==== Front Cureus Cureus 2168-8184 Cureus 2168-8184 Cureus Palo Alto (CA) 10.7759/cureus.39790 Cardiac/Thoracic/Vascular Surgery Oncology Resection of Contralateral Scapular Oligometastasis in Non-small Cell Lung Cancer Post Right Salvage Pneumonectomy Muacevic Alexander Adler John R Djouani Adam 1 Maddipati Teja 1 Smith Alexander 1 Okiror Lawrence 1 1 Thoracic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, GBR Adam Djouani a.djouani@nhs.net 31 5 2023 5 2023 15 5 e3979031 5 2023 Copyright © 2023, Djouani et al. 2023 Djouani et al. https://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This article is available from https://www.cureus.com/articles/159253-resection-of-contralateral-scapular-oligometastasis-in-non-small-cell-lung-cancer-post-right-salvage-pneumonectomy A 74-year-old male was diagnosed with right hilar T4N1M0 squamous cell carcinoma of the lung. Radical oncological treatment was initiated with curative intent. Despite this, a post-operative computed tomography scan showed residual disease. Therefore, right thoracotomy and salvage pneumonectomy were performed. The patient recovered well post-operatively. Unfortunately, seven months later, he re-presented with a left scapula subcutaneous mass, with a biopsy confirming metastatic lung squamous cell carcinoma. Radiotherapy was not possible as it would have irradiated the remaining lung, and therefore, surgical resection and chest wall reconstruction were undertaken. The patient remains free of disease at 6 months follow-up. We present an interesting case of surgical management of oligometastatic lung cancer. thoracic oncosurgery salvage procedure post pneumonectomy non-small cell lung carcinoma (nsclc) oligometastatic ==== Body pmcIntroduction Lung cancer remains the leading cause of cancer-related deaths in the UK [1]. A total of 85% of lung cancer cases are non-small cell lung cancer (NSCLC) which comprises adenocarcinoma, squamous cell carcinoma, and large cell carcinoma [2]. Cigarette smoking remains the most important risk factor. Curative surgical management for NSCLC is offered to medically fit patients with early-stage disease. In contrast, the prognosis for patients with advanced non-small cell lung cancer (NSCLC) has historically been poor. However, with developments in chemotherapy and novel immunotherapeutic approaches, outcomes are improving. Despite this, failure of treatment continues to occur with several acquired mutations known to render tumors treatment-resistant [3]. Salvage surgery may be defined as the surgical resection of disease following the failure of other treatment modalities where surgical resection was not the primary intended mode of treatment [4]. In the context of NSCLC cancer, salvage surgery is an option in individuals where chemo-radiotherapy/immunotherapy has down-staged unresectable disease to resectable, and in cases where initial oncological therapy has failed or where disease relapse has occurred following an initial treatment response. Surgical management of disease recurrence in NSCLC has historically been confined to local disease [5]. However, new studies have demonstrated that resection of solitary or limited metastatic disease, also called ‘oligometastases’ [6], may improve outcomes. There is evidence for favorable outcomes for surgical resection of oligometastatic lung cancer with isolated adrenal and brain metastasis [7][8]. We present an interesting case of surgical resection for oligometastatic metachronous lung cancer to the contralateral scapula in a patient who had previously undergone salvage pneumonectomy after radical chemo-radiotherapy. Case presentation A 74-year-old male, with a sixty-pack-year smoking history, was initially investigated for a persistent dry cough. Further imaging and biopsy led to the diagnosis of T4 N1 M0 squamous cell carcinoma of the right hilum (primary lesion encasing the right main bronchus, not causing collapse). He was treated with concurrent chemo-radiotherapy with curative intent, consisting of four cycles of Carboplatin and Vinorelbine, and radiotherapy in the form of 55Gy in 20 fractions. His oncological treatment was successfully completed a month later, with a good radiological response (Figure 1).  Figure 1 Initial CT scan demonstrating right perihilar lesion (left panel). CT scan post-chemo-radiotherapy demonstrating a reduction in tumor size (right panel). Nine months later, follow-up imaging with a [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed local recurrence (Figure 2). Figure 2 Follow-up PET scan demonstrating disease recurrence in the right perihilar region Following multidisciplinary discussion, he underwent a right posterolateral thoracotomy and salvage pneumonectomy, recovering well post-operatively. Histology confirmed a fully resected ypT2a ypN0 squamous cell carcinoma (yp prefix indicating pathological staging post systemic treatment). The lesion measured thirty-one millimetres in maximum diameter. The postoperative course was uneventful. Seven months later, the patient experienced some left shoulder pain and subsequently a CT scan demonstrated a 52 x 48 x 42mm subcutaneous mass on the left posterior chest wall. Further imaging proved the lesion to be FDG-avid (figure 3) and a biopsy confirmed a squamous cell carcinoma metastasis isolated to the left chest wall adjacent to the scapula.  