Surgical treatment of oligometastatic non-small cell lung cancer

Down-regulated microRNA-375 expression as a predictive biomarker in non-small cell lung cancer brain metastasis and its prognostic significance

Brain metastases (BM) are common among patients with non-small cell lung cancer (NSCLC) and have been associated with significant morbidity and limited survival. Early and sensitive detection of BM is essential for improving prognosis. Recently, microRNA-375(miR-375) which is specifically expressed in the brain has been found significantly dysregulated in many human cancers. However, there is still no data whether miR-375 is associated with higher risk of BM development in NSCLC. In this study, we detected the miR-375 expression using quantitative real-time PCR (qRT-PCR) and assessed its predictive and prognostic significance. Our result showed that miR-375 expression was significantly down-regulated in NSCLC patients with BM(BM+, N=30) compared with NSCLC without BM(BM-, N=30) (P<0.001). Statistical analysis indicated that low miR-375 expression was linked to advanced disease stage (P<0.001) and brain metastasis (P<0.001) in NSCLC patient. Survival analysis suggested that low-expression group had significantly shorter overall survival than high-expression group in NSCLC patients with BM(log-rank test: P<0.05) as well as the total cases(log-rank test: P<0.01). Multivariate Cox proportional hazards model analysis indicated that low miR-375 expression was independently linked to poor survival of patients with NSCLC (HR=5.48, 95% CI: 1.93-15.56, P=0.001). In addition, we found that VEGF and MMP-9 were over-expressed in down-regulated miR-375 expression cases. Collectively, this study demonstrated that miR-375 may play an important role as a predictive biomarker in brain metastasis and an independent prognostic factor in NSCLC. Over-expression of VEGF and MMP-9 may be the reason for poor prognosis of NSCLC patients with low miR-375 expression.

Ablative Therapy for Oligometastatic Non-Small Cell Lung Cancer

The oligometastatic state represents a distinct entity among those with metastatic disease and consists of patients with metastases limited in number and location, representing an intermediate state between locally confined and widely metastatic cancer. Although similar, "oligorecurrence" (limited number of metachronous metastases under conditions of a controlled primary lesion) and "oligoprogressive" (disease progression at a limited number of sites with disease controlled at other disease sites) states are distinct entities. In non-small cell lung cancer (NSCLC), the oligometastatic state is relatively common, with 20% to 50% of patients having oligometastatic disease at diagnosis. This subgroup of patients when receiving ablative therapy, such as surgery or stereotactic body radiation radiotherapy, can obtain markedly long progression-free and overall survival. The role of radical treatment for intracranial oligometastases is well established. Fewer data exist regarding radical treatment of extracranial metastases in lung cancer; however, retrospective series using surgery or stereotactic body radiotherapy for extracranial oligometastatic disease in NSCLC have shown excellent local control, with a suggestion of improvement in progression-free survival. In the present report, we have reviewed the data on the treatment of brain metastases in oligometastatic NSCLC and the results of ablative treatment of extracranial sites. Recently, the first randomized trial comparing ablative treatment versus control in oligometastatic disease was reported, and those data are reviewed in the context of smaller series. Finally, areas of controversy are discussed and a therapeutic approach for patients with oligometastatic disease is proposed.

Surgical treatment in non-small cell lung cancer with pulmonary oligometastasis

BACKGROUND

Previous studies have demonstrated survival benefits for local treatment in solitary metastatic non-small cell lung cancer (NSCLC).This study aimed to investigate the effect of local surgery for NSCLC with pulmonary oligometastasis.

METHODS

This study included 21 patients of NSCLC with pulmonary oligometastasis between January 2003 and December 2013, which were divided into two groups, group A (11 cases) for local surgery and group B (10 cases) for systematic chemotherapy, compared the median survival time (MST) and 5-year survival rate between the two groups, and analyzed the impact of the pathological types, the TNM and pN stage of primary tumor, the site, and the mode and number of oligometastatic nodule on group A.

RESULTS

The MST of group A and B were 37 and 11.6 months respectively, 5-year survival rates were 18.2 and 9.1% respectively (p < 0.05). Patients with single nodule, oligo-recurrence, primary tumor of pN0, TNM stage I or II obtained higher survival rate than those with multiple nodules, sync-oligometastases, pN1-2, stage III or IV in group A (p < 0.05). There was no significant survival time difference among pathological types of primary tumor and oligometastatic site (p > 0.05).

CONCLUSION

Local surgery significantly prolonged the overall survival time and 5-year survival rate of primary NSCLC with pulmonary oligometastasis.

Local consolidative therapy versus maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer without progression after first-line systemic therapy: a multicentre, randomised, controlled, phase 2 study

BACKGROUND

Evidence from retrospective studies suggests that disease progression after first-line chemotherapy for metastatic non-small-cell lung cancer (NSCLC) occurs most often at sites of disease known to exist at baseline. However, the potential effect of aggressive local consolidative therapy for patients with oligometastatic NSCLC is unknown. We aimed to assess the effect of local consolidative therapy on progression-free survival.

METHODS

In this multicentre, randomised, controlled, phase 2 study, eligible patients from three hospitals had histological confirmation of stage IV NSCLC, three or fewer metastatic disease lesions after first-line systemic therapy, an Eastern Cooperative Oncology Group performance status score of 2 or less, had received standard first-line systemic therapy, and had no disease progression before randomisation. First-line therapy was four or more cycles of platinum doublet therapy or 3 or more months of EGFR or ALK inhibitors for patients with EGFR mutations or ALK rearrangements, respectively. Patients were randomly assigned (1:1) to either local consolidative therapy ([chemo]radiotherapy or resection of all lesions) with or without subsequent maintenance treatment or to maintenance treatment alone, which could be observation only. Maintenance treatment was recommended based on a list of approved regimens, and observation was defined as close surveillance without cytotoxic treatment. Randomisation was not masked and was balanced dynamically on five factors: number of metastases, response to initial therapy, CNS metastases, intrathoracic nodal status, and EGFR and ALK status. The primary endpoint was progression-free survival analysed in all patients who were treated and had at least one post-baseline imaging assessment. The study is ongoing but not recruiting participants. This study is registered with ClinicalTrials.gov, number NCT01725165.

