Single organ metastatic disease and local disease status, prognostic factors for overall survival in stage IV non-small cell lung cancer: Results from a population-based study

Single organ metastatic sites in non-small cell lung cancer: Patient characteristics, treatment patterns and outcomes from a large retrospective Canadian cohort

BACKGROUND

There is a paucity of information about the characteristics, treatment patterns, and outcomes of non-small cell lung cancer (NSCLC) patients with single organ metastasis (SOM).

METHODS

This retrospective cohort study includes all patients with a diagnosis of stage IV NSCLC diagnosed from 2014 to 2016 and treated at Princess Margaret Cancer Centre. We compared baseline characteristics and patterns of metastatic sites between patients with SOM versus multiple (M)OM. Additionally, we identified treatment modalities and outcomes for patients with SOM. Cox multivariable models (MVA) were utilized to evaluate differences in overall survival (OS) between the SOM and MOM cohorts.

RESULTS

Of 893 pts analyzed, 457 (51 %) had SOM, while 436 (49 %) had MOM at initial diagnosis. Demographics were comparable between the two groups. Brain was the most common site of metastasis for SOM patients. When compared to the MOM group, the SOM group had lower percentages of liver and adrenal metastases. Amongst SOM patients, 54 % received single modality treatment, and 20 % did not receive any treatment for their SOM. In MVA, patients with liver (HR 2.4), bone (HR 1.8), and pleural (HR 1.7) metastasis as their SOM site had the worst outcomes, with median OS of 6.8 months, 12.1 months, and 13.0 months respectively. Patients with SOM had a significantly improved median OS compared to those with MOM (15.9 months vs. 10.6 months; HR 0.56, 95 % CI 0.47-0.66, p < 0.001).

CONCLUSION

In NSCLC patients who presented with SOM, survival correlated with the initial organ involved and was better overall compared to patients with MOM. SOM NSCLC may benefit from specific management strategies and SOM patients could be considered as a specific subgroup for survival analyses in observational and non-randomized interventional studies. In clinical trials, SOM can be considered as a stratification factor in the future.

Metabolic tumor volume and sites of organ involvement predict outcome in NSCLC immune-checkpoint inhibitor therapy

PURPOSE

The purpose of this study was to assess the ability of pretreatment PET parameters and peripheral blood biomarkers to predict progression-free survival (PFS) and overall survival (OS) in NSCLC patients treated with ICIT.

METHODS

We prospectively included 87 patients in this study who underwent pre-treatment [18F]-FDG PET/CT. Organ-specific and total metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were measured using a semiautomatic software. Sites of organ involvement (SOI) were assessed by PET/CT. The log-rank test and Cox-regression analysis were used to assess associations between clinical, laboratory, and imaging parameters with PFS and OS. Time dependent ROC were calculated and model performance was evaluated in terms of its clinical utility.

RESULTS

MTV increased with the number of SOI and was correlated with neutrophil and lymphocyte cell count (Spearman's rho = 0.27 or 0.32; p =.02 or 0.003; respectively). Even after adjustment for known risk factors, such as PD-1 expression and neutrophil cell count, the MTV and the number of SOI were independent risk factors for progression (per 100 cm3; adjusted hazard ratio [aHR]: 1.13; 95% confidence interval [95%CI]: 1.01-1.28; p =.04; single SOI vs. ≥ 4 SOI: aHR: 2.26, 95%CI: 1.04-4.94; p =.04). MTV and the number of SOI were independent risk factors for overall survival (per 100 cm3 aHR: 1.11, 95%CI: 1.01-1.23; p =.03; single SOI vs. ≥ 4 SOI: aHR: 4.54, 95%CI: 1.64-12.58; p =.04). The combination of MTV and the number of SOI improved the risk stratification for PFS and OS (log-rank test p <.001; C-index: 0.64 and 0.67).

CONCLUSION

The MTV and the number of SOI are simple imaging markers that provide complementary information to facilitate risk stratification in NSCLC patients scheduled for ICIT.

Case Report: Recurrent colonic metastasis from lung cancer-diagnostic pitfalls and therapeutic challenge of a peculiar case

Lung cancer (LC) mortality exceeds 20%, and detecting metastases from LC is becoming a challenging step in understanding the real prognostic role of specific localization. We report a case of a patient with lung metastasis to the colon with local recurrence at the anastomosis after radical resection for metastasis. In both cases, the diagnosis was on oncological follow-up, and surgery was offered in consideration of reasonable life expectancy, good control of LC, and high risk of intestinal occlusion. A 67-year-old male, with a history of LC 18 months ago, was referred to our surgical unit after a positron emission tomography CT total body, where an area of intense glucose metabolism (SUV max: 35.6) at the hepatic colic flexure was reported. A colonoscopy revealed an ulcerated, bleeding large neoplasm distally to hepatic flexure, almost causing resulting total occlusion. Histologic examination revealed a tumor with complete wall thickness infiltration, which appears extensively ulcerated, from poorly differentiated squamous carcinoma (G3), not keratinizing, with growth in large solid nests, often centered by central necrosis. Two of the 30 isolated lymph nodes were metastatic. The omental flap and resection margins were free from infiltration. The malignant cells exhibited strong positive immunoreactivity only for p40. The features supported metastatic squamous carcinoma of lung origin rather than primary colorectal adenocarcinoma. After 8 months from surgery, intense Fluorodeoxyglucose (FDG) uptake of tissue was confirmed in the transverse colon. Colonoscopy evidenced an ulcerated substenotic area that involved ileocolic anastomosis on both sides. Reoperation consisted of radical resection of ileocolic anastomosis with local lymphadenectomy and ileotransverse anastomosis. The second histologic examination also revealed poorly differentiated squamous carcinoma (G3), not keratinizing, with positive immunoreactivity only for p40, suggesting the origin of LC. This case report confirmed that the possibility of colonic secondary disease should be part of the differential diagnosis in asymptomatic patients and those with a history of LC diagnosis. In addition, relapse of colonic metastasis is infrequent but should be considered during follow-up of LC. More studies on colonic metastasis of LC are required to better understand the clinical features and outcomes.

Construction and validation of a novel prognostic nomogram for predicting overall survival in lung adenocarcinoma patients with different patterns of metastasis

OBJECTIVE

Metastasis of lung cancer is an important factor affecting survival. The present study proposed to establish and verify a nomogram for predicting overall survival (OS) in lung adenocarcinoma (LUAD) patients with different patterns of metastasis.

METHODS

A total of 9727 patients diagnosed with metastatic LUAD patients from 2010 to 2015 were enrolled based on surveillance, epidemiology and end results (SEER) Database and then randomly divided into training and validation cohorts, and 136 patients in our Cancer Center were enrolled as the external validation cohort. Univariate and multivariate analyses were performed to evaluate the prognostic impact on OS. A prognostic nomogram was constructed and evaluated by C-index, calibration curve, decision curve analysis (DCA), and risk stratification system.

RESULTS

Ultimately, 6809 and 2918 patients diagnosed with metastatic LUAD in the training and validation cohorts were enrolled in the study, respectively. A male sex, a later T and N stage, a larger tumor size, treatment including no surgery, no chemotherapy and no radiotherapy, metastasis sites were found to be independent risk factors in LUAD patients for worse OS, and then incorporated into the nomogram. The frequency of bone metastasis was the highest, and in single site metastasis, the prognosis of liver metastasis was the worst. Two-site metastasis is more common than three-site and four-site metastasis, and co-metastasis eventually leads to a worse survival outcome. The C-index value of nomogram for predicting OS were 0.798, 0.703 and 0.698 in the internal training, validation and external validation cohorts, separately. The calibration curves for the 6-months, 1-year and 2-year showed significant agreement between nomogram models and actual observations. The DCA curves indicated nomogram was more beneficial than the AJCC TNM stage. Patients were further divided into low-risk and high-risk groups according to nomogram predicted scores and developed a survival risk classification system.

