Results and prognostic factors of surgery in the management of non-small cell lung cancer with solitary brain metastasis

Operation and Chemotherapy: Prognostic Factors for Lung Cancer With One Synchronous Metastasis

BACKGROUND

Stage IV non-small cell lung cancer (NSCLC) is considered incurable; however, some patients with only few metastases may benefit from treatment with a curative intent. We aimed to identify the prognostic factors for stage IV NSCLC with synchronous solitary M1.

METHODS

A database constructed from our weekly multidisciplinary thoracic oncology meetings was retrospectively screened from 1993 to 2012. Consecutive patients with NSCLC stages I to IV were included.

RESULTS

Of the 6,760 patients found, 4,832 patients were studied. Among the 1,592 patients (33%) with stage IV NSCLC, 109 (7%) had a synchronous solitary M1. Metastasis involved the brain in 64% of patients. Median overall survival was significantly longer in synchronous solitary M1 than in other stage IV (18.9 months, interquartile range [IQR]: 9.9 to 34.6 months versus 6.1 months, IQR: 2.3 to 13.7 months], respectively, p < 10^-4). Among patients with synchronous solitary M1, 90 (83%) received a local treatment with curative intent at the primary and metastatic sites. Factors independently associated with survival were age older than 63 years (hazard ratio [HR] 1.63, 95% confidence interval [CI]: 1.01 to 2.63), Performance status of 3 or 4 (HR 7.91, 95% CI: 2.23 to 28.03), use of chemotherapy (HR 0.38, 95% CI: 0.23 to 0.64), and operation conducted at both sites (HR 0.35, 95% CI: 0.19 to 0.65).

CONCLUSIONS

Synchronous solitary M1 treated with chemotherapy and operation at both sites resulted in better survival. Survival of NSCLC with synchronous solitary M1 was more similar to stage III than other stage IV NSCLCs. The eighth TNM classification takes this into account by distinguishing between stages M1b and M1c.

Predictors of Survival After Treatment of Oligometastases After Esophagectomy

BACKGROUND

Recurrent esophageal carcinoma (EC) has a dismal prognosis. However, prior studies showed that selected patients with isolated recurrence may benefit from definitive therapy. The aim of this study was to identify the predictors of postrecurrence survival (PRS) in patients with isolated EC recurrence who were treated with curative intent.

METHODS

A retrospective review of a prospective database (1988 to 2015) was performed to identify all recurrent EC patients after curative esophagectomy. Demographic and clinicopathologic data were reviewed. The probability of PRS was estimated with the Kaplan-Meier method. Predictors of PRS after definitive therapy for isolated EC recurrence were determined by the multivariable Cox proportional hazards model.

RESULTS

Of the 640 curative esophagectomies, 241 patients (37.7%) experienced recurrences (median follow-up 50 months). Fifty-six patients (9%) received definitive treatment of isolated EC recurrence (31 were treated surgically with or without chemotherapy-radiotherapy [CTRT] and 25 received definitive CTRT alone). Median time to recurrence (TTR) was 19 months. The 1- and 3-year PRSs were 78% and 38% (median survival 26 months). On multivariable analysis; TTR was the only significant independent predictor for survival after recurrence (hazards ratio 0.98, 95% confidence interval: 0.96 to 0.99, p = 0.034). No pronounced difference was found in disease-free survival or in PRS between recurrent patients treated with operation with or without CTRT and patients who received definitive CTRT.

CONCLUSIONS

A select subgroup of patients with isolated EC recurrence can be treated with curative intent. TTR was the best predictor for PRS.

Long-term survival in patients with non-small cell lung cancer and synchronous brain metastasis treated with whole-brain radiotherapy and thoracic chemoradiation

BACKGROUND

Brain metastases occur in 30-50% of Non-small cell lung cancer (NSCLC) patients and confer a worse prognosis and quality of life. These patients are usually treated with Whole-brain radiotherapy (WBRT) followed by systemic therapy. Few studies have evaluated the role of chemoradiotherapy to the primary tumor after WBRT as definitive treatment in the management of these patients.

