Is surgical resection indicated for a solitary non-small cell lung cancer recurrence?

Complex situations in lung cancer: multifocal disease, oligoprogression and oligorecurrence

With the emergence of lung cancer screening programmes and newly detected localised and multifocal disease, novel treatment compounds and multimodal treatment approaches, the treatment landscape of non-small cell lung cancer is becoming increasingly complex. In parallel, in-depth molecular analyses and clonality studies are revealing more information about tumorigenesis, potential therapeutical targets and the origin of lesions. All can play an important role in cases with multifocal disease, oligoprogression and oligorecurrence. In multifocal disease, it is essential to understand the relatedness of separate lesions for treatment decisions, because this information distinguishes separate early-stage tumours from locally advanced or metastatic cancer. Clonality studies suggest that a majority of same-histology lesions represent multiple primary tumours. With the current standard of systemic treatment, oligoprogression after an initial treatment response is a common scenario. In this state of induced oligoprogressive disease, local ablative therapy by either surgery or radiotherapy is becoming increasingly important. Another scenario involves the emergence of a limited number of metastases after radical treatment of the primary tumour, referred to as oligorecurrence, for which the use of local ablative therapy holds promise in improving survival. Our review addresses these complex situations in lung cancer by discussing current evidence, knowledge gaps and treatment recommendations.

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.

Oligometastatic Disease in Non-Small-Cell Lung Cancer: An Update

Simple Summary

Approximately 7–50% of patients with non-small-cell lung cancer (NSCLC) develop oligometastases, which are new tumors found in another part of the body, arising from cancer cells of the original tumor that have travelled through the body. In recent years, these patients have been increasingly regarded as a distinct group that could benefit from treatment that intends to cure the disease, rather than palliative care, to achieve a better clinical outcome. Various treatment procedures have been developed for treating NSCLC patients with different oligometastatic sites. In addition, the newly proposed uniform definition for oligometastases as well as ongoing trials may lead to increased appropriate patient selection and evaluation of treatment effectiveness. The aim of this review article is to summarize the latest evidence regarding optimal management strategies for NSCLC patients with oligometastases.

Abstract

Oligometastatic non-small-cell lung cancer (NSCLC) is a distinct entity that is different from localized and disseminated diseases. The definition of oligometastatic NSCLC varies across studies in past decades owing to the use of different imaging modalities; however, a uniform definition of oligometastatic NSCLC has been proposed, and this may facilitate trial design and evaluation of certain interventions. Patients with oligometastatic NSCLC are candidates for curative-intent management, in which local ablative treatment, such as surgery or stereotactic radiosurgery, should be instituted to improve clinical outcomes. Although current guidelines recommend that local therapy for thoracic and metastatic lesions should be considered for patients with oligometastatic NSCLC with stable disease after systemic therapy, optimal management strategies for different oligometastatic sites have not been established. Additionally, the development of personalized therapies for individual patients with oligometastatic NSCLC to improve their quality of life and overall survival should also be addressed. Here, we review relevant articles on the management of patients with oligometastatic NSCLC and categorize the disease according to the site of metastases. Ongoing trials are also summarized to determine future directions and expectations for new treatment modalities to improve patient management.

Multicentre study of microwave ablation for pulmonary oligorecurrence after radical resection of non-small-cell lung cancer

BACKGROUND

Microwave ablation (MWA) is an effective minimally invasive technique for lung tumours. We aim to evaluate its role for pulmonary oligorecurrence after radical surgery of non-small-cell lung cancer (NSCLC).

METHODS

From June 2012 to Jan 2020, a total of 103 patients with pulmonary oligorecurrence after previous radical surgical resection of NSCLC were retrospectively analysed. The primary endpoint was postoperative progression-free survival (PFS). Secondary endpoints were postoperative overall survival (OS), patterns of failure, complications and predictive factors associated with prognosis.

RESULTS

Of the 103 patients identified, 135 pulmonary oligorecurrences developed at a median interval of 34.8 months. In total, 143 sessions of MWA were performed to ablate all the nodules. The median PFS and OS were 15.1 months and 40.6 months, respectively. After MWA, 15 (14.6%) patients had local recurrence as the first event, while intrathoracic oligorecurrence and distant metastases were observed in 45 (43.7%) and 20 (19.4%) patients, respectively. In the multivariate analysis, local recurrence and intrathoracic oligorecurrence were not significant predictors for OS (P = 0.23 and 0.26, respectively). However, distant metastasis was predictive of OS (HR = 5.37, 95% CI, 1.04-27.84, P = 0.04).

CONCLUSION

MWA should be considered to be an effective and safe treatment option for selected patients with pulmonary oligorecurrence after NSCLC radical surgical resection.