CONCLUSIONS

Our prognostic nomogram is expected to be an accurate and individualized clinical predictive tool for predicting OS in LUAD patients with different patterns of metastasis.

Local control strategies for management of NSCLC with oligoprogressive disease

Progresses of systemic treatments in advanced non-small cell lung cancer (NSCLC), such as immune checkpoint blockers (ICB) and targeted therapies, led to the increased incidence of oligoprogressive disease (OPD). The OPD is a subtype of oligometastatic disease (OMD) defined as a progression of a limited number of lesions during systemic treatment exposure. The hypothesis was formulated that local radical treatments (LRT) could eradicate progressive lesions resulting from resistant clones, ultimately leading to systemic treatment sensitivity restoration. Recently published international consensuses and guidelines aim to obtain a uniform definition of OMD NSCLC, to standardize the inclusion of these patients in future clinical trials, as well as their management in daily practice. Although there is no specific definition of OPD, LRT strategies in OPD are supported after reporting promising results. Both retrospective and preliminary prospective randomized data of LRT for patients with OPD NSCLC are encouraging. More clinical and translational data are needed for selecting best scenarios where LRT should be delivered. In this review, we analyze the current available literature on LRT for patients with OPD in advanced NSCLC and discuss about future trial design and challenges.

Impact of Liver Metastases and Number of Metastatic Sites on Immune-Checkpoint Inhibitors Efficacy in Patients with Different Solid Tumors: A Retrospective Study

Background: ICIs have dramatically improved patient outcomes in different malignancies. However, the impact of liver metastases (LM) and number of metastatic sites (MS) remains unclear in patients treated with single-agent anti-PD(L)1. Methods: We aimed to assess the prognostic impact of LM and MS number on progression-free survival (PFS) and overall survival (OS) in a large single-arm retrospective multicentric cohort (IMMUCARE) of patients treated with anti-PD(L)-1 for different solid tumors. Results: A total of 759 patients were enrolled from January 2012 to October 2018. The primary tumor types were non-small cell lung cancer (71%), melanoma (19%), or urologic cancer (10%). At the time of ICI initiation, 167 patients (22%) had LM and 370 patients (49%) had more than MS. LM was associated with a shorter median PFS of 1.9 months (95% CI: 1.8−2.5) vs. 4.0 months (95% CI: 3.6−5.4) in patients without LM (p < 0.001). The median OS of patients with LM was of 5.2 months (95% CI: 4.0−7.7) compared with 12.8 months (95% CI: 11.2−15.1) (p < 0.001). Interestingly, LM were not associated with shorter PFS, or OS compared to other MS types (brain, bone, or lung) in patients with only one MS. Patients with multiple MS also had poor clinical outcomes compared to patients with only one MS. The presence of LM and MS number were independent prognostic factors on overall survival. Conclusion: The presence of LM or multiple MS were associated with poorer survival outcomes in patients treated with anti-PD(L)-1.

Definitive local therapy for extracranial single-organ oligorecurrent non-small-cell lung cancer: A single institutional retrospective study

Oligometastatic non-small-cell lung cancer (NSCLC) is potentially curable. Oligo-recurrence occurs with oligometastatic disease characterized by well-controlled primary lesion. The purpose of the present study was to explore the value of definitive local therapy (DLT) for extracranial single-organ oligorecurrent NSCLC. A total of 81 patients with NSCLC who had extracranial single-organ oligorecurrence after receiving radical treatment at the Cancer Hospital of the University of Chinese Academy of Sciences from January 2010 to December 2017 were analyzed. The primary endpoint was progression-free survival (PFS), and the secondary endpoint was overall survival (OS). The median follow-up time of the 81 patients was 65.8 months. A total of 39 patients received DLT. A large proportion of patients who did not accept DLTs received specific tyrosine kinase inhibitors (TKIs). The results of multivariate analysis showed that DLT and specific TKI therapy were favorable prognostic factors significantly related to PFS. Further analysis showed that for patients without specific TKI therapy, DLT significantly improved PFS and the 5-year PFS rate. The 5-year OS rate also improved, but the improvement was not significant. For extracranial single-organ oligorecurrent NSCLC, PFS was significantly superior in patients receiving DLT. Among them, for the subgroup of patients who did not receive specific TKI therapy, DLT is expected to improve long-term prognostic outcomes.

The Effect of immunotherapy on oligometastatic non-small cell lung cancer patients by sites of metastasis

Introduction

The efficacy of immunotherapy for treatment of patients with oligometastatic non-small cell lung cancer (NSCLC) at different metastatic sites remains controversial. We investigated the effect of different metastatic sites on immunotherapy for oligometastatic NSCLC following local treatment (LT).

Methods

We retrospectively analyzed patients with oligometastatic NSCLC from the latest 2018 registry on the SEER Stat software (8.3.9. Version) and a Chinese single-center cohort. The effects of immunotherapy on OS (overall survival) and CSS (cancer specific survival) were estimated for patients with different metastatic sites.

Results

A total of 483 patients in the SEER-18 database and 344 patients in the single-center cohort were included. Immunotherapy was significantly correlated with improved OS (SEER: Hazard ratio 0.754, 95% CI 0.609–0.932; P=0.044; China: Hazard ratio 0.697, 95% CI 0.542–0.896; P=0.005) and CSS (SEER: Hazard ratio 0.743, 95% CI 0.596–0.928; P=0.009; China: Hazard ratio 0.725, 95% CI 0.556–0.945; P=0.018). Subgroup analysis showed that OS was improved after immunotherapy in the BRM (SEER: Hazard ratio 0.565, 95% CI 0.385–0.829; P=0.004; China: Hazard ratio 0.536, 95% CI 0.312–0.920; P=0.024) and MOM (SEER: Hazard ratio 0.524, 95% CI 0.290–0.947; P=0.032; China: Hazard ratio 0.469, 95% CI 0.235–0.937; P=0.032) subgroups, but not in the BOM (SEER: P=0.334; China: P=0.441), LIM (SEER: P=0.301; China: P=0.357), or OTM (SEER: P=0.868; China: P=0.489) subgroups.

Conclusions

This study showed that immunotherapy conferred survival benefits on patients with oligometastatic NSCLC. Our subgroup analysis suggested that patients with oligometastatic NSCLC in the brain or multiple organs may particularly benefit from aggressive front-line therapies.

Treatment strategy, overall survival and associated risk factors among patients with unresectable stage IIIB/IV non-small cell lung cancer in China (2015-2017): A multicentre prospective study

BACKGROUND

There are limited studies on treatment and survival analysis among patients with unresectable Stage IIIB or IV non-small cell lung cancer (NSCLC) in routine practice in China. To address this gap, we conducted a prospective observational study in a cohort of patients treated at 11 hospitals in China.

METHODS

This was a multicentre, prospective cohort study including patients with newly diagnosed unresectable Stage IIIB or IV NSCLC from June 26th, 2015 to April 28th, 2017. Patient baseline characteristics, disease characteristics, and anti-cancer treatments were obtained by medical chart review. The overall survival (OS) from the initiation of first-line treatment was analysed by the Kaplan-Meier method. Factors associated with survival were analysed by univariate and multivariate Cox regression models.

