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Local Ablative Therapies for Oligometastatic and Oligoprogressive Non-Small Cell Lung Cancer. ACTA ACUST UNITED AC 2021; 26:129-136. [PMID: 32205537 DOI: 10.1097/ppo.0000000000000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
More than half of all patients with non-small cell lung cancer (NSCLC) have metastatic disease at the time of diagnosis. A subset of these patients has oligometastatic disease, which exists in an intermediary state between locoregional and disseminated metastatic disease. In addition, some metastatic patients on systemic therapy may have limited disease progression, or oligoprogression. Historically, treatment of metastatic NSCLC was palliative in nature, with little expectation of long-term survival. However, an accumulation of evidence over the past 3 decades now demonstrates that local ablative therapy to sites of limited metastases or progression can improve patient outcomes for this complex disease. This review examines the evidence behind local ablative therapy in oligometastatic and oligoprogressive NSCLC, with a focus on surgery, stereotactic radiotherapy, and radiofrequency ablation.
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Koutras AK, Marangos M, Kourelis T, Partheni M, Dougenis D, Iconomou G, Vagenakis AG, Kalofonos HP. Surgical Management of Cerebral Metastases from Non-Small Cell Lung Cancer. TUMORI JOURNAL 2018; 89:292-7. [PMID: 12908786 DOI: 10.1177/030089160308900312] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background The objective of the study was to assess the efficacy of surgical resection of solitary brain metastasis in patients with non-small-cell lung cancer. Methods and Study Design We report a retrospective analysis of 32 patients with single brain metastasis surgically excised at our hospital. All but one patient underwent postoperative whole brain radiation therapy. Results The median survival of patients was 12.5 months postoperatively (mean, 17 months), and the overall 1-year survival was 53%. Thirteen patients had recurrence of brain metastasis: 6 of 13 underwent reoperation for the recurrent lesion, and 1 of the 6 patients had a third craniotomy. Baseline characteristics, which significantly influenced survival, included age less than 60 years, tumor histology (ie, adenocarcinoma), and treatment of the primary lung cancer. The analysis did not yield any significant differences between treatment modalities. Conclusions Our findings correspond well with those reported in the literature and suggest that surgical resection of single brain metastasis in patients with non-small cell lung cancer can improve survival over conservative management. Furthermore, surgical treatment of the primary tumor and the single brain metastasis, combined or not with radiotherapy and chemotherapy, represents an approach that merits further investigation with more patients and a prospective longitudinal design.
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Affiliation(s)
- Angelos K Koutras
- Division of Oncology, Department of Medicine, University Hospital, Patras Medical School, Rion, Greece
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Lee HW, Lee JI, Lee SJ, Cho HJ, Song HJ, Jeong DE, Seo YJ, Shin S, Joung JG, Kwon YJ, Choi YL, Park WY, Lee HM, Seol HJ, Shim YM, Joo KM, Nam DH. Patient-derived xenografts from non-small cell lung cancer brain metastases are valuable translational platforms for the development of personalized targeted therapy. Clin Cancer Res 2014; 21:1172-82. [PMID: 25549722 DOI: 10.1158/1078-0432.ccr-14-1589] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The increasing prevalence of distant metastases from non-small cell lung cancer (NSCLC) indicates an urgent need for novel therapeutic modalities. Brain metastasis is particularly common in NSCLC, with severe adverse effects on clinical prognosis. Although the molecular heterogeneity of NSCLC and availability of various targeted agents suggest personalized therapeutic approaches for such brain metastases, further development of appropriate preclinical models is needed to validate the strategies. EXPERIMENTAL DESIGN We established patient-derived xenografts (PDX) using NSCLC brain metastasis surgical samples and elucidated their possible preclinical and clinical implications for personalized treatment. RESULTS NSCLC brain metastases (n = 34) showed a significantly higher successful PDX establishment rate than primary specimens (n = 64; 74% vs. 23%). PDXs derived from NSCLC brain metastases recapitulated the pathologic, genetic, and functional properties of corresponding parental tumors. Furthermore, tumor spheres established in vitro from the xenografts under serum-free conditions maintained their in vivo brain metastatic potential. Differential phenotypic and molecular responses to 20 targeted agents could subsequently be screened in vitro using these NSCLC PDXs derived from brain metastases. Although PDX establishment from primary NSCLCs was significantly influenced by histologic subtype, clinical aggressiveness, and genetic alteration status, the brain metastases exhibited consistently adequate in vivo tumor take rate and in vitro tumor sphere formation capacity, regardless of clinical and molecular conditions. CONCLUSIONS Therefore, PDXs from NSCLC brain metastases may better represent the heterogeneous advanced NSCLC population and could be utilized as preclinical models to meet unmet clinical needs such as drug screening for personalized treatments.
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Affiliation(s)
- Hye Won Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Jeong Lee
- Department of Anatomy and Cell Biology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Jung Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Jin Song
- Department of Anatomy and Cell Biology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Da Eun Jeong
- Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yun Jee Seo
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Shin
- Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Je-Gun Joung
- Samsung Genome Institute (SGI), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong-Jun Kwon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yoon-La Choi
- Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woong-Yang Park
- Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Genome Institute (SGI), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Mog Shim
- Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Kyeung Min Joo
- Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Department of Anatomy and Cell Biology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. Samsung Biomedical Research Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Abstract
In the absence of persuasive findings from the trials outlined earlier, the available evidence supports treating patients with a solitary site of M1 disease with induction chemotherapy followed by resection of all sites of disease as long as patients understand that this multimodality approach has not been proven to be superior to either surgery alone or chemotherapy alone.
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Affiliation(s)
- Robert J Downey
- Thoracic Service, Department of Surgery, Memorial Hospital, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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5
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Bailon O, Kallel A, Chouahnia K, Billot S, Ferrari D, Carpentier AF. [Management of brain metastases from non-small cell lung carcinoma]. Rev Neurol (Paris) 2011; 167:579-91. [PMID: 21546046 DOI: 10.1016/j.neurol.2011.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 01/03/2011] [Accepted: 01/17/2011] [Indexed: 01/08/2023]
Abstract
INTRODUCTION In France, approximately 30,000 new patients per year develop brain metastases (BM), most of them resulting from a lung cancer. STATE OF THE ART Surgery and radiosurgery of all the BM must be considered when possible. In other cases, whole brain radiotherapy remains the standard of care. PERSPECTIVES The role of chemotherapy, poorly investigated so far, should be revisited. CONCLUSION This review focused on BM secondary to a non-small cell lung carcinoma.
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Affiliation(s)
- O Bailon
- Service de neurologie, hôpital Avicenne, AP-HP, 125, route de Stalingrad, 93000 Bobigny, France
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Mercier O, Fadel E, Mussot S, Fabre D, Chataigner O, Chapelier A, Dartevelle P. Faut-il opérer les métastases surrénaliennes isolées des cancers bronchopulmonaires non à petites cellules? Presse Med 2007; 36:1743-52. [PMID: 17851028 DOI: 10.1016/j.lpm.2007.04.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 02/21/2007] [Accepted: 04/11/2007] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND No consensus yet governs management of solitary adrenal metastasis of non-small cell lung cancer (NSCLC). Although classically considered incurable, various case reports and small series indicate that surgical treatment may improve long-term survival. The aim of this study was to review our experience and to identify factors that may affect survival. METHODS From January 1989 through June 2006, 26 patients (21 men and 5 women; mean age: 54+/-10 years) underwent complete resection of an isolated adrenal metastasis after surgical treatment of NSCLC. The adrenal metastasis was diagnosed at the same time as the NSCLC in 6 patients and subsequently in 20 patients. Median disease-free interval for patients with metachronous metastasis was 13.8 months (range: 4.5 to 60.1 months). RESULTS The overall 5- and 10-year survival rates were 31 and 21% respectively. Univariate and multivariate analysis showed that a disease-free interval longer than 6 months was a significant independent predictor of longer survival in patients after adrenalectomy. All patients with a disease-free interval of less than 6 months died within 2 years of surgery. After resection of an isolated adrenal metastasis diagnosed more than 6 months after lung resection, the 5-year survival rate was 49%. Adjuvant therapy and pathological staging of NSCLC did not affect survival. CONCLUSION Surgical resection of subsequent isolated adrenal metastasis with a disease-free interval longer than 6 months can lead to long-term survival in patients with previous complete resection of the primary NSCLC.
