Surgical treatment for non-small cell lung cancer with ipsilateral pulmonary metastases

Distant metastasis patterns among lung cancer subtypes and impact of primary tumor resection on survival in metastatic lung cancer using SEER database

This research aimed to systematically uncover the metastatic characteristics and survival rates of lung cancer subtypes and to evaluate the impact of surgery at the primary tumor site on cancer-specific survival in DM lung cancer. We used the Surveillance, Epidemiology, and End Results (SEER) database (2010-2019) to identify primary lung cancers with DM at presentation (M1). Kaplan-Meier (KM) survival curves were generated and compared utilizing log-rank tests. Cox regression methods were employed to determine hazard ratios (HR) and 95% confidence intervals related to CSS factors. Inverse probability of treatment weighting (IPTW) was applied to reduce bias. We analyzed 77,827 M1 lung cancer cases, with 41.22% having DM at presentation. Bone metastasis was most common in ADC, ASC, SCC, LCC; brain in LCNEC; liver in SCLC. Lung was common in TC + AC and SCC. Long-term survival was best in TC + AC and worst in SCLC (p < 0.001). Male gender, age < 50, primary tumor site (main bronchus, lower lobe), large tumor diameter, ADC/SCLC/SCC pathology, and regional lymph node involvement were significant risk factors for multiorgan metastasis. Age ≥ 50, male, large tumor diameter, positive lymph nodes, and multiorgan metastases were associated with lower CSS. In contrast, radiotherapy, chemotherapy, systemic therapy, and surgery were associated with higher CSS rates. Primary tumor resection improved survival in lung cancer patients (excluding small cell lung cancer, SCLC) with single organ metastases (KM log rank p < 0.001, HR = 0.6165; 95% CI (0.5468-0.6951)), especially in brain (p < 0.001, HR = 0.6467; 95% CI (0.5505-0.7596)) and bone (p = 0.182, HR = 0.6289; p < 0.01), but not in liver or intrapulmonary metastases after IPTW. Significant differences in DM patterns and corresponding survival rates exist among lung cancer subtypes. Primary tumor resection improves survival in lung cancer patients (excluding small cell lung cancer, SCLC) with single organ metastases, with better outcomes in patients with brain and bone metastases, while no significant benefit was seen in patients with liver and intrapulmonary metastases.

Pathological T3 Non-Small Cell Lung Cancer with satellite nodules: Number or size, what does matter?

BACKGROUND

Non-small Cell Lung Cancer (NSCLC) with intralobar satellite nodule are defined as T3 (T3SN). We investigated the main features of these tumors and analyzed their impact on Overall Survival (OS).

METHODS

This was a retrospective multicentric study including all pT3SN NSCLC operated on between 2005 and 2020, excluding patients with multifocal ground-glass opacities; who received induction therapies; N3 or stage IV. The diameter of largest (LgN) and smallest nodule (SmN), the total diameter (sum of diameter of all nodules, TS), and the number of SN were measured.

RESULTS

Among 102 patients, 64.7 % were male. 84.3 % of patients had one SN (84.3 %), 9.8 % two SN while 5.9 % more than 2 SN. 63 patients were pN0. LgN (p = 0.001), SN (p = 0.005) and TS (p = 0.014) were significantly related to lymph-node metastasis; the LgN and TS were related to visceral pleural invasion (p < 0.001). Five-year OS was 65.1 %; at univariable analysis more than 2 satellite nodules, LgN and TS were significantly related to worse OS; at multivariable analysis, TS (Hazard Ratio [HR] 1.116 95 % Confidence Interval [CI] 1.008-1.235, p = 0.034) was an independent prognostic factors for OS. No significant prognostic factors were found for DFS at multivariable analysis. In pN0 patients, LgN (HR 1.051, 95 % CI 1.066-1.099, p = 0.027) and non-adenocarcinoma (HR 5.315 CI 95 % 1.494-18.910, p = 0.010) influenced OS.

CONCLUSIONS

Tumor size is related to tumor's local invasiveness. TS is an independent prognostic factor for OS. Patients with more than 2 SN seem to be at higher risk for death and recurrence.

Reconsidering T component of cancer staging for T3/T4 non-small-cell lung cancer with additional nodule

Background

Non-small-cell lung cancer (NSCLC) with additional nodule(s) located in the same lobe or ipsilateral different lobe were designated as T3 and T4, respectively, which was merely defined by anatomical location of additional nodule(s), regardless of other prognostic factors.

Methods

A total of 4711 patients with T1-4, N0-2, M0 NSCLC undergoing complete resection were identified between 2009 and 2014, including 145 patients with additional nodule(s) in the same lobe (T3-Add) and 174 patients with additional tumor nodule(s) in ipsilateral different lobe (T4-Add). Overall survival (OS) was compared using multivariable Cox regression models and propensity score matching analysis (PSM).

Results

T3-Add patients [T3-Add versus T3, hazard ratio (HR), 0.695; 95% confidence interval (CI), 0.528-0.915; p = 0.009] and comparable OS with T2b patients through multivariable Cox analysis, and further validated by PSM. T4-Add patients carried a wide spectrum of prognosis, and the largest diameter of single tumor was screened out as the most effective indicator for distinguishing prognosis. T4-Add (⩽3 cm) patients had better OS than T4 patients [T4-Add (⩽3 cm) versus T4, HR, 0.629; 95% CI, 0.455-0.869; p = 0.005] and comparable OS with T3 patients. And T4-Add (>3 cm) patients had comparable OS with T4 patients.

