Clinical predictors of metastatic disease to the brain from non-small cell lung carcinoma: primary tumor size, cell type, and lymph node metastases

Prophylactic cranial irradiation in non-small cell lung cancer patients: who might be the candidates?

Objectives

Brain metastases (BMs) often advance the course of non-small cell lung cancer (NSCLC). We performed an observational study in order to investigate the possible correlation of selected clinical and epidemiological factors with BM appearance in patients suffering from different histological subtypes of NSCLC stage I–IV.

Methods

The study included 161 consecutive patients with NSCLC. Analyzed data included patient- and tumor-related characteristics.

Results

Thirty-nine patients (24.2%) presented BMs within 12 (0–36) weeks of diagnosis. BMs decreased the mean overall survival significantly (15.6 versus 50.7 weeks, P < 0.001), with hazard ratio (95% confidence interval) 3.60 (2.42–5.35). The age of the patients with BM was significantly lower than that of the patients without BM (60.8 ± 8.9 versus 66.5 ± 8.5, P < 0.001). Patients with BM had significantly higher pack-years consumption (75.9 ± 23.9 versus 58.9 ± 31.9, P = 0.003) and larger tumor size compared with patients without BM (size in mm: 55.1 ± 20.1 versus 45.9 ± 19.3, P = 0.012). The presence of BM was also correlated with the absence of lung (P < 0.001), bone (P = 0.005), and adrenal (P = 0.046) metastases.

Conclusion

Younger NSCLC patients with high tobacco consumption, large tumor size, and absence of metastases in other organs (lung, bones, adrenal metastases) are at high risk of BM appearance during the course of NSCLC and are candidates for prophylactic cranial irradiation early in the course of the disease.

Case of metastatic pulmonary carcinoma in optic disc diagnosed from results of biopsy performed during vitrectomy surgery

BACKGROUND

Most intraocular metastatic tumors occur in the uveal tract, while isolated metastasis to the optic nerve is rarely found. We report a case of metastasis to the optic disc from primary lung cancer, diagnosed from biopsy findings obtained during a vitrectomy.

PATIENT AND METHODS

A 69-year-old male presented with gradual visual impairment due to a milky white tumour that extended from the optic disc into the vitreous cavity. A systemic examination revealed primary squamous cell lung cancer.

RESULTS

A biopsy specimen was obtained from the optic disc tumor during a vitrectomy, which led to a diagnosis of metastasis from lung cancer. Despite courses of chemotherapy and radiotherapy, the patient died of brain metastasis.

DISCUSSION

There are few reports of secondary optic disc tumors and pathological biopsy findings are rare. When a milky white tumor is observed extending from the optic disc, a possible differential diagnosis is metastatic neoplasm.

Incidence of brain metastasis in patients with esophageal carcinoma

AIM: To determine the incidence of brain metastasis in a contemporary group of patients with carcinoma of the esophagus.

METHODS: Retrospective analysis of 53 patients with esophageal carcinoma who received radiotherapy as a component of treatment between 1998 and 2007, including patient and tumor characteristics, and subsequent diagnosis of brain metastasis. The association between the histological type of esophageal cancer and the incidence of brain metastasis was assessed using Fisher’s exact test.

RESULTS: Forty-four of the fifty-three patients in this study had adenocarcinoma and nine had squamous cell carcinoma, ranging from stage IIA-IVB. Primary treatment was surgery with neoadjuvant chemoradiotherapy (trimodality therapy) in 19% of patients; chemoradiotherapy in 42%; and surgery and adjuvant radiotherapy in 7%. Twenty-five percent of patients in this study received palliative radiotherapy. The overall incidence of brain metastasis in this cohort was 13%. Adenocarcinoma was the primary tumor histology in all of the patients who developed brain metastasis, representing an incidence of 16% in this subgroup. No patients with squamous cell carcinoma received trimodality therapy. The association between histology and brain metastasis was not statistically significant.

CONCLUSION: The incidence of brain metastasis in this contemporary cohort of patients with esophageal carcinoma is higher than previously reported and was confined to those with adenocarcinoma.