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Affiliation(s)
- Olaf Mercier
- Service de chirurgie thoracique et vasculaire et de transplantation cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson.
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8
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M18-04: Treatment and prevention of CNS metastases in NSCLC. J Thorac Oncol 2007. [DOI: 10.1097/01.jto.0000282983.03866.9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chao ST, Barnett GH, Liu SW, Reuther AM, Toms SA, Vogelbaum MA, Videtic GMM, Suh JH. Five-year survivors of brain metastases: A single-institution report of 32 patients. Int J Radiat Oncol Biol Phys 2006; 66:801-9. [PMID: 16904847 DOI: 10.1016/j.ijrobp.2006.05.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 05/19/2006] [Accepted: 05/25/2006] [Indexed: 11/20/2022]
Abstract
PURPOSE To report on 32 patients who survived > or = 5 years from brain metastases treated at a single institution. METHODS AND MATERIALS The records of 1288 patients diagnosed with brain metastases between 1973 and 1999 were reviewed. Patients were treated with whole-brain radiation therapy (WBRT), surgery, and/or stereotactic radiosurgery (SRS). Thirty-two (2.5%) > or = 5-year survivors were identified. Factors contributing to long-term survival were identified. RESULTS Median survival was 9.3 years for > or = 5-year survivors. Seven of these patients lived > or = 10 years. Female gender was the only patient characteristic that correlated with better survival (p = 0.0369). When these patients were compared with < 5-year survivors, age < 65 years (p = 0.0044), control of the primary at diagnosis (p = 0.0052), no systemic disease (p = 0.0012), recursive partitioning analysis (RPA) Class 1 (p = 0.0002 with Class 2; p = 0.0022 with Class 3), and single brain metastasis (p = 0.0018) were associated with long-term survival in the univariate logistic regression model. In the multivariate model, RPA Class 1 compared with Class 2 (OR = 0.39, p = 0.0196), surgery (OR = 0.16, p < 0.0001), and SRS (OR = 0.41, p = 0.0188) were associated with long-term survival. CONCLUSIONS For patients with good prognostic factors such as young age, good RPA characteristics and single metastasis, treatment with surgery or SRS offers the best chance for long-term survival.
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Affiliation(s)
- Samuel T Chao
- Department of Radiation Oncology, Brain Tumor Institute, Taussig Cancer Center, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Girard N, Cottin V, Tronc F, Etienne-Mastroianni B, Thivolet-Bejui F, Honnorat J, Guyotat J, Souquet PJ, Cordier JF. Chemotherapy is the cornerstone of the combined surgical treatment of lung cancer with synchronous brain metastases. Lung Cancer 2006; 53:51-8. [PMID: 16730853 DOI: 10.1016/j.lungcan.2006.01.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Revised: 01/17/2006] [Accepted: 01/23/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Lung cancer accounts for about 50% of brain metastases, of which nearly 25% are eligible for neurosurgery, providing a neurological control rate of up to 70% when followed by whole brain radiation therapy. How to manage the primary lung carcinoma remains elusive. METHODS We undertook a retrospective study of consecutive patients who underwent surgical resection for synchronous brain metastases from non-small cell lung cancer in a single institution, to determine overall survival and prognostic factors, with particular attention to the treatment of the primary lung tumor. RESULTS Fifty-one patients underwent surgical resection of synchronous brain metastases from non-small cell lung cancer. Median survival was 13.2 months. Prognosis mainly depended of the treatment of the lung tumor, with a marked survival advantage in the 29 patients receiving a focal treatment (thoracic surgery or radiotherapy), compared to the 22 other patients: median, 1-year, and 2-year survival were 22.5 months, 69%, and 42%, versus 7.1 months, 33%, and 5%, respectively (p<0.001); response to pre-operative chemotherapy before focal treatment was the main favorable prognostic factor (p=0.023), and further identified patients who had benefit from resection of the lung tumor, with a significantly better outcome. CONCLUSIONS Chemotherapy, by its therapeutic and prognostic value, may be considered as the cornerstone of the combined medical and surgical therapeutic sequence whereby brain metastasectomy is followed by chemotherapy and further focal treatment of the primary lung tumor in responders to chemotherapy.
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Affiliation(s)
- Nicolas Girard
- Department of Respiratory Medicine, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
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I H, Lee JI, Nam DH, Ahn YC, Shim YM, Kim K, Choi YS, Kim J. Surgical treatment of non-small cell lung cancer with isolated synchronous brain metastases. J Korean Med Sci 2006; 21:236-41. [PMID: 16614507 PMCID: PMC2733997 DOI: 10.3346/jkms.2006.21.2.236] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study is a retrospective examination of our experiences with patients who underwent treatment of isolated synchronous brain metastases coupled with primary non-small cell lung cancer. From January 1995 to June 2004, 12 patients presented with isolated synchronous brain metastases coupled with primary non-small cell lung cancer. The patient was comprised of 8 men and 4 women. The median age was 52 yr, in a range of 32 to 75 yr. Median follow-up duration was 10.6 months, in a range of 2 to 55.8 months. Recurrence developed in 7 patients, and the median interval from 1st treatment to recurrence was 4.5 months (2.8-6.5 months). The overall 1-yr survival rate was 61.7%. The 1-yr survival rates for pathologic N0 and N1 cases were 75% and 66.7%, respectively. The median survival duration for pathologic N2 was 6.2 months (95% CI, 4.8-7.5 months). The 1-yr survival rate for cases of single brain metastasis was 75%. Based on our current observations, we could speculate that aggressive management of primary non-small cell lung cancer and isolated synchronous brain metastases was beneficial in a selected group of patients, as long as the brain lesions and pulmonary lesions were limited or resectable.
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Affiliation(s)
- Hoseok I
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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12
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Abstract
BACKGROUND Non-small-cell lung cancer is a leading cause of cancer morbidity and mortality in Australia. Brain metastases are common, and rapidly fatal if untreated. Optimal management consists of resection and whole brain irradiation. However, there is a paucity of local data documenting survival after such treatment. METHODS Medical records for all patients who underwent complete resection of non-small-cell lung cancer at one institution between January 1999 and December 2003 were reviewed in order to determine survival after initial surgery. The survival of all patients was compared with patients who underwent resection of synchronous or metachronous brain metastases and whole brain irradiation as part of their lung cancer management. RESULTS Between 1 January 1999 and 31 December 2003, 170 patients underwent complete resection of non-small-cell lung cancer by a thoracic surgeon. Resection of synchronous or metachronous brain metastases followed by whole brain irradiation was also carried out on 15 of these patients. Complete cerebral resection was achieved in 12 cases. The overall 5-year survival after attempted curative resection of brain metastases and successful complete resection was 60% and 70%, respectively. The survival of patients with both cerebral metastasectomy and lung cancer resection approximated that of the cohort of patients that only required complete resection of their lung cancer. CONCLUSIONS Control of local disease at each site and long-term survival after lung resection and resection of either synchronous or metachronous brain METASTASIS and whole brain irradiation is readily achievable. We believe this should continue as the standard of care for this presentation.
