Surgical Treatment of Extrapulmonary Oligometastatic Non-small Cell Lung Cancer

Multimodal therapy for synchronous bone oligometastatic NSCLC: The role of surgery

OBJECTIVES

The study aimed to assess the feasibility of radical surgical treatment for selected bone-oligometastatic non-small cell lung cancer (NSCLC) patients and to identify prognostic factors associated with survival.

MATERIALS AND METHODS

The clinical records of 27 patients with bone synchronous oligometastatic NSCLC were retrospectively analyzed.

RESULTS

Thirteen (48.1%) bone metastases were treated by surgery and 14 (51.9%) by local radiotherapy. Eighteen (66.7%) patients underwent induction chemotherapy before lung surgery, and 3 (11.1%) concurrent radiotherapy. Pulmonary surgery was a major lung resection in 23 (85.2%) cases. Intraoperative and 30-days mortality was null. Only one major (ARDS) and 10 (37.04%) mild complications (like air leakage, arrhythmia, and mucus retention) were recorded. 1-year and 5-years OS from the diagnosis and 1-year, 3- years disease-free survival (DFS) were 96%, 38%, and 66%, 30%, respectively. After stepwise Cox regression analysis, local recurrence (p = 0.05) and metachronous metastases (p = 0.04) maintained their independent prognostic value as overall survival negative determinants. Nodal upstaging (p = 0.04) and nonsurgical treatment of bone lesion (p = 0.03) turned out to be independent risk factors for shorter DFS; the vertebral localization of bone metastases showed only a remarkable trend towards significance (p = 0.06) as a risk factor for a worse DFS.

CONCLUSIONS

In selected patients, surgical treatment of primary NSCLC and bone synchronous metastasis seems to be safe and feasible and rewarding survivals may be expected.

Complications of Chest Wall Resection in Conjunction with Pulmonary Resection

Techniques for chest wall resection and reconstruction have evolved over the years. Chest wall resection in conjunction with pulmonary resection has several complications, including pulmonary and infectious. Risk factors for complications are related to the size of the defect, number of ribs resected, and the addition of a pulmonary resection. Material used for reconstruction does not impact the overall complication rate.

Epidemiology of oligometastatic non-small cell lung cancer: results from a systematic review and pooled analysis

Background

To describe the incidence and the clinical characteristics of oligometastatic non-small cell lung cancer (NSCLC) patients. Oligometastatic NSCLC is gaining recognition as a clinical condition with a different prognosis compared to multi metastatic disease. Usually, four different scenarios of oligometastatic disease can be described but not epidemiological data are available. To date, it is difficult to delineate an exhaustive epidemiological scenario because no uniform or shared definition of oligometastatic status exists, even though a recent consensus defined synchronous oligometastatic disease as having a maximum of 5 metastases in 3 different organs.

Methods

A systematic review and a pooled analysis of literature were performed. Article selection was based on the following characteristics: focus on lung cancers; dealing with oligometastatic settings and providing a definition of oligometastatic disease; number of metastatic lesions with or without the number of organs involved; providing some incidence or clinical characteristics of oligometastatic NSCLC patients. Series focusing on a specific single metastatic organ were excluded. The research was launched in MEDLINE (OvidSP) in March 2020. Full articles were individually and collectively read by the authors according to the previous criteria. Each author inspected the reference list included in the eligible articles. If the selection criteria were recognized, the article was reviewed by all authors and then included. Data on patient clinical features were pooled together from 31 articles selected.

Results

A total number of 31 articles have been selected for the analysis. The following variables were extracted from the publications: (I) number of metastases, (II) number of organs involved, (III) number of patients, (IV) number and percentage of males and females, (V) number and percentage of squamous and non-squamous histology, (VI) T and N status and/or stage of primary disease for oligometastatic setting. The data collected have been analyzed according to the oligometastatic setting.

Conclusions

Oligometastatic status is globally identified as a different clinical condition from multi metastatic NSCLC, although the clinical characteristics were consistent in the general metastatic population, even with a lower-than-expected TN status. The brain and bones were the most frequent organs involved. Lacking consensus definition, these results must be interpreted cautiously and a prospective evaluation is urgently needed.

Presentation of cervical metastases and pathological mandibular fracture due to pulmonal adenocarcinoma: A case report

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Oral metastatic tumors due to malignancies at distant locations are very rare.

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Cervical metastases of level I and II due to adenocarcinoma of the lung have hardly been described before.

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Diagnosis of unclear oral lesions requires extensive staging.

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In cases of oligometastases in the oral region tumor resection may be a curative treatment.

