the recurrence of lung cancer after complete resection generally results in a poor prognostic situation with less than one year of life expectancy .
when a single lung nodule is detected during follow - up , it is usually one of the manifestations of the systemic metastasis . however , one distinct feature is a second primary metachronous lung cancer appearing after the initial treatment of the primary lung cancer .
although there are criteria that can be applied in this situation , it is sometimes very difficult in clinical practice to distinguish between a new lung cancer and a metastatic one .
therefore , some researchers have insisted an aggressive surgical approach , whenever possible , as the survival rate after surgery is quite good ( 1 - 7 ) . on the other hand
, many doubts have been expressed concerning the utility of repeated surgery for recurrent lung cancer , as it is associated with a poor overall survival ( 8 , 9 ) .
we are convinced of the value of the aggressive surgical approach for all the cases whose the functional condition makes resection possible .
the aim of this study is to report the result of re - resection for recurrent lung cancer while focusing on the rationale for this aggressive surgical approach .
there were 1,461 patients who underwent operations for primary lung cancer from december 1994 to december 2003 .
the operations were performed by a group of three thoracic surgeons in a single hospital .
every patient was followed - up by the same surgeons on a regular follow - up schedule ( every 3 - 4 months for 2 yr , every 6 months for the next 3 yr and then every year ) .
when recurrent disease in the lung was suspected , repeated ct scan were performed at 2 months intervals , and positron emission tomography ( pet ) , bronchoscopy and/or percutaneous needle aspiration ( pcna ) were also performed .
there were 29 consecutive patients who underwent repeated surgical resections for recurrent lung cancer after curative resection for lung cancer . at the time of initial operation , histology and pathological staging are shown in table 1 .
the diagnostic methods of recurrent lung cancer were chest ct in 11 patients , pet in 9 patients , pcna in 6 patients , and bronchoscopic biopsy in 3 patients .
the second primary lung cancers were defined using the criteria outlined by martini and melamed ( 10 ) .
a neoplasm was defined as a metastatic lung cancer if it was a same histology occurring in the same anatomic site within 2 yr after first operation .
a second primary cancer was a tumor of different histology , or if histology was the same , the disease free interval of recurrent cancers was at least 2 yr or the second cancer was in different lobe or lung , or origin from carcinoma in situ in the absence of other extrapulmonary or common lymphatic metasitasis . on the repeated lung operations , mediastinoscopy was not performed because most of the patients already had had mediastinoscopy performed at the first lung resection . however ,
careful intraoperative nodal staging was performed by dissecting the intrapulmonary , hilar and ipsilateral mediastinal nodes .
although the extent of resection of recurrent lung cancer in early period was dependent on the surgeon 's preference , thereafter we have made an attempt to avoid limited resection if patients had predictive post - operative fev1 of more than 1.0 l and acceptable cardiac function .
postoperatively , the same follow - up plan was applied as for the first lung operation .
we analyzed included types of operation , the time between two surgical interventions , operative findings and histology , operative and post - operative complications and the hospital mortality as well as late death .
the descriptive statistics are summarized as the median or mean for the continuous variables and as frequencies and percentages for the categorical variables .
survival and the disease free rate were analyzed by the kaplan - meier and log - rank methods on spss for window , release 10.0 ( spss inc . ,
29 consecutive patients underwent surgical resections for recurrent lung cancer after curative resection for lung cancer .
the median age of patients was 61 yr ( range , 45 to 75 yr ) and the male / female ( 22/7 ) ratio was 3.1:1 .
the second primary tumor was discovered on the same side as the first tumor in 19 patients .
the mean time interval between the first operation and the second operation was 20.315 months ( table 1 ) .
the mean time interval between the first resection and the second resection was 25.415.1 months for the second primary lung cancers and 8.95.7 months for the metastatic lung cancer .
the second operations were completion pneumonectomy in 11 patients , lobectomy in 5 patients , wedge resection in 12 patients , and resection and anastomosis of the trachea in 1 patient ( table 2 ) .
the causes of death were pulmonary embolism in one patient and respiratory failure in the other patient .
major morbidity was observed in 6 ( 21% ) patients after the repeated lung resection ; bronchopleural fistula was noted in 3 patients , myocardial infarction and cerebral vascular accident were noted in 1 patient , pulmonary artery embolism occurred in 1 patient and respiratory failure occurred in 1 patient .
tumor recurrence after reoperation was observed in 14 patients ( 48% ) . in four of these 14 patients
, we performed the third operation ; a completion pneumonectomy in 1 patient , wedge resection in 2 patients and multiple rib resection and chest wall reconstruction in 1 patient .
the remaining ten patients were referred for radiation therapy , chemotherapy or supportive care only ( table 4 ) .
overall follow - up after reoperation ranged from 3 to 103 months with a mean of 41.422.3 months .
the overall actuarial 5-yr survival rate was 69% and the 5-yr disease free rate following reoperation was 44% ( n=29 ) .
no significant difference was detected in survival and the disease free rate between the second primary lung cancer patients and the metastatic lung cancer patients ( table 3 , fig . 1 , 2 ) .
the disease free rate following reoperation was significantly different between the wedge resection group and anatomically curative resections such as lobectomy / completion pneumonectomy group ( p=0.008 ) , but the survival rate was not significantly different ( fig .
recent improvements of such diagnostic tools as high - resolution ct scan or pet scan allow physicians to detect recurrent lung cancer much earlier than before .
however , there is not yet a consensus for the postoperative follow - up strategy of patients after complete resection for nsclc .