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Affiliation(s)
- Marissa Daniels
- St Vincent's Hospital, Cardiothoracic Care Centre, St Vincent's Hospital, University of Melbourne Clinical School, Victoria, Australia
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Mercier O, Fadel E, de Perrot M, Mussot S, Stella F, Chapelier A, Dartevelle P. Surgical treatment of solitary adrenal metastasis from non-small cell lung cancer. J Thorac Cardiovasc Surg 2005; 130:136-40. [PMID: 15999053 DOI: 10.1016/j.jtcvs.2004.09.020] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of solitary adrenal metastasis from non-small cell lung cancer is still debated. Although classically considered incurable, various reports with small numbers of patients have shown that surgical treatment might improve long-term survival. The aim of this study was to review our experience and to identify factors that could affect survival. METHODS From January 1989 through April 2003, 23 patients underwent complete resection of an isolated adrenal metastasis after surgical treatment of non-small cell lung cancer. There were 19 men and 4 women, with a mean age of 54 +/- 10 years. The diagnosis of adrenal metastasis was synchronous with the diagnosis of non-small cell lung cancer in 6 patients and metachronous in 17 patients. The median disease-free interval for patients with metachronous metastasis was 12.5 months (range, 4.5-60.1 months). RESULTS The overall 5-year survival was 23.3%. Univariate and multivariate analysis demonstrated that a disease-free interval of greater than 6 months was an independent and significant predictor of increased survival in patients after adrenalectomy. All patients with a disease-free interval of less than 6 months died within 2 years of the operation. The 5-year survival was 38% after resection of an isolated adrenal metastasis that occurred more than 6 months after lung resection. Adjuvant therapy and pathologic staging of non-small cell lung cancer did not affect survival. CONCLUSIONS Surgical resection of metachronous isolated adrenal metastasis with a disease-free interval of greater than 6 months can provide long-term survival in patients previously undergoing complete resection of the primary non-small cell lung cancer.
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Affiliation(s)
- Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, France
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Vesselle H, Turcotte E, Wiens L, Schmidt R, Takasugi JE, Lalani T, Vallières E, Wood DE. Relationship between Non-Small Cell Lung Cancer Fluorodeoxyglucose Uptake at Positron Emission Tomography and Surgical Stage with Relevance to Patient Prognosis. Clin Cancer Res 2004; 10:4709-16. [PMID: 15269143 DOI: 10.1158/1078-0432.ccr-03-0773] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Because the tumor stage is the most significant prognostic factor for non-small cell lung cancer (NSCLC) and given that NSCLC [(18)F]fluorodeoxyglucose ((18)F-FDG) uptake appears to have prognostic significance, we examined the relationship between NSCLC (18)F-FDG uptake and surgical stage. EXPERIMENTAL DESIGN One hundred seventy-eight patients with a proven diagnosis of NSCLC were enrolled, then imaged with (18)F-FDG positron emission tomography and their disease thoroughly staged. Primary tumor size at computed tomography and (18)F-FDG uptake were compared to overall tumor stage and to T, N, and M stage descriptors. Tumor uptake was quantitated by maximum pixel-standardized uptake value (maxSUV) and then partial volume corrected for lesion size using recovery coefficients. RESULTS A significant difference in tumor size was associated with tumors of different TNM stage, T status, N status, or M status. Similarly, the primary tumor maxSUV was significantly associated with TNM stage, T status, and M status. However, we observed no significant difference in the partial-volume-corrected tumor maxSUV for different stages; different T, N, or M descriptors; tumors without evidence of spread (N(0)M(0)) versus tumors with nodal spread (N(1,2,3)M(0)); or tumors without spread (N(0)M(0)) versus all others. CONCLUSIONS We found an association between tumor stage and (18)F-FDG maxSUV, but this relationship disappeared after correction of tumor uptake for lesion size. Therefore, if partial-volume-corrected (18)F-FDG uptake is prognostic of NSCLC outcome, it is not on the basis of a relationship with tumor stage but through a different mechanism.
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Affiliation(s)
- Hubert Vesselle
- Department of Radiology, University of Washington, Seattle, Washington 98195, USA.
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15
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Abstract
The standard treatment for patients with stage IV non-small cell lung cancer (NSCLC) is chemotherapy. Retrospective series suggest, however, that some patients with stage IV lung cancer with a solitary synchronous site of extrathoracic metastatic (M1) disease are effectively treated by resection of both the primary tumor and the meststasis. Although these patients represent a small minority of those with stage IV lung cancer, it appears reasonable to consider highly selected patients with a solitary resectable metastasis from NSCLC for surgical resection of all evident disease or for chemotherapy without surgery. Because of the results of the current author's trial, however, it is difficult to recommend the regimen of combined medical and surgical therapies used in the current protocol in the management of solitary M1 disease. Future trials could be designed to include newer, less toxic chemotherapeutic regimens.
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Affiliation(s)
- Robert J Downey
- Division of Thoracic Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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16
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Abstract
BACKGROUND Systemic cancer is the second most common cause of death for adults in the United States. Twenty percent of these patients develop neurologic symptoms sometime during their illness. An apparent increase in the incidence of both systemic cancers and resulting brain metastases are posing an increasing challenge to health care providers. Neurologic complications lead to significant morbidity and mortality in these patients. Therefore, it is important to understand the current concepts of diagnosis and treatment of patients with brain metastases. REVIEW SUMMARY This review summarizes the epidemiology, clinical features, pathophysiology, and diagnostic evaluation of brain metastases. The section on current treatments is presented from the perspective of the three most common primary tumor locations along with the treatment approach to other metastatic tumors. This review includes a thorough evaluation of the literature, highlights controversies over treatment options, and provides insight into novel approaches currently under investigation. Clinical studies needed for further study are also discussed. CONCLUSIONS A clearer understanding of the pathophysiology of metastatic tumors and advances in diagnostic technology have paved the road to a better approach to treatment of brain metastases. Although no curative treatments are available to date, significant improvement in a patient's quality of life and life expectancy can be achieved with the available therapy. A better understanding of different primary cancers leading to brain metastases leads to a more effective treatment. More studies are needed to critically analyze the clear benefit of these treatment options in selected patients.
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Furák J, Troján I, Tiszlavicz L, Micsik T, Puskás LG. Development of brain metastasis 5 years before the appearance of the primary lung cancer: "messenger metachronous metastasis". Ann Thorac Surg 2003; 75:1016-7. [PMID: 12645740 DOI: 10.1016/s0003-4975(02)04396-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a patient with a brain metastasis that presented 5 years before the primary adenocarcinoma of the lung from which it originated. The metastasis and the primary tumor were removed. To confirm their common origin, we used comparative genomic hybridization. We have named this type of metastasis "messenger metachronous metastasis." The patient remains well 79 months after the brain metastasectomy and 18 months after the lung surgery.
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Affiliation(s)
- József Furák
- Division of Thoracic Surgery, University of Szeged, Szeged, Hungary.
