Pulmonary resection in patients with nonsmall-cell lung cancer treated with gamma-knife radiosurgery for synchronous brain metastases

Surgical management of non-small cell lung cancer with limited metastatic disease involving only the brain

OBJECTIVE

The optimal primary site treatment modality for non-small cell lung cancer with brain oligometastases is not well established. This study sought to evaluate the long-term survival of patients with non-small cell lung cancer with isolated brain metastases undergoing multimodal therapy with or without thoracic surgery.

METHODS

Patients with cT1-3, N0-1, M1b-c non-small cell lung cancer with synchronous limited metastatic disease involving only the brain treated with brain stereotactic radiosurgery or neurosurgical resection in the National Cancer Database (2010-2017) were included. Long-term overall survival of patients who underwent multimodal therapy including thoracic surgery ("Thoracic Surgery") versus systemic therapy with or without radiation to the lung ("No Thoracic Surgery") was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching.

RESULTS

Of the 1240 patients with non-small cell lung cancer with brain-only metastases who received brain stereotactic radiosurgery or neurosurgery and met study inclusion criteria, 270 (21.8%) received primary site resection. The Thoracic Surgery group had improved overall survival compared with the No Thoracic Surgery group in Kaplan-Meier analysis (P < .001) and after multivariable-adjusted Cox proportional hazards modeling (P < .001). In a propensity score-matched analysis of 175 patients each in the Thoracic Surgery and No Thoracic Surgery groups, matching on 13 common prognostic variables, thoracic surgery was associated with better survival (P = .012).

CONCLUSIONS

In this national analysis, patients with cT1-3, N0-1, M1b-c non-small cell lung cancer with isolated limited brain metastases had better overall survival after multimodal therapy including thoracic surgery compared with systemic therapy without surgery. Multimodal thoracic treatment including surgery can be considered for carefully selected patients with non-small cell lung cancer and limited brain metastases.

Survival Benefit of Perioperative Systemic Chemotherapy for Patients With N0 to N1 NSCLC Having Synchronous Brain Metastasis

Introduction

In stage IV NSCLC with solitary or oligometastatic brain metastasis, surgical resection of the primary and definitive management of the brain metastasis is an accepted standard. However, the effect of systemic chemotherapy after surgical resection on overall survival is not well-established.

Methods

We used the National Cancer Database to retrospectively identify individuals with NSCLC as the primary tumor along with synchronous brain metastases who underwent thoracic resection with or without adjuvant chemotherapy. Chi-square and Wilcoxon rank sum tests were performed to compare categorical and continuous variables, respectively, across the treatment groups. Kaplan-Meier and Cox proportional modeling were done to determine the survival benefit.

Results

A total of 310 (71.9%) of the cohort received perioperative chemotherapy, most of whom (79.4%) received it in the adjuvant setting. Patients receiving chemotherapy were likely to be younger (p = 0.002), privately insured (p = 0.01), and receive radiation (p < 0.001). Perioperative chemotherapy was significantly associated with survival on both univariate (hazard ratio = 0.71[0.52 - 0.99]) and multivariable (hazard ratio = 0.66 [0.47 - 0.92]) in addition to age (p = 0.03), Charlson-Deyo score (p = 0.02), pathologic N stage (p = 0.02), and adenocarcinoma histology (p = 0.02). Kaplan-Meier analysis confirmed this result with a significantly better survival with perioperative chemotherapy (p = 0.02). Further subgroup analysis using pathologic N stage revealed similar effect in pN1 (p = 0.001), but not pN0 (p = 0.2) patients.

Conclusions

Perioperative chemotherapy for pN0-1 NSCLC with synchronous brain metastasis is associated with improved OS in this analysis.

Improved Survival With Surgical Treatment of Primary Lung Lesions in Non-Small Cell Lung Cancer With Brain Metastases: A Propensity‐Matched Analysis of Surveillance, Epidemiology, and End Results Database

Objectives

Non-small cell lung cancer (NSCLC) with Brain metastases (BM) is an advanced disease with poor prognosis and low survival rate. Our study evaluated the survival benefit of primary lung resection with mediastinal lymph node dissection in NSCLC patients with BM using Surveillance, Epidemiology, and End-result (SEER) databases.