METHODS

We reviewed the outcome of 30 patients with primary NSCLC and brain metastasis at diagnosis without evidence of other metastatic sites. Patients were treated with WBRT and after induction chemotherapy with paclitaxel and cisplatin for two cycles. In the absence of progression, concurrent chemoradiotherapy for the primary tumor with weekly paclitaxel and carboplatin was indicated, with a total effective dose of 60 Gy. If disease progression was ruled out, four chemotherapy cycles followed.

RESULTS

Median Progression-free survival (PFS) and Overall survival (OS) were 8.43 ± 1.5 and 31.8 ± 15.8 months, respectively. PFS was 39.5% at 1 year and 24.7% at 2 years. The 1- and 2-year OS rates were 71.1 and 60.2%, respectively. Three-year OS was significantly superior for patients with N0-N1 stage disease vs. N2-N3 (60 vs. 24%, respectively; Response rate [RR], 0.03; p= 0.038).

CONCLUSIONS

Patients with NSCLC and brain metastasis might benefit from treatment with WBRT and concurrent thoracic chemoradiotherapy. The subgroup of N0-N1 patients appears to achieve the greatest benefit. The result of this study warrants a prospective trial to confirm the benefit of this treatment.

Surgical Therapies in Brain Metastasis

Brain metastases are the most common intracranial tumors in adults and source of the most common neurological complications of systemic cancer. The treatment approach to brain metastases differs essentially from treatment of systemic metastases due to the unique anatomical and physiological characteristics of the brain. Surgery and radiosurgery are important components in the complex treatment of brain metastases and can prolong survival and improve the quality of life (QOL). Aggressive intervention may be indicated for selected patients with well-controlled systemic cancer and good performance status in whom central nervous system (CNS) disease poses the greatest threat to functionality and survival. In this review the respective roles of surgery and radiosurgery, patient selection, general prognostic factors and tailoring of optimal surgical management strategies for cerebral metastases are discussed.

Chemotherapy is the cornerstone of the combined surgical treatment of lung cancer with synchronous brain metastases

BACKGROUND

Lung cancer accounts for about 50% of brain metastases, of which nearly 25% are eligible for neurosurgery, providing a neurological control rate of up to 70% when followed by whole brain radiation therapy. How to manage the primary lung carcinoma remains elusive.

METHODS

We undertook a retrospective study of consecutive patients who underwent surgical resection for synchronous brain metastases from non-small cell lung cancer in a single institution, to determine overall survival and prognostic factors, with particular attention to the treatment of the primary lung tumor.

RESULTS

Fifty-one patients underwent surgical resection of synchronous brain metastases from non-small cell lung cancer. Median survival was 13.2 months. Prognosis mainly depended of the treatment of the lung tumor, with a marked survival advantage in the 29 patients receiving a focal treatment (thoracic surgery or radiotherapy), compared to the 22 other patients: median, 1-year, and 2-year survival were 22.5 months, 69%, and 42%, versus 7.1 months, 33%, and 5%, respectively (p<0.001); response to pre-operative chemotherapy before focal treatment was the main favorable prognostic factor (p=0.023), and further identified patients who had benefit from resection of the lung tumor, with a significantly better outcome.

CONCLUSIONS

Chemotherapy, by its therapeutic and prognostic value, may be considered as the cornerstone of the combined medical and surgical therapeutic sequence whereby brain metastasectomy is followed by chemotherapy and further focal treatment of the primary lung tumor in responders to chemotherapy.

Which Patients with Stage III Non‐Small Cell Lung Cancer Should Undergo Surgical Resection?