FINDINGS

Between Nov 28, 2012, and Jan 19, 2016, 74 patients were enrolled either during or at the completion of first-line systemic therapy. The study was terminated early after randomisation of 49 patients (25 in the local consolidative therapy group and 24 in the maintenance treatment group) as part of the annual analyses done by the Data Safety Monitoring Committee of all randomised trials at MD Anderson Cancer Center, and before a planned interim analysis of 44 events. At a median follow-up time for all randomised patients of 12·39 months (IQR 5·52-20·30), the median progression-free survival in the local consolidative therapy group was 11·9 months (90% CI 5·7-20·9) versus 3·9 months (2·3-6·6) in the maintenance treatment group (hazard ratio 0·35 [90% CI 0·18-0·66], log-rank p=0·0054). Adverse events were similar between groups, with no grade 4 adverse events or deaths due to treatment. Grade 3 adverse events in the maintenance therapy group were fatigue (n=1) and anaemia (n=1) and in the local consolidative therapy group were oesophagitis (n=2), anaemia (n=1), pneumothorax (n=1), and abdominal pain (n=1, unlikely related).

INTERPRETATION

Local consolidative therapy with or without maintenance therapy for patients with three or fewer metastases from NSCLC that did not progress after initial systemic therapy improved progression-free survival compared with maintenance therapy alone. These findings suggest that aggressive local therapy should be further explored in phase 3 trials as a standard treatment option in this clinical scenario.

FUNDING

MD Anderson Lung Cancer Priority Fund, MD Anderson Cancer Center Moon Shot Initiative, and Cancer Center Support (Core), National Cancer Institute, National Institutes of Health.

Prognostic Impact of Newly Proposed M Descriptors in TNM Classification of Non-Small Cell Lung Cancer

INTRODUCTION

The International Association for the Study of Lung Cancer recently proposed new M descriptors for the next edition of the TNM classification for NSCLC, subdividing the current M1b category into two subcategories: M1b, which indicates a solitary extrathoracic metastasis in a single organ, and M1c, which indicates multiple extrathoracic metastasis. The purpose of this study was to validate the prognostic value of the newly proposed M descriptors in an independent cohort with multivariate and subgroup analysis.

METHODS

A total of 1024 patients in a consecutive lung cancer database who had stage IV NSCLC treated between 2011 and 2014 were analyzed. Newly proposed M staging was used for classification and comparison of survival. Adjustment for other clinical covariates and subgroup analysis was conducted.

RESULTS

According to the newly proposed M descriptors, 262 patients (25.6%), 152 patients (14.8%), and 610 patients (59.6%) were classified into the subgroups M1a, M1b, and M1c, respectively. The median overall survival times were 22.5, 17.8, and 13.6 months for the M1a, M1b, and M1c groups, respectively (p < 0.001). After adjustment for other covariates, Cox proportional hazards regression revealed statistically significantly shorter overall survival for the M1b group than for the M1a group (hazard ratio = 1.30; 95% confidence interval: 1.03-1.65, p = 0.03) and for the M1c than the M1b group (hazard ratio = 1.57; 95% confidence interval: 1.28-1.93, p < 0.001). These differences showed a consistent tendency regardless of pathologic and molecular subtypes.

CONCLUSIONS

The newly proposed M descriptors have prognostic value in patients with stage IV NSCLC.

Clinical outcomes of cytoreductive surgery combined with intrapleural perfusion of hyperthermic chemotherapy in advanced lung adenocarcinoma with pleural dissemination

BACKGROUND

This study aimed to investigate the safety and feasibility of intrapleural perfusion hyperthermic chemotherapy (IPHC) followed by cytoreductive surgery as a part of multimodal strategy for the treatment of advanced lung adenocarcinoma.

METHODS

Medical records of advanced lung cancer patients with pleural dissemination who underwent surgical treatment between 2003 and 2013 were reviewed retrospectively. Enrolled patients were divided into a surgery group comprising patients who underwent surgery only and an IPHC group, which consisted of patients who underwent surgery combined with IPHC.

RESULTS

A total of 33 patients were enrolled in this study. Twenty-three patients underwent IPHC after surgical resection, and 10 patients underwent surgical resection only. The complication rate of the IPHC group was estimated to be 34.8% (8 cases), none of which included postoperative mortality. The complication rate of the surgery group was 40.0% (4 cases), which included one postoperative mortality. The 6-month, 1-year, and 3-year overall survival rates for the IPHC group were 95.7%, 91.3% and 38.6%, respectively, while those of the surgery group were 80.0%, 80.0% and 37.5%. The 6-month, 1-year and 3-year progression-free survival rates for the IPHC group were 87.0%, 47.8% and 24.3%, while those of surgery group were 44.4%, 33.3% and 0.0%, respectively. There were significant differences in overall survival rates between two groups (P=0.045); however, progression-free survival was not different between the two groups.

CONCLUSIONS

IPHC combined with cytoreductive surgery for advanced lung adenocarcinoma associated with pleural seeding could be performed safely and feasible. It would be part of multimodality therapy for certain category of advanced lung adenocarcinoma. However, the long-term benefits for survival is uncertain. More extensive and precisely designed studies are warranted to further evaluate the effectiveness of IPHC.

Radiation Therapy for Oligometastatic Non-Small Cell Lung Cancer: Theory and Practice

Management paradigms for metastatic non-small cell lung cancer (mNSCLC) are evolving. Locally ablative therapies are now being increasingly integrated into combined-modality treatment strategies for mNSCLC patients with limited burdens of metastatic foci, termed oligometastases. Concurrently, techniques allowing for precise high-dose radiotherapy delivered over 1 to 5 total treatments, termed stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy (SABR), have emerged as a powerful means of noninvasive tumor ablation with broad patient candidacy. Strong rationale exists for ablative therapy in the setting of oligometastatic NSCLC, including patterns-of-failure analyses and data supporting local ablation of oligoprogressive disease for patients with oncogene-addicted mNSCLC treated with tyrosine kinase inhibitors. In this article, we examine the theoretical basis for ablation of oligometastatic NSCLC and review the growing clinical literature of mNSCLC patients treated with ablative radiation therapy.