Introduction

Oral metastatic tumors due to malignancies at distant locations are very rare. There are only few cases in the literature reporting about mandible/cervical metastases. Sometimes the oral finding is the manifestation of the disease.

Presentation of case

We report on a 50-year-old patient who was diagnosed with a pathological mandibular fracture and cervical lymph node metastases due to an adenocarcinoma of the lung without other peripheral metastases. Following the interdisciplinary tumor board decision, resection and ipsilateral neck dissection including a mandible reconstruction using a microvascular fibula transplant was performed. The patient received an adjuvant chemotherapy with carboplatin/pemetrexed.

Discussion

The combination of cervical metastases and a pathological mandibular fracture has not been reported before. Distinction between oligometastatic and polymetastatic disease may be difficult. Bone lesions and a high number of metastases are associated with a negative outcome. In cases of limited oligometastatic diseases, metastasectomy might sometimes be indicated. Due to the absence of other peripheral metastases decision of metastasectomy was made.

Conclusion

Due to rare occurrence of cervical metastases special attention should be paid to the incidence of possible metastases of distant malignancies at uncommon regions.

Defining Synchronous Oligometastatic Non-Small Cell Lung Cancer: A Systematic Review

INTRODUCTION

Synchronous oligometastatic (sOM) disease is an oncological concept characterized by a limited cancer burden. Patients with oligometastasis could potentially benefit from local radical treatments. Despite the fact that the sOM condition is well recognized, a universal definition, including a specific definition for NSCLC, is not yet available. The aim of this systematic review was to summarize the definitions of and staging requirements for use of the term synchronous oligometastatic in the context of NSCLC.

METHODS

The key issue was formulated in one research question according to the population, intervention, comparator, and outcomes strategy. The question was introduced in MEDLINE (OvidSP). All articles dealing with sOM NSCLC and providing a definition of synchronous oligometastasis in NSCLC were selected and analyzed.

RESULTS

A total of 21 eligible articles focusing on sOM NSCLC were retrieved and analyzed. In 17 studies (81%), patients had to be staged with magnetic resonance imaging or computed tomography of the brain, thoracic and abdominal computed tomography, and positron emission tomography. The total number of metastases allowed in the definitions ranged from one to eight, but in 38.1% of studies the maximum number was 5. Most of the publications did not define the number of involved organs or the maximum number of metastases per organ. For mediastinal lymph node involvement, only five articles (27.8%) counted this as a metastatic site.

CONCLUSIONS

No uniform definition of sOM NSCLC could be retrieved by this systematic review. However, extended staging was mandated in most of the studies. An accepted oncological definition of synchronous oligometastasis is essential for patient selection to define prospective clinical trials.

Prognostic differences between oligometastatic and polymetastatic extensive disease-small cell lung cancer

Purpose

Oligometastasis is a state in which cancer patients have a limited number of metastatic tumors; patients with oligometastases survive longer than those with polymetastases. Extensive disease (ED)-small cell lung cancer (SCLC) is considered a systemic disease and a poor survival. This study investigated whether the concept of oligometastases is prognostic factor also applicable to patients with ED-SCLC.

Methods

We performed a retrospective study of 141 consecutive patients with ED-SCLC between 2008 and 2016. The patients were divided into four subgroups: group 1; patients with solitary metastatic site in one organ (n = 31), group 2; patients with 2–5 metastatic sites in one organ (n = 18), group 3; patients with over 6 metastases in one organ (n = 15), and group 4; patients with 2 or more metastatic organs (n = 77).

Results

It was identified that 49 patients with ED-SCLC had oligometastases (groups 1 + 2) and 92 had polymetastases (groups 3 + 4). The prognoses of patients with ED-SCLC and oligometastases, defined as ≤5 metastases in a single organ, were significantly superior to those of patients with polymetastases [16.0 (95% CI, 11.0–21.0) months vs. 6.9 (95% CI, 6.0–7.8) months; p<0.001]. 43 of 49 patients with ED-SCLC and oligometastases were relapsed after initial chemotherapy, and 38 (88%) experienced local recurrence.

Conclusions

Patients with ED-SCLC and oligometastases may have improved survival than those with polymetastases. As oligometastatic ED-SCLC tends to recur locally, local therapy combined with systemic chemotherapy may be a treatment option.

Prognostic factors of oligometastatic non-small cell lung cancer: a meta-analysis

Background

The prognostic factors of oligometastatic non-small cell lung cancer (NSCLC) are uncertain. We performed a meta-analysis to assess the prognostic factors of oligometastatic NSCLC patients who are most likely to achieve long-term survival.