FINDINGS

Among 1324 patients enrolled with median follow-up duration of 15·0 (range: 0·0-42·1) months, 83·5% (1105/1324) of them received first-line chemotherapy of which platinum-based compounds were the dominated agents. Overall, 30·9% (409/1324) of patients received targeted therapy as 1st-line treatment including 65·0% (266/409) EGFR-TKIs and 5·1% (21/409) ALK-TKIs. Of all eligible patients, gene testing rates were 44·0% (583/1324) for EGFR mutations, 17·0% (225/1324) for EML4-ALK gene fusions, and 8·3% (110/1324) for ROS1 gene fusions. The EGFR-TKIs were administered to 63·9% (179/280) of EGFR mutated patients as first-line treatment. The overall median OS was 23·2 (95%CI 19·5-25·5) months, and patients treated at tier 1 cities had better OS than that of tier 2 cities. Also, the OS in patients with EGFR mutation was longer than those with EGFR wild type. Multivariate Cox regression models suggested that male, education below high school, tier 2 cities, smoking history, and multiple metastases were associated with poor survival.

INTERPRETATION

The gene test coverage was relatively low among the studied population, and over half of EGFR mutated patients received EGFR-TKIs, suggesting that the result of genetic tests in real-world settings may not always indicate the selection of treatment. The OS benefit observed from patients treated in tier 1 cities and those with EGFR mutation may indicate a need for broader gene test coverage, providing NSCLC patients with personalized treatment according to the results of genetic tests.

FUNDING

Roche Holding AG.TRANSLATED ABSTRACT: This translation in Chinese was submitted by the authors and we reproduce it as supplied. It has not been peer reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as reference for this manuscript.:IIIBIV(NSCLC)., ,, 11.:,, 20156262017428IIIBIVNSCLC.,.Kaplan-Meier(OS), Cox.:1324, 15.0(:0.0-42.1), 83.5%(1105/1324), ., 30.9%(409/1324), 65.0%(266/409)EGFR-TKI5.1%(21/409)ALK-TKI., EGFR,EML4-ALKROS144.0%(583/1324),17.0%(225/1324)8.3%(110/1324).63.9%(179/280)EGFREGFR-TKI.23.2 (95% 19·5-25·5) , ., EGFREGFR.Cox, ,,,.:, EGFREGFR-TKI, , .EGFR, , NSCLC.

Immunotherapy in NSCLC Patients With Brain and Leptomeningeal Metastases

Immunotherapy has now been integrated as a treatment strategy for most patients with non-small cell lung cancer (NSCLC). However, the pivotal clinical trials that demonstrated its impressive efficacy often did not include patients with active, untreated brain metastases or leptomeningeal carcinomatosis. Nevertheless, NSCLC is the most common tumor to metastasize to the brain, and patients develop brain and meningeal involvement in approximately 40 and 10% of cases, respectively. Consequently, the appropriate care of these patients is a recurrent clinical concern. Although there are many aspects that would merit further investigation to explain the mechanism of intracranial response to immune checkpoint inhibitors (ICPs), some data suggest that they are able to cross the blood–brain barrier, resulting in local tumor microenvironment modification. This results in a similar clinical benefit in patients with stable, previously treated brain metastases compared to the general population. Despite important limitations, some real-life studies have described that the ICPs’ efficacy was maintained also in less selected patients with untreated or symptomatic brain metastases. In contrast, few data are available about patients with leptomeningeal carcinomatosis. Nevertheless, neurological complications due to ICP treatment in patients with brain metastases have to be evaluated and carefully monitored. Despite the fact that limited data are available in the literature, the purpose of this review is to show that the multimodal treatment of these patients with brain metastases and/or leptomeningeal disease should be discussed during tracing of the history of the disease, participating in the local and possibly systemic control of NSCLC.

EGFR Mutation Status and Subtypes Predicted by CT-Based 3D Radiomic Features in Lung Adenocarcinoma

Objective

In this study, we aim to establish a non-invasive tool to predict epidermal growth factor receptor (EGFR) mutation status and subtypes based on radiomic features of computed tomography (CT).

Methods

A total of 233 lung adenocarcinoma patients were investigated and randomly divided into the training and test cohorts. In this study, 2300 radiomic features were extracted from original and filtered (Exponential, Laplacian of Gaussian, Logarithm, Gabor, Wavelet) CT images. The radiomic features were divided into four categories, including histogram, volumetric, morphologic, and texture features. An RF-BFE algorithm was developed to select the features for building the prediction models. Clinicopathological features (including age, gender, smoking status, TNM staging, maximum diameter, location, and growth pattern) were combined to establish an integrated model with radiomic features. ROC curve and AUC quantified the effectiveness of the predictor of EGFR mutation status and subtypes.

Results

A set of 10 features were selected to predict EGFR mutation status between EGFR mutant and wild type, while 9 selected features were used to predict mutation subtypes between exon 19 deletion and exon 21 L858R mutation. To predict the EGFR mutation status, the AUC of the training cohort was 0.778 and the AUC of the test cohort was 0.765. To predict the EGFR mutation subtypes, the AUC of training cohort was 0.725 and the AUC of test cohort was 0.657. The integrated model showed the most optimal predictive performance with EGFR mutation status (AUC = 0.870 and 0.759) and subtypes (AUC = 0.797 and 0.554) in the training and test cohorts.

Conclusion

CT-based radiomic features can extract information on tumor heterogeneity in lung adenocarcinoma. In addition, we have established a radiomic model and an integrated model to non-invasively predict the EGFR mutation status and subtypes of lung adenocarcinoma, which is conducive to saving clinical costs and guiding targeted therapy.

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.

Sequence For Surgical Resection of Primary Lung Tumor For Oligometastatic Non-Small Cell Lung Cancer

BACKGROUND

Differing surgical series for the treatment of primary lung tumor with synchronous oligometastatic stage IV non-small cell lung cancer (NSCLC) have been published; however, outcomes remain ambiguous.

METHODS

Patients with synchronous oligometastatic stage IV NSCLC treated from 2005 to 2017 were enrolled to identify the impact of treatment sequence (primary lung resection versus systemic treatment) on progression-free survival (PFS) and overall survival (OS).

RESULTS

Fifty-one patients received tumor resection (84% adenocarcinoma, 55% non-smokers, and 65% driver gene mutation). Resection occurred before or after systemic treatment in 33 (64.7%) and 18 (35.3%) patients, respectively. Patients who received resection first were older (62.1 vs. 54 year) and at a less advanced intrathoracic stage (18% vs. 44%). No significant differences were noted regarding perioperative complication (30% vs. 28%), length of hospital stay (9.0 vs. 10.5 days), percentage of disease progression (91% vs. 94%), overall death (70% vs. 78%), median PFS (14.0 vs. 22.8 months) and OS (44.6 vs. 53.2 months). Patients with single-organ metastasis had significantly longer PFS and OS than those with oligometastases (17.5 vs. 12.8 months, p=0.040 and 55.6 vs. 39.8 months, p=0.035), respectively. Multivariable Cox analysis identified non-solitary metastasis as the only independent predictor of PFS (hazard ratio 2.27; 95% CI, 1.07-4.81, p=0.033).

CONCLUSIONS

Primary lung resection before or after induction systemic therapy may benefit patients with oligometastatic NSCLC. Future randomized clinical trials examining the effect of treatment sequence is recommended.

Radiation for Oligometastatic Lung Cancer in the Era of Immunotherapy: What Do We (Need to) Know?

Simple Summary

The historical standard treatment of metastatic non-small cell lung cancer (NSCLC) consisted of palliative chemotherapy, with limited influence on survival. With the introduction of immuno- and targeted therapy, the prognosis improved largely. A subset of NSCLC patients with limited metastatic disease, called oligometastatic, might obtain long-term survival by adding a local ablative treatment on all visible disease sites, in addition to the standard systemic treatment. The evidence for this combined treatment is still scarce and comes mainly from the pre-immunotherapy era. As radiotherapy might stimulate the immune system making immunotherapy more efficient, here we review the evidence before and in the era of immunotherapy, and discuss the challenges and prospects of the combined treatment.

