thoracic extension of recurrent hepatocellular carcinoma treated by electroporation can be performed via video-assisted thoracic surgery. Resection is followed by reconstruction with a synthetic mesh.

Paraneoplastic syndrome and survival in thymic epithelial tumors (TET): The Indiana University experience.

8574 Background: Paraneoplastic syndromes (PNS) are commonly associated with thymic epithelial tumors (TET), especially thymoma. The purpose of this analysis is to examine the clinical impact of PNS in TET. Methods: Patients with pathologically diagnosed TET at a single institution were reviewed retrospectively. The primary and second endpoints for this study were overall survival (OS) and recurrence rates. Clinical factors included age, gender, race, performance score, histology, WHO classification, Masaoka stage, post-operative status, tumor size and number of positive lymph nodes. Cox proportional hazards model was used to identify significant prognostic factors for OS between different PNS groups. Results: From 1975 to 2016, 733 patients with TET (thymoma (T) -71%, thymic carcinoma (TC) -26% and neuroendocrine tumor (NET)-3%) were seen at Indiana University. Of these, 203 (28%) had PNS including myasthenia gravis (n = 130), red cell aplasia (n = 20), hypogammaglobulinemia (n = 14), systemic lupus erythematosus (n = 12) or other PNS (n = 64). Among these, 37 (18%) had two or more types of PNS. PNS were seen in 35% (183/523) of T, 9% (16/187) of TC and 15% (3/20) of NET ( p &lt; 0.001), respectively. Recurrence rates and mortality at 5 year were 8% and 10% in PNS (+) group compared to 13% and 16% in PNS (-) group ( p &lt; 0.05). Intrathoracic recurrences were more common in PNS (+) patients (89% vs 77%; p = 0.016). In both groups, adverse factors for survival included: older age, advanced stage, number of positive lymph nodes and TC histology (all p-values &lt; 0.05). However, post-operative R1/2 status was adverse prognostic factor only in the PNS (-) group ( p = 0.001). Conclusions: PNS is common in TETs. Patients with PNS have lower risk of recurrence and mortality compared to patients without PNS, but may have a higher risk of intrathoracic recurrence.

Characteristics and timing of recurrence during postoperative surveillance after curative resection for lung adenocarcinoma

To establish the most effective methods of postoperative surveillance to detect early recurrence of lung adenocarcinoma. The subjects of this retrospective study were 485 patients with p-stage I-III lung adenocarcinoma, who underwent postoperative surveillance. We examined the sites and detection modes of recurrence and calculated the recurrence-free probabilities. Patients with stage I disease were divided into low- and high-risk recurrence groups using a risk score calculated by assigning points proportional to risk factor regression coefficients. Of the 112 patients with recurrence, 86 had intrathoracic recurrence. Routine computed tomography (CT) revealed recurrence in 60 patients. The recurrence-free probability curves showed that 95% of recurrences were identified within the first 4years after resection in patients with stage II/III disease. In patients with stage I disease, the predictors of recurrence included male sex, positive pleural lavage cytology, moderate-to-poor differentiation, and visceral pleural invasion. Postoperative recurrences were detected throughout the follow-up period in the high-risk group. Routine chest CT plays an important role in the postoperative surveillance of lung adenocarcinoma. We recommend intensive follow-up during the early post-resection period for patients with advanced stage disease and long-term follow-up for high-risk patients with stage I disease.

Which patients with ES-SCLC are most likely to benefit from more aggressive radiotherapy: A secondary analysis of the Phase III CREST trial

IntroductionIn ES-SCLC patients with residual intrathoracic disease after first-line chemotherapy, the addition of thoracic radiotherapy reduces the risk of intrathoracic recurrence, and improves 2-year survival. To identify patient subgroups for future trials investigating higher dose (extra)thoracic radiotherapy, we investigated the prognostic importance of number and sites of metastases in patients included in the CREST trial. Materials/ methodsAdditional data on sites and numbers of metastases were collected from individual records of 260 patients from the top 9 recruiting centers in the randomized CREST trial (53% of 495 study patients), which compared thoracic radiotherapy (TRT) to no TRT in ES-SCLC patients after any response to chemotherapy. All patients received prophylactic cranial irradiation. ResultsThe clinical characteristics and outcomes of the 260 patients analyzed here did not differ significantly from that of the other 235 patients included in the CREST trial, except that fewer patients had a WHO=0 performance status (24% vs 45%), and a higher proportion had WHO=2 (15% vs 5%; p<0.0001). No distant metastases were recorded in 5%, 39% had metastases confined to one organ, 34% to two, and 22% to three or more organ sites. Metastases were present in the liver (47%), bone (40%), lung (28%), extrathoracic (non-supraclavicular) lymph nodes (19%), supraclavicular nodes (18%), adrenals (17%) and other sites (12%). The OS (p=0.02) and PFS (p=0.04) were significantly better in patients with 2 or fewer metastases, with OS significantly worse if liver (p=0.03) and/or bone metastases (p=0.04) were present. DiscussionThis analysis of patients recruited from the top 9 accruing centers in the CREST trial suggests that future studies evaluating more intensive thoracic and extra-thoracic radiotherapy in ES-SCLC should focus on patients with fewer than 3 distant metastases.