Clinical Outcomes and Prognostic Factors of Salvage Stereotactic Body Radiotherapy for Post-Surgical Thoracic Oligo-Recurrence/Metastasis of Non-Small-Cell Lung Cancer

Purpose

The study aimed to assess the efficacy and safety of stereotactic body radiotherapy (SBRT) using CyberKnife (CK) in patients with postoperative thoracic oligo-recurrence/metastasis of non-small-cell lung cancer (NLCLC), and to analyze the prognostic factors affecting overall survival after SBRT.

Patients and Methods

A total of 44 patients with postoperative thoracic oligo-recurrence/metastatic of NLCLC treated with SBRT were reviewed. Thoracic oligo-recurrence/was defined as 1–3 loco-regional confined to lung lobe, hilar/mediastinal lymph nodes, bronchial stump, or chest wall. Primary endpoints included local control (LC), overall survival (OS), progression-free survival (PFS) and toxicity. Prognostic factors that affected these patients were analyzed by the univariate and multivariate analysis by Kaplan–Meier methods and Cox regression models, respectively.

Results

The median follow-up time after salvage SBRT was 48.5 months. Measuring from the date of salvage SBRT, the median OS of the 44 patients was 52.60 (95% CI: 29.59–75.60) months. 1-,3-and 5-year OS rates were 97.7%, 65.3% and 47.7%, respectively. The 1-,3-year and 5-year LC rates were 97.7%, 85.1% and 80.1%, respectively. At 1, 3 and 5 years, the PFS rates were 77.1%, 28.8% and 5.3%, respectively. Multivariate analysis demonstrated that pre-SBRT neutrophil-to-lymphocyte ratio (NLR) and Charlson comorbidity index (CCI) were independent prognostic factors (p < 0.05). The treatment-related side-effects were well tolerated. No patients developed grade 3 or greater pulmonary toxicity.

Conclusion

SBRT is a promising salvage therapeutic option for postoperative thoracic oligo-recurrence/metastasis of non-small-cell lung cancer with acceptable toxicity. Low pre-SBRT neutrophil-to-lymphocyte ratio (NLR) and low Charlson comorbidity index (CCI) were associated with a better prognosis and longer survival and might be considered as reliable and independent prognostic factors in these patients treated with SBRT.

Radiotherapy for local recurrence of non-small-cell lung cancer after lobectomy and lymph node dissection-can local recurrence be radically cured by radiation?

BACKGROUND

There is no standard therapeutic approach for local recurrence of non-small cell lung cancer (NSCLC) after complete resection. We investigated the outcomes of radiotherapy (RT) for patients with local recurrence.

METHODS

We reviewed 46 patients who underwent curative-intent RT for local recurrence after lobectomy or pneumonectomy accompanied with mediastinal lymph node dissection between 2002 and 2014. We analyzed overall survival (OS), progression-free survival (PFS), local control, tumour response and the re-recurrence pattern.

RESULTS

Among the 46 patients, 16 received concurrent chemotherapy. The median follow-up period was 48 months. The response rate was 91%. The 5-year OS and local control rates were 47.9 and 65.3%, respectively, and the 5-year PFS rate was 22.8%. Female sex and complete response to radiation were favourable prognostic factors. Of the 33 patients with recurrence after radiation, 32 (97%) had distant metastasis.

CONCLUSIONS

Although RT for local recurrence has high efficacy, distant relapse after radiation remains a major issue. Therefore, combination systemic therapy for local recurrence at any site should be further investigated. Since it is difficult to achieve a radical cure for local recurrence using RT, further study, for the administration of post-operative adjuvant therapy, is recommended.

Hepatectomy for oligo-recurrence of non-small cell lung cancer in the liver

BACKGROUND

The prognosis of metastatic recurrent non-small cell lung cancer (NSCLC) is poor, and chemotherapy improves survival by only a few months. The concept of oligo-recurrence, defined as a small number of new lesions at a distant site theoretically curable by local therapy, has recently been proposed for several cancers. To evaluate the possible benefits of surgical resection for oligo-recurrence, we report the outcomes of seven patients who underwent hepatic resection for oligo-recurrence of NSCLC in the liver.

METHODS

Among the 2038 patients who underwent resection for NSCLC between January 1997 and December 2015 at the Department of Chest Surgery, Chiba Cancer Center, 7 (0.34%) with oligo-recurrence in the liver underwent hepatectomy. Perioperative data were retrospectively reviewed, including recurrence-free and overall survival.

RESULTS

Primary tumor histopathological types included five cases of squamous cell carcinoma, one case of adenocarcinoma, and one case of large-cell carcinoma. All patients underwent complete tumor resection without complication. The median survival duration following hepatectomy was 24.0 (range 15.2-30.2) months. Four patients were alive at the end of follow-up (23.4-30.2 months), whereas three died between 15.2 and 24.5 months. There was no evidence of second recurrence in two patients.

CONCLUSIONS

Hepatectomy may be equally effective as multidisciplinary therapy for oligo-recurrence of NSCLC in the liver.

