Therapeutic strategy for postoperative recurrence in patients with non-small cell lung cancer

Abstract

Postoperative recurrence occurs in approximately half of patients with non-small cell lung cancer (NSCLC), even after complete resection. Disease recurrence after surgical resection reduces the patient's life expectancy sharply. The prognosis after postoperative recurrence is considered to largely depend on both the mode of first recurrence (distant, locoregional or combined) and the treatment modality: (1) The majority of cases of postoperative recurrence involve distant metastasis with or without locoregional recurrence. Platinum-based systemic chemotherapy is practically accepted as the treatment for these diseases on the basis of evidence for original stage IV disease. The advent of both pemetrexed and molecular-targeted drugs has improved the survival of nonsquamous NSCLC and changed the chemotherapeutic algorithm for NSCLC; (2) Among patients with distant metastatic recurrence without locoregional recurrence at the primary tumor site, the metastasis is often limited in both organ and number. Such metastases are referred to as oligometastases. Local therapy, such as surgical resection and radiotherapy, has been suggested to be the first-line treatment of choice for oligometastatic recurrence; and (3) While locoregional recurrence is likely to cause troublesome symptoms, it is a potentially limited disease. Therefore, providing local control is important, and radiation is usually beneficial for treating local recurrence. In order to obtain better control of the disease and provide treatment with curative intent in patients with limited disease, the administration of concurrent platinum-based chemoradiotherapy is recommended according to the results of originally nonresectable stage IIIA and IIIB disease.

Keywords: Distant metastasis; Local treatment; Locoregional recurrence; Non-small cell lung cancer; Oligometastases; Postoperative recurrence.

Figure 1

Postrecurrence survival according to the mode of postoperative recurrence. From 1994 through 2004, 418 consecutive patients with NSCLC underwent complete resection at Kyushu University Hospital. Of these patients, 138 experienced postoperative recurrence by December 2005, and were followed until the end of 2009.

Figure 2

Mode of postoperative recurrence in reference to the initial stages of disease.

Figure 3

Mode of postoperative recurrence and treatment modality.

Figure 4

Chemotherapeutic algorithm. PEM: Pemetrexed; GEM: Gemcitabine; CDDP: Cisplatin; CBDCA: Carboplatin; DOC: Docetaxel; EGFR-TKI: Epidermal growth factor receptor tyrosine kinase inhibitor; ALK: Anaplastic lymphoma kinase fusion gene.