Effect of synchronous solitary bone metastasectomy and lung cancer resection on non-small cell lung cancer patients

Lung cancer is the most frequent cause of cancer-associated mortality among men and women globally. The skeleton is one of the most common metastatic sites. The majority of patients exhibiting bone metastases are treated using systemic therapy or symptom-based palliative approaches without surgery. The present study attempted to improve the therapeutic effects of synchronous surgeries in resectable non-small cell lung cancer patients exhibiting solitary bone metastasis. A total of 5 patients underwent synchronous lung cancer resections and solitary bone metastasectomies between October 2009 and November 2011 in the Department of Cardiothoracic Surgery, Shanghai Sixth People's Hospital (Shanghai, China). All patients had received fluorodeoxyglucose positron emission tomography-computed tomography or bone scintigraphy to demonstrate the presence of solitary bone metastasis and to exclude the presence of metastases at alternative sites. The patients received standard lung cancer and mediastinal lymph node resections. In addition, bone lesions were assessed by orthopedists and operated on synchronously with standard procedures. Following surgery, all patients were administered standard chemotherapeutic regimens. Perioperative indicators, including time for thoracic drainage, length of hospital stay, incidence of post-operative complications and progression-free survival (PFS) time, were observed. The average time for post-operative drainage was 4.6±1.1 days, and the average length of post-operative hospitalization was 8.8±2.2 days. All procedures were performed safely with no serious complications. The PFS of the patients was 13.2±7.7 months. While 2 patients presenting with spinal metastases succumbed at ~1 year post-surgery, the remaining 3 patients presenting with limb bone metastases survived for >16 months post-surgery, and were alive at the last follow-up. In conclusion, the present study indicated that a synchronous metastasectomy and lung tumor resection is a safe method of treatment. The PFS time and survival results demonstrated that on the rare occasion that a patient exhibits solitary bone metastasis, aggressive surgical treatment may be a potential therapeutic option.

Cost-Effectiveness of Surgery, Stereotactic Body Radiation Therapy, and Systemic Therapy for Pulmonary Oligometastases

INTRODUCTION

Pulmonary oligometastases have conventionally been managed with surgery and/or systemic therapy. However, given concerns about the high cost of systemic therapy and improvements in local treatment of metastatic cancer, the optimal cost-effective management of these patients is unclear. Therefore, we sought to assess the cost-effectiveness of initial management strategies for pulmonary oligometastases.

METHODS AND MATERIALS

A cost-effectiveness analysis using a Markov modeling approach was used to compare average cumulative costs, quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) among 3 initial disease management strategies: video-assisted thoracic surgery (VATS) wedge resection, stereotactic body radiation therapy (SBRT), and systemic therapy among 5 different cohorts of patient disease: (1) melanoma; (2) non-small cell lung cancer adenocarcinoma without an EGFR mutation (NSCLC AC); (3) NSCLC with an EGFR mutation (NSCLC EGFRm AC); (4) NSCLC squamous cell carcinoma (NSCLC SCC); and (5) colon cancer. One-way sensitivity analyses and probabilistic sensitivity analyses were performed to analyze uncertainty with regard to model parameters.

RESULTS

In the base case, SBRT was cost effective for melanoma, with costs/net QALYs of $467,787/0.85. In patients with NSCLC, the most cost-effective strategies were SBRT for AC ($156,725/0.80), paclitaxel/carboplatin for SCC ($123,799/0.48), and erlotinib for EGFRm AC ($147,091/1.90). Stereotactic body radiation therapy was marginally cost-effective for EGFRm AC compared to erlotinib with an incremental cost-effectiveness ratio of $126,303/QALY. For colon cancer, VATS wedge resection ($147,730/2.14) was the most cost-effective strategy. Variables with the greatest influence in the model were erlotinib-associated progression-free survival (EGFRm AC), toxicity (EGFRm AC), cost of SBRT (NSCLC SCC), and patient utilities (all histologies).

CONCLUSIONS

Video-assisted thoracic surgery wedge resection or SBRT can be cost-effective in select patients with pulmonary oligometastases, depending on histology, efficacy, and tolerability of treatment and patient preferences.

TELEHEALTH ALLOWS FOR CLINICAL TRIAL PARTICIPATION AND MULTIMODALITY THERAPY IN A RURAL PATIENT WITH STAGE 4 NON-SMALL CELL LUNG CANCER

Oligometastatic non-small cell lung cancer (NSCLC) has a poor prognosis for rural patients with traditional therapies. Implementation of multi-modality systemic therapy in conjunction with surgical resection can dramatically improve overall survival, leading to clinical complete remission. The currently accepted indications for resection in oligometastatic NSCLC include brain and adrenal metastases. Rural populations are known to have disparities in care of complex malignancies and the use of telehealth has been shown to improve outcomes. We present a case of a rural patient with stage IV NSCLC, who was able to participate in two clinical trials, undergo trimodality therapy, and remain disease-free for 18 months, whose care was facilitated via telehealth video conferencing with a tertiary care center.

Impact of preoperative 18F-FDG PET/CT on survival of resected mono-metastatic non-small cell lung cancer

OBJECTIVES

Surgery has been available for the treatment of mono-metastatic, non-small cell lung cancer (NSCLC) and promising overall survival was observed in some retrospective studies with selected patients. This study investigated whether the preoperative 18-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) scan influences survival in this patient group. Furthermore we tried to identify other prognostic factors associated with survival and aimed to clarify if synchronous metastases are different from metachronous disease.

METHODS

Between 1994 and 2012, 181 patients underwent resection for solitary metastases. Sixty-six patients underwent surgery after an initial FDG-PET/CT scan, whereas 115 patients underwent conventional preoperative staging by a spiral CT scan.

RESULTS

The overall 5-year survival rate was 38.8%. The 5-year survival rates after preoperative evaluation by FDG-PET/CT and by conventional CT were 58% and 33%, respectively (p=0.01). A higher 5-year survival rate was observed in patients without thoracic lymph node involvement (pN0: 44% vs. pN1-3: 33%, p=0.028). In patients with a solitary pulmonary metastasis, we observed a 5-year survival rate of 45.7%, whereas in patients with extrapulmonary metastases, the 5-year survival rate was 27.1% (p=0.001). In patients with a locally limited primary lung cancer according to the pT descriptor, we observed a 5-year survival rate of 53.1%, whereas in patients with a pT>1 descriptor, the 5-year survival rate was 33.6% (p=0.016). By multivariate analyses, we showed that preoperative FDG-PET/CT evaluation, no thoracic lymph node metastases, and sole pulmonary metastatic disease were favorable predictors of survival, whereas the time of metastasis (synchronous vs. metachronous) and maximum standardized uptake value was not.

CONCLUSIONS

We conclude that resection of the primary tumor and metastasectomy for mono-metastatic NSCLC can be performed after a comprehensive evaluation with FDG-PET/CT. N-stage and the site of the oligometastases have a significant influence on overall survival.

The evolving role of radiotherapy in treatment of oligometastatic NSCLC

Non-small cell lung cancer (NSCLC) patients with metastases limited in site and number, termed oligometastases, may represent a unique subpopulation of advanced NSCLC with improved prognosis. The optimal management of these patients remains unclear with the treatment approach currently undergoing a paradigm shift. The potential benefit of aggressive metastasis directed local treatment with surgery and/or radiotherapy (RT) in combination with systemic therapy is bolstered predominantly by retrospective analyses but also by a growing number of non-randomized prospective studies regarding the use of ablative RT techniques including stereotactic body radiotherapy (SBRT), alternatively termed stereotactic ablative radiotherapy (SABR), directed at the primary tumor (if present) and all metastatic sites. Long-term survival is possible in a subset of patients treated aggressively in this manner. The challenge for the clinical oncology community moving forward is appropriately selecting patients for this treatment approach based on clinical, imaging, and molecular features and increasing enrollment of patients to prospective clinical trials to more definitively determine the added benefit and appropriate timing of aggressive metastasis directed therapy in the oligometastatic setting.