Post-recurrence survival analysis of stage I non-small-cell lung cancer

Background The aim of this retrospective study was to review recurrence patterns of stage I non-small-cell lung cancer and identify prognostic factors for post-recurrence survival. Methods Among 940 patients with pathological stage I non-small-cell lung cancer who underwent curative resection, 261 experienced a recurrence; of these, 188 had adenocarcinoma and 62 had squamous cell carcinoma. Oligo-recurrence was defined as 1-3 recurrent lesions restricted to a single organ. Potentially curative local treatment included surgery, stereotactic radiotherapy, and photodynamic therapy. Results The median follow-up duration was 65 months (range 4-186 months). The most common site of recurrence was the lung in 145 patients, followed by mediastinal lymph nodes in 49, pleura in 30, and brain in 27. Local treatment for recurrent tumors included surgery in 59 patients, stereotactic radiotherapy in 46, photodynamic therapy in 2, and other radiotherapy in 41. Seventy-eight patients received chemotherapy only, and 35 received conservative treatment. Among 125 patients who were evaluated for an epidermal growth factor receptor gene mutation, 31 were treated with epidermal growth factor receptor-tyrosine kinase inhibitor. The 3- and 5-year post-recurrence survival rates were 49.1% and 33.8%, respectively. Age at recurrence, adenocarcinoma cell type, disease-free interval, epidermal growth factor receptor-tyrosine kinase inhibitor treatment, and potentially curative local treatment were independent prognostic factors for survival in multivariate analysis. Conclusions Local treatment for recurrence should be considered in selected candidates, and use of epidermal growth factor receptor-tyrosine kinase inhibitor I is reasonable if an epidermal growth factor receptor mutation is detected.

Targeted therapy of multiple liver metastases after resected solitary gastric metastasis and primary pulmonary adenocarcinoma

Gastric metastases from lung adenocarcinoma are rare and usually asymptomatic. A 61-year-old woman was referred to our department because of a right lower pulmonary mass found on a chest X-ray film in August 2012. Right lower lobectomy was performed for pulmonary adenocarcinoma. Four months later, she developed epigastric discomfort. A fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT) scan showed a malignancy at the cardias of the stomach. A biopsy diagnosed poorly differentiated carcinoma and a gastric carcinoma was suspected. She underwent a subtotal gastrectomy and part of esophagectomy. The histologic diagnosis was metastasis from the pulmonary adenocarcinoma. She visited us again for her increasing level of carcinoembryonic antigen (CEA) after two months. FDG-PET/CT showed multiple malignant lesions in her liver, considering metastases from pulmonary origin. As she harbored activating epidermal growth factor receptor (EGFR) mutation, she received erlotinib from April, 2013. She survives 4 years after the lung resection and is still on erotinib treatment with complete response. Although gastric metastasis from lung cancer is considered a late stage of the disease, a radical resection might provide survival in solitary metastasis. Moreover, systemic therapy was emphasized after local treatment in some late stage cases.

Approach for oligometastasis in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) harboring a limited number of distant metastases, referred to as the oligometastatic state, has been indicated for surgery for the past several decades. However, whether the strategy of surgical treatment results in a survival benefit for such patients remains controversial. Experientially, however, thoracic surgeons often encounter long-term survivors among surgically resected oligometastatic NSCLC patients. In this article, the current situation of surgical approach and potential future perspective for oligometastatic NSCLC are reviewed.

Stereotactic Radiosurgery/Stereotactic Body Radiotherapy for Recurrent Lung Neoplasm: An Analysis of Outcomes in 100 Patients

BACKGROUND

A significant number of patients have recurrent or persistent lung cancer despite complete resection or treatment with definitive chemoradiation. Stereotactic radiosurgery (SRS)/stereotactic body radiation therapy is emerging as an important modality for the treatment of early-stage lung neoplasm; SRS may also offer an alternative treatment option for patients with recurrent lung disease. We evaluated outcomes after treatment with SRS for recurrent lung neoplasm in a large series of patients.

METHODS

Selected patients with limited recurrent, persistent, or progressive disease after one or more prior treatments for lung cancer were offered SRS. Thoracic surgeons evaluated all patients, placed fiducials when needed, and planned treatment in close collaboration with radiation oncologists and medical physicists. In our early experience, a single fraction of 20 Gy radiation was prescribed and was subsequently increased to 45 to 60 Gy in three to five fractions. The primary endpoint evaluated was overall survival.

RESULTS

We treated 100 patients with recurrent lung cancer (median age 72 years) with SRS. The postprocedure 30-day mortality rate was 0%; median follow-up was 51 months (range, 5 to 123). The median overall survival for the entire group was 23 months (95% confidence interval: 19 to 41). The probability of 2-year and 5-year overall survival was 49% (95% confidence interval: 40% to 60%) and 31% (95% confidence interval: 23% to 43%), respectively.