Figure 3 [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) demonstrating left posterior chest wall metastasis No evidence of extension into the ribs or thoracic cavity was found. There was no evidence of further metastases. Following a multidisciplinary discussion, it was deemed that radiotherapy to the lesion would not be possible due to the risk of radiation-induced lung injury of the remaining lung. The metastasis appeared to be potentially resectable and the patient subsequently consented to left chest wall resection and reconstruction. The procedure involved a 22cm oblique incision over the chest wall mass. The latissimus dorsi was found uninvolved, and therefore, spared, and the mass was identified as arising from the angle of the scapula to the medial spine. A successful en block resection of the scapula and serratus anterior muscle was conducted with good margins. The thoracic cavity was not entered. Reconstruction of the scapula and serratus anterior was done using a 5x5cm 1.5mm thick porcine dermal collagen implant (PermacolTM Medtronic UK). A Redivac drain was sited, and this was followed by routine layered closure.  In the immediate postoperative period, the patient developed a left-sided tension pneumothorax requiring urgent decompression with a surgical chest drain. This was performed successfully, following which he was transferred to the critical care unit for monitoring. Ultimately, he was discharged home upon resolution of these issues. Histology of the left chest mass confirmed lung squamous cell carcinoma with clear resection margins. At 6 months post-surgery, there continues to be no evidence of cancer recurrence.  Discussion With advances in oncological management for patients with NSCLC, the number of patients who are now receiving treatment with curative intent is ever-increasing. Invariably there are cases where disease relapse occurs post-chemo-radiotherapy/immunotherapy. If such disease is confined to local spread, then a so-called ‘salvage surgery’ may be attempted. Salvage surgery is generally accepted to encompass surgical resection of local disease recurrence following the failure of prior treatments. However, it does not include surgical management of distant metastases [9]. In a study by Li et al., salvage surgery with lung resection following immunotherapy treatment failure in NSCLC was shown to be associated with improved progression-free survival compared with immunotherapy alone (23.4 months vs 12.9 months p< 0.0004) [10]. In addition, an analysis of 27 patients by Romero-Vielva et al. demonstrated that salvage surgery consisting of either lobectomy, bilobectomy, or pneumonectomy in NSCLC post definitive chemo-radiotherpay was associated with an overall survival (time between surgical resection and last follow-up) of 75 months [11].  Whilst local disease spread may benefit from ‘salvage surgery’, indications for surgery in distant metastatic NSCLC remain less clear. With the advent and widespread availability of highly sensitive imaging modalities, distant solitary or limited so-called ‘oligometastases’ are becoming increasingly identified posing challenges to clinicians in terms of identifying the optimum management strategy. At present, the use of stereotactic body radiotherapy (SBRT) is gaining popularity due to its non-invasive nature and relatively low side-effect burden. A randomized open-label phase 2 trial involving 99 patients has demonstrated that compared to standard palliative treatment, SBRT was associated with improved overall survival of 41 months vs 28 months in standard palliative treatment (hazard ratio 0.57 95% CI 0.3-1.1) [12].  Whilst there are no direct comparisons of radiotherapy and surgery in the management of oligometastases, there are studies demonstrating the potential benefit of surgical resection in certain cases. In a retrospective analysis of 37 patients with NSCLC who underwent surgical resection of isolated adrenal metastases, a survival benefit at 5 years was shown when compared to non-operative treatment (34% vs 0% p< 0.002) [13]. In addition, a 10-year multicentre retrospective study carried out by De Wolf et al. involving 59 patients with adrenalectomy in oligometastatic NSCLC was shown to be associated with a 5-year survival rate of 59% [14]. It should be noted that 40% of patients received additional treatment with chemo/radiotherapy post metastasectomy. In a study of 36 NSCLC patients with solitary brain metastases with mutations to epidermal growth factor receptor (eGFR), surgical resection of the brain and lung lesions followed by immunotherapy was shown to lead to a survival benefit when compared to radiotherapy followed by immunotherapy (28 vs 16 months p< 0.044) [15]. Data for oligometastases of the skeletal system is rare; however, a case report by Hirano et al. did demonstrate that resection of solitary skeletal metastases in patients with NSCLC oligometastases was associated with no disease recurrence at 5 years [16].  