Methods

All cases analyzed were from Surveillance, Epidemiology, and End Results database. The data of the patients with BM of NSCLC from 2010 to 2016 was retrospectively analyzed. Patients (N=203) patients who underwent radical surgical treatment for primary lung lesions and patients (N=15500) who did not undergo surgery were compared. We successfully analyzed patients using propensity score matching (PSM). Kaplan‐Meier and Cox‐ regression analyses were applied to assess prognosis.

Results

The median survival in the surgery group was longer than in the control group (27 months vs 5 months; P &lt; 0.001) in the overall sample, 21 months longer compared to the control group (27 months vs 6 months; P&lt;0.001) in a PSM cohort. Cox regression analysis showed that underwent surgery patients in the propensity-matched sample had a significantly lower risk of mortality (HR:0.243, 95%CI: 0.162-0.365, P &lt; 0.001) compared with untreated patients. Multivariate analysis identified the following as independent risk factors for NSCLC with BM: no primary resection surgery, age &gt;65 years, worse differentiation, squamous cell carcinoma, lymphatic metastasis, no systemic therapy. Subgroup analysis revealed that radical resection of the primary lung provided a survival benefit regardless of marital status, tumor size, tumor grade, tumor T stage, and mediastinal lymph node metastasis after PSM.

Conclusion

Radical resection of primary lung can improve the survival of NSCLC patients with BM. Male, age&gt;65years, poorly differentiated tumor, tumor size&gt;5cm, and mediastinal lymph node metastasis were factors for poor survival.

Radiotherapy for oligometastatic non-small cell lung cancer: a narrative review

Preclinical and early clinical evidence suggest that radical radiotherapy of oligometastatic disease in non-small cell lung cancer (NSCLC) patients can impact outcomes with relatively limited toxicity. Whilst data from phase 2 randomized trials suggesting an improved overall survival (OS) with this treatment is promising, it has also illustrated the heterogeneity in this patient population and treatment. Oligometastatic disease in itself comprises a broad spectrum of patients, in terms of tumor load and location, stage of the disease and treatment history. This real-life variety in patient characteristics is often reflected in studies to a certain extent, hinting to the fact that all might benefit from radical radiotherapy to limited metastatic disease, yet leaving the question unanswered as to whom the ideal candidate is. Furthermore, differences between and within studies with regards to treatment modality, timing, radiation technique, and radiation dose are substantial. Also, preclinical and early clinical trials suggest that radiotherapy can work synergistically with checkpoint inhibitors by acting as an in situ cancer vaccine, therefore the combination of these two treatments in oligometastatic patients might entail the largest benefit. Ongoing randomized controlled phase 3 trials and prospective registry trials will further elucidate the true extent of benefit of this local treatment strategy and aid in identifying the ideal patient population and therapy. The current narrative review summarizes the clinical evidence on radiotherapy for oligometastatic NSCLC and highlights the remaining unknowns.

Results of surgical resection in lung cancer with synchronous brain metastasis

Background

This study aims to investigate the factors affecting the survival of operated non-small cell lung cancer patients with synchronous brain metastasis.

Methods

Clinical outcomes of a total of 16 patients (14 males, 2 females; mean age 60 years; range, 41 to 71 years) who were diagnosed with non-small cell lung cancer and concomitant solitary/oligo brain metastasis and who underwent an intervention primarily for cranium, followed by lung resection in our clinic between January 2012 and January 2016 were retrospectively analyzed. Cranial surgery or gamma-knife radiosurgery was performed in the treatment of brain metastases.

Results

Twelve patients with solitary brain metastasis underwent cranial surgery, while four patients with solitary/oligo metastases underwent gamma-knife radiosurgery prior to pulmonary resection. Definitive pathological examination revealed adenocarcinoma in 13 patients and squamous-cell lung carcinoma in three patients. Mean survival time was 15.3±8.6 months. One-year and two-year survival rates were 56.2% and 32%, respectively. The number of brain metastases, treatment type, tumor cell type, resection type, and status of lymph nodes were not statistically significantly associated with survival (p>0.05).

Conclusion

Cranial surgery or gamma-knife radiosurgery followed by aggressive lung resection can be effectively applied in selected non-small cell lung cancer patients with synchronous brain metastasis. However, the suitability of the primary tumor and brain metastases for complete resection is of utmost importance in patient selection.