CONCLUSIONS

Our experience indicates that SRS is safe, and offers an alternative modality for selected patients with recurrent oligometastatic or persistent lung cancer. Thoracic surgeons should actively participate in SRS and continue to evaluate the efficacy of this treatment strategy.

Simultaneous Esophageal and Gastric Metastases from Lung Cancer

We report of a patient with metastatic adenocarcinoma of the esophagus and stomach from lung cancer. The patient was a 68-year-old man receiving radiotherapy and chemotherapy for stage IV lung cancer, without metastases to the gastrointestinal (GI) tract at the time of the initial diagnosis. During the treatment period, dysphagia and melena newly developed. Upper GI endoscopy revealed geographic erosion at the distal esophagus and multiple volcano-shaped ulcers on the stomach body. Endoscopic biopsy was performed for each lesion. To determine whether the lesions were primary esophageal and gastric cancer masses or metastases from the lung cancer, histopathological testing including immunohistochemical staining was performed, and metastasis from lung cancer was confirmed. The disease progressed despite chemotherapy, and the patient died 5 months after the diagnosis of lung cancer. This is a case report of metastatic adenocarcinoma in the esophagus and stomach, which are very rare sites of spread for lung cancer.

Postoperative oligo-recurrence of non-small-cell lung cancer: clinical features and survival†

OBJECTIVES

Postoperative recurrences of non-small-cell lung cancer (NSCLC) are usually disseminated and systemic. Recently, the concept of oligo-recurrence, which is theoretically curable by definitive local therapy (DLT), has been proposed in several cancers. The aim of this study was to clarify clinical features and outcomes of patients with postoperative oligo-recurrence of NSCLC.

METHODS

From 3275 patients with resected pathological stage IA-IIIB NSCLC between 1993 and 2011, a total of 768 patients who developed recurrence were included in this study. Oligo-recurrence was defined as 1-3 loco-regional or distant recurrent lesions restricted to a single organ. Other recurrences were classified as poly-recurrence. Second primary lung cancers and suspected lesions were excluded. DLT included surgery, stereotactic radiotherapy and radiotherapy with a 45 Gy or higher dose, performed with curative intent.

RESULTS

Oligo-recurrence was identified in 162 (21%) patients, mainly as a solitary recurrence (n = 129, 80%) in regional lymph nodes, brain, lung, bone and adrenal gland, and the proportion of patients with oligo-recurrence increased gradually year by year. The patients with oligo-recurrence had more early-staged disease at initial surgery and a longer time to recurrence than those with poly-recurrence. The entire population of oligo-recurrence patients had better post-recurrence survival (PRS) than those with poly-recurrence (5-year PRS: 32.9 vs 9.9%, P < 0.001). For oligo-recurrence, DLT was totally conducted in 105 (65%) patients as initial treatment. Multivariate analyses revealed that the initial DLT was associated with improved PRS [odds ratio (OR) 0.44; 95% confidence interval (CI) 0.29-0.68]. The recurrence location and initial pathological stage did not affect PRS. The 5-year PRS and postoperative progression-free survival rates after DLT were 38.6 and 22.3%, respectively. Of the 10 long-term (≥5-year) progression-free survivors, 9 were those with a solitary recurrence.

CONCLUSIONS

Initial DLT for oligo-recurrence achieved favourable PRS in a selected population. Oligo-recurrence curable by DLT was found in a subset of patients who received DLT, mostly as a solitary recurrence.

Survival outcomes for oligometastasis in resected non-small cell lung cancer

BACKGROUND

We investigated the factors associated with post-recurrence survival and the treatment for non-small-cell lung cancer patients with postoperative distant recurrence, especially oligometastasis.

METHODS

We reviewed the data of 272 patients with distant recurrence who underwent resection of non-small-cell lung cancer from January 2000 through December 2011.

RESULTS

The type of distant recurrence was classified as oligometastasis (n = 76, 28%) or polymetastasis (n = 196, 72%). Forty-seven (62%) patients with oligometastasis received local therapy (surgery 5, radiotherapy 9, sequential local and systemic therapy 28, chemoradiotherapy 5). Multivariate analysis revealed older age, non-adenocarcinoma, shorter disease-free interval, no pulmonary metastasis, liver metastases, bone metastases, and polymetastasis had significant associations with unfavorable post-recurrence survival. Subgroup analysis of patients with oligometastasis showed histology and disease-free interval had a great impact on survival. Smoking history and histology were associated with survival in patients with lung oligometastasis, whereas systemic treatment and longer disease-free interval were related to increased post-recurrence survival in those with brain oligometastasis.

CONCLUSIONS

This study showed that an oligometastatic state per se was a significant favorable factor. Optimization of personalized systemic treatment and adding local treatment are important in the management of patients with non-small-cell lung cancer and oligometastasis.

Post-recurrence survival of elderly patients 75 years of age or older with surgically resected non-small cell lung cancer

PURPOSE

The purpose of this study was to evaluate the outcomes of elderly patients 75 years of age or older with recurrent non-small cell lung cancer (NSCLC).