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18
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Downey RJ, Ng KK, Kris MG, Bains MS, Miller VA, Heelan R, Bilsky M, Ginsberg R, Rusch VW. A phase II trial of chemotherapy and surgery for non-small cell lung cancer patients with a synchronous solitary metastasis. Lung Cancer 2002; 38:193-7. [PMID: 12399132 DOI: 10.1016/s0169-5002(02)00183-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Retrospective reports suggest that selected patients with non-small cell lung cancer (NSCLC) and a solitary synchronous site of M(1) disease may be effectively treated by resection of all disease sites. The feasibility and potential benefit of combining surgery and chemotherapy in this setting are unclear. Therefore, we performed a prospective trial to test this therapeutic approach. METHODS Patients with solitary synchronous M(1) NSCLC with or without N(2) disease were to receive three cycles of mitomycin, vinblastine, cisplatin (MVP) chemotherapy, followed by resection of all disease sites, and then two cycles of VP chemotherapy. Solitary brain metastases were to be resected before chemotherapy. RESULTS From 10/92-2/99, 23 patients (12 men, 11 women, median age = 55 years) were enrolled. Mediastinoscopy, performed in 22 patients, showed involved N(2) nodes in 12. The M(1) sites included brain (14 patients) adrenal (3), bone (3), spleen (1), lung (1), and colon (1). Of 12 patients who completed all three induction therapy cycles, 8 underwent R(0) resections. Another 5 patients had R(0) resections without completing induction therapy. Eight of the 13 patients undergoing R(0) resections completed postoperative chemotherapy. The median survival was 11 months; 2 patients survived to 5 years without disease. CONCLUSIONS (1) The number of patients with solitary M(1) disease who qualified for this combined modality therapy was small; (2) MVP was poorly tolerated as induction chemotherapy in this patient population; (3) Compared to historical experience with surgery alone, overall survival does not appear to be superior with this treatment strategy.
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Affiliation(s)
- Robert J Downey
- Thoracic Services, Memorial Sloan-Kettering Cancer Center, Division of Thoracic Surgery, 1275 York Avenue, New York, NY 10021, USA.
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Abrahams JM, Torchia M, Putt M, Kaiser LR, Judy KD. Risk factors affecting survival after brain metastases from non-small cell lung carcinoma: a follow-up study of 70 patients. J Neurosurg 2001; 95:595-600. [PMID: 11596953 DOI: 10.3171/jns.2001.95.4.0595] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors present their experience with the treatment of brain metastases from non-small cell lung carcinoma (NSCLC). METHODS A retrospective review was conducted in which records from 74 patients treated at the authors' institution between 1994 and 1999 were assessed. Survival and functional outcome were reviewed relative to individual patient variables. The median survival time was 12.9 months, with 1-, 2-, and 5-year survival milestones reached by 52.2%, 30.7%. and 18.1% of patients, respectively. Patients were stratified into groups composed of those with synchronous brain metastases (tumors diagnosed within 3 months of NSCLC) and metachronous brain metastases (tumors diagnosed 3 months after NSCLC). The median survival time and 5-year survival rate were 18 months and 28.9% for metachronous, compared with 9.9 months and 0% for synchronous brain metastases. In univariate analyses, the stage of brain metastases, an initial Karnofsky Performance Scale (KPS) score of 90 or less, and conservative therapy for NSCLC were associated with worse outcomes (p < 0.05). In analyses in which tumors were stratified by synchronous compared with metachronous brain metastases, a preoperative KPS score of 90 or less and radiation therapy (RT) alone for brain metastases were associated with worse outcomes in patients with metachronous brain metastases but not with synchronous tumors (p < 0.05). When stratified by preoperative KPS score, the synchronous brain metastases stage or treatment of brain metastases with RT alone were associated with worse outcome in patients with KPS scores of 100, but had no discernible effect on patients with KPS scores of 90 or less (p < 0.05). CONCLUSIONS The tumor stage and preoperative KPS score were significantly associated with survival. Craniotomy plus RT significantly improved the prognosis in patients with metachronous brain metastases or those with a preoperative KPS score of 100.
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Affiliation(s)
- J M Abrahams
- Department of Neurosurgery, The Hospital of the University of Pennsylvania, Philadelphia 19104, USA.
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20
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Ambrogi V, Tonini G, Mineo TC. Prolonged survival after extracranial metastasectomy from synchronous resectable lung cancer. Ann Surg Oncol 2001; 8:663-6. [PMID: 11569782 DOI: 10.1007/s10434-001-0663-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Combined resection of solitary synchronous brain metastases and non-small-cell lung cancer has been shown to be successful. Thus, we proposed combining the surgery of solitary, extracranial metastases, and resectable lung cancer. METHODS Between March 1987 and December 1994, surgery was performed on nine patients with non-small-cell lung cancer with synchronous, solitary, extracranial, or distant metastasis: adrenal (n = 5), cutaneous (n = 2), axillary lymph node (n = 1) and kidney (n = 1). Criteria for operating on these patients included: primary tumor that was locally resectable in a radical manner, non-small-cell histology, no preoperative evidence of N2 disease, complete resection of histologically proven metastasis, and absence of other metastases found with computed tomography or bone scan. RESULTS Resection of the primary tumor and solitary metastases was achieved in all patients. Primary tumor was always resected by lobectomy. No mortality or major morbidity was reported. Five-year survival rate was 55.6%. Five patients who had adrenal (n = 3), or skin (n = 1), or axillary (n = 1) metastases, survived more than 5 years. All N2 patients (n = 2) died. CONCLUSIONS The presence of solitary, distant metastasis should not be considered, per se, a factor for denying surgery for locally resectable, non-small-cell lung cancer. Unexpected, prolonged survival was demonstrated in our limited series.
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Affiliation(s)
- V Ambrogi
- Department of Thoracic Surgery, Tor Vergata University, Rome, Italy
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21
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Rock JP, Haines S, Recht L, Bernstein M, Sawaya R, Mikkelsen T, Loeffler J. Practice parameters for the management of single brain metastasis. Neurosurg Focus 2000; 9:ecp2. [PMID: 16817694 DOI: 10.3171/foc.2000.9.6.12] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectIn January 1998 the Guidelines and Outcomes Committee of the American Association of Neurological Surgeons (AANS) issued a charge for the development of evidence-based practice parameters focusing on the treatment of patients with single metastasis to the brain. The charge was imposed in response to the significant controversy surrounding questions relating to the optimal management strategies for patients with single brain metastasis.MethodsA team consisting of physicians from the AANS, the American Academy of Neurology, and the American Association of Therapeutic Radiation Oncology convened and the literature was reviewed. Methodically drawing from the best of Class I, II, and III levels of available evidence, authors sought to determine how the literature addressed and disposed of the question of the optimal management for an adult with a known history of cancer and a single meta-static brain lesion. Framing the question in this specific manner allowed researchers to focus directly on treatment issues, without having to consider diagnostic issues.ConclusionsThe results of the evidence-based analysis demonstrated that there was insufficient information to establish standards of care. Data from the literature does, however, support a guideline stating that surgical resection accompanied by whole brain radiation therapy is associated with the best survival rate. Additional lower-quality evidence supports an option for management with radiosurgery.