Conclusion

NSCLC patients with additional nodule(s) in the same lobe and ipsilateral different lobe (maximum tumor diameter ⩽ 3 cm) should be further validated and considered restaging as T2b and T3 in the forthcoming 9th tumor, node, and metastasis staging system.

Histopathologic and molecular approach to staging of multiple lung nodules

Distinguishing multiple primary lung cancers from intrapulmonary metastases in patients with synchronous multifocal lung adenocarcinomas can be challenging. The most recent 8th edition American Joint Committee on Cancer staging manual (AJCC staging manual) distinguishes four disease patterns in patients with multiple lung nodules: (I) two or more distinct and histologically different masses (considered unrelated and staged as individual cancers); (II) multiple ground-glass or part-solid nodules, histologically of with lepidic growth pattern (considered separate tumors, T staged based on highest T stage lesion); (III) patchy areas of ground-glass and consolidations, histologically often invasive mucinous adenocarcinomas (considered single tumor with diffuse "pneumonic-type" involvement); and (IV) separate nodules with the same histologic features based on comprehensive histologic subtyping (considered intrapulmonary metastases). Histologic and molecular features, in conjunction with clinical and radiological information, can all be tools to assist with staging of multiple nodules. Histologic features of adenocarcinomas are best characterized using comprehensive histologic subtyping (percentage of lepidic, acinar, solid, papillary and micropapillary pattern). Genomic alterations are commonly assessed using fluorescence in-situ hybridization and next generation sequencing (NGS). The AJCC considers exactly matching breakpoints by comparative genomic hybridization (CGH) as the only evidence for intrapulmonary metastases, and clearly different histologic types or subtypes as the only evidence for separate primary tumors. Similar histologic subtypes or the same biomarker pattern are considered merely relative arguments in favor of a single tumor source. When assessing multifocal lung cancer, pathologists should consider, and carefully weigh the importance of, molecular testing results in addition to the tumor's histologic features. For many cases encountered in routine clinical practice, absolute certainty cannot be reached as to whether they represent multiple primary cancers or intrapulmonary metastases. Classification of difficult cases often benefits from multidisciplinary discussion.

[pT4 non-small cell lung cancer: Surgical characteristics in present practice]

INTRODUCTION

pT4 is a group of miscellaneous tumors: our goal was to revisit their surgical reality.

METHODS

The different characteristics and prognostic factors of lung pT4 (n=403) were analysed according to three subgroups: G1 - by direct extension; G2 - by nodule in other ipsilateral lobe; G3 - because of both.

RESULTS

There were 332 males and 71 females mean aged 61.5 years. Surgery [exploratory: 89 (22.1 %), lobectomy: 149 (37 %), pneumonectomy: 169 (41.9 %)] was followed by 26 postoperative deaths (6.5 %), 82 complications (20.3 %) and concerned few pN0 (47.6 %). G1 (n=196) and G3 (n=53) were not different. By comparison with them, G2 (n=53) were mainly females (24\13 %), with less explorative thoracotomy (2.6\34 %), more complete R0 resections (77\29 %), less pneumonectomy (31\47 %), more small sized tumors (mean: 37\57 mm), more adenocarcinoma (67\32 %), more N0 tumors (48\31.7 %) and stages IIIA disease (46.7\56 %). G2 5-year survival rates were higher (G2: 22 %; G1: 13 %; G3: 15 %); G1 rates depended of the invaded structure (20.9 % for the vertebra down to 0 % for the esophagus and carina). pN2 rates were not very high but not different between groups (G1: 13.6 %; G2: 15.6 %; G3: 14.3 %; P=0.52). Multivariate analysis demonstrated completeness and type of resection, stage and age as independent factors of prognosis.

CONCLUSION

Surgery for pT4 is justified provided rigorous selection of extension forms. However, assimilating extension and ipsilateral lobe nodule in a same group does not obey to surgical reality.

Prognosis associated with surgery for non-small cell lung cancer and synchronous brain metastasis

PURPOSE

Several reports have described extended survival after aggressive surgical treatment for non-small cell lung cancer (NSCLC) and synchronous brain metastasis. This retrospective analysis assesses the prognostic factors in this population.

METHODS

We reviewed retrospectively the medical records of 29 patients with synchronous brain metastasis from NSCLC, who underwent surgical treatment in our institution between 1980 and 2008. All patients underwent chest surgery to remove the primary lesion. The impact of several variables on survival was assessed.

RESULTS

The median follow-up period was 9.6 months and the 5-year survival rate from the time of lung cancer resection was 20.6 %. Univariate analysis demonstrated that the carcinoembryonic antigen (CEA) level, primary tumor size, and the presence of lymph node involvement were predictive of overall survival (p < 0.05). Multivariate analysis also identified those factors to be independent favorable prognostic factors.

CONCLUSIONS

Although the survival of patients with brain metastasis from non-small cell lung cancer remains poor, surgical resection may benefit a select group of patients, particularly those with a normal CEA level, small tumor size, and node-negative status.