Abstract

Oligometastatic cancer is recognized as a separate entity within the spectrum of metastatic disease. It was suggested that patients with oligometastatic disease can obtain long-term survival by giving local ablative therapy (LAT) to all visible disease locations. However, the true extent from which metastatic cancer should be called “oligometastatic” is unknown, although a consensus definition for oligometastatic disease is proposed by research organizations, such as the EORTC (maximum of five metastases in three organs). Different states of the oligometastatic disease are defined, such as synchronous vs. metachronous, oligopersistent vs. oligoprogressive disease. All clinical trials including patients with non-small cell lung cancer (NSCLC) are small and most are not randomized. Two small randomized phase II trials on synchronous disease showed an improvement in progression free survival, with the addition of LAT, and one also demonstrated an overall survival benefit. Immune checkpoint inhibitors (ICI) were not part of the treatment in these trials, while ICI significantly improved long-term outcomes of patients with metastatic NSCLC. Radiotherapy might improve the prognosis of patients treated with ICI because of its immunostimulatory effects and the possibility to eradicate metastatic deposits. Here, we summarize the data for adding ablative radiotherapy to the treatment of oligometastatic NSCLC, especially in the ICI era, and discuss the challenges of combined treatment.

Epidermal Growth Factor Receptor Mutation Status and Response to Tyrosine Kinase Inhibitors in Advanced Chinese Female Lung Squamous Cell Carcinoma: A Retrospective Study

Background

The frequency of epidermal growth factor receptor (EGFR) mutations and the efficacy of tyrosine kinase inhibitor (TKI) in Chinese female patients with lung squamous cell carcinoma (SCC) are unknown. This study was designed to investigate the incidence of EGFR mutations and the role of targeted therapy in advanced Chinese female lung SCC patients.

Methods

Advanced female patients diagnosed with lung SCC at the Shanghai Chest Hospital between January 2013 and December 2018 were retrospectively analyzed.

Results

A total of 4223 advanced lung SCC patients were screened, and there were 154 female lung SCC patients who had underwent EGFR mutation detection. Positive EGFR mutations were found in 29.9% (46/154) of female lung SCC patients, including twenty-three 19del mutation (14.9%), twenty-one 21L858R mutation (13.6%) and other mutations (1.4%, 21861Q and 20ins). For 45 EGFR positive mutation female SCC patients, the median progression-free survival (PFS) of patients who received EGFR-TKI therapy (n=38) was 8.0 months (95% CI, 5.4-10.7 months), which was significantly longer than patients who were treated with chemotherapy (8.0 vs. 3.2 months, p=0.024), and the median overall survival (OS) was also longer (24.9 months vs. 13.9 months, p=0.020). The objective response rate (ORR) was 44.7% (17/38), and the disease control rate (DCR) was 81.6% (31/38). For 105 female SCC patients with EGFR negative mutation, the median OS was 18.6 months (95% CI, 14.2-22.9 months) and it was no different from that of EGFR positive mutation patients (18.6 vs. 22.8 months, p=0.377).

Conclusion

For advanced Chinese female lung SCC patients with EGFR positive mutations, targeted therapy could confer longer PFS and OS than chemotherapy, but the survival was similar with patients who were negative EGFR mutations.

Solitary adrenal metastasis from salivary duct carcinoma of the parotid gland successfully treated by surgery: A case report

RATIONALE

Salivary duct carcinoma (SDC) is a rare and highly aggressive cancer with a poor prognosis. SDC demonstrates a potential for invasive growth with early regional and distant metastasis to organs, such as bone, lung, liver, and brain. Because, adrenal gland metastasis from SDC is rare, its treatment options are not well established. Herein, we report a case of SDC metastasis from the parotid gland to the adrenal gland, which was successfully treated by surgery.

PATIENT CONCERNS

The patient had an abnormal but painless lump on the right parotid gland. The size of the mass had increased over a period of 3 years. The patient underwent complete removal of the right parotid gland and radical neck dissection followed by adjuvant radiotherapy and chemotherapy. Two years later, a mass was identified in the left adrenal gland by computed tomography. As no local recurrence or metastasis to other organs was observed, the patient underwent adrenalectomy.

DIAGNOSES

Metastasis of SDC in the adrenal gland was confirmed by histopathological examination of the adrenalectomized specimen.

INTERVENTIONS

After adrenalectomy, the patient was followed-up without adjuvant therapy.

OUTCOMES

The patient was well and alive during the 13-month postoperative follow-up period without any complications.

LESSONS

Surgical resection of solitary metastatic lesion may show a survival benefit with metastatic SDC.

Treatment of advanced nonsmall cell lung cancer: First line, maintenance and second line - Indian consensus statement update

The management of advanced nonsmall cell lung cancer (NSCLC) patients is becoming increasingly complex with the identification of driver mutations/rearrangements and development/availability of appropriate targeted therapies. In 2017, an expert group of medical oncologists with expertise in treating lung cancer used data from published literature and experience to arrive at practical consensus recommendations on treatment of advanced NSCLC for use by the community oncologists. This was published subsequently in the Indian Journal of Cancer with a plan to be updated annually. The present document is an update to the 2017 document.

Survival analysis and factors affecting survival in patients who presented to the medical oncology unit with non-small cell lung cancer

Background/aim

This study aimed to investigate the effect of clinical and pathological indicators at the time of the diagnosis on overall survival in patients recently diagnosed with non-small cell lung cancer.

Materials and methods

The study population consisted of patients who were diagnosed at the Faculty of Medicine at Isparta Süleyman Demirel University Hospital between January 1, 2010 and December 31, 2017 and presented to the medical oncology outpatient clinic.

Results

A total of 518 patients were evaluated, including 260 patients with squamous cell carcinoma, 207 patients with adenocarcinoma, 50 patients with non-small cell lung cancer-not otherwise specified, and 1 patient with large cell carcinoma. The average life expectancy was found to be 11.50 ± 1.40 months in patients with squamous cell carcinoma, 12.60 ± 1.59 months in patients with adenocarcinoma, and 8.70 ± 1.87 months in the other patients. The estimated 5-year relative survival rate for non-small cell lung cancer was 8% (7% for men and 18% for women). In the multivariate analysis, sex being male (HR, 2.41; P < 0.001), a performance status >2 (HR, 1.70; P < 0.001), the stage of cancer (HR, 1.37; P = 0.045), the presence of bone or liver metastasis (HR, 1.44, P = 0.009, HR, 1.57; P = 0.016, respectively), and the patient not having received radiotherapy (HR, 3.25; P < 0.001) or chemotherapy (HR, 1.85; P = 0.001) were defined as statistically significant predictive factors that reduced the overall survival.

Conclusions

In this study, sex, stage, performance status, the presence of liver or bone metastases, and treatment had an effect on overall survival.

Epidemiology of liver metastases

AIMS

The objectives of this study were to (1) characterize the epidemiology of liver metastases at the time of primary cancer diagnosis (synchronous liver metastases), (2) characterize the incidence trends of synchronous liver metastases from 2010-2015 and (3) assess survival of patients with synchronous liver metastases.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 was queried to obtain cases of patients with liver metastases at the time of primary cancer diagnosis. The primary cancers with an incidence rate of liver metastasis >0.1 are presented in this analysis.