Methods

We searched PubMed, EMBASE, the Cochrane to identify eligible articles and performed the meta-analysis of all randomized controlled trials (RCTs) and retrospective comparative studies revealing the prognostic factors of oligometastatic NSCLC. The primary endpoint of interest was overall survival (OS).

Results

We analyzed data from twenty-four eligible studies, including data from 1,935 patients with oligometastatic NSCLC. In the univariate analysis, we found no significant difference in OS of prognostic factors including age [hazard ratios (HRs) 1.02, 95% CI: 0.80-1.31, P=0.86], smoking status (HR 1.08, 95% CI: 0.80-1.46, P=0.62), type of metastases (HR 1.61, 95% CI: 0.86-3.03, P=0.14), but significantly positive prognoses containing female (HR 1.21, 95% CI: 1.02-1.45, P=0.03), (y)pN0 stage (HR 1.82, 95% CI: 1.40-2.36, P<0.00001), adenocarcinoma (HR 1.44, 95% CI: 1.10-1.88, P=0.008). In the multivariate analysis, patients with (y)pN0 stage had an obvious survival benefit compared with (y)pN1 (HR 1.63, 95% CI: 1.27-2.10, P=0.001), but no significant survival in contrast with (y)pN2 (HR 2.01, 95% CI: 0.80-5.03, P=0.14). In subgroup analyses, neither thoracic stage (HR 2.06, 95% CI: 1.52-2.78, P=0.55), (y)pT-stage of primary lung cancer (HR 1.38, 95% CI: 0.86-2.21, P=0.14) nor tumorous histology (HR 2.99, 95% CI: 2.10-4.28, P=0.91) and oligometastatic number (HR 1.25, 95% CI: 0.97-1.62, P=0.98) were significantly different in OS. However, patients with aggressive thoracic treatment (ATT) had improved survival (HR 0.56, 95% CI: 0.37-0.83, P=0.001), and notably, different strategies of ATT received by oligometastatic NSCLC patients might significantly influence survival (HR 0.54, 95% CI: 0.36-0.82, P<0.00001).

Conclusions

Overall, factors including age, smoking status, type of metastasis were not associated with long-term survival of oligometastatic NSCLC patients. However, our finding suggests that aggressive therapies in the primary lung cancer, as well as female, (y)pT-stage, absence of nodal diseases, adenocarcinoma histology have been clarified as positive prognosis. Further studies of prospective study for these patients are warranted.

Surgical approach in oligometastatic non-small cell lung cancer

The vast majority of lung cancer (80%) are non-small cell lung cancer (NSCLC) presenting in huge proportion of patients in a metastatic stage at the time of diagnosis with an overall survival (OS) of only 6 months. Standard treatment at this stage involves systemic platinum based chemotherapy improving the OS for only few months. For the vast majority of patients disease progression occurs and cure cannot achieved. An exception to this general rule is represented by patients with a limited number of metastasis (approximately 7% of patients with metastatic NSCLC): in 1995 Hellman and Weichselbaum introduced the term "oligometastatic" for a selected group of patients with metastatic disease. Several retrospective studies have been published and documented an improved outcome in patients managed surgically. The purpose of this narrative review is to gather all relevant information and present the various clinicopathological and generic aspects of diagnosis, management strategies and prognostic factors in patients with oligometastatic NSCLC. The key for long term survival includes radical treatment of the primary NSCLC, single organ site with either synchronous or metachronous presentation, a disease free interval to be as long as possible and the absence of intrathoracic lymph node spread (N0). A more accurate staging with combination of FDG-PET and CT scan can have on impact on the survival rates due to an increased accuracy in mediastinal staging and in the diagnosis of distant metastasis. No randomized data but only retrospective series are available to date to address this topic: in the future, additional prospective studies will be necessary to provide robust evidence to support the surgical resection as treatment of oligometastatic NSCLC.

Prognostic factors in patients with skeletal-related events at non-small-cell lung cancer diagnosis

The aim of the present study was to detect prognostic factors in patients with skeletal-related events (SREs) and bone metastasis at the time of non-small-cell lung cancer (NSCLC) diagnosis. A total of 85 NSCLC patients were retrospectively enrolled, 47 (55.2%) of whom presented with SREs at the time of NSCLC diagnosis. Multivariate logistic regression analysis identified squamous cell carcinoma as a risk factor for SRE. Kaplan-Meier analysis demonstrated that there was no difference in the overall survival between the SRE and no SRE groups. Cox hazard model revealed that a higher Eastern Cooperative Oncology Group (ECOG) performance status (PS) score was a risk factor for poor prognosis, while surgery for bone metastasis and molecular-targeted therapy were factors for better prognosis in patients with SREs at the time of NSCLC diagnosis. Multivariate analysis revealed that a higher ECOG PS score and metastasis to the adrenal gland were risk factors for poor prognosis, while surgery for bone metastasis and molecular-targeted therapy were factors for better prognosis. Thus, while surgical treatment and molecular-targeted therapy appear to improve the prognosis of patients with bone metastasis at the time of NSCLC diagnosis, those with a higher ECOG PS score and adrenal metastasis may benefit more from radiotherapy or supportive care.

