Van Breussegem Annemie, Hendriks Jeroen M, Lauwers Patrick, Van Schil Paul E
Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Antwerp, Belgium.
J Thorac Dis. 2017 Apr;9(Suppl 3):S193-S200. doi: 10.21037/jtd.2017.03.88.
Salvage surgery is a relatively new entity in thoracic surgery and oncology. Salvage resection after radiotherapy refers to surgery as only remaining therapeutic option in patients who were treated with high-dose stereotactic radiotherapy (SRT) for early-stage lung cancer or full-dose chemoradiation for locally advanced lung cancer. Indications include locally progressive tumors, recurrent local or locoregional disease, or specific complications after radiotherapy such as lung abscesses or infected, necrotic cavities. Small, retrospective series demonstrate that salvage surgery after high-dose radiotherapy is feasible and may yield good long-term results. A clear distinction should be made between salvage surgery after SRT for early-stage lung cancer and salvage procedures after full-dose chemoradiation for lung cancers with locoregional extension into the mediastinum. Salvage surgery after SRT may be rather straightforward and in specific cases even feasible by a minimally invasive approach. In contrast, surgery after a full dose of chemoradiation delivered several months or years earlier, can be quite challenging and the dissection of the pulmonary artery and mediastinal lymph nodes technically demanding. Due to the more central irradiation an intrapericardial dissection is often required. To prevent a bronchopleural fistula protection of the bronchial stump with well-vascularized flaps is recommended. Each individual patient in whom salvage surgery is considered, should be discussed thoroughly within a multidisciplinary board, detailed cardiopulmonary functional evaluation is required, and the operation should be performed by an experienced team including a thoracic surgeon, anaesthesiologist and intensive care physician. At the present time only retrospective series are available. Carefully designed prospective studies are necessary to more precisely define indications and results of salvage surgery not only after SRT for peripherally localized lesions but also following full-dose chemoradiation for locoregionally advanced disease.
挽救性手术在胸外科和肿瘤学领域是一个相对较新的概念。放疗后的挽救性切除是指对于接受高剂量立体定向放疗（SRT）治疗早期肺癌或全剂量放化疗治疗局部晚期肺癌的患者，手术是仅有的剩余治疗选择。适应证包括局部进展性肿瘤、局部或区域复发性疾病，或放疗后出现的特定并发症，如肺脓肿或感染、坏死性空洞。小型回顾性系列研究表明，高剂量放疗后的挽救性手术是可行的，并且可能产生良好的长期效果。对于早期肺癌SRT后的挽救性手术和纵隔局部扩展的肺癌全剂量放化疗后的挽救性手术，应明确区分。SRT后的挽救性手术可能相当直接，在特定情况下甚至可通过微创方法实现。相比之下，数月或数年之前接受全剂量放化疗后的手术可能极具挑战性，肺动脉和纵隔淋巴结的解剖在技术上要求很高。由于照射范围更靠近中心，通常需要进行心包内解剖。为防止支气管胸膜瘘，建议用血运丰富的皮瓣保护支气管残端。对于每一位考虑进行挽救性手术的患者，都应在多学科委员会中进行充分讨论，需要进行详细的心肺功能评估，并且手术应由包括胸外科医生、麻醉师和重症监护医生在内的经验丰富的团队进行。目前仅有回顾性系列研究。需要精心设计前瞻性研究，以更精确地确定挽救性手术的适应证和结果，不仅是SRT治疗周围局限性病变后的情况，还有全剂量放化疗治疗局部晚期疾病后的情况。