International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma

INTRODUCTION

Adenocarcinoma is the most common histologic type of lung cancer. To address advances in oncology, molecular biology, pathology, radiology, and surgery of lung adenocarcinoma, an international multidisciplinary classification was sponsored by the International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society. This new adenocarcinoma classification is needed to provide uniform terminology and diagnostic criteria, especially for bronchioloalveolar carcinoma (BAC), the overall approach to small nonresection cancer specimens, and for multidisciplinary strategic management of tissue for molecular and immunohistochemical studies.

METHODS

An international core panel of experts representing all three societies was formed with oncologists/pulmonologists, pathologists, radiologists, molecular biologists, and thoracic surgeons. A systematic review was performed under the guidance of the American Thoracic Society Documents Development and Implementation Committee. The search strategy identified 11,368 citations of which 312 articles met specified eligibility criteria and were retrieved for full text review. A series of meetings were held to discuss the development of the new classification, to develop the recommendations, and to write the current document. Recommendations for key questions were graded by strength and quality of the evidence according to the Grades of Recommendation, Assessment, Development, and Evaluation approach.

RESULTS

The classification addresses both resection specimens, and small biopsies and cytology. The terms BAC and mixed subtype adenocarcinoma are no longer used. For resection specimens, new concepts are introduced such as adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) for small solitary adenocarcinomas with either pure lepidic growth (AIS) or predominant lepidic growth with ≤ 5 mm invasion (MIA) to define patients who, if they undergo complete resection, will have 100% or near 100% disease-specific survival, respectively. AIS and MIA are usually nonmucinous but rarely may be mucinous. Invasive adenocarcinomas are classified by predominant pattern after using comprehensive histologic subtyping with lepidic (formerly most mixed subtype tumors with nonmucinous BAC), acinar, papillary, and solid patterns; micropapillary is added as a new histologic subtype. Variants include invasive mucinous adenocarcinoma (formerly mucinous BAC), colloid, fetal, and enteric adenocarcinoma. This classification provides guidance for small biopsies and cytology specimens, as approximately 70% of lung cancers are diagnosed in such samples. Non-small cell lung carcinomas (NSCLCs), in patients with advanced-stage disease, are to be classified into more specific types such as adenocarcinoma or squamous cell carcinoma, whenever possible for several reasons: (1) adenocarcinoma or NSCLC not otherwise specified should be tested for epidermal growth factor receptor (EGFR) mutations as the presence of these mutations is predictive of responsiveness to EGFR tyrosine kinase inhibitors, (2) adenocarcinoma histology is a strong predictor for improved outcome with pemetrexed therapy compared with squamous cell carcinoma, and (3) potential life-threatening hemorrhage may occur in patients with squamous cell carcinoma who receive bevacizumab. If the tumor cannot be classified based on light microscopy alone, special studies such as immunohistochemistry and/or mucin stains should be applied to classify the tumor further. Use of the term NSCLC not otherwise specified should be minimized.

CONCLUSIONS

This new classification strategy is based on a multidisciplinary approach to diagnosis of lung adenocarcinoma that incorporates clinical, molecular, radiologic, and surgical issues, but it is primarily based on histology. This classification is intended to support clinical practice, and research investigation and clinical trials. As EGFR mutation is a validated predictive marker for response and progression-free survival with EGFR tyrosine kinase inhibitors in advanced lung adenocarcinoma, we recommend that patients with advanced adenocarcinomas be tested for EGFR mutation. This has implications for strategic management of tissue, particularly for small biopsies and cytology samples, to maximize high-quality tissue available for molecular studies. Potential impact for tumor, node, and metastasis staging include adjustment of the size T factor according to only the invasive component (1) pathologically in invasive tumors with lepidic areas or (2) radiologically by measuring the solid component of part-solid nodules.

Factors associated with the development of brain metastases: analysis of 975 patients with early stage nonsmall cell lung cancer

BACKGROUND

The risk of developing brain metastases after definitive treatment of locally advanced nonsmall cell lung cancer (NSCLC) is approximately 30%-50%. The risk for patients with early stage disease is less defined. The authors sought to investigate this further and to study potential risk factors.

METHODS

The records of all patients who underwent surgery for T1-T2 N0-N1 NSCLC at Duke University between the years 1995 and 2005 were reviewed. The cumulative incidence of brain metastases and distant metastases was estimated by using the Kaplan-Meier method. A multivariate analysis assessed factors associated with the development of brain metastases.