Postoperative oligo-recurrence of non-small-cell lung cancer: clinical features and survival†

OBJECTIVES

Postoperative recurrences of non-small-cell lung cancer (NSCLC) are usually disseminated and systemic. Recently, the concept of oligo-recurrence, which is theoretically curable by definitive local therapy (DLT), has been proposed in several cancers. The aim of this study was to clarify clinical features and outcomes of patients with postoperative oligo-recurrence of NSCLC.

METHODS

From 3275 patients with resected pathological stage IA-IIIB NSCLC between 1993 and 2011, a total of 768 patients who developed recurrence were included in this study. Oligo-recurrence was defined as 1-3 loco-regional or distant recurrent lesions restricted to a single organ. Other recurrences were classified as poly-recurrence. Second primary lung cancers and suspected lesions were excluded. DLT included surgery, stereotactic radiotherapy and radiotherapy with a 45 Gy or higher dose, performed with curative intent.

RESULTS

Oligo-recurrence was identified in 162 (21%) patients, mainly as a solitary recurrence (n = 129, 80%) in regional lymph nodes, brain, lung, bone and adrenal gland, and the proportion of patients with oligo-recurrence increased gradually year by year. The patients with oligo-recurrence had more early-staged disease at initial surgery and a longer time to recurrence than those with poly-recurrence. The entire population of oligo-recurrence patients had better post-recurrence survival (PRS) than those with poly-recurrence (5-year PRS: 32.9 vs 9.9%, P < 0.001). For oligo-recurrence, DLT was totally conducted in 105 (65%) patients as initial treatment. Multivariate analyses revealed that the initial DLT was associated with improved PRS [odds ratio (OR) 0.44; 95% confidence interval (CI) 0.29-0.68]. The recurrence location and initial pathological stage did not affect PRS. The 5-year PRS and postoperative progression-free survival rates after DLT were 38.6 and 22.3%, respectively. Of the 10 long-term (≥5-year) progression-free survivors, 9 were those with a solitary recurrence.

CONCLUSIONS

Initial DLT for oligo-recurrence achieved favourable PRS in a selected population. Oligo-recurrence curable by DLT was found in a subset of patients who received DLT, mostly as a solitary recurrence.

Survival outcomes for oligometastasis in resected non-small cell lung cancer

BACKGROUND

We investigated the factors associated with post-recurrence survival and the treatment for non-small-cell lung cancer patients with postoperative distant recurrence, especially oligometastasis.

METHODS

We reviewed the data of 272 patients with distant recurrence who underwent resection of non-small-cell lung cancer from January 2000 through December 2011.

RESULTS

The type of distant recurrence was classified as oligometastasis (n = 76, 28%) or polymetastasis (n = 196, 72%). Forty-seven (62%) patients with oligometastasis received local therapy (surgery 5, radiotherapy 9, sequential local and systemic therapy 28, chemoradiotherapy 5). Multivariate analysis revealed older age, non-adenocarcinoma, shorter disease-free interval, no pulmonary metastasis, liver metastases, bone metastases, and polymetastasis had significant associations with unfavorable post-recurrence survival. Subgroup analysis of patients with oligometastasis showed histology and disease-free interval had a great impact on survival. Smoking history and histology were associated with survival in patients with lung oligometastasis, whereas systemic treatment and longer disease-free interval were related to increased post-recurrence survival in those with brain oligometastasis.

CONCLUSIONS

This study showed that an oligometastatic state per se was a significant favorable factor. Optimization of personalized systemic treatment and adding local treatment are important in the management of patients with non-small-cell lung cancer and oligometastasis.

The role of stereotactic body radiation therapy in the management of oligometastatic lung cancer

A growing body of evidence has surfaced over the past 20 years that supports the use of surgery for metastasis limited in number termed ‘oligometastases’. Local therapy for oligometastases results in long progression free survival in the absence of systemic therapy, including non-small-cell lung cancer (NSCLC). Stereotactic body radiation therapy (SBRT) allows for the delivery of anatomically precise, ablative doses of radiation therapy able to achieve local control rates of approximately 80% with minimal toxicity. In NSCLC, SBRT is emerging as an effective therapy in the management of sites resistant to targeted therapy. This review summarizes the published evidence for the use of local therapy in the management of oligometsatic cancer, with a focus on SBRT and NSCLC.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review

OBJECTIVES

To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas.

METHODS

Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival.

RESULTS

There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively.

CONCLUSIONS

Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.

Molecular determinants of lung cancer metastasis to the central nervous system

Lung cancer remains the leading cause of cancer-related mortality worldwide. The propensity for metastasis to the central nervous system (CNS) is a major clinical hurdle contributing to the low five-year survival rate of advanced disease. CNS metastases significantly outnumber primary brain tumors and carry a dismal prognosis in part due to the inability of therapeutic agents to cross the blood brain barrier. Standard treatment using radiation has been largely ineffective in improving mortality, suggesting the need for new agents targeting the critical metastatic drivers. The genetic and molecular events governing CNS metastasis from the lung are poorly understood at this time. This review highlights genetic events associated with CNS dissemination from the lung and molecular mechanisms associated with CNS metastasis. In vivo model systems that faithfully recapitulate escape from the lung and colonization of the CNS are described as tools for understanding the metastatic phenotype and for testing new therapeutic agents. A deeper understanding of the mechanisms of lung cancer metastasis to the CNS is needed to elucidate novel therapeutic avenues towards the improvement of the mortality associated with advanced stage lung cancer.

Stereotactic body radiotherapy for liver metastases

The role for local ablative therapies in the management paradigm of oligometastatic liver disease is increasing. The evidence base supporting the use of stereotactic body radiotherapy for liver metastases has expanded rapidly over the past decade, showing high rates of local control with low associated toxicity. This review summarises the evidence base to date, discussing optimal patient selection, challenges involved with treatment delivery and optimal dose and fractionation. The reported toxicity associated with liver stereotactic body radiotherapy is presented, together with possible pitfalls in interpreting the response to treatment using standard imaging modalities. Finally, potential avenues for future research in this area are highlighted.