ED14.02 Thoracic Radiotherapy of SCLC

ED14.02 Thoracic Radiotherapy of SCLC

Stereotactic Body Radiation Therapy as Salvage for Intrathoracic Recurrence in Patients With Previously Irradiated Locally Advanced Non–Small Cell Lung Cancer

The purpose of this study is to provide data on the outcomes of using stereotactic body radiotherapy (SBRT) as a means of salvage for non-small cell lung cancer (NSCLC) relapses previously treated with radiation. The records of 128 consecutive patients treated with thoracic SBRT from 2009 through 2012 were retrospectively reviewed. Twenty-seven patients (29 lesions) treated with prior thoracic radiation for stage IIB-IIIB NSCLC with subsequent recurrences and retreated with SBRT were identified. The median prior radiation dose was 64.8 Gy (range, 45 to 74 Gy) with a median retreatment dose of 50 Gy (range, 30 to 54 Gy), corresponding to a biological equivalent dose of 100 Gy (range, 48 to 151 Gy), at a median time of 13.4 months from prior radiation. The mean follow-up after salvage SBRT was 22 months. Local failure following salvage was 11%, nodal failure was 37%, and distant failure was 30%. The local recurrence-free survival at 2 years was 72%. Out-of-field failure was predictive for worse local control (hazard ratio, 47.38; 95% confidence interval, 5.795-64.899). Progression-free survival at 1 year was 55% and 38% at 2 years. Overall survival at 2 years from SBRT salvage was 79%. Salvage biological equivalent dose ≥100 Gy was predictive of improved progression-free survival (48% vs. 18%, P=0.021) and overall survival (91% vs. 52%, P=0.004) at 2 years. The rate of symptomatic pneumonitis was 63% and chest wall pain reported was 26%. We observed improved outcomes following SBRT as a means of salvage for locally advanced recurrent NSCLC over traditional radiation therapy options. The toxicities were greater than expected from naive lung irradiation, but the adverse effects remained controlled with medications.

Video assisted thoracic surgery (VATS) for recurrent thymoma.

Between 10-30% of patients that undergo a radical operation for thymoma develop a recurrence in a variable range of time. The surgical treatment of thymoma relapses is an established and effective therapeutic approach, particularly for a single intrathoracic recurrence; however, no agreement has been reached on the best surgical approach and the extent of surgical resection, particularly in the most common event of pleural relapses. In the era of minimally invasive approach for most thoracic pathologies, the role of the video assisted thoracic surgery (VATS) approach for thymoma recurrence resection is still unclear and controversial: to date, only few authors have reported in their series a thoracoscopic resection of pleuro-pulmonary relapses, mostly when a single lesion was present. Furthermore, a thoracoscopic approach for mediastinal recurrence has been rarely reported after a previous sternotomy to resect the primary tumor. It is likely that in the future, the role of VATS for thymic recurrence resection will be better defined and extensively studied.

Available evidence on re-irradiation with stereotactic ablative radiotherapy following high-dose previous thoracic radiotherapy for lung malignancies.

Patients affected with intra-thoracic recurrences of primary or secondary lung malignancies after a first course of definitive radiotherapy have limited therapeutic options, and they are often treated with a palliative intent. Re-irradiation with stereotactic ablative radiotherapy (SABR) represents an appealing approach, due to the optimized dose distribution that allows for high-dose delivery with better sparing of organs at risk. This strategy has the goal of long-term control and even cure. Aim of this review is to report and discuss published data on re-irradiation with SABR in terms of efficacy and toxicity. Results indicate that thoracic re-irradiation may offer satisfactory disease control, however the data on outcome and toxicity are derived from low quality retrospective studies, and results should be cautiously interpreted. As SABR may be associated with serious toxicity, attention should be paid for an accurate patients' selection.

Long-Term Outcomes and Patterns of Failure After Surgical Resection of Small-Cell Lung Cancer

BackgroundThe role of surgical resection as a treatment option for early-stage small-cell lung cancer (SCLC) is controversial, and few data exist regarding the patterns of treatment failure in these patients. Patients and MethodsThe medical records of all patients receiving definitive surgical management of SCLC at Mayo Clinic (Rochester, MN) from January 1, 1985 to December 31, 2012 were reviewed. Estimates of survival and recurrence risk were recorded using the Kaplan-Meier method, and comparative analyses were performed with Cox regression analysis. ResultsA total of 54 patients were identified. The median follow-up period was 5.9 years. At 5 years, overall survival was 37% and recurrence-free survival 44%. Intrathoracic recurrence, the most frequent treatment failure, occurred in 14 patients, with an estimated intrathoracic recurrence-free survival at 3 years of 64.4%. Patients undergoing wedge resection or segmentectomy, rather than lobectomy or pneumonectomy, had an increased risk of intrathoracic recurrence (hazard ratio, 3.5; P = .01). Overall survival was improved at 5 years after lobectomy or pneumonectomy compared with wedge resection or segmentectomy (48% vs. 15%, respectively; P = .03). ConclusionSurgical resection of SCLC can achieve reasonable treatment outcomes and can be considered for well-selected patients with clinical early-stage disease. Intrathoracic recurrence is the most common site of treatment failure. Caution should be taken with patients who are unable to tolerate at least lobectomy, because they are at a high risk of local recurrence.

Surgical therapy for pulmonary metastases from malignant melanoma

Results of previous studies question the benefits of pulmonary surgery in patients with pulmonary metastases from malignant melanoma. A systematic literature search and analysis of articles published since 1 January 2000 was carried out to investigate the advantages of metastasectomy and alternative forms of therapy. Patients reached a median survival time of 17-40 months and 5-year survival rates between 18% and 39.4% after metastasectomy. Intrathoracic recurrence occurred in 30 % of patients but could be successfully treated with re-operations in some cases. Various monoclonal antibodies are currently available and achieve a median survival time of up to 17 months. Pulmonary metastasectomy is the treatment of choice in selected patients; however, in the future the benefits should be revalidated in comparison with pharmaceuticals of the current generation.