METHODS

A total of 1237 consecutive patients with NSCLC underwent pulmonary resection at our institution. Of these patients, 280 experienced postoperative recurrence. The rate of the post-recurrence survival and predictors were analyzed independently in a group of younger patients (<75 years) and a group of elderly patients (≥75 years).

RESULTS

There were 215 younger patients (<75 years) and 65 elderly (≥75 years) patients at the time of diagnosis of recurrence. The median post-recurrence survival time and the five-year survival rate of all cases were 25 months and 20.8%, respectively. There were no significant survival differences between the younger and elderly groups (p = 0.20). A univariate analysis determined that gender, Eastern Cooperative Oncology Group performance status, smoking status, histological type and epithelial growth factor receptor (EGFR) mutation status were factors influencing the post-recurrence survival among the elderly patients. In addition, a multivariate analysis determined the EGFR mutation status to be an independent prognostic factor for the post-recurrence survival.

CONCLUSIONS

Elderly patients 75 years of age or older in this study achieved satisfactory long-term outcomes.

Predictors of post-recurrence survival in patients with non-small-cell lung cancer initially completely resected

OBJECTIVES

Despite recent progress in diagnostic technology and therapeutic approaches to non-small-cell lung cancer (NSCLC), 30-75% of patients develop tumour recurrence after resection. However, the details of post-recurrence survival (PRS) are not well understood. We aimed to investigate the predictors of PRS in patients with NSCLC initially completely resected.

METHODS

A series of 568 NSCLC patients who had undergone complete resection between 2000 and 2009 were evaluated retrospectively. Patients who had developed recurrent NSCLC after complete resection were subjected to the current analysis. We examined PRS using the Kaplan-Meier method and multivariate Cox regression analyses.

RESULTS

Of the 568 patients, 138 (24.3%) were identified as having disease recurrence. The 2-year and 5-year PRS rates were 44.6 and 25.9%, respectively, while the median PRS time was 22.5 months. Non-adenocarcinoma histology [hazard ratio (HR) = 2.825, 95% confidence interval (CI): 1.825-4.367, P < 0.001], serum carcinoembryonic antigen (CEA) at recurrence ≥5.0 mg/dl (HR = 2.205, 95% CI: 1.453-3.344, P < 0.001) and no systemic chemotherapy (HR = 2.137, 95% CI: 1.304-3.247, P = 0.002) were independent prognostic factors for PRS.

CONCLUSIONS

The current results showed that non-adenocarcinoma histology, elevated serum CEA at recurrence and no systemic chemotherapy were independent unfavourable post-recurrence prognostic factors. The current data can be informative for patient follow-up after complete resection and further clinical investigation may give us more information about PRS and accurate treatment strategy for recurrent NSCLC after initial complete resection.

Therapeutic strategy for postoperative recurrence in patients with non-small cell lung cancer

Postoperative recurrence occurs in approximately half of patients with non-small cell lung cancer (NSCLC), even after complete resection. Disease recurrence after surgical resection reduces the patient’s life expectancy sharply. The prognosis after postoperative recurrence is considered to largely depend on both the mode of first recurrence (distant, locoregional or combined) and the treatment modality: (1) The majority of cases of postoperative recurrence involve distant metastasis with or without locoregional recurrence. Platinum-based systemic chemotherapy is practically accepted as the treatment for these diseases on the basis of evidence for original stage IV disease. The advent of both pemetrexed and molecular-targeted drugs has improved the survival of nonsquamous NSCLC and changed the chemotherapeutic algorithm for NSCLC; (2) Among patients with distant metastatic recurrence without locoregional recurrence at the primary tumor site, the metastasis is often limited in both organ and number. Such metastases are referred to as oligometastases. Local therapy, such as surgical resection and radiotherapy, has been suggested to be the first-line treatment of choice for oligometastatic recurrence; and (3) While locoregional recurrence is likely to cause troublesome symptoms, it is a potentially limited disease. Therefore, providing local control is important, and radiation is usually beneficial for treating local recurrence. In order to obtain better control of the disease and provide treatment with curative intent in patients with limited disease, the administration of concurrent platinum-based chemoradiotherapy is recommended according to the results of originally nonresectable stage IIIA and IIIB disease.

Evaluating the utility of local therapy for oligometastatic lung cancer

SUMMARY 

In patients with metastatic non-small-cell lung cancer, limited metastases are identified as ‘oligometastases’, and such patients are expected to be long-term progression-free, or possibly curable by local control of those lesions. Especially for oligometastatic recurrence after complete resection of the original primary tumor, local treatment should be taken into consideration as a choice of treatment. Oligoprogression after the administration of EGF receptor tyrosine kinase inhibitors for EGFR-mutated non-small-cell lung cancer might also be indicated for local treatment while continuing the EGF receptor tyrosine kinase inhibitor treatment. Since stereotactic radiotherapy delivery is now available, its potential for local control is nearly comparable to that of surgery. These two major modalities of local therapy should be selected for the treatment of oligometastases after carefully considering both the oligometastatic status (organs, number) and patient status.