Conclusions This case report is unique in that it combines both salvage surgery and subsequent surgical management of skeletal oligometastases. Although isolated skeletal metastases post salvage pneumonectomy is likely to be a rare occurrence, due to the risk of radiation-associated lung injury, radiotherapy is not a viable option in this patient cohort. Surgical resection of oligometastatic disease was possible in this case as patient fitness was maintained following initial treatment and salvage surgery. However, in cases where fitness is not maintained, such an approach would be precluded.  In this case, we have demonstrated that an isolated skeletal metastasis may be successfully managed with surgical resection and chest wall reconstruction. Whilst the patient developed a complication in the form of a tension pneumothorax in the immediate postoperative period, the long-term outcome was favorable. In such complex cases, a tailored approach involving a multidisciplinary team and careful consideration of the patient’s circumstances is necessary for a satisfactory outcome. Further studies are likely to be required to evaluate longer-term outcomes and feasibility in a larger patient population.  Human Ethics Consent was obtained or waived by all participants in this study The authors have declared that no competing interests exist. ==== Refs References 1 The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer Health Technol Assess Field JK Duffy SW Baldwin DR 1 146 20 2016 2 Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship Mayo Clin Proc Molina JR Yang P Cassivi SD Schild SE Adjei AA 584 594 83 2008 18452692 3 Combination atezolizumab, bevacizumab, pemetrexed and carboplatin for metastatic EGFR mutated NSCLC after TKI failure Lung Cancer Lam TC Tsang KC Choi HC 18 26 159 2021 34303276 4 Salvage lung resection after definitive radiation (>59 Gy) for non-small cell lung cancer: surgical and oncologic outcomes Ann Thorac Surg Bauman JE Mulligan MS Martins RG Kurland BF Eaton KD Wood DE 1632 1639 86 2008 19049763 5 Long-term survival after salvage surgery for local failure after definitive chemoradiation therapy for locally advanced non-small cell lung cancer Thorac Cardiovasc Surg Schreiner W Dudek W Lettmaier S Fietkau R Sirbu H 135 141 66 2018 28992654 6 Oligometastases J Clin Oncol Hellman S Weichselbaum RR 8 10 13 1995 7799047 7 Survival after adrenalectomy for metastatic lung cancer Ann Surg Oncol Krumeich LN Roses RE Kuo LE 2571 2579 29 2022 34989938 8 Evidence for surgical resections in oligometastatic lung cancer J Thorac Dis Fernandez RA Lau RW Ho JY Yu PS Chow SC Wan IY Ng CS 0 75 11 2019 9 Salvage surgery after definitive chemoradiotherapy for patients with non-small cell lung cancer Transl Lung Cancer Res Hamada A Soh J Mitsudomi T 555 562 10 2021 33569336 10 Salvage surgery following downstaging of advanced non-small cell lung cancer by targeted therapy Thorac Cancer Li K Cao X Ai B 2161 2169 12 2021 34128318 11 Salvage surgery after definitive chemo-radiotherapy for patients with non-small cell lung cancer Lung Cancer Romero-Vielva L Viteri S Moya-Horno I Toscas JI Maestre-Alcácer JA Ramón Y Cajal S Rosell R 117 122 133 2019 31200817 12 Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial Lancet Palma DA Olson R Harrow S 2051 2058 393 2019 30982687 13 Outcomes of patients with isolated adrenal metastasis from non-small cell lung carcinoma Ann Thorac Surg Raz DJ Lanuti M Gaissert HC Wright CD Mathisen DJ Wain JC 1788 1792 92 2011 21944257 14 Exhaustive preoperative staging increases survival in resected adrenal oligometastatic non-small-cell lung cancer: a multicentre study Eur J Cardiothorac Surg De Wolf J Bellier J Lepimpec-Barthes F 698 703 52 2017 29156014 15 Prolonged survival of patients with EGFR-mutated non-small cell lung cancer with solitary brain metastases treated with surgical resection of brain and lung lesions followed by EGFR TKIs World J Surg Oncol Gui Q Liu J Li D Xu C 184 15 2017 29037198 16 Long-term survival cases of lung cancer presented as solitary bone metastasis Ann Thorac Cardiovasc Surg Hirano Y Oda M Tsunezuka Y Ishikawa N Watanabe G 401 404 11 2005 https://pubmed.ncbi.nlm.nih.gov/16401990/ 16401990