RESULTS

Among 2.4 million cancer patients, 5.14 % of cancer patients presented with synchronous liver metastases. The most common primary site was breast cancers for younger women (ages 20-50), and colorectal cancers for younger men. As patients get older, a more heterogenous population of the top cancers with liver metastases emerges including esophageal, stomach, small intestine, melanoma, and bladder cancer in addition to the large proportion of lung, pancreatic, and colorectal cancers. The 1-year survival of all patients with liver metastases was 15.1 %, compared to 24.0 % in those with non-hepatic metastases. Regression analysis showed that the presence of liver metastasis was associated with reduced survival, particularly in patients with cancers of the testis, prostate, breast, and anus, and in those with melanoma.

CONCLUSIONS

The most common primary sites for patients with liver metastases varied based on age at diagnosis. Survival for patients with liver metastasis was significantly decreased as compared to patients without liver metastasis.

Pemetrexed-Based Chemotherapy Is Inferior to Pemetrexed-Free Regimens in Thyroid Transcription Factor 1 (TTF-1)-Negative, EGFR/ALK-Negative Lung Adenocarcinoma: A Propensity Score Matched Pairs Analysis

INTRODUCTION

Thyroid transcription factor 1 (TTF-1) is a prognostic biomarker in lung adenocarcinoma; however, TTF-1-positive patients also display more favorable factors like actionable target mutations. In contrast, TTF-1-negative cancer is a poorly described entity. We performed a retrospective study to characterize a TTF-1-negative phenotype and to evaluate outcome depending on the chemotherapy regimen applied in the EGFR/ALK-negative population.

PATIENTS AND METHODS

Phenotypic traits were analyzed in 741 patients with evaluable TTF-1 expression status, among them 529 patients with platinum-based first-line chemotherapy, with disease diagnosed between 2009 and 2016 at a tertiary referral university hospital. The influence of TTF-1 and several cofactors on progression-free survival and overall survival (OS) were analyzed using a 1:1 propensity score matching model, depending on the platinum doublet chemotherapy's incorporating pemetrexed or not, with subsequent Cox regression.

RESULTS

TTF-1 negativity implied a distinct cancer phenotype with the predominance of male sex, worse Eastern Cooperative Oncology Group performance status, greater metastatic burden at primary diagnosis, and more adrenal gland metastases. These patients had improved progression-free survival (hazard ratio, 0.42; P = .001) and OS (hazard ratio, 0.40; P < .001) when gemcitabine-, taxane-, or vinorelbine-based regimens were provided instead of pemetrexed. None of the regimens was superior in TTF-1-positive patients with regard to OS. Overall, TTF-1 expression was strongly prognostic with a substantial increase in progression-free survival (hazard ratio, 0.54; P < .001) and OS (hazard ratio, 0.53; P < .001).

CONCLUSION

TTF-1 negativity is associated with a distinct cancer phenotype. Incorporation of this biomarker may be helpful when choosing an appropriate therapy regimen.

Stereotactic Body Radiation Therapy for Extracranial Oligometastatic Non-small-cell Lung Cancer: A Systematic Review

Stereotactic body radiation therapy (SBRT) has emerged as a treatment modality for selected patients with oligometastatic non-small-cell lung cancer (NSCLC). The objectives of this systematic review were to explore the benefits and risks of SBRT for extracranial oligometastatic NSCLC. The MEDLINE, Embase, PubMed, and CENTRAL databases were searched for relevant articles from January 1, 2000 to July 23, 2019. Fully published phase III or phase II trials of any sample size were included. Retrospective series published in manuscript form with at least 50 patients were also included. Four prospective phase II randomized trials (total, 188 participants), 4 prospective non-randomized studies (total, 140 participants), and eleven retrospective studies (total, 1288 participants) were included in this systematic review. A variety of dose fractionation schemes were used. The median overall survival (OS) ranged from 13.5 to 55 months. Progression-free survival (PFS) ranged from 4.4 to 14.7 months. Quality of life outcomes were reported in 2 studies. None of the studies reported symptom control outcomes. There are no fully completed phase III randomized trials that clarify the risks and benefits of SBRT for oligometastatic NSCLC. Higher PFS and OS with SBRT were reported in 4 phase II randomized studies. The results from mature phase III randomized data regarding whether SBRT for oligometastatic NSCLC benefits patients in terms of OS, PFS, quality of life, and symptom control are needed.

Incorporation of EGFR mutation status into M descriptor of new TNM classification influences survival curves in non-small cell lung cancer patients

Background The 8th edition of tumor node metastasis (TNM) staging system for lung cancer introduced a revision of M descriptor. The limitation of new classification to predict prognosis is its focus on anatomical extent of the disease only. Information on molecular status of the tumor significantly influences treatment response and survival; however, data addressing this issue is scarce. This report points to the impact of epidermal growth factor receptor (EGFR) mutation in non-small cell lung cancer (NSCLC) patients on survival in view of new M descriptors of TNM classification system. Patients and methods Medical records of 479 consecutive metastatic NSCLC patients treated between 2009 and 2011, all tested for EGFR mutations, were retrospectively reviewed. For 355 patients medical records included sufficient information to be appropriately categorized into one of the new subgroups according to the M descriptor in 8th TNM classification, of those 89 (25.1%) patients harboured EGFR mutations (EGFR-m). Results Median overall survival (mOS) of EGFR-m patients was significantly longer than mOS of patients without EGFR mutations (20.6 months vs. 8.3 months, p < 0.001). Patients with limited disease burden (M1b sub-group) had the longest mOS among EGFR wild type patients (EGFR-wt) and also among EGFR-m patients, 14.4 months and 39.2 month, respectively. In spite of widespread metastatic disease of M1c EGFR-m patients, their mOS (18.8 months) was longer than mOS of oligometastatic EGFR-wt patients (M1b), who had the lowest disease burden (14.4 months). Median follow up was 53.9 months. Conclusions Incorporation of EGFR mutation status in advanced NSCLC further differentiates survival curves of M categories in 8th TNM classification and more precisely predicts survival compared to number of metastasis or number of metastatic sites alone.

Pathological complete response after afatinib treatment of stage IV oligometastatic adenocarcinoma of the lung: the role of pulmonary surgery

BACKGROUND

Some oligometastatic lung cancer patients, after induction systemic chemotherapy or tyrosine kinases inhibitor treatment, followed by aggressive radical consolidative treatment, have improved overall survival. Unfortunately, clinical criteria cannot assess such patients.

CASE PRESENTATION

We hereby reported the case of a 55-year-old female with lower back pain and bilateral lower leg numbness for months and who had an osteolytic bone lesion over the third lumbar vertebra. In February 2017, a third lumbar vertebra biopsy showed metastatic adenocarcinoma, compatible with lung origin (thyroid transcription factor-1 positive [TTF-1], L858R mutation positive). Complete imaging of the right lower lobe (RLL) showed a spiculated mass of about 3.4 × 2.2 cm, and a trans-bronchoscopic lung biopsy revealed non-small cell carcinoma of lung origin (positive for TTF-1 and negative for p40). Tentative diagnosis was RLL adenocarcinoma, cT2aN0M1b, with bone metastasis at L3. The epidermal growth factor receptor-tyrosine kinase inhibitor afatinib was prescribed beginning April 2017. A November 2018 follow-up CT scan showed regression in the RLL lung mass. A whole-body positron emission tomography-computed tomography showed RLL lung nodule with faint uptake and mildly increased uptake in the L3 vertebra. After providing informed consent, the patient received uniportal video-assisted thoracoscopic RLL lobectomy and radical mediastinal lymph node dissection on December 25, 2018. The final pathology report was fibrotic scar with no residual tumor cells, compatible with post-treatment status, ypT0N0. Curative intent radiotherapy was also applied to the L3 vertebra after the operation. The patient is still alive for more than 32 months after initially diagnosed with metastatic lung adenocarcinoma.