Impact of the epidermal growth factor receptor mutation status on the post-recurrence survival of patients with surgically resected non-small-cell lung cancer

OBJECTIVES

The impact of epidermal growth factor receptor (EGFR) status and the use of EGFR-tyrosine kinase inhibitor (EGFR-TKI) therapy have not been well discussed only in recurrent non-small-cell lung cancer (NSCLC). The purpose of this study was to identify the prognostic factors associated with post-recurrence survival after surgical resection of NSCLC in terms of the EGFR mutation status and the use of EGFR-TKI therapy.

METHODS

From 2000 through 2011, 1237 consecutive patients with NSCLC underwent pulmonary resection at our institution. Of these patients, 280 experienced postoperative recurrence by the end of 2012. We reviewed the cases of recurrence and analysed the predictors and length of post-recurrence survival.

RESULTS

The median post-recurrence survival time and the 5-year survival rate of all patients were 25 months and 20.8%, respectively. A multivariate analysis identified the Eastern Cooperative Oncology Group (ECOG) performance status (PS), brain metastasis, number of sites of recurrence and EGFR mutation status to be independent prognostic factors for post-recurrence survival. Among all cases, the median post-recurrence survival time according to the use of EGFR-TKI therapy was as follows: 49 months in the EGFR mutation-positive patients treated with EGFR-TKI therapy, 20 months in the EGFR wild or unknown cases treated with EGFR-TKI therapy and 17 months in the patients not treated with EGFR-TKI therapy. As to EGFR mutation-positive cases, the patients treated with EGFR-TKIs exhibited significantly longer post-recurrence survival time than the patients treated without EGFR-TKIs (49 vs 12 months).

CONCLUSIONS

It is essential for recurrent NSCLC patients to be examined for the EGFR mutation status. Patients with a positive EGFR mutation status receive significant benefits from EGFR-TKI therapy.

Radiotherapy for postoperative thoracic lymph node recurrence of non-small-cell lung cancer provides better outcomes if the disease is asymptomatic and a single-station involvement

OBJECTIVE

Thoracic lymph node recurrence after complete resection is common in non-small-cell lung cancer but it mostly occurs along with distant metastases. The recurrent disease might be localized and curative intent radiation therapy is the treatment of choice if no evidence of hematogenous metastasis is observed. We sought to describe the outcomes of thoracic radiotherapy for thoracic lymph node recurrences.

METHODS

Fifty patients who had developed thoracic lymph node recurrence after complete resection received curative intent radiotherapy between 1997 and 2009. The clinical endpoints included the tumor response, overall survival, progression-free survival, locoregional recurrence within the irradiated field, and any other recurrence.

RESULTS

The planned total radiotherapy was completed in 49 patients with minor toxicity. The median follow-up time after radiotherapy was 41 (19-98) months among the survivors. The response to treatment was complete response in 65%, partial response in 24%, and progressive disease in 10% of the evaluated patients. The median overall survival after radiotherapy was 37.3 months. The 5-year overall survival, progression-free survival, and local control rate were 36.1%, 22.2%, and 61.1%, respectively. A multivariate analysis revealed that the absence of symptoms and the involvement of a single lymph node station were significant factors associated with a better overall survival.

CONCLUSIONS

Radiation therapy for thoracic lymph node recurrence after complete resection is safe and provides acceptable disease control. This treatment provides a better outcome if the disease is asymptomatic and has a single-station involvement. Early detection of the recurrence may thus improve the effectiveness of this treatment.

Surgically resected gastric metastasis of pulmonary squamous cell carcinoma

Gastric metastasis of pulmonary carcinoma has been reported to range from 0.19%-5.1%. An autopsy review of cancer disclosed 1.7%-29.6% of gastric metastases, primarily from breast cancer, lung cancer and melanoma. A 71-year-old man was referred to our department because of persistent cough, sputum and sweating for 20 d. Chest posteroanterior view and chest computed tomography scan demonstrated an irregular tumor mass measuring 5.8 cm with central necrosis at the right lower lung. Bronchoscopic biopsy revealed pulmonary squamous carcinoma. Esophagogastroduodenoscopy revealed a huge bleeding ulcer at the body of the stomach and a biopsy diagnosed a metastatic lesion. We performed a palliative total gastrectomy, splenectomy and distal pancreatectomy. The patient did not receive any adjuvant chemotherapy due to his refusal. He was controlled conservatively and survived for 11 mo after surgery. Surgical resection may provide an option for safe palliative treatment. Although gastric metastasis from lung cancer is associated with dismal outcomes, a longer survival or more favorable outcome has been demonstrated in patients undergoing palliative surgical resection of the metastatic site. Considerable improvements in the understanding of metastatic diseases and therapeutic strategies are needed to improve the clinical outcome.