Thoracic radiotherapy (TRT) improved survival in both oligo- and polymetastatic extensive stage small cell lung cancer

There has been no previous study on the efficacy of the thoracic radiotherapy (TRT) in oligometastatic or polymetastatic extensive stage small-cell lung cancer (ES-SCLC) to the overall survival (OS). In a group of 270 ES-SCLC cases retrospective study, 78 patients (28.9%) had oligometastases and 192 (71.1%) had polymetastases, among which 51 oligometastatic patients (65.4%) and 93 polymetastatic patients (51.6%) received TRT. Propensity score matching (PSM) was utilized. The 2-year OS, progression free survival (PFS) and local control (LC) in oligometastatic and polymetastatic patients were 22.8% and 4.5% (p < 0.001), 12.0% and 3.8% (p < 0.001), and 36.7% and 6.1% (p < 0.001), respectively. The 2-year OS in oligometastatic patients with the chemotherapy + radiotherapy and chemotherapy alone were 25.2% and 12.7% (p = 0.002), in contrast to 10.0% and 6.8% (p = 0.030) in polymetastatic patients. The estimated hazard ratios for survival were 2.9 and 1.7 for both oligometastatic and polymetastatic patients with radiotherapy. The polymetastatic group has a lower LC (6.1% v.s. 36.7%, (p < 0.001)), due to polymetastases patients receiving involved-sites radiotherapy with low dose schemas. TRT improved OS of patients with oligometastases and polymetastases. Our study demonstrated that aggressive TRT might be a suitable addition of chemotherapy when treating ES-SCLC patients with oligometastases and polymetastases.

Overexpression of PTEN suppresses non-small-cell lung carcinoma metastasis through inhibition of integrin αVβ6 signaling

Studies have demonstrated that the abnormal expression of phosphatase and tensin homolog deleted on chromosome 10 (PTEN) is associated with multiple malignancies, but its functional role in non-small-cell lung carcinoma (NSCLC) metastasis remains to be elucidated. In the present study, we investigated the role of PTEN in regulating proliferation, migration, and invasion of NSCLC cells by establishing NSCLC cell strains with constitutively silenced or elevated PTEN expression. We demonstrated that ectopic expression of PTEN inhibits migration and invasion of NSCLC cells in vitro through wound healing and Transwell invasion assays. Furthermore, PTEN overexpression in NSCLC cells greatly inhibits cell viability and colony formation, which was confirmed by MTT and colony formation assays. Conversely, further analysis indicated that suppression of PTEN expression via shRNA promotes metastasis and growth of NSCLC cells. Finally, our findings demonstrate that PTEN promotes invasion and migration of NSCLC cells through the integrin αVβ6 signaling pathway. Overall, this study provides novel insights into the role of PTEN as a crucial regulator of NSCLC cell metastasis, and suggests that targeted treatment of PTEN-expressing tumors serves as a new therapeutic target for NSCLC.

Short-Term Outcomes and Safety of Computed Tomography-Guided Percutaneous Microwave Ablation of Solitary Adrenal Metastasis from Lung Cancer: A Multi-Center Retrospective Study

Objective

To retrospectively evaluate the short-term outcomes and safety of computed tomography (CT)-guided percutaneous microwave ablation (MWA) of solitary adrenal metastasis from lung cancer.

Materials and Methods

From May 2010 to April 2014, 31 patients with unilateral adrenal metastasis from lung cancer who were treated with CT-guided percutaneous MWA were enrolled. This study was conducted with approval from local Institutional Review Board. Clinical outcomes and complications of MWA were assessed.

Results

Their tumors ranged from 1.5 to 5.4 cm in diameter. After a median follow-up period of 11.1 months, primary efficacy rate was 90.3% (28/31). Local tumor progression was detected in 7 (22.6%) of 31 cases. Their median overall survival time was 12 months. The 1-year overall survival rate was 44.3%. Median local tumor progression-free survival time was 9 months. Local tumor progression-free survival rate was 77.4%. Of 36 MWA sessions, two (5.6%) had major complications (hypertensive crisis).

Conclusion

CT-guided percutaneous MWA may be fairly safe and effective for treating solitary adrenal metastasis from lung cancer.