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Affiliation(s)
- J P Rock
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan 48202, USA
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Harrison J, Ali A, Bonomi P, Prinz R. The Role of Positron Emission Tomography in Selecting Patients with Metastatic Cancer for Adrenalectomy. Am Surg 2000. [DOI: 10.1177/000313480006600503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Metastases to the adrenal glands usually signal disseminated disease. However, isolated metastases do occur that may be curable with adrenalectomy. Functional imaging with positron emission tomography (PET) can differentiate benign from malignant pathology and isolated from disseminated metastases. The purpose of this study was to determine whether PET scanning can influence the outcome of adrenalectomy for metastatic disease. We conducted a retrospective review of eight patients undergoing adrenalectomy for presumed isolated metastatic disease from 1985 through 1997. The patients included six women and two men with an average age of 58 (range, 36–74). Their primary tumors were six lung carcinomas, one renal cell carcinoma, and one colon carcinoma. The adrenal masses were located on the right in six patients, on the left in one, and bilaterally in one. Before operation, all patients were evaluated by chest and abdominal CT. Four patients were also evaluated by PET scan. Six right, one left, and one bilateral adrenalectomies were performed. Associated organ resections included two right partial nephrectomies and one right total nephrectomy, one left partial nephrectomy, two distal pancreatectomies, one splenectomy, and two partial hepatic resections. All eight patients survived operation. There were no major perioperative complications, but one patient required readmission for congestive heart failure. Three of the four patients who did not have PET scanning died from 4 to 48 months after operation with disseminated disease from lung, colon, and renal carcinoma respectively. The remaining patient who did not have PET scanning is alive and well 11 years later. Two of the four patients who had PET scans showing isolated disease are alive at 28 and 43 months after operation, whereas the other two died of disseminated disease at 29 and 36 months after operation. We conclude that 1) adrenalectomy can provide survival benefit in patients with isolated metastases, and 2) PET scanning is useful in confirming isolated metastatic disease and selecting patients for adrenalectomy.
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Affiliation(s)
- Jacqueline Harrison
- Department of General Surgery, Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois
| | - Amjad Ali
- Department of Radiology Section of Nuclear Medicine, Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois
| | - Philip Bonomi
- Department of Medicine Section of Oncology, Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois
| | - Richard Prinz
- Department of General Surgery, Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois
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Chidel MA, Suh JH, Greskovich JF, Kupelian PA, Barnett GH. Treatment outcome for patients with primary nonsmall-cell lung cancer and synchronous brain metastasis. RADIATION ONCOLOGY INVESTIGATIONS 1999; 7:313-9. [PMID: 10580901 DOI: 10.1002/(sici)1520-6823(1999)7:5<313::aid-roi7>3.0.co;2-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to evaluate the outcome of treatment for patients with newly diagnosed nonsmall-cell lung cancer (NSCLC) with an isolated, single, synchronous brain metastasis. A retrospective review was performed evaluating any patient diagnosed between 1982 and 1996 at the Cleveland Clinic Foundation with NSCLC metastatic only to the brain. Patients with multiple brain metastases or with systemic metastases to any other organ were excluded. Survival was measured from the date of the first treatment for malignancy. All hospital records were thoroughly reviewed in a retrospective manner. Thirty-three patients were identified who met the study criteria. Twelve patients had primary disease limited to the lung and hilar nodes, and 21 had more advanced primary disease with involvement of the mediastinum. Treatment of the chest was considered aggressive in 13 patients and palliative in 15. The primary tumor was observed in 5 patients. The management of the brain metastasis was as follows: 21 patients underwent surgical resection and postoperative whole brain radiotherapy (WBRT), 5 underwent stereotactic radiosurgery (SRS) and WBRT, 3 had resection alone, 2 had SRS alone, and 2 underwent WBRT alone. The median overall and disease-free survival for all patients was 6.9 months and 3.3 months, respectively. Overall survival was markedly improved with the addition of WBRT (P = 0.002) and with the aggressive management of the primary tumor (P = 0.005). A total of 9 patients experienced CNS failure, including both patients receiving WBRT alone. CNS failures were divided as follows: 3 local, 5 distant, and 1 local and distant. Two of the 4 patients with a local failure were salvaged, and ultimate local control of the original brain metastasis was achieved in 93.6% of cases. Survival remains poor for patients with Stage IV NSCLC even when metastatic disease is limited to a single site within the brain; however, aggressive therapy of both the lung primary and the brain metastasis may provide a survival advantage. Excellent local control of single brain metastases was achieved with a combination of WBRT with either surgical resection or SRS.
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Affiliation(s)
- M A Chidel
- Department of Radiation Oncology, Cleveland Clinic Foundation, Ohio 44195, USA
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25
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Bendinelli C, Lucchi M, Buccianti P, Iacconi P, Angeletti CA, Miccoli P. Adrenal masses in non-small cell lung carcinoma patients: is there any role for laparoscopic procedures? J Laparoendosc Adv Surg Tech A 1998; 8:119-24. [PMID: 9681423 DOI: 10.1089/lap.1998.8.119] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Surgical treatment of adrenal metastases from non-small cell lung carcinoma (NSCLC) is a current and controversial issue. We analyze our experience with the laparoscopic treatment of NSCLC solitary adrenal metastases. In the last 4 years, six patients underwent laparoscopic adrenalectomy for suspected solitary NSCLC metastasis. A metastasis was removed in four patients and a cortical adenoma in two. Laparoscopy with intraoperative ultrasonography was demonstrated to be an excellent procedure for the diagnostic and therapeutic management of the patient affected by a solitary adrenal metastasis from NSCLC. Longer follow-up and a larger series are necessary to enable definitive conclusions to be drawn about the impact on survival of laparoscopic adrenalectomy for NSCLC metastasis.
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Affiliation(s)
- C Bendinelli
- Department of Surgery, University of Pisa, Italy
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26
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Kelly K, Bunn PA. Is it time to reevaluate our approach to the treatment of brain metastases in patients with non-small cell lung cancer? Lung Cancer 1998; 20:85-91. [PMID: 9711526 DOI: 10.1016/s0169-5002(98)00020-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Brain metastases from non-small cell lung cancer develop in approximately one-third of patients. If not treated, neurological deterioration occurs quickly. Treatment with whole brain irradiation is advisable to palliate symptoms but despite this treatment, survival remains poor at 3-6 months. Recently, aggressive approaches with surgical resection and stereotactic radiosurgery have dramatically improved the control of brain metastases resulting in a meaningful survival advantage for a subset of eligible patients. New evidence also suggests a possible role for chemotherapy in the treatment of brain metastases. With several options now available to treat brain metastases proper patient selection is needed. This article will stratify patients with brain metastases and discuss the treatment modalities for each category.
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Affiliation(s)
- K Kelly
- Lung Cancer Program, University of Colorado Cancer Center, Denver 80262, USA.
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27
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Abstract
Key elements in the modern surgical treatment of metastatic brain tumors are a firm grasp of criteria for selection of proper surgical candidates and a thorough grounding in the surgical approaches to, and the anatomy of, cerebral metastases. It is important to realize that the presence of multiple or recurrent brain metastases does not automatically contraindicate surgery because in properly selected patients, resection of multiple metastases or reoperation for recurrent metastases can extend survival and enhance the quality of life. Appropriate treatment of metastatic brain tumors frequently requires the judicious use of modalities such as open craniotomy, whole brain radiotherapy, and stereotactic radiosurgery. In order to assure the best outcome of patients with cerebral metastases, it is necessary to have an awareness of how these modalities can best complement one another and to apply them accordingly.