Radiofrequency ablation for ground-glass opacity-dominant lung adenocarcinoma

PURPOSE

To evaluate retrospectively the clinical utility of lung radiofrequency (RF) ablation for the treatment of ground-glass opacity (GGO)-dominant lung adenocarcinoma.

MATERIALS AND METHODS

From August 2004 through May 2012, 33 consecutive patients (14 men and 19 women; mean age, 71.1 y; age range, 46-84 y) with 42 lung tumors having ≥ 50% GGO component received lung RF ablation. The mean maximum tumor diameter was 1.6 cm ± 0.9 (range, 0.7-4.0 cm). Feasibility, safety, local tumor progression, and survival were evaluated.

RESULTS

For the 42 RF sessions, after RF electrodes were placed in each target tumor, planned ablation protocols were completed in all sessions (100%; 42 of 42). No deaths related to the RF procedure occurred. Major and minor complication rates were 4.8% and 23.8%, respectively. Local tumor progression developed in 6 tumors (14.3%; 6 of 42) during a mean follow-up of 42 months ± 23 (range, 5-92 mo). Four of six tumors with local progression were controlled by repeated RF ablation. No evidence of disease was achieved in 31 of 33 patients (93.9%) at the end of the follow-up period. All but one patient (who died of brain hemorrhage) are alive today. Overall and cancer-specific survival rates were 100% and 100% at 1 year, 96.4% (95% confidence interval [CI], 77.5%-99.5%) and 100% at 3 years, and 96.4% (95% CI, 77.5%-99.5%) and 100% at 5 years, respectively.

CONCLUSIONS

Lung RF ablation is a feasible, safe, and useful therapeutic option to control GGO-dominant lung adenocarcinoma.

The lung adenocarcinoma guidelines: what to be considered by surgeons

In 2011 the International Association for the Study of Lung Cancer (IASLC), the American Thoracic Society (ATS), and the European Respiratory Society (ERS), have proposed a new subclassification of lung adenocarcinomas. This new classification was founded on an evidence-based approach to a systematic review of 11,368 citations from the related literature. Validation has involved projects relating to histologic and cytologic analysis of small biopsy specimens, histologic subtyping, grading, and observer variation among expert pathologists. As enormous resources are being spent on trials involving molecular and therapeutic aspects of adenocarcinoma of the lung, the development of standardized criteria is of great importance and should help advance the field, increasing the impact of research, and improving patient care. This classification is needed to assist in determining patient therapy and predicting outcome. The 2011 IASLC/ATS/ERS adenocarcinoma classification can have an impact on TNM staging. It may help in comparing histologic characteristics of multiple lung adenocarcinomas to determine whether they are intrapulmonary metastases versus separate primaries. Use of comprehensive histologic subtyping along with other histologic characteristics has been shown to have good correlation with molecular analyses and clinical behavior. Also, it may be more meaningful clinically to measure tumor size in lung adenocarcinomas that have a lepidic component by using invasive size rather than total size to determine the size T factor.

Unique metastases of ALK mutated lung cancer activated to the adnexa of the uterus

Anaplastic lymphoma kinase (ALK) fusion positive non-small cell lung cancer (NSCLC) is a relatively novel molecular subtype in lung cancer. ALK targeted therapies such as crizotinib increase survival benefit in this patient population. However, further understanding of the disease subtype including patterns of metastasis and pathways of treatment resistance are needed. We describe a 50 year-old-woman diagnosed with stage IV NSCLC, T2N3M1b, ALK fusion positive disease. Although her initial sites of metastasis included the liver and bone, her story is notable for crizotinib resistant growth of a metastatic lesion to her adnexa. This report brings to attention unique mechanisms of metastasis in ALK positive patients.

Definitive primary therapy in patients presenting with oligometastatic non-small cell lung cancer

PURPOSE

Although palliative chemotherapy is the standard of care for patients with diagnoses of stage IV non-small cell lung cancer (NSCLC), patients with a small metastatic burden, "oligometastatic" disease, may benefit from more aggressive local therapy.

METHODS AND MATERIALS

We identified 186 patients (26% of stage IV patients) prospectively enrolled in our institutional database from 2002 to 2012 with oligometastatic disease, which we defined as 5 or fewer distant metastatic lesions at diagnosis. Univariate and multivariable Cox proportional hazards models were used to identify patient and disease factors associated with improved survival. Using propensity score methods, we investigated the effect of definitive local therapy to the primary tumor on overall survival.

RESULTS

Median age at diagnosis was 61 years of age; 51% of patients were female; 12% had squamous histology; and 33% had N0-1 disease. On multivariable analysis, Eastern Cooperate Oncology Group performance status ≥ 2 (hazard ratio [HR], 2.43), nodal status, N2-3 (HR, 2.16), squamous pathology, and metastases to multiple organs (HR, 2.11) were associated with a greater hazard of death (all P<.01). The number of metastatic lesions and radiologic size of the primary tumor were not significantly associated with overall survival. Definitive local therapy to the primary tumor was associated with prolonged survival (HR, 0.65, P=.043).

CONCLUSIONS

Definitive local therapy to the primary tumor appears to be associated with improved survival in patients with oligometastatic NSCLC. Select patient and tumor characteristics, including good performance status, nonsquamous histology, and limited nodal disease, may predict for improved survival in these patients.

An individual patient data metaanalysis of outcomes and prognostic factors after treatment of oligometastatic non-small-cell lung cancer

INTRODUCTION/BACKGROUND

An individual patient data metaanalysis was performed to determine clinical outcomes, and to propose a risk stratification system, related to the comprehensive treatment of patients with oligometastatic NSCLC.

MATERIALS AND METHODS

After a systematic review of the literature, data were obtained on 757 NSCLC patients with 1 to 5 synchronous or metachronous metastases treated with surgical metastectomy, stereotactic radiotherapy/radiosurgery, or radical external-beam radiotherapy, and curative treatment of the primary lung cancer, from hospitals worldwide. Factors predictive of overall survival (OS) and progression-free survival were evaluated using Cox regression. Risk groups were defined using recursive partitioning analysis (RPA). Analyses were conducted on training and validating sets (two-thirds and one-third of patients, respectively).

RESULTS

Median OS was 26 months, 1-year OS 70.2%, and 5-year OS 29.4%. Surgery was the most commonly used treatment for the primary tumor (635 patients [83.9%]) and metastases (339 patients [62.3%]). Factors predictive of OS were: synchronous versus metachronous metastases (P < .001), N-stage (P = .002), and adenocarcinoma histology (P = .036); the model remained predictive in the validation set (c-statistic = 0.682). In RPA, 3 risk groups were identified: low-risk, metachronous metastases (5-year OS, 47.8%); intermediate risk, synchronous metastases and N0 disease (5-year OS, 36.2%); and high risk, synchronous metastases and N1/N2 disease (5-year OS, 13.8%).