Stage IV lung cancer: Is cure possible?

Reporting a case, 53 years old male with stage IV Nonsamall cell lung cancer in view of cytologically proven malignant pleural effusion. Usually the management of stage IV lung cancer is with palliative intent where the patient receives palliative chemotherapy along with palliative radiotherapy and surgery if required. Most of the data on curative management of oligometastatic non-small cell lung cancer includes patient with adrenal metastasis and some reports with brain metastasis. There is scarce literature on the surgical management of stage IV lung cancer with pleural effusion.

Local treatment of oligometastatic recurrence in patients with resected non-small cell lung cancer

OBJECTIVES

We previously reported a retrospective study indicating the prognostic impact of the local treatment of oligometastatic recurrence after a complete resection for non-small cell lung cancer (NSCLC). In the present study, we prospectively observed postoperative oligometastatic patients and investigated the effects of local treatment on progression-free survival (PFS).

METHODS

Using a prospectively maintained database of patients with completely resected NSCLC treated between October 2007 and December 2011, we identified 52 consecutive patients with postoperative recurrence, excluding second primary lung cancer. Of these patients, 31 suffering from distant metastases alone without primary site recurrence were included in this study. According to the definition of 'oligometastases' as a limited number of distant metastases ranging from one to three, 17 patients had oligometastatic disease. Of those 17 patients, four patients with only brain metastasis were excluded from the analysis.

RESULTS

The oligometastatic sites included the lungs in five patients, bone in four patients, the lungs and brain in two patients, the adrenal glands in one patient and soft tissue in one patient. Eleven of the 13 patients first received local treatment. Three patients (lung, adrenal gland, soft tissue) underwent surgical resection, and the remaining eight patients received radiotherapy. The median PFS was 20 months in the oligometastatic patients who received local treatment. There were five patients with a PFS of longer than two years. The metastatic sites in these patients varied, and one patient had three lesions. On the other hand, the two remaining patients first received a systemic chemotherapy of their own selection. The PFS of these two patients was five and 15 months, respectively.

CONCLUSION

Local therapy is a choice for first-line treatment in patients with postoperative oligometastatic recurrence.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Postoperative surveillance for non-small cell lung cancer resected with curative intent: developing a patient-centered approach

Local recurrence or the development of metachronous cancer after surgical therapy for early-stage non-small cell lung cancer (NSCLC) is not uncommon, and these conditions are often amenable to curative therapy. Predictors of recurrence based on surgical, patient, and pathologic factors are well known. A literature search was performed for articles regarding identification or treatment with curative intent of early local recurrence or metachronous cancer after resection of NSCLC. A patient-centered algorithm for surveillance after resection can be developed based on both risk of recurrence and potential benefit from further treatment to optimize individual follow-up algorithms.

Solitary metachronous gastric metastasis from pulmonary adenocarcinoma: Report of a case

INTRODUCTION

Gastric metastases from lung adenocarcinoma are rare and usually associated with disseminated disease. The great majority is asymptomatic and in few cases discovered during autopsy studies. Reports of single metachronous metastases during the lifetime are anecdotal. We describe a case of solitary gastric metastasis 5 years after lung surgery.

PRESENTATION OF CASE

A 68-year-old male submitted in 2006 to right lobectomy for lung adenocarcinoma was referred at Emergency Room department in 01/2011 because of chronic epigastric pain. Radiologic and endoscopic evaluation showed a bulky lesion inside the stomach, originating from the muscular layer, suspected for GIST. He underwent a subtotal gastrectomy and the pathologic examination revealed an undifferentiated adenocarcinoma, positive for Thyroid Transcriptional Factor-1, Cytokeratin 7, AE 1/3 and CEA, confirming the pulmonary origin.

DISCUSSION

At the time of diagnosis about 50% of lung cancer are metastatic, with survival rates of 1% at 5-year. Gastric metastasis is very rare; autopsy studies report an incidence of 0.2-0.5%. They develop in the submucosa, usually without any symptom and the diagnosis is incidental during the staging of primary cancer or the follow-up. There are no guidelines about surgical treatment; however few cases of long-term survival following the operation were reported. Pathologic diagnosis is difficult, but the immunohistochemical staining helps to recognize the primary origin.

CONCLUSION

Solitary metachronous gastric metastasis from pulmonary adenocarcinoma is an exceptional event, but it could happen during the follow-up. It seems that a radical resection, in absence of systemic implants, might provide survival benefits in selected patients.