CONCLUSIONS

Our case provides additional data to support that tissue assessment through primary lung tumor resection after systemic treatment of oligometastic lung cancer by minimally invasive surgery can reveal the treatment effect and potentially provide a surrogate endpoint in further clinical trials.

Impact of sites versus number of metastases on survival of patients with organ metastasis from newly diagnosed cervical cancer

Objective

The aim of this study was to investigate the potential associations of the sites and the number of specific metastases with survival in patients newly diagnosed with cervical cancer.

Methods

Medical records of patients with organ metastases of newly diagnosed cervical cancer at Zhejiang Cancer Hospital from October 2006 to December 2016 were reviewed retrospectively. Survival times were compared using the Kaplan-Meier method. Variables associated with survival were identified using univariate and multivariate Cox proportional hazards models.

Results

A total of 99 patients with newly diagnosed organ metastatic cervical cancer were identified. Median follow-up was 11.6 months (range, 0.5–114.7 months). Median overall survival (OS) time was 11.7 months from diagnosis, with 1, 2, and 5-year OS rates of 48.2%, 22.8%, and 12.6%, respectively. The most common site of organ metastasis was bone (36.8%), followed by lung (32.8%) and liver (24%). In univariate analysis, OS rates were better for bone metastasis than visceral metastasis (P=0.013), oligometastasis than non-oligometastasis (P=0.003) and single organ metastasis than multiple organ metastases (P=0.016), while that for liver metastasis was poorer than non-liver metastases (P<0.001). In multivariate analysis, liver metastasis (hazard ratio [HR] =4.02; 95% confidence interval [CI], 1.15-14.05, P=0.029) was significantly and independently related to poor overall survival.

Conclusion

Our data revealed the site of metastasis is associated with overall survival of patients with newly diagnosed organ metastatic cervical cancer, with liver metastasis signifying particularly poor overall survival. Individualized treatments should be administered to patients depending on the specific metastatic sites.

Definition of Synchronous Oligometastatic Non-Small Cell Lung Cancer-A Consensus Report

INTRODUCTION

Improved outcome has been shown in patients with synchronous oligometastatic (sOM) NSCLC when treated with radical intent. As a uniform definition of sOM NSCLC is lacking, we developed a definition and diagnostic criteria by a consensus process.

METHODS

A pan-European multidisciplinary consensus group was established. Consensus questions were built on the basis of current controversies, and definitions were extracted from a survey, cases and a systematic review. This statement was formulated during a consensus meeting.

RESULTS

It was determined that definition of sOM NSCLC is relevant when a radical treatment that may modify the disease course (leading to long-term disease control) is technically feasible for all tumor sites with acceptable toxicity. On the basis of the review, a maximum of five metastases and three organs was proposed. Mediastinal lymph node involvement was not counted as a metastatic site. Fludeoxyglucose F 18 positron emission tomography-computed tomography and brain imaging were considered mandatory. A dedicated liver magnetic resonance imaging scan was advised for a solitary liver metastasis, and thoracoscopy and biopsies of distant ipsilateral pleural sites were recommended for a solitary pleural metastasis. For mediastinal staging, fludeoxyglucose F 18 positron emission tomography-computed tomography was deemed the minimum requirement, with pathological confirmation recommended if this influences the treatment strategy. Biopsy of a solitary metastatic location was mandated unless the multidisciplinary team is of the opinion that the risks outweigh the benefits.

CONCLUSION

A multidisciplinary consensus statement on the definition and staging of sOM NSCLC has been formulated. This statement will help to standardize inclusion criteria in future clinical trials.

Efficacy and safety of nivolumab for metastatic biliary tract cancer

Objective

PD-1 inhibitors have improved efficacy in many cancers. There are currently no reports of the use of PD-1 inhibitors, such as nivolumab, for metastatic biliary tract cancer (mBTC). This study reviewed the efficacy and safety of nivolumab for mBTC with the aim of exploring ways to improve efficacy and survival.

Methods

Thirty patients with mBTC were voluntarily treated with nivolumab at the PLA General Hospital. Nivolumab 3 mg/kg was administered. Progression-free survival (PFS) and overall survival were evaluated by Kaplan-Meier and univariate and multivariate analyses were carried out for clinical characteristics. Objective response rate (ORR), disease control rate (DCR), and treatment-related adverse events (AEs) were also evaluated.

Results

The median treatment cycle is four cycles. One case was complete response, 5 cases partial response, 12 cases stable, and 12 cases progression. ORR was 20%, DCR was 60%, and PFS was 3.1 months (95% CI: 2.13-4.06). The AEs of nivolumab monotherapy were fatigue (three cases), fever (two cases), hypothyroidism (one case), skin reaction (one case), and liver injury (one case). Nivolumab combined with chemotherapy related grade 1-2 hematologic toxicity were leukopenia (five cases) and thrombocytopenia (two cases), and grade 3-4 were leukopenia (three cases). Non-hematologic toxicity grade 1-2 were nausea and vomiting (four cases), fatigue (four cases), fever (three cases), peripheral neurotoxicity (three cases), and hypothyroidism (one case). Univariate analysis showed that PFS of nivolumab combined with chemotherapy was statistically significant compared with that of nivolumab monotherapy (4.1 vs 2.3 months, P=0.031). Programmed death-ligand 1 (PD-L1) expression positively has no relationship with better PFS in contrast with PD-L1 negatively (3.6 vs 3.0 months P>0.05). Multivariate analysis show nivolumab combined with chemotherapy was only the independent factor for longer PFS (HR: 0.432, P<0.05).

Conclusion

The safety of nivolumab in mBTC is controllable. Further selection of superior populations is needed to improve the efficacy of nivolumab in mBTC.

Prognostic impact of combining whole-body PET/CT and brain PET/MR in patients with lung adenocarcinoma and brain metastases

PURPOSE

The role of brain FDG-PET in patients with lung cancer and brain metastases remains unclear. Here, we sought to determine the prognostic significance of whole-body PET/CT plus brain PET/MR in predicting the time to neurological progression (nTTP) and overall survival (OS) in this patient group.

METHODS

Of 802 patients with non-small cell lung cancer who underwent primary staging by a single-day protocol of whole-body PET/CT plus brain PET/MR, 72 cases with adenocarcinoma and brain metastases were enrolled for a prognostic analysis of OS. On the basis of the available follow-up brain status, only 52 patients were eligible for prognostic analysis of nTTP. Metastatic brain tumors were identified on post-contrast MR imaging, and the tumor-to-brain ratio (TBR) was measured on PET images.

RESULTS

Multivariate analysis revealed that FDG-PET findings and eligibility for initial treatment with targeted therapy were significant independent predictors of nTTP and OS. A new index, termed the molecular imaging prognostic (MIP) score, was proposed to define three disease classes. MIP scores were significant predictors of both nTTP and OS (P < 0.001). Pre-existing prognostic indices such as Lung-molGPA scores were significant predictors of OS but did not predict nTTP.

CONCLUSIONS

When staging is performed with whole-body PET/CT plus brain PET/MR, our new prognostic index may be helpful to stratify the outcomes of patients with lung adenocarcinoma and brain metastases. The superior prognostic power of this index for nTTP might be used to select appropriate patients for intracranial control and thereby achieve better quality of life.

Progression-Free Survival and Overall Survival Beyond 5 Years of NSCLC Patients With Synchronous Oligometastases Treated in a Prospective Phase II Trial (NCT 01282450)

INTRODUCTION

Two randomized studies have shown an increased progression-free survival (PFS) by adding a radical local treatment to systemic therapy in responding patients with oligometastatic NSCLC, but long-term data are lacking. We updated the results of our previous phase II trial with a minimal follow-up exceeding 7 years.