CONCLUSION

Significant OS differences were observed in oligometastatic patients stratified according to type of metastatic presentation, and N status. Long-term survival is common in selected patients with metachronous oligometastases. We propose this risk classification scheme be used in guiding selection of patients for clinical trials of ablative treatment.

A prospective study of surgical procedures for patients with oligometastatic non-small cell lung cancer

BACKGROUND

Purely localized, oligometastatic, and widely metastatic tumors are likely to require different therapeutic strategies. Although surgical procedures for isolated pulmonary, brain, or adrenal metastases from lung cancer have been extensively evaluated, most data are from retrospective studies; accordingly, we conducted a prospective multicenter trial.

METHODS

Patients were eligible if they had previously untreated clinical T1-2N0-1 lung cancer with single-organ metastasis, or single-organ metachronous metastasis after complete resection of pathologic T1-2N0-1 lung cancer. Metastatic lesions were classified into three groups: group A included metastasis in single organs other than brain or lung; group B included synchronous brain metastasis; and group C included pulmonary metastasis. The treatment intervention was surgical resection of metachronous metastasis or of both synchronous metastasis and primary lung cancer.

RESULTS

From December 2002 through June 2011, 36 patients were enrolled. Two patients were ineligible, and the remaining 34 were analyzed; 6 (18%) had a benign lesion and no metastasis, 5 patients (15%) underwent incomplete resection of primary lung cancer, and 20 patients (59%) underwent complete resection of both primary lung cancer and metastasis. The 5-year survival rate for these 20 cases was 44.7%.

CONCLUSIONS

Clinical T1-2N0-1 lung cancer with a single-organ metastatic lesion was a good candidate for surgical resection. A 5-year survival rate of about 40% can be expected, which could be comparable with that for stage II non-small cell lung cancer.

Stage IV lung cancer: Is cure possible?

Reporting a case, 53 years old male with stage IV Nonsamall cell lung cancer in view of cytologically proven malignant pleural effusion. Usually the management of stage IV lung cancer is with palliative intent where the patient receives palliative chemotherapy along with palliative radiotherapy and surgery if required. Most of the data on curative management of oligometastatic non-small cell lung cancer includes patient with adrenal metastasis and some reports with brain metastasis. There is scarce literature on the surgical management of stage IV lung cancer with pleural effusion.

Radical treatment of synchronous oligometastatic non-small cell lung carcinoma (NSCLC): patient outcomes and prognostic factors

OBJECTIVES

Metastatic non-small cell lung carcinoma (NSCLC) generally carries a poor prognosis, and systemic therapy is the mainstay of treatment. However, extended survival has been reported in patients presenting with a limited number of metastases, termed oligometastatic disease. We retrospectively reviewed the outcomes of such patients treated at two centers.

MATERIALS AND METHODS

From September 1999-July 2012, a total of 61 patients with 1-3 synchronous metastases, who were treated with radical intent to all sites of disease, were identified from records of two cancer centers. Treatment was considered radical if it involved surgical resection and/or delivery of radiation doses ≥13 × 3 Gy.

RESULTS

Besides the primary tumor, 50 patients had a solitary metastasis, 9 had two metastases, and 2 had three metastases. Locations of metastases included the brain (n = 36), bone (n = 11), adrenal (n = 4), contralateral lung (n = 4), extra-thoracic lymph nodes (n = 4), skin (n = 2) and colon (n = 1). Only one patient had metastases in two different organs. Median follow-up was 26.1 months (m), median overall survival (OS) was 13.5m, median progression free survival (PFS) was 6.6m and median survival after first progression (SAFP) was 8.3m. The 1- and 2-year OS were, 54% and 38%, respectively. Significant predictors of improved OS were: smaller radiotherapy planning target volume (PTV) (p = 0.004) and surgery for the primary lung tumor (p < 0.001). Factors associated with improved SAFP included surgery for the primary lung tumor, presence of brain metastases, and absence of bone metastases. No significant differences in outcomes were observed between the two centers.

CONCLUSION

Radical treatment of selected NSCLC patients presenting with 1-3 synchronous metastases can result in favorable 2-year survivals. Favorable outcomes were associated with intra-thoracic disease status: patients with small radiotherapy treatment volumes or resected disease had the best OS. Future prospective clinical trials, ideally randomized, should evaluate radical treatment strategies in such patients.

Radical treatment of non-small-cell lung cancer patients with synchronous oligometastases: long-term results of a prospective phase II trial (Nct01282450)

BACKGROUND

Stage IV non-small-cell lung cancer (NSCLC) patients with oligometastases (< 5 metastatic lesions) may experience long-term survival when all macroscopic tumor sites are treated radically, but no prospective data on NSCLCs with synchronous oligometastases are available.

METHODS

A prospective single-arm phase II trial was conducted. The main inclusion criteria were pathologically proven NSCLC stage IV with less than five metastases at primary diagnosis, amendable for radical local treatment (surgery or radiotherapy). The study is listed in clinicaltrials.gov, number NCT01282450.

RESULTS

Forty patients were enrolled, 39 of whom were evaluable (18 men, 21 women); mean age was 62.1 ± 9.2 years (range, 44-81). Twenty-nine (74%) had local stage III; 17 (44%) brain, seven (18%) bone, and four (10%) adrenal gland metastases. Thirty-five (87%) had a single metastatic lesion. Thirty-seven (95%) of the patients received chemotherapy as part of their primary treatment. Median overall survival (OS) was 13.5 months (95% confidence interval 7.6-19.4); 1-, 2-, and 3-year OS was 56.4%, 23.3%, and 17.5%, respectively. Median progression-free survival (PFS) was 12.1 months (95% confidence interval 9.6-14.3); 1-year PFS was 51.3%, and both 2- and 3-year PFS was 13.6%. Only two patients (5%) had a local recurrence. No patient or tumor parameter, including volume and F-deoxyglucose uptake was significantly correlated with OS or PFS. The treatment was well tolerated.

CONCLUSION

In this phase II study, long-term PFS was found in a subgroup of NSCLC patients with synchronous oligometastases when treated radically. Identification of this favorable subgroup before therapy is needed.