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Affiliation(s)
- F F Lang
- Department of Neurosurgery, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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28
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Kuratsu JI, Kochi M, Yoshida A, Uemura S, Marubayashi T, Ushio Y. Long-term survival after successful surgical treatment of a solitary brain metastasis. Int J Clin Oncol 1997. [DOI: 10.1007/bf02488993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Abstract
BACKGROUND Metastatic non-small cell lung cancer (NSCLC) carries a dismal prognosis, which is minimally affected by chemotherapy. Solitary brain metastases from NSCLC have been resected with 5-year survivals of 10% to 30%. The objective of this study was to determine if resection of isolated adrenal metastases improves survival. METHODS Isolated adrenal metastases were found in 14 patients with NSCLC. Eight patients had resection after cis-platinum-based chemotherapy, and 6 received chemotherapy alone. RESULTS Median survival in the surgical group was significantly greater than that in the chemotherapy group (31 versus 8.5 months; p = 0.03). All patients in the chemotherapy group were dead by 22 months. Three-year actuarial survival in the surgical group was 38%. No difference in locoregional stage, size of adrenal metastases, patient age, or performance status was present between the two groups. CONCLUSIONS Long-term disease-free survival is possible after resection of isolated adrenal metastases from NSCLC. Resection of isolated adrenal metastases should be considered if the primary NSCLC is resectable.
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Affiliation(s)
- J D Luketich
- Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA
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32
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Goldberg M. Surgical approaches in special situations. Curr Probl Cancer 1996; 20:179-96. [PMID: 8866209 DOI: 10.1016/s0147-0272(96)80307-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Andrews RJ, Gluck DS, Konchingeri RH. Surgical resection of brain metastases from lung cancer. Acta Neurochir (Wien) 1996; 138:382-9. [PMID: 8738387 DOI: 10.1007/bf01420299] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The role of surgical resection for brain metastases is evolving. The most common primary for brain metastases is lung; in the US in 1992, for example, there were nearly 40,000 deaths with symptomatic brain metastases from lung cancer. We reviewed a series of 25 consecutive patients with non small cell lung cancer (NSCLC) undergoing open resection of one or more symptomatic brain metastases to consider the role of open resection. Twenty-three of the 28 resected lesions were 3 cm or greater in diameter; 19 were solid and nine cystic. Surgical adjuncts included (where indicated): stereotactic biopsy, cyst drainage, and craniotomy; intra-operative ultrasound; and intra-operative evoked potential mapping of the sensorimotor area. Six patients underwent thoracotomy for resection of the lung primary (in all but one case, prior to craniotomy). Except for two patients who had whole brain radiation therapy (WBXRT) prior to referral to Neurosurgery, all patients underwent WBXRT (30 to 60 Gy) postoperatively. The mean survival from date of craniotomy was 13.1 months, with two patients still alive at ten and seventeen months post-craniotomy. Survival comparisons which were significantly different included (1) lung surgery versus no lung surgery (25.7 months versus 9.1 months, P < 0.001), and (2) metachronous presentation of the lung primary and brain metastasis versus synchronous presentation (17.6 months versus 9.5 months, P = 0.025). Survival comparisons which were not significantly different included single versus multiple metastases, complete versus incomplete resection, adenocarcinoma versus large or squamous or cell histology, supratentorial versus infratentorial location, solid versus cystic metastasis, and age < or = 60 years versus > 60 years. These results, when compared with the literature on brain metastases, suggest that aggressive resection of symptomatic metastases from lung cancer (even if multiple) can improve functional survival over conservative management, and that small, asymptomatic lesions are well-controlled by WBXRT. They also confirm the previous finding that surgical treatment of both the lung primary and the brain metastases may afford the greatest period of functional survival for these patients.
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Affiliation(s)
- R J Andrews
- Department of Neurosurgery, Stanford University Medical Center, CA, USA
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34
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Yokoi K, Miyazawa N, Arai T. Brain metastasis in resected lung cancer: value of intensive follow-up with computed tomography. Ann Thorac Surg 1996; 61:546-50; discussion 551. [PMID: 8572765 DOI: 10.1016/0003-4975(95)01096-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Brain metastases are a common mode of recurrence in resected lung cancer and are usually associated with an ominous outcome. METHODS To assess the usefulness of follow-up using computed tomography of the brain for early detection and effective treatment of brain metastases, we prospectively studied 128 patients with completely resected non-small cell lung cancer. Follow-up computed tomographic scans were obtained every 2 to 6 months over 24 postoperative months in 69 patients and every 2 months for 6 postoperative months in 59. RESULTS Brain metastases were discovered in 11 patients (8.6%), and 7 patients were neurologically asymptomatic when the metastases were diagnosed. Single metastasis was found in 5 patients and multiple metastases in 6. The maximal size of all but one lesion was less than 25 mm. The median survival time and 5-year survival rate in all 11 patients with brain metastases were 10 months and 24%, respectively. Furthermore, those in 7 asymptomatic patients were 25 months and 38%, respectively. CONCLUSIONS We consider intensive follow-up with computed tomography to be worthwhile for early detection and effective treatment of brain metastases in patients with completely resected lung cancer.
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Affiliation(s)
- K Yokoi
- Division of Thoracic Surgery, Tochigi Cancer Center, Utsunomiya, Japan
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35
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Weber F, Riedel A, Köning W, Menzel J. The role of adjuvant radiation and multiple resection within the surgical management of brain metastases. Neurosurg Rev 1996; 19:23-32. [PMID: 8738362 DOI: 10.1007/bf00346606] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Cerebral metastases occur in 25% to 35% of all cancer patients. The advances in systemic and topical treatment as well as the rising incidence of lung cancer and melanomas are associated with an increasing incidence of cerebral metastases. More than 20,000 patients die every year in the Federal Republic of Germany of this disease. This retrospective analysis covers 145 patients who underwent surgery. Survival analysis of different subgroups was performed. The patients were grouped according to their clinical status and the different therapeutical procedures which were performed. Group A, consisting of all those patients where a gross total resection could be performed and where no systemic disease was apparent at the time of craniotomy showed the best results, having the highest portion of long term survivors. Group B, consisting of those patients who underwent a subtotal resection and who had no systemic disease at the time of craniotomy, had a worse outcome. Group C patients (gross total resection and systemic disease) as well as Group D (subtotal resection and systemic disease) presented the poorest results with respect to survival. A benefit was mediated by adjuvant radiation as well as multiple resections. Surgery is the method of choice for the treatment of a single metastasis. Advances in microsurgery nowadays sometimes justify even the removal of multiple metastases, depending on their location, on the general condition of the patient and on prognosis.
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Affiliation(s)
- F Weber
- Department of Neurosurgery, Heinrich Heine-University, Düsseldorf, Fed. Rep. of Germany
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36
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Shahidi H, Kvale PA. Long-term survival following surgical treatment of solitary brain metastasis in non-small cell lung cancer. Chest 1996; 109:271-6. [PMID: 8549197 DOI: 10.1378/chest.109.1.271] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Dissemination of lung cancer beyond the intrathoracic lymph nodes (stage IV disease) implies surgical unresectability. However, solitary brain metastases (SBMs) from non-small cell lung cancer (NSCLC) have often been treated by combined resection of the primary tumor and its metastasis. Such an aggressive approach appears to substantively improve patient outcome and provide better quality of life in selected cases. A search of the literature reveals extended survival (10 years or longer) in 16 patients following combined surgical excision. We report three patients with NSCLC and isolated central nervous system involvement who achieved exceptionally long survival. The existing literature on SBMs from NSCLC is reviewed.