METHODS

This is a prospective single-arm phase II trial. The main inclusion criteria were pathologically proven NSCLC stage IV with less than five metastases at primary diagnosis, amendable for radical local treatment (surgery or radiotherapy). No previous response to systemic treatment was needed.

RESULTS

Forty patients were enrolled, 39 of whom were evaluable (18 men, 21 women); mean age was 62.1 ± 9.2 years (range, 44 to 81 years). Twenty-nine (74%) had N2 or N3 disease; 17 (44%) brain, 7 (18%) bone, and 4 (10%) adrenal gland metastases. Thirty-five (87%) had a single metastatic lesion. Thirty-seven (95%) of the patients received chemotherapy as part of their primary treatment. Median overall survival (OS) was 13.5 months (95% confidence interval: 7.6-19.4 months); 1-, 2-, 3-, 5-, and 6- year OS was 56.4%, 23.3%,12.8%, 10.3%, 7.7%, and 5.1%, respectively. Median PFS was 12.1 months (95% confidence interval: 9.6-14.3 months); 1-, 2-, 3-, 5-, and 6- year OS was 51.3%, 13.6%, %,12.8%, 7.7%, 7.7%, and 2.5%, respectively. Only three patients (7.7%) had a local recurrence.

CONCLUSIONS

In patients who were not selected according to response to systemic treatment, the PFS at 5 years was 8%. Entering patients in trials combining local therapy with novel systemic agents (e.g., immunotherapy) remains mandatory.

Impact of number versus location of metastases on survival in stage IV M1b non-small cell lung cancer

BACKGROUND

To assess the impact of location versus number of extra-pulmonary metastatic sites (EPMS) on survival in stage IV non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

Retrospective analysis was conducted on patients diagnosed during 1999-2013 with stage IV, M1b (AJCC 7th edition) NSCLC using the large, institutional Glans-Look Database, which contains patient demographic, clinical, pathological, treatment, and outcome information. We assessed the impact of location and number of EPMS and identified correlates of overall survival using the Kaplan-Meier method and Cox regression.

RESULTS

We identified a total of 2065 NSCLC patients with EPMS. Median age was 67 (IQR 58-75) years, 52% were men, and 78% were current or former smokers. 60% had one EPMS, and 40% had two or more EPMS. Among those with only one EPMS, most frequent organ involvement included bone (40%), brain (32%), and liver (13%). Median overall survival (mOS) was worst in those with liver metastasis and best in those with adrenal metastasis (2.0 vs. 5.2 months, p = 0.015). However, outcomes based on site of organ involvement were not significantly different in multivariable analysis. Compared to patients with one EPMS, individuals with two or more EPMS experienced worse outcomes (mOS ≤ 2.9 vs. 3.9 months, p < 0.001), and were associated with worse prognosis in Cox regression analysis (HR 1.5, 95% CI 1.3-1.7, p < 0.001).

CONCLUSIONS

Number rather than location of EPMS is a prognostic factor in patients with stage IV M1b NSCLC. This information is relevant for accurate prognostication, stratification of participants in future clinical trials, and timely and appropriate advanced care planning.

Applicability of a prognostic CT-based radiomic signature model trained on stage I-III non-small cell lung cancer in stage IV non-small cell lung cancer

OBJECTIVES

Recently it has been shown that radiomic features of computed tomography (CT) have prognostic information in stage I-III non-small cell lung cancer (NSCLC) patients. We aim to validate this prognostic radiomic signature in stage IV adenocarcinoma patients undergoing chemotherapy.

MATERIALS AND METHODS

Two datasets of chemo-naive stage IV adenocarcinoma patients were investigated, dataset 1: 285 patients with CTs performed in a single center; dataset 2: 223 patients included in a multicenter clinical trial. The main exclusion criteria were EGFR mutation or unknown mutation status and non-delineated primary tumor. Radiomic features were calculated for the primary tumor. The c-index of cox regression was calculated and compared to the signature performance for overall survival (OS).

RESULTS

In total CT scans from 195 patients were eligible for analysis. Patients having a prognostic index (PI) lower than the signature median (n = 92) had a significantly better OS than patients with a PI higher than the median (n = 103, HR 1.445, 95% CI 1.07-1.95, p = 0.02, c-index 0.576, 95% CI 0.527-0.624).

CONCLUSION

The radiomic signature, derived from daily practice CT scans, has prognostic value for stage IV NSCLC, however the signature performs less than previously described for stage I-III NSCLC stages. In the future, machine learning techniques can potentially lead to a better prognostic imaging based model for stage IV NSCLC.

Indian consensus statement for treatment of advanced non small cell lung cancer: First line, maintenance, and second line

The management of advanced nonsmall cell lung cancer (NSCLC) patients is becoming complex with the identification of driver mutations and targeted therapies. The expert group of academic medical oncologists used data from published literature, practical experience to arrive at practical consensus recommendations to treat advanced NSCLC for use by the community oncologists.

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.

Prognostic utility of differential tissue characterization of cardiac neoplasm and thrombus via late gadolinium enhancement cardiovascular magnetic resonance among patients with advanced systemic cancer

BACKGROUND

Late gadolinium enhancement (LGE-) cardiovascular magnetic resonance (CMR) is well-validated for cardiac mass (CMASS) tissue characterization to differentiate neoplasm (CNEO) from thrombus (CTHR): Prognostic implications of CMASS subtypes among systemic cancer patients are unknown.

METHODS

CMASS + patients and controls (CMASS -) matched for cancer diagnosis and stage underwent a standardized CMR protocol, including LGE-CMR (IR-GRE) for tissue characterization and balanced steady state free precession cine-CMR (SSFP) for cardiac structure/function. CMASS subtypes (CNEO, CTHR) were respectively defined by presence or absence of enhancement on LGE-CMR; lesions were quantified for tissue properties (contrast-to-noise ratio (CNR); signal-to-noise ratio (SNR) and size. Clinical follow-up was performed to evaluate prognosis in relation to CMASS etiology.

RESULTS

The study population comprised 126 patients with systemic neoplasms referred for CMR, of whom 50% (n = 63) had CMASS + (CNEO = 32%, CTHR = 18%). Cancer etiology differed between CNEO (sarcoma = 20%, lung = 18%) and CTHR (lymphoma = 30%, GI = 26%); cardiac function (left ventricular ejection fraction: 63 ± 9 vs. 62 ± 10%; p = 0.51∣ right ventricular ejection fraction: 53 ± 9 vs. 54 ± 8%; p = 0.47) and geometric indices were similar (all p = NS). LGE-CMR tissue properties assessed by CNR (13.1 ± 13.0 vs. 1.6 ± 1.0; p < 0.001) and SNR (29.7 ± 20.4 vs. 15.0 ± 11.4, p = 0.003) were higher for CNEO, consistent with visually-assigned diagnostic categories. CTHR were more likely to localize to the right atrium (78% vs. 25%, p < 0.001); nearly all (17/18) were associated with central catheters. Lesion size (17.3 ± 23.8 vs. 2.0 ± 1.5 cm2; p < 0.001) was greater with CNEO vs. CTHR, as was systemic disease burden (cancer-involved organs: 3.6 ± 2.0 vs. 2.3 ± 2.1; p = 0.02). Mortality during a median follow-up of 2.5 years was markedly higher among patients with CNEO compared to those with CTHR (HR = 3.13 [CI 1.54-6.39], p = 0.002); prognosis was similar when patients were stratified by lesion size assessed via area (HR = 0.99 per cm2 [CI 0.98-1.01], p = 0.40) or maximal diameter (HR = 0.98 per cm [CI 0.91-1.06], p = 0.61). CTHR conferred similar mortality risk compared to cancer-matched controls without cardiac involvement (p = 0.64) whereas mortality associated with CNEO was slightly higher albeit non-significant (p = 0.12).