The treatment of patients with stage III NSCLC remains controversial. Stage III NSCLC comprises a fairly heterogeneous group of tumors, and furthermore only sparse data from randomized clinical trials exist to guide therapy decisions. This review article proposes a management algorithm for patients with stage III NSCLC that is based upon the currently available data on surgical therapy, chemotherapy, and radiation therapy. By necessity, given the paucity of strong data, a good deal of opinion is offered. The choice to proceed with aggressive, combined modality treatment is presented in light of extent of local disease as well as patient performance status.

Relationship between Non-Small Cell Lung Cancer Fluorodeoxyglucose Uptake at Positron Emission Tomography and Surgical Stage with Relevance to Patient Prognosis

PURPOSE

Because the tumor stage is the most significant prognostic factor for non-small cell lung cancer (NSCLC) and given that NSCLC [(18)F]fluorodeoxyglucose ((18)F-FDG) uptake appears to have prognostic significance, we examined the relationship between NSCLC (18)F-FDG uptake and surgical stage.

EXPERIMENTAL DESIGN

One hundred seventy-eight patients with a proven diagnosis of NSCLC were enrolled, then imaged with (18)F-FDG positron emission tomography and their disease thoroughly staged. Primary tumor size at computed tomography and (18)F-FDG uptake were compared to overall tumor stage and to T, N, and M stage descriptors. Tumor uptake was quantitated by maximum pixel-standardized uptake value (maxSUV) and then partial volume corrected for lesion size using recovery coefficients.

RESULTS

A significant difference in tumor size was associated with tumors of different TNM stage, T status, N status, or M status. Similarly, the primary tumor maxSUV was significantly associated with TNM stage, T status, and M status. However, we observed no significant difference in the partial-volume-corrected tumor maxSUV for different stages; different T, N, or M descriptors; tumors without evidence of spread (N(0)M(0)) versus tumors with nodal spread (N(1,2,3)M(0)); or tumors without spread (N(0)M(0)) versus all others.

CONCLUSIONS

We found an association between tumor stage and (18)F-FDG maxSUV, but this relationship disappeared after correction of tumor uptake for lesion size. Therefore, if partial-volume-corrected (18)F-FDG uptake is prognostic of NSCLC outcome, it is not on the basis of a relationship with tumor stage but through a different mechanism.

Solitary sites of metastatic disease in non-small cell lung cancer

Metastatic (stage IV) non-small cell lung cancer is a lethal disease, with few patients surviving longer than 5 years. Surgery is not an option, and adjuvant therapy regimens (platinum-based chemotherapy, radiation therapy, and supportive care) have been structured around palliation and maximizing the quality of life for patients. However, patients with solitary foci of metastatic disease represent a subgroup with a better prognosis. Studies have indicated that surgical resection may enhance the survival rate of patients in this setting. Patients who have resectable primary tumors and a solitary site of metastasis, based on a thorough metastatic work-up, benefit from surgical resection (primary tumor and solitary metastasis). The role of adjuvant chemotherapy and radiation depends on the individual and patient setting. There have been several case series indicating an improvement in the long-term (5-year) survival rates of patients after surgical resection of solitary metastases of the brain, adrenal gland, and other sites. Prospective trials will be required to determine the magnitude of benefit of surgical resection for patients and the role of multimodality therapy. The standard of care for patients with solitary metastases in non-small cell lung cancer should include consideration of surgical resection and ablation. Favorable criteria include control of the primary tumor, a negative metastatic survey, good performance status, and a significant metachronous interval.

Brain metastasis in resected lung cancer: value of intensive follow-up with computed tomography

BACKGROUND

Brain metastases are a common mode of recurrence in resected lung cancer and are usually associated with an ominous outcome.

METHODS

To assess the usefulness of follow-up using computed tomography of the brain for early detection and effective treatment of brain metastases, we prospectively studied 128 patients with completely resected non-small cell lung cancer. Follow-up computed tomographic scans were obtained every 2 to 6 months over 24 postoperative months in 69 patients and every 2 months for 6 postoperative months in 59.