Surgical Treatment of Extrapulmonary Oligometastatic Non-small Cell Lung Cancer

The prognosis of metastatic non-small cell lung cancer (NSCLC) is poor, and platinum-based chemotherapy improves the median survival for only a few months. A subgroup of patients with oligometastatic disease may benefit from surgical resection, but only very limited data are available to date. We conducted a retrospective review of all patients with synchronous extrapulmonary oligometastatic NSCLC undergoing surgical resection in our department. Data regarding medical history, histology, number of metastases, and survival status were extracted from the medical database of the University Medical Center, Freiburg. Fifty-six patients underwent surgical resection for oligometastatic lung cancer. Five patients were lost during follow-up and therefore censored. One patient died perioperatively due to acute respiratory distress syndrome. The remaining 50 patients had an overall median survival time of 14.6 months. Analyzing the influence of metastatic site, we found a median overall survival of 23.4 months for patients with soft tissue metastasis, 16.7 months for patients with brain metastasis, 9.5 months for patients with adrenal gland involvement, and only 4.3 months for patients with bone metastasis (p < 0.005). Upon multivariate analysis, bone metastasis was the only significant parameter influencing median overall survival (p < 0.004). Based on our data, we conclude that an aggressive surgical approach for oligometastatic NSCLC can be performed with acceptable mortality and morbidity. In this rare constellation, surgical therapy may be an option in selected cases.

Local ablative therapy of oligoprogressive disease prolongs disease control by tyrosine kinase inhibitors in oncogene-addicted non-small-cell lung cancer

INTRODUCTION

Many patients with oncogene-driven non-small-cell lung cancer (NSCLC) treated with tyrosine kinase inhibitors experience limited sites of disease progression. This study investigated retrospectively the benefits of local ablative therapy (LAT) to central nervous system (CNS) and/or limited systemic disease progression and continuation of crizotinib or erlotinib in patients with metastatic ALK gene rearrangement (ALK+) or EGFR-mutant (EGFR-MT) NSCLC, respectively.

METHODS

Patients with metastatic ALK+ NSCLC treated with crizotinib (n = 38) and EGFR-MT NSCLC treated with erlotinib (n = 27) were identified at a single institution. Initial response to the respective kinase inhibitors, median progression-free survival (PFS1), and site of first progression were recorded. A subset of patients with either nonleptomeningeal CNS and/or four sites or fewer of extra-CNS progression (oligoprogressive disease) suitable for LAT received either radiation or surgery to these sites and continued on the same tyrosine kinase inhibitors. The subsequent median progression-free survival from the time of first progression (PFS2) and pattern of progression were recorded.

RESULTS

Median progression-free survival in ALK+ patients on crizotinib was 9.0 months, and 13.8 months for EGFR-MT patients on erlotinib. Twenty-five of 51 patients (49%) who progressed were deemed suitable for local therapy (15 ALK+, 10 EGFR-MT; 24 with radiotherapy, one with surgery) and continuation of the same targeted therapy. Post-LAT, 19 of 25 patients progressed again, with median PFS2 of 6.2 months.

DISCUSSION

Oncogene-addicted NSCLC with CNS and/or limited systemic disease progression (oligoprogressive disease) on relevant targeted therapies is often suitable for LAT and continuation of the targeted agent, and is associated with more than 6 months of additional disease control.

Brain-only metastatic breast cancer is a distinct clinical entity characterised by favourable median overall survival time and a high rate of long-term survivors

BACKGROUND

The clinical course of breast cancer patients with brain metastases (BM) as only metastatic site (brain-only metastatic breast cancer (BO-MBC)) has been insufficiently explored.

METHODS

All breast cancer patients with BM treated at our institution between 1990 and 2011 were identified. For each patient, full information on follow-up and administered therapies was mandatory for inclusion. Oestrogen receptor, progesterone receptor and Her2 status were determined according to standard protocols. Statistical analyses including computation of survival probabilities was performed.

RESULTS

In total, 222 female patients (26% luminal; 47% Her2; 27% triple negative) with BM of MBC were included in this study. In all, 38/222 (17%) BM patients did not develop extracranial metastases (ECM) during their disease course and were classified as BO-MBC. Brain-only-MBC was not associated with breast cancer subtype or number of BM. The median overall survival of BO-MBC patients was 11 months (range 0-69) and was significantly longer than in patients with BM and ECM (6 months, range 0-104; P=0.007). In all, 7/38 (18%) BO-MBC patients had long-term survival of >3 years after diagnosis of BM and long-term survival was significantly more common in BO-MBC patients as compared with BM patients with ECM (P<0.001).

CONCLUSIONS

Brain-only metastatic behaviour occurs in around 17% of breast cancer with BM and is not associated with breast cancer subtype. Exploitation of all multimodal treatment options is warranted in BO-MBC patients, as these patients have favourable prognosis and long-term survival is not uncommon.

Survival of patients treated surgically for synchronous single-organ metastatic NSCLC and advanced pathologic TN stage

INTRODUCTION

Patients with stage IV metastatic non-small cell lung cancer (NSCLC) are generally not considered for surgery due to their poor median survival ranging from 4 to 11 months. However published results suggested that carefully selected patients with oligometastatic disease may benefit from resection of both the primary and metastatic sites in a multidisciplinary treatment approach. The aim of the study was to analyze and detect prognostic factors in surgically treated patients with synchronous single-organ metastasis from NSCLC.

METHODS

This is a retrospective single-center study including 29 patients with synchronous single-organ metastatic NSCLC who underwent lung resection and local treatment of the metastasis between 2002 and 2008. Overall survival was estimated from the date of lung surgery until last follow-up. The impact on survival of nine variables (age, pT, pN, site of metastasis, presence of solitary metastasis, R-resection status, presence of neoadjuvant or adjuvant treatment, tumor histology) were further assessed.

RESULTS

Twenty-nine patients (20 males, 69%) with a median age of 62 (from 44 to 77) were included. Site of metastatic disease was the brain in 19, the lung in 8 and the adrenal glands in 2 patients. Histology was adenocarcinoma in 21, large-cell carcinoma in 3, squamous-cell carcinoma in 2 and other in 3 patients. Type of lung resection performed for primary tumors were pneumonectomy in 3, bilobar resection in 3, lobar resection in 17 and sublobar resection in 6 patients. Survival at 1 and 5 years for the overall population reached 65% and 36%, respectively. Median survival was 20.5 months. Univariate regression model analysis identified pathologic T stage as a predictor of survival. Patients with pT1-2 behaved statistically significantly better (p=0.007) compared to patients with pT3-4 tumors. No impact on survival for the other 8 variables has been shown.

CONCLUSIONS

The 5-year survival rate of 36% confirms that multimodality treatment including surgical lung resection should be considered in the therapy of single-site metatastatic NSCLC for selected patients. Pathologic T stage appeared to have significant impact on predicting patient survival.

Combined robotic lobectomy and adrenalectomy for lung cancer and solitary adrenal metastasis

Combined robotic lobectomy and adrenalectomy in select patients is oncologically sound and associated with the benefits of minimally invasive surgery.