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Affiliation(s)
- H Shahidi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
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37
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Luketich JD, Martini N, Ginsberg RJ, Rigberg D, Burt ME. Successful treatment of solitary extracranial metastases from non-small cell lung cancer. Ann Thorac Surg 1995; 60:1609-11. [PMID: 8787451 DOI: 10.1016/0003-4975(95)00760-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recurrence after resection of non-small cell lung carcinoma is generally associated with a poor outcome and is treated with either systemic agents or palliative irradiation. Recently, long-term survival has been reported after resection of isolated brain metastases from non-small cell lung carcinoma, but resection of other metastatic sites has not been explored fully. METHODS We have identified 14 patients who had solitary extracranial metastases treated aggressively after curative treatment of their non-small cell lung carcinoma. The histology was squamous carcinoma in 5, adenocarcinoma in 8, and large cell carcinoma in 1. Initially, 3 patients had stage I, 5 stage II, and 6 stage IIIa disease. RESULTS The sites of metastases included extrathoracic lymph nodes (six), skeletal muscle (four), bone (three), and small bowel (one). The median disease-free interval before metastases was 19.5 months (range, 5 to 71 months). Complete surgical resection of the metastatic site was the treatment in 12 of 14 patients. Two patients received only curative irradiation to the metastatic site, with complete response. The overall 10-year actuarial survival (Kaplan-Meier) was 86%. To date, 11 patients are alive and well after treatment of their metastases (17 months to 13 years), 1 has recurrent disease, 1 died of recurrent widespread metastases, and 2 died of unrelated causes. CONCLUSION Long-term survival is possible after treatment of isolated metastases to various sites from non-small cell lung carcinoma, but patient selection is critical.
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Affiliation(s)
- J D Luketich
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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38
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Ayabe H, Tsuji H, Hara S, Tagawa Y, Kawahara K, Tomita M. Surgical management of adrenal metastasis from bronchogenic carcinoma. J Surg Oncol 1995; 58:149-54. [PMID: 7898109 DOI: 10.1002/jso.2930580303] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Surgical treatment for metastatic lesions from lung cancer is seldom performed. We have treated three patients with a unilateral adrenal metastasis with adrenalectomy. Simultaneous resection of primary lung cancer and adrenal metastasis was performed in two cases. This is the first report of such surgical management. Adrenalectomy after lung resection was done in the third case. Two of the patients are alive and well more than 5 years after adrenalectomy. These cases are presented, and the literature is reviewed.
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Affiliation(s)
- H Ayabe
- First Department of Surgery, Nagasaki University School of Medicine, Japan
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Kodama K, Doi O, Higashiyama M, Yokouchi H, Nakagawa H, Mori Y. Surgery for brain metastases from nonsmall cell lung carcinomas and tissue cultures from the resected specimens. J Surg Oncol 1994; 57:121-8. [PMID: 7934063 DOI: 10.1002/jso.2930570210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Between 1978 and 1989, 44 patients underwent 44 thoracotomies and 55 craniotomies for nonsmall cell lung carcinoma (NSCLC) and its brain metastases. Patients ages ranged from 20 to 75 years. There were no intraoperative mortalities. The 2-, 3-, and 5-year survival rates following the initial craniotomy were 23%, 10%, and 10%, respectively. Patient survival did not differ with respect to solitary or multiple metastases or the sequence of surgery for primary lesion and brain metastases. Moreover, there was no significant difference in survival between patients treated by surgery alone and those receiving surgery followed by whole brain radiotherapy. After 1985, in vitro tissue culture was attempted using freshly resected specimens of brain metastases obtained from 30 consecutive cases. Of those specimens, nine (30%) were successfully established as permanent cell lines. Eight of those cell lines revealed DNA-aneuploid pattern on flow cytometric analysis. The remaining cell line was not analyzed. Karyotype analysis was also performed in eight of nine established cell lines. Two adenocarcinoma cell lines showed the presence of +3p- chromosome, and three showed +7q- chromosome as recurrent chromosomal abnormalities. These findings provide new evidence concerning the presence of 3p- and/or 7q- marker chromosomes in certain adenocarcinoma cell lines established from brain metastases. The prognosis was poorer in the group with in vitro tumor growth than that in the group showing no in vitro tumor growth. These cell lines established from brain metastases may be useful materials not only for studying the biological characteristics and chemo-sensitivity testing, but also for estimating prognoses after resection of brain metastases.
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Affiliation(s)
- K Kodama
- Department of Thoracic Surgery, Center for Adult Diseases, Osaka, Japan
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40
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Penar PL, Wilson JT. Cost and survival analysis of metastatic cerebral tumors treated by resection and radiation. Neurosurgery 1994; 34:888-93; discussion 893-4. [PMID: 8052388 DOI: 10.1227/00006123-199405000-00016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The surgical treatment of metastatic brain tumors remains controversial, primarily because of the limited prognosis of patients with metastatic cancer. The cost effectiveness of even standard therapies is of increasing concern to third-party payers. We reviewed the records of patients who had a single metastatic brain tumor resected at the Medical Center Hospital of Vermont (a referral center in a rural state) since cost data recording began. The 32 patients ranged in age from 35 to 77 years, with a 2.2:1 female-to-male ratio. Thirty-four percent of tumors originated in the lung, 15.6% were renal, 12.5% were breast, 12.5% were gynecological, 9.4% were gastrointestinal, and 9.4% were ultimately of unknown origin. Thirty-one tumors were completely resected; 30 patients were irradiated, most after surgery (mean dose, 3,908 +/- 1,250 cGy). Karnofsky scores improved from 80 +/- 11 to 88 +/- 16 postoperatively (P = 0.0038, one-tailed paired t-test). Patients were hospitalized an average of 8.22 +/- 6.26 days postoperatively, with total operative and postoperative charges of $19,190 +/- 5,684, noninclusive of radiotherapy. The expected median survival of all patients was 26 months (Kaplan-Meier estimate). The presence of disseminated disease was not significantly correlated with survival (P = 0.237). The number of postoperative days was more for patients with disseminated disease (P = 0.0274), but not for patients with infratentorial tumors (P = 0.6991). Age higher than the median was not correlated with an increased number of postoperative days (P = 0.1366) nor was a preoperative Karnofsky score of 70 or less (P = 0.1382).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P L Penar
- Department of Surgery, University of Vermont College of Medicine, Burlington
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Busch E, Verazin G, Antkowiak JG, Driscoll D, Takita H. Pulmonary complications in patients undergoing thoracotomy for lung carcinoma. Chest 1994; 105:760-6. [PMID: 8131538 DOI: 10.1378/chest.105.3.760] [Citation(s) in RCA: 116] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
One hundred three consecutive patients undergoing 106 thoracotomies for primary lung carcinoma were reviewed to determine factors associated with the development of postoperative pulmonary complications. Pulmonary complications occurred in 40 of 104 (39 percent) patients. Minor complications occurred in 17 of 104 (16 percent) patients and major in 23 of 104 (22 percent). There were six deaths in the entire series of 103 patients (6 percent), two of which were directly caused by a pulmonary complication and one where it was a contributing factor. Extended surgical resections were associated with an increased risk of complications. Pulmonary complications occurred in 9 of 11 (82 percent) patients undergoing extended resections involving chest wall resection. The use of neoadjuvant chemotherapy also was associated with an increase in the rate of major complications. Poor nutritional status as measured by a history of weight loss and preoperative serum albumin levels also was associated with an increased risk of any pulmonary complication. Cardiac complications were significantly increased in the group of patients having pulmonary complications. Pulmonary complications continue to present a major source of morbidity and mortality for patients undergoing thoracotomy for lung carcinoma. Determination of factors associated with increased risk is important in order to identify patients who might be predisposed to the development of these complications.
