Preoperative evaluation of adrenal lesions based on imaging studies and laparoscopic adrenalectomy in patients with otherwise operable lung cancer

Treatment outcomes in oligometastatic non-small-cell lung cancer: A single-centre experience

BACKGROUND

Even in oligometastatic stage 4 disease, survival rates are higher when curative approaches focus on both the primary tumour and metastasis. So, we aim to analyse our results of oligometastatic disease retrospectively.

METHODS

In total, data on 52 non-small-cell lung cancer (NSCLC) patients with limited metastasis (one to three synchronous/metachronous) were retrospectively analysed. All treatment modalities associated with various treatment modalities [surgery, chemoradiotherapy (CRT), supportive care and palliative chemotherapy] were compared in terms of survival. Curative treatment consisted of surgery or CRT (concurrent or sequential).

RESULTS

The median overall survival (OS) time was 35.2 ± 4.1 months. Surgery was superior to CRT in terms of OS (36.7 months vs 27.4 months, P > 0.05). Progression-free survival was 29.4 ± 3.9 months, and survival after first progression (SAFP) was 15.6 ± 2.8 months. Patients in whom a metastasectomy was performed had significantly higher rate of SAFP as compared with those who did not have a metastasectomy (20.07 ± 3.8 months vs 7.9 ± 1.7 months P = 0.046). According to pathological type, an adenocarcinoma was associated with better SAFP than a non-adenocarcinoma (23 ± 4.1 vs 6.4 ± 1.5, P = 0.002). The 1- and 2-years OS rates were 67% and 50.4%, respectively. Among the curative treatment group, the OS of patients younger than 65 years (n = 25) was 31 months, whereas that of patients older than 65 years (n = 13) was 22 months (P = 0.88).

CONCLUSION

In well-selected NSCLC patients with limited metastasis, survival rates can reach up to 3 years, even in a geriatric population. Clinical N staging and co-morbidity are important prognostic factors.

Surgical approach of non-small cell lung cancer with extrapulmonary metastasis

Bronchogenic carcinoma is the leading cause of death due to cancer worldwide. Nearly 75% of patients have a disseminated carcinoma at diagnosis. Up to 50% of patients with a localized disease will develop metastasis. Nevertheless, the current scientific evidence has demonstrated that when the metastatic disease is limited, particularly in specific locations such as the brain and the adrenal glands, a multidisciplinary approach with radical intent could achieve a longer survival. This review analyses the clinical evidence available in the literature that supports the treatment of both the primary and the metastatic disease, as well as the preoperative study and the most widely accepted indications.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

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.

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.

[The conceptual oligometastatic non-small cell lung cancer and therapeutic strategies]

非小细胞肺癌是发病率及致死率最高的恶性肿瘤之一。约20%-50%会发生远处转移，最常见的转移部位为脑、骨、肝及肾上腺。寡转移状态是一段肿瘤生物侵袭性较温和的时期，存在于局限性原发灶与广泛性转移之间的过渡阶段，转移瘤数目有限并且转移器官具有特异性。“寡转移”来源于微转移，肿瘤细胞已具有器官特异性，但尚不具备全身播散的遗传倾向。治疗寡转移状态的关键是局部控制，需要兼顾预防远处转移、治疗隐匿性转移灶、治疗寡转移灶和全身治疗结束后清除残留癌灶四个方面。本文旨在对“寡转移”概念在非小细胞肺癌常见转移脏器治疗中的应用作一综述。

Management of non-small cell lung cancer with oligometastasis

Patients with oligometastatic Non-Small Cell Lung Cancer (NSCLC) present a potential opportunity for curative therapy; however, the challenge remains the definitive treatment of their localized disease and ablation of their limited overt metastatic sites of disease. In selecting patients with oligometastatic NSCLC for definitive therapy, proper staging through radiographic studies, including PET and brain MRI, and the pathologic staging of the mediastinal lymph nodes and potential sites of metastatic disease, are critical. With that in mind, the available literature suggests that in highly selected patients with solitary metastases to the brain, adrenals and other organs, long term survival may be achieved with combined definitive therapy of both the primary lung tumor and the solitary metastatic site.