Background and Objectives:

Surgical resection of isolated adrenal metastasis in primary lung cancer is associated with improved survival. We report a combined robotic lobectomy and adrenalectomy for resection of a primary lung cancer and metastasis to the adrenal gland.

Methods:

A 69-year-old male with a significant smoking history and shortness of breath was found to have a 3-cm left upper lobe mass with an enlarged left adrenal gland measuring 1.5cm. The adrenal gland was biopsied confirming metastatic poorly differentiated carcinoma, likely lung cancer. Computed tomography, positron emission tomography, and mediastinoscopy revealed no evidence of disease outside the adrenal gland.

Results:

Following induction chemotherapy, the patient underwent combination robotic lobectomy, lymphadenectomy, and adrenalectomy while in the same lateral decubitus position. Thoracic and urologic oncology teams performed their respective portions of the operation. Overall operative time was 4 hours, and length of hospital stay was 3 days. Estimated blood loss was 150mL with no narcotic requirements beyond the first postoperative day. Final pathology revealed large cell carcinoma of the lung with metastasis to the adrenal. All surgical margins were negative.

Conclusions:

Combination robotic lobectomy and adrenalectomy is feasible and can be associated with a short convalescence, minimal pain, and an oncologically sound approach.

Percutaneous cryoablation of metastatic lesions from non-small-cell lung carcinoma: initial survival, local control, and cost observations

PURPOSE

To assess feasibility, complications, local tumor recurrences, overall survival (OS), and estimates of cost effectiveness for multisite cryoablation (MCA) of oligometastatic non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

A total of 49 computed tomography- and/or ultrasound-guided percutaneous MCA procedures were performed on 60 tumors in 31 patients (19 women and 12 men) with oligometastatic NSCLC. Average patient age was 65 years. Tumor location was grouped according to common metastatic sites. Median OS was determined by Kaplan-Meier method and defined life-years gained (LYGs). Estimates of MCA costs per LYG were compared with established values for systemic therapies.

RESULTS

Total numbers of tumors and cryoablation procedures for each anatomic site were as follows: lung, 20 and 18; liver, nine and seven; superficial, 12 and 11; adrenal, seven and seven; paraaortic/isolated, two and two; and bone, 10 and seven. A mean of 1.6 procedures per patient were performed, with a median clinical follow-up of 11 months. Major complication and local recurrence rates were 8% (four of 49) and 8% (five of 60), respectively. Median OS for MCA was 1.33 years, with an estimated 1-year survival rate of approximately 53%. MCA appeared cost-effective even when added to the cost of best supportive care or systemic regimens, with an adjunctive cost-effectiveness ratio of $49,008-$87,074.

CONCLUSIONS

MCA was associated with very low morbidity and local tumor recurrence rates for all anatomic sites, and possibly increased OS. Even as an adjunct to systemic therapies, MCA appeared cost-effective for palliation of oligometastatic NSCLC.

[Non-small cell lung cancer with oligometastases: treatment with curative intent]

Published series suggest that, in carefully selected patients, long-term survival can be obtained when a complete resection of the primary site and metastasis is achieved. It comprises resection of additional malignant nodules in the contralateral lung (at present classified as M1a, but the additional nodule may be a second primary lung cancer), complete resection of the primary associated with limited metastatic pleural involvement (M1a), and resection of the primary with an isolated extrathoracic metastasis (mostly a single brain or adrenal). All these topics are discussed.

[The conceptual oligometastatic non-small cell lung cancer and therapeutic strategies]

非小细胞肺癌是发病率及致死率最高的恶性肿瘤之一。约20%-50%会发生远处转移，最常见的转移部位为脑、骨、肝及肾上腺。寡转移状态是一段肿瘤生物侵袭性较温和的时期，存在于局限性原发灶与广泛性转移之间的过渡阶段，转移瘤数目有限并且转移器官具有特异性。“寡转移”来源于微转移，肿瘤细胞已具有器官特异性，但尚不具备全身播散的遗传倾向。治疗寡转移状态的关键是局部控制，需要兼顾预防远处转移、治疗隐匿性转移灶、治疗寡转移灶和全身治疗结束后清除残留癌灶四个方面。本文旨在对“寡转移”概念在非小细胞肺癌常见转移脏器治疗中的应用作一综述。

Oligometastatic disease at presentation or recurrence for nonsmall cell lung cancer

Oligometastatic Non-Small Cell Lung Cancer (NSCLC) presents a unique opportunity for potential curative therapy. Improved cancer staging using PET/CT, MRI, and future cellular and molecular staging with circulating tumor cells and/or molecular markers will identify more patients with truly oligometastasis disease that will benefit from definitive local treatment. Recent development of noninvasive local ablative therapy such as stereotactic radiotherapy makes it possible to eradicate multiple local diseases with minimal side effect. Novel systemic therapy may also control systemic spread and therefore make it possible to improve survival by eliminating local diseases. More research, particularly prospective studies, is ideally randomized studies are needed to validate the concept of oligometastasis.

Prognostic impact of radiation therapy to the primary tumor in patients with non-small cell lung cancer and oligometastasis at diagnosis

PURPOSE

We investigated prognostic factors associated with survival in patients with non-small cell lung cancer (NSCLC) and oligometastatic disease at diagnosis, particularly the influence of local treatment to the primary site on prognosis.

METHODS AND MATERIALS

From January 2000 through June 2011, 78 consecutive patients with oligometastatic NSCLC (<5 metastases) at diagnosis underwent definitive chemoradiation therapy (≥45 Gy) to the primary site. Forty-four of these patients also received definitive local treatment for the oligometastases. Survival outcomes were estimated using the Kaplan-Meier method, and risk factors were identified by univariate and multivariate analyses.

RESULTS

Univariate Cox proportional hazard analysis revealed better overall survival (OS) for those patients who received at least 63 Gy of radiation to the primary site (P=.002), received definitive local treatment for oligometastasis (P=.041), had a Karnofsky performance status (KPS) score >80 (P=.007), had a gross tumor volume ≤124 cm³ (P=.002), had adenocarcinoma histology (P=.002), or had no history of respiratory disease (P=.016). On multivariate analysis, radiation dose, performance status, and tumor volume retained significance (P=.004, P=.006, and P<.001, respectively). The radiation dose also maintained significance when patients with and without brain metastases were analyzed separately.

CONCLUSIONS

Tumor volume, KPS, and receipt of at least 63 Gy to the primary tumor are associated with improved OS in patients with oligometastatic NSCLC at diagnosis. Our results suggest that a subset of such patients may benefit from definitive local therapy.