CONCLUSIONS

Among a broad cancer cohort with cardiac masses, CNEO defined by LGE-CMR tissue characterization conferred markedly poorer prognosis than CTHR, whereas anatomic assessment via cine-CMR did not stratify mortality risk. Both CNEO and CTHR are associated with similar prognosis compared to CMASS - controls matched for cancer type and disease extent.

Prognostic significance of sites of extrathoracic metastasis in patients with non-small cell lung cancer

BACKGROUND

Metastatic non-small cell lung cancer (NSCLC) continues to have a poor prognosis despite recent advances in both targeted radiotherapy methodologies such as stereotactic body radiotherapy (SBRT) and immunotherapies. The impact of location of metastatic disease in patients with NSCLC has not been investigated; we aimed to investigate this using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

We included 39,910 patients from the SEER database treated for M1b NSCLC from 2010-2013. We identified patients with metastatic disease in the brain, lung, liver, and bone. We used Kaplan-Meier analyses and Cox proportional hazards models to assess the impact of varying sites of metastatic disease on overall survival (OS).

RESULTS

Patients with disease coded as in the brain without other disease in the lung, liver, or bone had improved OS relative to all other comers with M1b disease (HR =0.84, 95% CI, 0.84-0.90, P<0.001). Likewise, patients with disease coded as in the bone without other disease in the lung, liver, or brain had improved OS relative to all other comers with M1b disease (HR =0.89, 95% CI, 0.86-0.92, P<0.001).

CONCLUSIONS

This hypothesis-generating analysis suggests that patients with limited metastatic NSCLC to the bone or brain may particularly benefit from aggressive upfront therapies.

Trends in treatment and relative survival among Non-Small Cell Lung Cancer patients in the Netherlands (1990-2014): Disparities between younger and older patients

BACKGROUND

This study aimed to describe trends over time regarding disparities in treatment and relative survival (RS) between younger and older patients with non-small cell lung cancer (NSCLC).

METHODS

All patients diagnosed with pathologically verified NSCLC in 1990-2014 were included from the Netherlands Cancer Registry (n=187,315). Treatment and RS (adjusted for sex, histology and treatment) were analyzed according to age group (<70 years versus ≥70 years), stage and five-year period of diagnosis.

RESULTS

Between 1990 and 2014, five-year RS increased from 17 to 22% among younger patients and from 12 to 16% among elderly. The application of surgery increased over time for elderly with stage I NSCLC, decreased for elderly with stage II, and was stable but higher for younger patients. Disparities in RS between age groups with stage I became smaller since 2000-2004, but did not change over time for stage II. For stage III and IV, both age groups showed strong increases over time in chemoradiotherapy and chemotherapy from 2000 onwards, although considerably less among elderly. One-, three- and five-year RS increased more strongly over time for the younger group leading to larger disparities between age groups with stage III or IV NSCLC.

CONCLUSION

More curative-intent treatment and improved RS for NSCLC were seen over time, but were less profound among elderly. Disparities herein between age groups seemed to become smaller over time for stage I NSCLC, did not change for stage II, and were widening for stage III and IV at the expense of elderly. Future prospective studies should focus on optimizing treatment selection and outcomes for elderly.

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.

Prognostic factors for long term survival in patients with advanced non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) represents 85% of all lung cancers. It is estimated that 60% of patients with NSCLC at time of diagnosis have advanced disease. The aim of this study was to investigate clinical and demographic prognostic factors of long term survival in patients with unresectable NSCLC.

METHODS

We retrospectively reviewed data of 1,156 patients with NSCLC stage IIIB or IV who survived more than 60 days from the time of diagnosis and treated from August 1987 until March 2013 in the Oncology Department of Pulmonary Clinic of the General Hospital Papanikolaou. Initially univariate analysis using the log-rank test was conducted and then multivariate analysis using the proportional hazards model of Cox. Also Kaplan Meier curves were used to describe the distribution of survival times of patients. The level of significance was set at 0.05.

RESULTS

The mean age at diagnosis was 62 years. About 11.9% of patients were women and 88.1% were male. The majority of cases were adenocarcinomas (42.2%), followed squamous (33%) and finally the large cell (6%). Unlike men, most common histological type among women was adenocarcinoma rather than squamous (63% vs. 10.9%). In univariate analysis statistically significant factors in the progression free survival (PFS) and overall survival (OS) were: weight loss ≥5%, histological type, line 1 drugs, line 1 combination, line 1 cycles and radio lung. Specifically radio lung gives clear survival benefit in the PFS and OS in stage IIIB (P=0.002) and IV (P<0.001). On the other hand, the number of distant metastases in stage IV patients did not affect OS, neither PFS. In addition patients who received platinum and taxane had better PFS (P=0.001) and OS (P<0.001) than those who received platinum without taxane. Also the third drug administration proved futile, since survival (682.06±34.9) (P=0.023) and PFS (434.93±26.93) (P=0.012) of patients who received less than three drugs was significantly larger. Finally, large cell carcinoma recorded the shortest OS and PFS compared with adenocarcinoma (P=0.043 and P=0.016 respectively) and squamous cell carcinoma (P=0.021 and P=0.004 respectively). In multivariate analysis the same predictors were statistically significant except for line 1 drugs.

CONCLUSIONS

This study confirms the increased incidence of adenocarcinoma in women than in men and the aggressiveness of large cell carcinoma. It also underlines the vitality of factors such as weight loss, radio lung and doublet platinum-based. On the other hand, it excludes significant factors such as gender, age and smoking.

Pattern and Prognostic Implications of Cardiac Metastases Among Patients With Advanced Systemic Cancer Assessed With Cardiac Magnetic Resonance Imaging

BACKGROUND

Cardiac magnetic resonance (CMR) imaging is well validated for tissue characterization of cardiac masses but has not been applied to study pattern and prognostic implications of cardiac metastases (CMETs) among patients with systemic cancer.

METHODS AND RESULTS

The population consisted of 60 patients with stage IV cancer (32 patients with CMETs, 28 diagnosis-matched controls) undergoing CMR. CMET was defined as a discrete mass with vascular tissue properties on delayed enhancement CMR. CMET-positive patients and controls had similar clinical characteristics, cardiac geometry, and function (P=NS). Leading cancer types associated with CMET were sarcoma, melanoma, and gastrointestinal. Patients with CMETs had similar distribution of extracardiac metastatic disease compared with controls (organs involved: 3.4±2.0 versus 2.7±1.9, P=0.17). In 94% of patients with CMETs, there were metastases involving ≥1 extracardiac organ (66% lung involvement). CMET location varied (right ventricle 44%, right atrium 19%, left ventricle 28%, left atrium 9%, pericardial 25%); 22% of cases had multichamber involvement. Right-sided chamber involvement was common in hematologic/lymphatic spread (67%); pericardial involvement was common with direct spread (64%). Regarding tissue properties on delayed enhancement CMR, CMETs commonly (59%) demonstrated heterogeneous enhancement (41% diffuse enhancement). Heterogeneous lesions were larger and had increased border irregularity (P<0.05). Survival 6 months post-CMR was numerically lower among patients with CMETs (56% [95% CI 39-74%]) versus stage IV cancer-matched controls (68% [95% CI 50-86%]), although differences between groups were nonsignificant (P=0.42).

CONCLUSIONS

CMETs vary regarding etiology, location, and tissue properties on CMR, highlighting need for comprehensive surveillance of cardiac involvement regardless of cancer origin. Prognosis remains poor with for patients with CMETs, albeit similar to that for stage IV cancer controls matched for cancer etiology.