RESULTS

Of 975 consecutive patients, 85% were stage I, and 15% were stage II. Adjuvant chemotherapy was given to 7%. The 5-year actuarial risk of developing brain metastases and distant metastases was 10%(95% confidence interval [CI], 8-13) and 34%(95% CI, 30-39), respectively. Of patients developing brain metastases, the brain was the sole site of failure in 43%. On multivariate analysis, younger age (hazard ratio [HR], 1.03 per year), larger tumor size (HR, 1.26 per cm), lymphovascular space invasion (HR, 1.87), and hilar lymph node involvement (HR, 1.18) were associated with an increased risk of developing brain metastases.

CONCLUSIONS

In this large series of patients treated surgically for early stage NSCLC, the 5-year actuarial risk of developing brain metastases was 10%. A better understanding of predictive factors and biological susceptibility is needed to identify the subset of patients with early stage NSCLC who are at particularly high risk.

Diagnostic efficacy of PET/CT plus brain MR imaging for detection of extrathoracic metastases in patients with lung adenocarcinoma

We aimed to evaluate prospectively the efficacy of positron emission tomography (PET)/computed tomography (CT) plus brain magnetic resonance imaging (MRI) for detecting extrathoracic metastases in lung adenocarcinoma. Metastatic evaluations were feasible for 442 consecutive patients (M:F=238:204; mean age, 54 yr) with a lung adenocarcinoma who underwent PET/CT (CT, without IV contrast medium injection) plus contrast-enhanced brain MRI. The presence of metastases in the brain was evaluated by assessing brain MRI or PET/CT, and in other organs by PET/CT. Diagnostic efficacies for metastasis detection with PET/CT plus brain MRI and with PET/CT only were calculated on a per-patient basis and compared from each other. Of 442 patients, 88 (20%, including 50 [11.3%] with brain metastasis) had metastasis. Regarding sensitivity of overall extrathoracic metastasis detection, a significant difference was found between PET/CT and PET/CT plus brain MRI (68% vs. 84%; P=0.03). As for brain metastasis detection sensitivity, brain MRI was significantly higher than PET/CT (88% vs. 24%; P<0.001). By adding MRI to PET/CT, brain metastases were detected in additional 32 (7% of 442 patients) patients. In lung adenocarcinoma patients, significant increase in sensitivity can be achieved for detecting extrathoracic metastases by adding dedicated brain MRI to PET/CT and thus enhancing brain metastasis detection.

Brain metastases admissions in Sweden between 1987 and 2006

Background:

Brain metastases (BM) constitute the most common intracranial tumours and are associated with considerable morbidity and mortality. Population-based studies of the epidemiology and time trends of BM are scarce.

Methods:

A population-based cohort of patients admitted to hospital with BM in Sweden between 1987 and 2006 (n=15 517) was identified and linked to nationwide registers of cancer incidence and death. Primary cancer types were assessed and time to hospitalisation and death was computed.

Results:

The annual age-adjusted incidence rate of hospitalisation for BM doubled from 7 to 14 patients per 100 000 between 1987 and 2006. The most common primary tumours among women were lung (33%), breast (33%) and colorectal cancer (7%), and among men lung cancer (44%), malignant melanoma (12%) and colorectal cancer (9%). The increase was most evident for BM patients with lung cancer (both sexes) and breast cancer (women). Survival was short, with a median of 2.7 months. It varied little by cancer type and did not improve over calendar time.

Conclusion:

The number of patients admitted with BM has increased rapidly in Sweden. In spite of recent improvements in the prognosis of common primary cancer types, any parallel improvement among patients with advanced cancer and BM is not indicated.

Tumor size matters differently in pulmonary adenocarcinoma and squamous cell carcinoma

Little about primary tumor size and nodal/distant metastases among different cell types in non-small cell lung cancer (NSCLC) was discussed. This study aimed to investigate distinct associations between tumor size and nodal/distant metastases in pulmonary adenocarcinoma and squamous cell carcinoma. The study also aimed to clarify the cutoff size relating to a higher likelihood of metastases. We retrospectively evaluated 932 NSCLC patients over a 3-year period and focused on cases with primary tumors less than 4.0 cm in size. Our data showed that 2.5 cm was the critical cutoff size regarding increased nodal/distant metastases in adenocarcinoma (p<0.001), but not in squamous cell carcinoma (p>0.05). In addition, the incidence of nodal/distant metastases reached a plateau of more than 80% in adenocarcinoma when the tumor size exceeded 2.5 cm. In contrast, there was no such correlation observed in squamous cell carcinoma. This study showed that tumor size mattered differently in pulmonary adenocarcinoma and squamous cell carcinoma.