Treatment of oligometastatic lung cancer with brain metastases using stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT)

Background

There is increasing interest in treating oligometastatic non-small cell lung cancer (NSCLC) patients with stereotactic radiation. We aimed to address whether patients definitively treated with synchronous thoracic stereotactic body radiation therapy (SBRT) and brain stereotactic radiosurgery (SRS) had favorable outcomes with local therapy.

Materials and methods

We reviewed a database of patients receiving lung SBRT as well as a database for brain metastasis patients treated with SRS between June 2004 and January 2016. We selected for cT1-2aN0M1 NSCLC patients with brain metastases and calculated their overall survival (OS), freedom from progression (FFP), and local control (LC) rates.

Results

Six patients had oligometastatic NSCLC with 1-3 synchronous brain metastases treated with lung SBRT and brain SRS. No patients received immunotherapy and two-thirds did not receive systemic therapy. Median follow-up was 9 months for the entire cohort (range, 2-95 months) and 95 months for the surviving patient. Median OS was 12.4 months (95% confidence interval [CI], 7-18 months). At 1 year, patients had 67% OS (95% CI, 29-100%), 17% FFP (95% CI, 0-46%), and 100% LC. Their brain disease had 80% 1-year LC (95% CI, 45-100%) and 53% 1-year FFP (95% CI, 5-100%). Two patients had no distant progression, two had brain progression, one had adrenal gland progression, and one had bone and liver progression.

Conclusion

In patients presenting with oligometastatic lung cancer limited to the brain, treatment with both lung SBRT and brain SRS achieves good LC of all sites with encouraging OS.

Validation of the Disease-Specific GPA for Patients With 1 to 3 Synchronous Brain Metastases in Newly Diagnosed NSCLC

BACKGROUND

The disease-specific graded prognostic assessment (DS-GPA) for brain metastases is a powerful prognostic tool but has not been validated for patients with synchronous brain metastases (SBM) in newly diagnosed non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We identified patients with newly diagnosed NSCLC with 1 to 3 SBM treated with stereotactic radiosurgery (SRS) between 1997 and 2012. We included patients whose brain metastases were treated with SRS alone or combined SRS and whole-brain radiotherapy (WBRT). Patients were stratified according to NSCLC DS-GPA to evaluate the accuracy of survival estimates.

RESULTS

One hundred sixty-four patients were treated with either SRS alone (n = 85; 52%) or SRS and WBRT (n = 79; 48%). Median overall survival (OS) stratified according to DS-GPA of 0 to 1, 1.5 to 2, 2.5 to 3, and 3.5 to 4 were 2.8, 6.7, 9.8, and 13.2 months, respectively, consistent with OS reported for brain metastases in NSCLC DS-GPA (3.0, 6.5, 11.3, and 14.8 months, respectively). No difference in median progression-free survival or OS was noted with combined use of SRS and WBRT: 6.0 versus 6.1 months (P = .81) and 8.5 versus 9.1 months (P = .093), respectively. In multivariable analysis, Karnofsky performance status (hazard ratio [HR], 0.98; P = .008), extracranial metastases (HR, 0.498; P = .0003), squamous histology (HR, 1.81; P = .02), and number of brain metastases (2 vs. 1; HR, 1.504; P = .04, and 3 vs. 1; HR, 1.66; P = .05) were significant predictors of OS.

CONCLUSION

The DS-GPA accurately estimates the prognosis of patients with SBM in newly diagnosed NSCLC. Patients with synchronous brain metastasis in newly diagnosed NSCLC should be carefully stratified for consideration of aggressive therapy.

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.

Lung resection is safe and feasible among stage IV cancer patients: An American College of Surgeons National Surgical Quality Improvement Program analysis

BACKGROUND

Operative resection can be associated with improved survival for selected patients with stage IV malignancies but may also be associated with prohibitive acute morbidity and mortality. We sought to evaluate rates of acute morbidity and mortality after lung resection in patients with disseminated malignancy with primary lung cancer and non-lung cancer pulmonary metastatic disease.

METHODS

For 2011-2012, 6,360 patients were identified from the American College of Surgeons National Surgical Quality Improvement Program undergoing lung resections, including 603 patients with disseminated malignancy. Logistic regression analyses were used to compare outcomes between patients with and without disseminated malignancy.

