Management of early stage non-small cell lung cancer in high-risk patients

Outcomes After Surgery in High-Risk Patients With Early Stage Lung Cancer

BACKGROUND

Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery.

METHODS

A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV1) 50% or less or diffusing capacity of lung for carbon monoxide (Dlco) 50% or less; and minor: (two of the following), age 75 years or more, FEV1 51% to 60%, or Dlco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ(2) test/Fisher's exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn.

RESULTS

In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV1 (57% versus 85%, p < 0.0001), and Dlco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients (p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients (p < 0.0001).

CONCLUSIONS

Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy.

Managing lung cancer in high-risk patients: what to consider

Lung cancer patients with medical comorbidity are a challenge for care providers. As with other solid tumors, treatment is stage dependent; but a critical difference is the invasive nature of lung resections and the resulting importance of surgical risk stratification for treatment of early stage disease. External beam radiation was considered the only treatment option for early stage disease in non-operative candidates 10-15 years ago. With recent advances in image-guided technologies, robotics, and the resurgence in interest of sublobar resection there are now numerous treatment options which offer excellent local control and reasonable short and long term survival. Extensive work has been done to clarify interventional risk, and accurately describe anticipated outcomes of these varied treatments in the high risk population. The aim of this article is to review recent literature and provide a better understanding of the considerations used in the management of these patients in the current era.

Gene expression ratio test distinguishes normal lung from lung tumors in solid tissue and FNA biopsies

Lung cancer is the leading cause of cancer-related deaths worldwide. Prognosis and survival are dependent on cell type, early detection, and surgical treatment. Hence, optimal screening strategies and new therapies are urgently required. Although surveillance with low-dose computed tomography can reduce lung cancer mortality by 20%, the number of false-positive detections is significant. Tissue diagnosis aids in the identification of benign nodules, reducing the number of false positive detections. To determine whether molecular testing of fine-needle aspirations (FNAs) can reduce false-positive detections, we developed a gene expression-based test that distinguishes normal from cancerous lung tissues. The test first was applied to published microarray data, showing overall sensitivity and specificity values of 95% (95% CI, 90%-98%) and 100% (95% CI, 40%-100%), respectively. Subsequently, it was validated on 30 solid and ex vivo FNA lung cancer tumor samples and matched normal lung specimens using real-time PCR. The validation test was 93% (95% CI, 78%-99%) sensitive and 100% (95% CI, 88%-100%) specific for the detection of tumor versus normal lung on solid samples, whereas FNA specimens yielded a sensitivity of 91% (95% CI, 72%-99%) and a specificity of 94% (95% CI, 70%-100%). This study supports the hypothesis that the gene-ratio approach reliably distinguishes normal lung from cancerous tissues in FNA samples and can be optimized to diagnose benign nodules.