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Pulmonary resection after concurrent chemotherapy and high dose (60 Gy) radiation for non-small cell lung cancer is safe and may provide increased survival

^a Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham (UAB), 703 19th Street S, ZRB 739, Birmingham, AL 35294, United States
^b University of Alabama at Birmingham School of Medicine, Birmingham, AL, United States
^c Summer Research Intern, University of Alabama at Birmingham, AL 35294, United States

Received 28 August 2008; received in revised form 25 November 2008; accepted 19 December 2008.

^_* Corresponding author. Tel.: +1 205 996 7561; fax: +1 205 975 2815. (Email: rcerfolio{at}uab.edu).

Background: We have used doses of 60 Gy or higher for neoadjuvant chemoradiotherapy for select patients with advanced non-small cell lung cancer (NSCLC), including patients with N2 disease and those with Pancoast lesions, to avoid gaps in radiotherapy in case surgery is ultimately not offered. Methods: A retrospective cohort study using a prospective database. Patients underwent initial staging with CT, PET/CT and lymph node biopsy (mediastinoscopy, endoscopic esophageal ultrasound and endobronchial ultrasound) and then received neoadjuvant high dose radiotherapy and chemotherapy, followed by thoracotomy with intent to cure. Results: Between January 1998 and June 2008 there were 216 patients who were eligible for this study. The median dose of radiation was 60 Gy (range 60–72 Gy). Lobectomy was performed in 152 patients (70%) about 7 weeks after radiotherapy finished (mean 51 days, range 34–89 days).The bronchus was buttressed with an intercostal muscle flap in 97% patients. Median hospital stay was 4.5 days (range 2–57). Major morbidity occurred in 17%. There were five (2.3%) deaths. There were no bronchial-pleural fistulas after lobectomy, but two occurred after right pneumonectomy. Predictors of morbidity were FEV₁ <50% (p < 0.001), DLCO <60% (p < 0.001) and age >75 years (p = 0.008). The overall 5-year Kaplan–Meier survival was 34%. It was 42% for those who underwent R0 resection, 38% for those with initial N2 disease and 45% for the 71 complete responders. Conclusions: Pulmonary resection after high dose (60 Gy) neoadjuvant chemoradiotherapy is safe. Lobectomy can be safely performed and bronchopleural fistula prevented. Sixty Gy allows for maximal medical therapy in case resection is not offered. Since complete response rates may be higher than when 45 Gy is used and since surgery is safe, its use deserves further investigation.

Abbreviations: CR = complete responder • CT = computed tomography • EBUS = endobronchial ultrasound • EUS-FNA = endoscopic ultrasound with fine needle aspiration • FDG-PET = 18F-fluorodeoxyglucose positron emission tomography • FEV₁% = percent predicted in 1 s of forced expiration • DLCO% = capacity of lung to diffuse carbon monoxide • maxSUV = maximum standardized uptake values • NSCLC = non-small cell lung cancer • POD = postoperative day • ROC curve = receiver operating characteristic curve

Key Words: Radiation • Pulmonary resection • Non-small cell lung cancer