RESULTS

After controlling for preoperative and intraoperative differences, we observed no statistically significant differences in rates of 30-day overall and serious morbidity or mortality between disseminated malignancy and non-disseminated malignancy patients (P > .05). Disseminated malignancy patients were less likely to have a prolonged duration of stay and be discharged to a facility compared to non-disseminated malignancy patients (P < .05). Subgroup analyses by procedure type and diagnosis showed similar results.

CONCLUSION

Disseminated malignancy patients undergoing lung resections experienced low rates of overall morbidity, serious morbidity, and mortality comparable to non-disseminated malignancy patients. These data suggest that lung resections may be performed safely on carefully selected, disseminated malignancy patients with both primary lung cancer and pulmonary metastatic disease, with important implications for multimodality care.

Prognostic factors and long-term survival in surgically treated brain metastases from non-small cell lung cancer

OBJECTIVE

Brain metastases (BMs) are the most common malignant brain tumors in adults. Despite multimodal treatment options such as microsurgery, radiotherapy and chemotherapy, prognosis still remains very poor. Non-small cell lung cancer (NSCLC) constitutes the most common source of brain metastases. In this study, prognostic factors in this patient population were identified through an in-depth analysis of clinical parameters of patients with BMs from NSCLC.

PATIENTS AND METHODS

Clinical data of 114 NSCLC cancer patients who underwent surgery for BMs at the University Hospital Heidelberg were retrospectively reviewed for age, gender, type of treatment, time course of the disease, presence of neurologic symptoms, Karnofsky Performance Status (KPS), smoking history, presence of extracranial metastases at initial diagnosis of NSCLC, number, location and size of brain metastases. Univariate and multivariate survival analyses were performed using the Log-rank test and Cox' proportional hazard model, respectively.

RESULTS

Median survival time from surgery for BMs was 11.2 months. 18.4% (21 of 114) patients were long-term survivors (>24 months; range 26.3-75.1 months). Age, gender, size and number of intracranial metastases were not significantly associated with patient survival. Univariate analysis identified complete resection, postoperative whole brain radiotherapy (WBRT) and a preoperative KPS of >80% as positive prognostic factors. Infratentorial location and presence of extracranial metastases were shown to be negative prognostic factors. Surgery for the primary tumor was associated with a superior patient outcome both in univariate and multivariate analyses.

CONCLUSION

Our data strongly suggest that surgical treatment of the primary tumor and complete resection of brain metastases in NSCLC patients followed by WBRT improve survival. Moreover, long-term survivors (>2 years) were more frequent than previously reported.

Comparison Between Surgical Resection and Stereotactic Radiosurgery in Patients with a Single Brain Metastasis from Non-Small Cell Lung Cancer

BACKGROUND

The management of patients with single brain metastasis (BM) from non-small cell lung cancer (NSCLC) is controversial. Surgical resection (SR) with adjuvant irradiation and stereotactic radiosurgery (SRS) are performed in the treatment of such lesions. This study compared both modalities in terms of tumor control and survival.

METHODS

During the period 2004-2011, 115 patients with single BM from NSCLC were treated with SR or SRS at our institution. Median patient age was 61 years. SR was performed in 43 patients, and SRS was performed in 72 patients. Most patients who underwent SR had adjuvant irradiation. Of patients, 63% in the SR group and 56% in the SRS group had synchronous presentation of BM and lung primary tumor. Thoracic disease was managed with curative intent in 60% of patients in the SR group compared with 50% of patients in the SRS group.

RESULTS

Median follow-up was 10.2 months. Local control was 72% in patients in the SR group and 79% in patients in the SRS group (P = 0.992). Median survival for patients in the SR group was 13.3 months, and median survival for patients in the SRS group was 7.8 months (P = 0.047). Multivariate analyses revealed aggressive treatment of the primary NSCLC as an independent factor associated with prolonged survival in patients undergoing SR. In the SRS group, patients with metachronous metastasis showed a better prognosis. Metachronous presentation was associated with more aggressive management of the primary tumor.

CONCLUSIONS

In this study, patients with single BM undergoing SR had a survival advantage. However, because SR and SRS achieved comparable local control of BM, patients receiving SRS should benefit from an equally aggressive treatment of the primary NSCLC, as thoracic management was the most important predictor of survival.