Imaging of adrenal masses with emphasis on adrenocortical tumors

Because of the more widespread and frequent use of cross-sectional techniques, mainly computed tomography (CT), an increasing number of adrenal tumors are detected as incidental findings (“incidentalomas”). These incidentaloma patients are much more frequent than those undergoing imaging because of symptoms related to adrenal disease. CT and magnetic resonance imaging (MRI) are in most patients sufficient for characterization and follow-up of the incidentaloma. In a minor portion of patients, biochemical screening reveals a functional tumor and further diagnostic work-up and therapy need to be performed according to the type of hormonal overproduction. In oncological patients, especially when the morphological imaging criteria indicate an adrenal metastasis, biopsy of the lesion should be considered after pheochromocytoma is ruled out biochemically. In the minority of patients in whom CT and MRI fail to characterize the tumor and when time is of essence, functional imaging mainly by positron emission tomography (PET) is available using various tracers. The most used PET tracer, [¹⁸F]fluoro-deoxy-glucose (¹⁸FDG), is able to differentiate benign from malignant adrenal tumors in many patients. ¹¹C-metomidate (¹¹C-MTO) is a more specialized PET tracer that binds to the 11-beta-hydroxylase enzyme in the adrenal cortex and thus makes it possible to differ adrenal tumors (benign adrenocortical adenoma and adrenocortical cancer) from those of non-adrenocortical origin.

Metomidate-based imaging of adrenal masses

Due to broader use of conventional imaging techniques, adrenal tumors are detected with increasing frequency comprising a wide variety of different tumor entities. Despite improved conventional imaging techniques, a significant number of adrenal lesions remain that cannot be easily determined. A particular diagnostic challenge are lesions in patients with known extra-adrenal malignancy because these patients frequently harbor adrenal metastases. Furthermore, adrenal masses with low fat content and no detectable hormone excess are difficult to diagnose properly. Fine needle biopsy is invasive, often unsuccessful, and puts patients at risk, e. g., in cases of pheochromocytoma or adrenal cancer. Noninvasive characterization using radiotracers has therefore been established in recent years. (18)F-FDG PET helps to differentiate benign from malignant lesions. However, it does not distinguish between adrenocortical or nonadrenocortical lesions (e.g., metastases or adrenocortical carcinoma). More recently, enzyme inhibitors have been developed as tracers for adrenal imaging. Metomidate is most widely used. It binds with high specificity and affinity to CYP11B enzymes of the adrenal cortex. As these enzymes are exclusively expressed in adrenocortical cells, uptake of labeled metomidate tracers has been shown to be highly specific for adrenocortical neoplasia. (11)C-metomidate PET and (123)I-iodometomidate SPECT imaging has been introduced into clinical use. Both tracers not only distinguish between adrenocortical and nonadrenocortical lesions but are also able to visualize metastases of adrenocortical carcinoma. The very specific uptake has recently led to first application of (131)I-iodometomidate for radiotherapy in ACC. In conclusion, metomidate-based imaging is an important complementary tool to diagnose adrenal lesions that cannot be determined by other methods.

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%.

[Diagnostic efficacy and discriminatory capacity of positron emission tomography combined with axial tomography of adrenal lesions]

INTRODUCTION

The usefulness of 18fluorodeoxyglucose positron emission tomography combined with axial tomography (PET-CT) in diagnosing whether adrenal tumours are benign or malignant is assessed.