Phase I study of concurrent whole brain radiotherapy and erlotinib for multiple brain metastases from non-small-cell lung cancer

PURPOSE

Erlotinib has shown activity in patients with brain metastases from non-small-cell lung cancer. The present dose-escalation Phase I trial evaluated the toxicity of whole brain radiotherapy (WBRT) with concurrent and maintenance erlotinib in this patient group.

METHODS AND MATERIALS

Erlotinib (Cohort 1, 100 mg/d; Cohort 2, 150 mg/d) was started 1 week before, and continued during, WBRT (30 Gy in 10 fractions). Maintenance erlotinib (150 mg/d) was continued until unacceptable toxicity or disease progression.

RESULTS

A total of 11 patients completed WBRT, 4 in Cohort 1 and 7 in Cohort 2. The median duration of erlotinib treatment was 83 days. No treatment-related neurotoxicity was observed. No treatment-related Grade 3 or greater toxicity occurred in Cohort 1. In Cohort 2, 1 patient developed a Grade 3 acneiform rash and 1 patient had Grade 3 fatigue. Two patients in Cohort 2 developed erlotinib-related interstitial lung disease, contributing to death during maintenance therapy. The median overall survival and interval to progression was 133 and 141 days, respectively. Six patients developed extracranial progression; only 1 patient had intracranial progression. In 7 patients with follow-up neuroimaging at 3 months, 5 had a partial response and 2 had stable disease.

CONCLUSION

WBRT with concurrent erlotinib is well tolerated in patients with brain metastases from non-small-cell lung cancer. The suggestion of a high intracranial disease control rate warrants additional study.

A diagnostic model to detect silent brain metastases in patients with non-small cell lung cancer

We aimed to discriminate subgroups according to the risk of brain metastases in patients with non-small cell lung cancer (NSCLC) lacking neurological symptoms. We performed a retrospective review of 433 patients with NSCLC who underwent chest computed tomography (CT), brain magnetic resonance imaging (MRI) and bone scans at an initial staging work-up between April 2003 and April 2007. Brain metastases were determined by MRI. Patients were stratified into groups according to the number of risk factors (0-3) identified by multivariate analysis. In multivariate analysis, histopathology with non-squamous cell carcinoma, nodal stage 2 on CT and presence of bone metastases were three risk factors for brain metastases. Patients were divided into four groups according to the number (0-3) of these predictive factors. The proportions of patients with brain metastases in the four groups were 2%, 3%, 17% and 35%, respectively, and these differences were significant (P<0.001). When analysis was performed in patients with localised disease, the number of risk factors was correlated with the prevalence of brain metastases (P=0.013) but stage was not (P=0.153). Although this diagnostic model should be validated through further studies, our data suggest that the number of risk factors might be a useful tool to identify silent brain metastases in patients with NSCLC.

Diagnostics and staging procedures in non-small cell lung cancer - is less more?

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a common cancer with approximately 85% of patients dying of the disease. The only chance for cure is in the early stages, when surgery or definite chemoradiotherapy can be performed. Diagnosis and staging of lung cancer can sometimes be difficult, particularly because the intrathoracic structures are not easy to reach.

OBJECTIVE

This review discusses the diagnosis and staging of lung cancer.

RESULTS

When performing lung cancer diagnostics, both invasive and noninvasive procedures, such as computed tomogram of the chest, bronchoscopy and abdominal ultrasound, are mandatory. Suspected mediastinal involvement should be differentiated: bulky disease, contralateral or high mediastinal nodes need further clarification by endoscopic ultrasound, endobronchial ultrasound or mediastinoscopy. In opposition to current guidelines, in all other cases, surgery should be performed. Positron emission tomography will gain even more importance when becoming widely accessible and might replace other imaging techniques in the future. In case of advanced disease, staging should be limited to those examinations with impact on symptom control.

CONCLUSION

The diagnosis and staging of lung cancer should involve both invasive and noninvasive diagnostic procedures. In the case of advanced disease, staging should be limited to those examinations with impact on symptom control, whereas early stages call for rapid and thorough diagnosis.