[Surgical treatment for non-small cell lung cancer patients with synchronous solitary brain metastasis]

BACKGROUND AND OBJECTIVE

Brain metastases are common in non-small cell lung cancer. Usual treatments include radiotherapy and chemotherapy. However, these methods result in poor patient prognosis. The aim of this study is to assess the effectiveness of surgical resection in the multimodality management of non-small cell lung cancer patients with synchronous solitary brain metastasis.

METHODS

The clinical data of 46 non-small cell lung cancer patients with synchronous solitary brain metastasis were retrospectively reviewed. All patients underwent surgical resection of primary lung tumor, followed by whole brain radiotherapy and chemotherapy. In addition, 13 out of the 46 patients underwent resection of brain metastasis, whereas the remaining 33 patients received stereotactic radiosurgery.

RESULTS

The median survival time of the enrolled patients was 16.8 months. The 1-, 2-, and 3-year survival rates were 76.1%, 20.9%, and 4.7%, respectively. The median survival times of the patients with brain metastasis resection or stereotactic radiosurgery were 18.3 and 15.8 months, respectively (P=0.091,2).

CONCLUSIONS

Surgical resection of primary lung tumor and brain metastasis may improve prognosis of non-small cell lung cancer patients with synchronous solitary brain metastasis. However, the survival benefit of surgical resection over brain metastasis resection or stereotactic radiosurgery is uncertain.

Survival outcomes after whole brain radiation therapy and/or stereotactic radiosurgery for cancer patients with metastatic brain tumors in Korea: a systematic review

AIM

To compare survival outcomes after whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS), and WBRT plus SRS combination therapy in Korea, by performing a quantitative systematic review.

MATERIALS AND METHODS

We searched 10 electronic databases for reports on Korean patients treated with WBRT or SRS for brain metastases published prior to July 2010. Independent reviewers screened all articles and extracted the data. When a Kaplan-Meier survival curve was available, median survival time and standard errors were calculated. Summary estimates for the outcomes in each study were calculated using the inverse variance random-effects method.

RESULTS

Among a total of 2,761 studies, 20 studies with Korean patients (n=1,053) were identified. A combination of 12 studies (n=566) with WBRT outcomes showed a median survival time of 6.0 months (95%CI: 5.9-6.2), an overall survival rate of 5.6% (95%CI: 1-24), and a 6-month survival rate of 46.5% (95%CI: 37.2-56.1). For nine studies (n=412) on SRS, the median survival was 7.9 months (95%CI: 5.1-10.8), and the 6-month survival rate was 63.1% (95%CI: 49.8-74.8). In six studies (n=75) using WBRT plus SRS, the median survival was 10.7 months (95%CI: 4.7-16.6), and the overall and 6-month survival rates were 16.8% (95%CI: 6.2-38.2) and 85.7% (95%CI: 28.3-96.9), respectively.

CONCLUSIONS

WBRT plus SRS showed better 1-year survival outcome than of WBRT alone for Korean patients with metastatic brain tumors. However, the results of this analysis have to be interpreted cautiously, because the risk factors of patients were not adjusted in the included studies.

Treatment of brain metastasis from lung cancer

Brain metastases are not only the most common intracranial neoplasm in adults but also very prevalent in patients with lung cancer. Patients have been grouped into different classes based on the presence of prognostic factors such as control of the primary tumor, functional performance status, age, and number of brain metastases. Patients with good prognosis may benefit from more aggressive treatment because of the potential for prolonged survival for some of them. In this review, we will comprehensively discuss the therapeutic options for treating brain metastases, which arise mostly from a lung cancer primary. In particular, we will focus on the patient selection for combined modality treatment of brain metastases, such as surgical resection or stereotactic radiosurgery (SRS) combined with whole brain irradiation; the use of radiosensitizers; and the neurocognitive deficits after whole brain irradiation with or without SRS. The benefit of prophylactic cranial irradiation (PCI) and its potentially associated neuro-toxicity for both small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are also discussed, along with the combined treatment of intrathoracic primary disease and solitary brain metastasis. The roles of SRS to the surgical bed, fractionated stereotactic radiotherapy, WBRT with an integrated boost to the gross brain metastases, as well as combining WBRT with epidermal growth factor receptor (EGFR) inhibitors, are explored as well.