MATERIAL AND METHODS

A retrospective study conducted between June 2005 and May 2009 on a consecutive series of patients on whom a PET-CT scan was performed to study suspected malignant adrenal disease. Focal uptakes were assessed, along with the maximum standard uptake value (SUV), and the ratio of the maximum adrenal/hepatic value. The sensitivity, specificity, positive and negative predictive value of the test, the maximum adrenal uptake values and the ratio for those where the diagnostic yield was maximum.

RESULTS

Fifteen patients were included. The final diagnosis showed malignancy in eight and seven were benign. Ten patients had adrenal uptake: three in benign lesions and seven in neoplasias, with a mean uptake value of 6.3 (3.2 in benign lesions and 9.0 in malignant lesions). The mean adrenal/hepatic ratio was 1.8 (0.9 in benign and 2.6 in malignant lesions). When the presence of adrenal uptake is associated with a final diagnosis of malignancy, we obtained a sensitivity of 87.5%, a specificity of 57.1%, and a positive and negative predictive value of 70% and 80%, respectively. An SUV cut-off value of 6, or an adrenal/hepatic uptake ratio of 2, gave a sensitivity of 75%, a specificity of 100%, and a positive and negative predictive value of 100% and 77.7%, respectively.

CONCLUSIONS

PET-CT has a high ability to discriminate between benign and malignant lesions in the adrenal disease studied.

Utility of PET/CT in differentiating benign from malignant adrenal nodules in patients with cancer

OBJECTIVE

The purpose of this retrospective study was to determine the sensitivity and specificity of combined PET/CT in differentiating benign from malignant adrenal nodules measuring at least 1 cm in diameter in patients with cancer.

MATERIALS AND METHODS

We reviewed the radiology reports and images of patients with known malignant disease who had undergone PET/CT for cancer staging or surveillance and who had adrenal nodules at least 1 cm in diameter. We identified 112 adrenal nodules in 96 patients. Two-dimensional PET had been performed 1 hour after administration of (18)F-FDG. Unenhanced CT was performed for attenuation correction, to determine lesion size, and for coregistration with PET data. Adrenal nodules were considered to have a positive PET result if the average standardized uptake value was greater than that of the liver. Follow-up data and biopsy reports were used to determine the pathologic status of the adrenal nodules.

RESULTS

Thirty adrenal lesions were malignant. Twenty-five of the 30 malignant nodules had positive PET results. Twelve of 82 benign nodules were PET positive with a sensitivity of 83.3% and specificity of 85.4%. Patients with four of five malignant nodules with negative PET results had received previous therapy. The positive predictive value for detection of malignant lesions was 67%, and the negative predictive value was 93%.

CONCLUSION

Adrenal masses that are not FDG avid are likely to be benign with a high negative predictive value. Especially in patients undergoing therapy, however, there is a small but statistically significant false-negative rate. A considerable proportion of benign nodules have increased FDG activity.

A diagnostic model to detect silent brain metastases in patients with non-small cell lung cancer

We aimed to discriminate subgroups according to the risk of brain metastases in patients with non-small cell lung cancer (NSCLC) lacking neurological symptoms. We performed a retrospective review of 433 patients with NSCLC who underwent chest computed tomography (CT), brain magnetic resonance imaging (MRI) and bone scans at an initial staging work-up between April 2003 and April 2007. Brain metastases were determined by MRI. Patients were stratified into groups according to the number of risk factors (0-3) identified by multivariate analysis. In multivariate analysis, histopathology with non-squamous cell carcinoma, nodal stage 2 on CT and presence of bone metastases were three risk factors for brain metastases. Patients were divided into four groups according to the number (0-3) of these predictive factors. The proportions of patients with brain metastases in the four groups were 2%, 3%, 17% and 35%, respectively, and these differences were significant (P<0.001). When analysis was performed in patients with localised disease, the number of risk factors was correlated with the prevalence of brain metastases (P=0.013) but stage was not (P=0.153). Although this diagnostic model should be validated through further studies, our data suggest that the number of risk factors might be a useful tool to identify silent brain metastases in patients with NSCLC.