Survival after salvage pulmonary resection for non-small cell lung cancer: a national cancer database analysis

Combination treatment with neoadjuvant chemoimmunotherapy is an emerging standard of care in early stage and locally advanced lung cancer. Salvage lung resections may be curative for persistent or recurrent lung cancer after definitive oncologic therapy including radiotherapy or chemoradiotherapy (CRT). The objective of this study is to describe the characteristics and overall survival (OS) of patients with non-small cell lung cancer (NSCLC) who underwent salvage pulmonary resections.

The 2004-2019 version of National Cancer Database (NCDB) was queried to identify patients with NSCLC who received salvage pulmonary resections after definitive therapy. The inclusion criteria were: (I) interval from completion of radiotherapy to surgery greater than 120 days; (II) chemotherapy that started concurrent with radiation (maximum 7 days before the first dose of radiation); (III) resection extent of at least a lobectomy; and (IV) resection site ipsilateral to the radiation site. The Kaplan-Meier estimator was used to calculate OS. The associations between the extent of the resection, the disease stage, the patients' age, sex, comorbidities score, and the administration of chemotherapy with OS were estimated using adjusted and unadjusted Cox proportional hazard regression models.

A total of 289 patients with NSCLC that underwent a salvage pulmonary resection were identified. Half of them were males (50.2%), 81.0% were identified as White and 61.6% had a Charlson-Deyo comorbidity score equal to zero. Most tumors were located in the right upper lobe (41.9%), followed by the left upper lobe (26.6%) and the right lower lobe (11.8%). The most common histological type was adenocarcinoma (44.6%) followed by squamous cell carcinoma (40.1%). According to the American Joint Committee on Cancer (AJCC) 8th edition, 29.8% of the identified patients were classified as stage I, 22.1% as stage II, 40.5% as stage III and 5.2% as stage IV. In terms of treatment, 91.0% of the patients received CRT and the median time between the last radiation dose and surgery was 153 [interquartile range (IQR), 134, 191] days. The most common salvage procedure performed was lobectomy or bilobectomy (69.9%), followed by pneumonectomy (19.4%). The median follow-up time for our cohort was 39.1 (IQR, 15.8, 71.7) months and the 1-, 5- and 10-year OS was 83.4%, 49.7% and 30.9%, respectively. Univariable survival analysis revealed that increased age, male gender and comorbidity score equal to three were associated with worse survival. Multivariable analysis confirmed these findings and suggested that stage II and stage III are also associated with worse survival.

Salvage pulmonary resection may be beneficial in terms of OS for patients with NSCLC previously treated with radiotherapy or CRT. The frequency of salvage surgery is increasing in recent years and more evidence is required to elucidate the role of this treatment in the armamentarium of thoracic surgeons.