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Affiliation(s)
- E Busch
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14263
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Luketich JD, van Raemdonck DE, Ginsberg RJ. Extended resection for higher-stage non-small-cell lung cancer. World J Surg 1993; 17:719-28. [PMID: 8109108 DOI: 10.1007/bf01659081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This report reviews the results of extended surgical resection for advanced lung cancer (stage IIIa, IIIb, IV) reported in the Anglo-American literature between 1980 and 1993. Complete resection of stage IIIa (T3) tumors with minimal or no nodal involvement resulted in a 5-year survival approaching 40%. Ipsilateral mediastinal nodal involvement (N2) lowered 5-year survival to 10-15% and to near 0% if bulky disease was present. Historically, resection of stage IIIb disease has failed to improve survival. Radiation therapy has decreased local recurrence in advanced-stage disease but has not improved survival. Preliminary results have recently been reported using induction chemotherapy or chemoradiotherapy followed by resection in subsets of patients with stage IIIa and IIIb disease. Induction chemotherapy for bulky N2 (IIIa) disease resulted in major response rates of up to 77% and a 5-year survival of up to 26% after complete resection. Preliminary results of resection of stage IIIb tumors following induction chemotherapy have achieved 2-year survivals of 40%. Metastatic lung cancer (stage IV) with disseminated disease remains virtually incurable with poor response rates to chemotherapy. However, resection of isolated brain metastases (M1 disease) resulted in a 5-year survival near 25%. Resection of other sites of isolated metastatic disease including the adrenal gland is under investigation. The major prognostic factor in these studies has been the ability to completely resect all tumor. To improve resectability rates, induction therapy and radical resections are being combined more frequently. The increased morbidity and mortality of these aggressive approaches requires careful patient selection.
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Affiliation(s)
- J D Luketich
- Department of Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
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Abstract
The literature on metastasectomy abounds in anecdote and retrospective studies of non-randomized patients. In this paper, the published evidence concerning the efficacy of metastasectomy in the lung, liver, brain, gastrointestinal tract and omentum is reviewed to formulate practical recommendations for patient selection and treatment. At some sites metastasectomy can be recommended with little hesitation for more widespread application, but surgery for liver metastases should still be regarded with some reservation.
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Affiliation(s)
- L C Barr
- Department of Surgery, Royal Marsden Hospital, London, UK
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Abstract
Locally advanced lung cancer (stage IIIa, IIIb) in which the primary tumor is proximal (T3) or has invaded adjacent structures (T3) or organs (T4) or in which mediastinal lymph nodes are involved (N2, N3) worsens the prognosis significantly. However, in stage IIIa (T3 or N2), when surgical treatment results in total removal of the primary tumor and involved lymph nodes, there still is a reasonable chance for ultimate cure. On the other hand, total excision can be very rarely performed in T4 or N3 tumors. Therefore, this group (stage IIIb) usually indicates unresectability. Disseminated lung cancer with distant metastasis (stage IV) is still considered to be incurable. Nevertheless, solitary metastatic sites (M1), especially brain, have been treated on occasion by resection of the primary tumor and removal of the solitary metastasis. This appears to improve median survival and does yield 5-year survival in selected patients. The results after surgical treatment in these patients with higher stage lung cancer reported over the last 10 years are reviewed.
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Wronski M, Burt M. Results and prognostic factors of surgery in the management of non-small cell lung cancer with solitary brain metastasis. Cancer 1992; 70:2021-3. [PMID: 1326399 DOI: 10.1002/1097-0142(19921001)70:7<2021::aid-cncr2820700736>3.0.co;2-i] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Smalley SR, Laws ER, O'Fallon JR, Shaw EG, Schray MF. Resection for solitary brain metastasis. Role of adjuvant radiation and prognostic variables in 229 patients. J Neurosurg 1992; 77:531-40. [PMID: 1527610 DOI: 10.3171/jns.1992.77.4.0531] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The authors reviewed 229 consecutive patients treated intramurally by resection of solitary cerebral metastasis. Patients were classified into four groups on the basis of whether a gross total resection or subtotal resection was performed and whether systemic disease was present or absent at the time of craniotomy. Group 1 had gross total resection and no systemic disease; Group 2 had subtotal resection and no systemic disease; Group 3 had subtotal resection and systemic disease; and Group 4 had gross total resection and systemic disease. All four groups were further subdivided into Subgroup A (adjuvant whole-brain radiation therapy) or Subgroup B (no adjuvant radiation). Data were collected regarding multiple patient and tumor variables for multivariate analysis. Survival data for the 46 patients in Group 1A (median 1.3 years, 2-year survival rate 41%, 5-year survival rate 21%) were markedly better than those for the 75 in Group 1B (median 0.7 year, 2-year survival rate 19%, 5-year survival rate 4%). The 20 patients in Group 2A also had superior survival data (median 1.1 years, 2-year survival rate 30%, 3-year survival rate 30%) when compared with the eight patients in Group 2B (median 3 months, 1-year survival rate 0%). However, the 16 and 22 patients in Groups 3A and 4A, respectively, had no discernible differences compared to the seven and 35 patients in their Group 3B and 4B counterparts. Multivariate analyses were performed to assess the association of survival with multiple patient, disease, and treatment variables. Poor neurological status and systemic disease were significantly associated with inferior survival, while longer (greater than 36 months) intervals between primary diagnosis and craniotomy were significantly associated with improved survival. After adjusting for the effects of other patient, disease, and treatment characteristics, adjuvant whole-brain radiotherapy was significantly associated with improved survival times. These data support the continued use of craniotomy followed by adjuvant whole-brain radiation therapy for treatment of solitary brain metastasis. However, this aggressive therapy appears relatively contraindicated in the face of either systemic disease or substantial neurological deficit.
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Affiliation(s)
- S R Smalley
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Chang DB, Yang PC, Luh KT, Kuo SH, Hong RL, Lee LN. Late survival of non-small cell lung cancer patients with brain metastases. Influence of treatment. Chest 1992; 101:1293-7. [PMID: 1316262 DOI: 10.1378/chest.101.5.1293] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The presence of brain metastasis in lung cancer patients is a highly unfavorable event that usually allows only palliative treatment. A retrospective study was conducted to evaluate the prognostic factors in patients with non-small cell lung cancer (NSCLC) associated with brain metastases. From July 1984 through June 1990, a total of 50 patients with NSCLC associated with symptomatic brain metastasis seen at National Taiwan University Hospital were included. Patients who had incomplete cancer staging workup or loss of follow-up were excluded. Several possible prognostic variables were analyzed initially with univariate analysis and subsequently with multivariate analysis with maximal partial likelihood ratio test in the Cox model. In the univariate analysis, several factors, including number of brain metastases, treatment for brain metastasis with brain tumor resection (BTR) or whole brain radiation therapy (WBRT), and chemotherapy (C/T) after brain metastasis were found to have significant influence on the survival. However, in the multivariate analysis, patients receiving BTR, WBRT, and/or C/T lived significantly longer. The median survival of patients treated with BTR was nine months, eight months in patients with C/T, and seven months in patients with WBRT. Taken together, these patients had a median survival of seven months, which was significantly longer than patients treated with supportive care only (with a median survival of two months). Treatment of brain metastases with WBRT, BTR, C/T, or in combinations also improved the quality of life. We conclude that NSCLC patients with brain metastases should be more aggressively treated with WBRT, BTR, C/T, or in combinations than supportive care only.
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Affiliation(s)
- D B Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, ROC
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