Surgical treatment of oligometastatic non-small cell lung cancer

Patients with stage IV metastatic non-small cell lung cancer (NSCLC) are generally believed to have an incurable disease. Patients with oligometastatic disease represent a distinct subset of patients among those with metastatic disease. There is evidence that these patients have synchronous or metachronous satellite nodules in different pulmonary lobes or have solitary extrapulmonary metastases. In these cases, evidence has shown that surgical resection may provide patients with survival benefit. This article discusses the biology of the oligometastatic state in patients with lung cancer and the selection of patients for surgery, as well as the prognostic factors that influence survival of the patient. To properly select patients for an aggressive local treatment regime, accurate clinical staging is of prime importance. The use of FDG-PET should be considered for restaging if oligometastatic disease is suspected based on a patient's CT scan. A limitation of retrospective clinical studies for oligometastatic disease is that it is difficult to summarize and evaluate the available evidence for the effectiveness of surgical resection due to selection bias, and to a high degree of variability among different clinical studies. Nevertheless, we can certainly learn from the clinical experience acquired from retrospective case series to identify prognostic factors. Following surgical resection, the overall 5-year actuarial survival rate is about 28% for patients with satellite nodules and 21% for patients with ipsilateral nodules. Patients with resected brain metastasis achieve 5-year survival rates between 11% and 30%, and those with adrenalectomy for adrenal metastasis achieve 5-year survival rates of 26%.

Prognostic impact of local treatment against postoperative oligometastases in non-small cell lung cancer

OBJECTIVES

In this study, we investigated prognostic factors associated with survival after distantly metastatic recurrence in surgically resected non-small cell lung cancer (NSCLC), and clarified the influence of local treatment on the prognosis for oligometastatic recurrence.

METHODS

From 1994 through 2004, 418 consecutive patients with NSCLC underwent complete resection; 138 experienced a postoperative recurrence by December 2005. Of those, we reviewed 93 patients with only distant metastases for clinicopathological information, treatment modality, and survival.

RESULTS

For the 93 patients with distant metastasis alone, the 2- and 5-year survival rates after recurrence were 43.9% and 38.7%, respectively. Of those patients, 44 first received local treatment, including radiotherapy in 31 and a surgical resection in 13. Their recurrent disease (oligometastases) was limited with the potential to be controlled with local treatment. The targeted metastatic organs were brain in 14 patients, bone in 14, lungs in 12, and other organs in 4. Significant prognostic factors for postrecurrence survival included adenocarcinoma histology, long disease-free interval (DFI) (1 year or longer), and the performance of local treatment for oligometastases.

CONCLUSION

Local therapy such as radiotherapy and surgery, might be considered first-line treatment in patients with postoperative oligometastatic recurrence, especially those with a DFI ≥ 1 year.

Long-term survival in two cases of resected gastric metastasis of pulmonary pleomorphic carcinoma

We report two pulmonary pleomorphic carcinoma patients both of which underwent surgical resection of solitary gastric metastases. A 69-year-old man developed anemia 5 months after right upper lobectomy for pulmonary pleomorphic carcinoma and gastric metastasis was detected endoscopically. He underwent distal gastrectomy and has survived for 5 years without any other recurrence or metastasis. Preoperative abdominal computed tomography detected a submucosal gastric tumor in a 62-year-old man with left upper lobe pleomorphic carcinoma. A gastrointestinal stromal tumor was suspected. Left upper lobectomy was performed followed by partial gastrectomy with splenectomy. The histologic diagnosis was primary pulmonary pleomorphic carcinoma with gastric metastasis. He has survived for 4 years without any other recurrence or metastasis. Resection of gastric metastasis following complete pulmonary pleomorphic carcinoma resection may be indicated if the metastasis is solitary.

Annual abdominal ultrasonographic examination after curative NSCLC resection

BACKGROUND

There is no established follow-up strategy in non-small cell lung cancer patients after complete resection. Follow-up regimens are different between nations, institutions, and surgeons. We tried to investigate the role of annual abdominal ultrasonographic examination in completely resected NSCLC patients.

METHODS

We reviewed 265 consecutive patients who had their NSCLC completely resected at our institution from July 1992 through December 2000 and were followed by a single surgeon. Annual abdominal ultrasonography was performed until 5 years after resection. Chest CT and abdominal CT are not included in our routine follow-up program. Instead, we used ultrasonography to survey the abdomen because abdominal ultrasonography is less costly than abdominal CT, is non-invasive, and does not require contrast media.

RESULTS

A total of 892 ultrasonographic examinations were performed. Fifty-nine (22.3%) patients developed recurrence. Annual ultrasonography detected lesions suspicious of recurrence in 15 patients. Further work-up diagnosed NSCLC recurrence in 2 (0.8%) patients (multiple liver metastases in one and right adrenal metastasis in one). The two patients soon developed disseminated disease and died in less than a year.

CONCLUSIONS

Annual abdominal ultrasonography in the follow-up protocol for completely resected NSCLC patients was not beneficial. Our experience in the present study may be used as valid evidence to exclude abdominal ultrasonography from future trials comparing follow-up regimens after complete resection of NSCLC. A better follow-up strategy needs to be established.