RESULTS

Brain metastases were discovered in 11 patients (8.6%), and 7 patients were neurologically asymptomatic when the metastases were diagnosed. Single metastasis was found in 5 patients and multiple metastases in 6. The maximal size of all but one lesion was less than 25 mm. The median survival time and 5-year survival rate in all 11 patients with brain metastases were 10 months and 24%, respectively. Furthermore, those in 7 asymptomatic patients were 25 months and 38%, respectively.

CONCLUSIONS

We consider intensive follow-up with computed tomography to be worthwhile for early detection and effective treatment of brain metastases in patients with completely resected lung cancer.

The role of adjuvant radiation and multiple resection within the surgical management of brain metastases

Cerebral metastases occur in 25% to 35% of all cancer patients. The advances in systemic and topical treatment as well as the rising incidence of lung cancer and melanomas are associated with an increasing incidence of cerebral metastases. More than 20,000 patients die every year in the Federal Republic of Germany of this disease. This retrospective analysis covers 145 patients who underwent surgery. Survival analysis of different subgroups was performed. The patients were grouped according to their clinical status and the different therapeutical procedures which were performed. Group A, consisting of all those patients where a gross total resection could be performed and where no systemic disease was apparent at the time of craniotomy showed the best results, having the highest portion of long term survivors. Group B, consisting of those patients who underwent a subtotal resection and who had no systemic disease at the time of craniotomy, had a worse outcome. Group C patients (gross total resection and systemic disease) as well as Group D (subtotal resection and systemic disease) presented the poorest results with respect to survival. A benefit was mediated by adjuvant radiation as well as multiple resections. Surgery is the method of choice for the treatment of a single metastasis. Advances in microsurgery nowadays sometimes justify even the removal of multiple metastases, depending on their location, on the general condition of the patient and on prognosis.

Long-term survival following surgical treatment of solitary brain metastasis in non-small cell lung cancer

Dissemination of lung cancer beyond the intrathoracic lymph nodes (stage IV disease) implies surgical unresectability. However, solitary brain metastases (SBMs) from non-small cell lung cancer (NSCLC) have often been treated by combined resection of the primary tumor and its metastasis. Such an aggressive approach appears to substantively improve patient outcome and provide better quality of life in selected cases. A search of the literature reveals extended survival (10 years or longer) in 16 patients following combined surgical excision. We report three patients with NSCLC and isolated central nervous system involvement who achieved exceptionally long survival. The existing literature on SBMs from NSCLC is reviewed.

Survival after surgical treatment of brain metastases from lung cancer: a follow-up study of 231 patients treated between 1976 and 1991

The authors reviewed the records of 231 patients who underwent resection of brain metastases from nonsmall-cell lung cancer between 1976 and 1991. Data regarding the primary disease and the characteristics of brain metastasis were retrospectively collected. Median survival in the group from the time of first craniotomy was 11 months; post-operative mortality was 3%. Survival rates of 1, 2, 3, and 5 years were 46.3%, 24.2%, 14.7%, and 12.5%, respectively. One hundred twelve women survived significantly longer than 119 men (13.8 vs. 9.5 months, p < 0.02). Patients with single metastatic lesions (200 patients) survived longer than those (31 patients) with multiple metastases (11.1 vs. 8.5 months, p < 0.02). Patients with supratentorial tumors survived longer than patients with cerebellar lesions. A high Karnofsky performance scale score before surgery also indicated increased survival. In multivariate analyses, incomplete resection or no resection of primary lung tumor, male gender, infratentorial location, presence of systemic metastases, and age older than 60 years were significantly correlated with shorter survival. Approximately one-third of the patients died of neurological causes, one-third of systemic disease, and one-third of a combination of both. The results of this series confirm that the overall prognosis for patients with even a single resectable brain metastasis is poor, but that aggressive therapy can prolong life with quality of life preserved and can occasionally permit long-term survival.