( 1 ) reported that intensive follow - up may improve patient survival by detecting recurrences at an asymptomatic stage after surgery for nsclc .
it has been reported that for detecting residual or recurrent nsclc , pet had a sensitivity of 100% and a specificity of 61.5 - 92% , but chest
ct only had a sensitivity of 67% and a specificity of 85% for the detection of tumor recurrence ( 12 )
. in our study , when the lesion was centrally located and the percutaneous needle aspiration was difficult to perform , pet was then used as a very effective diagnostic method . in our series ,
the diagnostic methods of recurrent lung cancer were chest ct in 11 patients , pet in 9 patients , pcna in 6 patients , and bronchoscopic biopsy in 3 patients .
when the recurrent lung cancer was difficult to diagnose with using chest ct or pet , we then performed invasive diagnostic methods .
the initiation of earlier therapy with the early detection of recurrences may have improved the outcome compared with the therapy given when the patient becomes symptomatic from the tumor ( 1 , 3 , 4 , 6 ) .
major complications occurred in 24% of our patients after the second resections , which is comparable to the previously reported results of pulmonary resection for recurrent lung cancers ( 3 , 4 , 17 ) .
martini and melamed ( 10 ) in 1975 outlined the criteria for differentiation between a second primary lung cancer and a metastatic or recurrent lung cancer .
some reports have suggested that patients with a second primary lung cancer have a more favorable prognosis than patients with locally recurrent or metastatic disease ( 13 - 15 ) .
however , other reports did not reveal a significantly different survival between patients operated on for a second primary lung cancer or those patients operated on for locally recurrent or metastatic disease ( 4 , 5 , 8 , 9 ) .
our data showed that the 5-yr survival rates were not different between second primary lung cancer and the possible second primary or metastatic lung cancer . yet the 5-yr disease free rates for lobectomy / completion pneumonectomy group were better than for wedge resection group .
it may be explained by the fact that the second operations had been wedge resections for eight patients of the second primary lung cancer subgroup ( n=12 ) who had suffered a second tumor recurrence .
the lung cancer study group ( 16 ) reported that a resection that is less extensive than lobectomy for primary lung cancer places the patient at an increased risk of local recurrence and this decreases the chances of long term survival .
the limited resections used in second primary lung cancer group might have resulted in an increased risk for locoregional recurrence , but the extents of the resection of recurrent lung cancer did not influence the survival in another study ( 6 , 17 ) .
( 7 ) reported that pulmonary resection of bronchogenic carcinoma after pneumonectomy was associated with acceptable morbidity and mortality .
wedge resection , when feasible , is the treatment of choice . voltolini et al .
( 4 ) has reported on the type of surgical treatment used in case of metachronous second primary lung tumor .
the wedge resection was a reasonable and safe alternative to the standard resections in the elderly patients or in those patients with a poor respiratory reserve and after a pneumonectomy .
if the tumor was not in the periphery and if it was less than 2 cm in diameter , they consider lobectomy as the treatment of choice even for the second resection .
the recurrence rate was lower in the lobectomy / completion pneumonectomy group than in the wedge resection group .
the mean disease free time for lobectomy / completion pneumonectomy patients was longer than for the wedge resection patients .
eight patients , who had undergone wedge resection of second primary lung cancer , were proven to show recurrence .
therefore , lobectomy or completion pneumonectomy is preferred to wedge resection as an operation for a second primary lung cancer .
surgical intervention for recurrent lung cancers can be performed with an acceptable mortality and morbidity . if it is tolerable , completion pneumonectomy or lobectomy are recommended procedures of choice for recurrent lung cancer .
 we reviewed our experience with resection of recurrent lung cancer to evaluate the benefit and risk of the procedure . from december 1994 to december 2003 , 29 consecutive patients underwent pulmonary resections for recurrent lung cancer . the mean duration from the first resection to second surgery was 25.415.1 months for the definite 2nd primary lung cancer ( n=20 ) and 8.95.7 months for metastatic lung cancer ( n=9 ) . 
 the procedures at the second operations were completion - pneumonectomy in 11 patients , lobectomy in 5 patients , wedge resection in 12 patients and resection and anastomosis of trachea in 1 patient . 
 morbidity was observed in 6 ( 21% ) of the patients and the in - hospital mortality was two patients ( 7% ) after the repeated lung resection . 
 tumor recurrence after reoperation was observed in 14 patients ( 48% ) . 
 the actuarial 5-yr survival rate was 69% and the 5-yr disease free rate following reoperation was 44% . 
 no significant difference was found in overall survival and disease free survival between the 2nd primary lung cancer group and the metastatic lung cancer group . 
 the recurrence rate following reoperation was significantly different between the wedge resection group and lobectomy / completion pneumonectomy group ( p=0.008 ) , but the survival rate was not significantly different ( p=0.41 ) . 
 surgical intervention for recurrent lung cancers can be performed with acceptable mortality and morbidity . if tolerable , completion pneumonectomy or lobectomy is recommended for resection of recurrent lung cancer . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION