Prognostic factors in surgical treatment of solitary brain metastasis after resection of non-small-cell lung cancer

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

Simple Summary

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

Abstract

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

The Debatable Benefit of Gross-Total Resection of Brain Metastases in a Comprehensive Treatment Setting

Simple Summary

In this monocentric retrospective analysis, the extent of resection of singular/solitary brain metastases has no impact on local recurrence and overall survival rates in patients receiving multidisciplinary adjuvant treatment. Since systemic disease progression is the leading cause of death, and an uncontrolled systemic disease status, along with adjuvant treatment, present independent predictors of overall survival, a comprehensive, multidisciplinary treatment concept is essential for patients with brain metastases.

Abstract

Background and Purpose: The value of gross-total surgical resection remains debatable in patients with brain metastases (BMs) as most patients succumb to systemic disease progression. In this study, we evaluated the impact of the extent of resection of singular/solitary BM on in-brain recurrence (iBR), focusing on local recurrence (LR) and overall survival (OS) in an interdisciplinary adjuvant treatment setting. Patients and Methods: In this monocentric retrospective analysis, we included patients receiving surgery of one BM and subsequent adjuvant treatment. A radiologist and a neurosurgeon determined in consensus the extent of resection based on magnetic resonance imaging. The OS was calculated using Kaplan–Meier estimates; prognostic factors for LR and OS were analysed by Log rank test and Cox proportional hazards. Results: We analyzed 197 patients. Gross-total resection was achieved in 123 (62.4%) patients. All patients were treated with adjuvant radiotherapy, and 130 (66.0%) received systemic treatment. Ninety-six (48.7%) patients showed iBR with an LR rate of 23.4%. LR was not significantly influenced by the extent of resection (p = 0.139) or any other parameter. The median OS after surgery was 18 (95%CI 12.5–23.5) months. In univariate analysis, the extent of resection did not influence OS (p = 0.6759), as opposed to adjuvant systemic treatment (p < 0.0001) and controlled systemic disease (p = 0.039). Systemic treatment and controlled disease status remained independent factors for OS (p < 0.0001 and p = 0.009, respectively). Conclusions: In this study, the extent of resection of BMs neither influenced the LR nor the OS of patients receiving interdisciplinary adjuvant treatment.

Long-term survival without surgery in NSCLC patients with synchronous brain oligometastasis: systemic chemotherapy revisited

Background

Among patients with metastatic non-small-cell lung cancer (NSCLC), patients with TNM stage N0 to N1 and brain oligometastases (BOM) (less than 5 metastases) as the sole distant lesion (N0-1 BOM) who receive surgical treatments for the primary and metastatic sites reportedly have a better prognosis. Little data is available regarding the outcomes of patients treated with only systemic chemotherapy for the primary site and definitive treatment for synchronous BOM, compared with the outcomes of patients receiving surgical treatment for the primary site.

Methods

Stage IV NSCLC patients with or without N0-1 BOM, who underwent chemotherapy for the primary site between January 2000 and December 2010 were identified from the records of our institution.

Results

Among 936 advanced NSCLC patients treated with systemic chemotherapy, 19 patients had N0-1 BOM at presentation. The median overall survival (OS) period of the N0-1 BOM patients was 16.0 months (95% CI, 11.8-20.2 months), while that of the N2-3 BOM + non-BOM patients was 14.5 months (95% CI, 13.2-15.8 months), compared with 7-9 months in previous reports. The median 3- and 5-year survival rates of the N0-1 BOM patients were 28% and 19%.

Conclusions

The treatment outcomes of the N0-1 BOM patients who did not receive surgery for the primary site were better than those of the N2-3 BOM + non-BOM patients. A randomized trial evaluating the efficacy of surgery for the primary site in N0-1 BOM patients is warranted.

Surgical Management of Non-small Cell Lung Cancer with Solitary Hematogenous Metastases

BACKGROUND/AIM

The treatment of patients with solitary hematogenous metastases from non-small cell lung cancer (NSCLC) remains controversial, although numerous retrospective studies have reported favorable results for patients offered combined surgical therapy. Our aim was to determine the role of surgical resection in the management of NSCLC with solitary extrapulmonary metastases and to investigate for possible prognostic factors.

PATIENTS AND METHODS

Between January 2004 and December 2012, 12 patients with NSCLC, from two Institutions, underwent metastasectomy for their solitary metastatic lesion. Sites of metastases included brain (n=3), adrenal gland (n=6), thoracic wall (n=2) and diaphragm (n=1). All patients had undergone pulmonary resections for their primary NSCLC.

RESULTS

Median survival for the entire cohort was 24.1 months, whereas 1- and 5-year survival rates were 73% and 39%, respectively. Patients with stage III intrathoracic disease had significantly worse survival than those with lower tumor stage. A tendency for adenocarcinomatous histology to positively affect survival was recognized, although it was proven not to be statistically significant.

CONCLUSION

Despite the retrospective nature of our study and the small cohort size, it is emerging that combined surgical resection might offer patients with NSCLC with solitary hematogenous metastases a survival benefit. Limited intrathoracic disease and adenocarcinomatous histology might be associated with better outcomes.

Clinical outcome of node-negative oligometastatic non-small cell lung cancer

Introduction

The concept of “oligometastasis” has emerged as a basis on which to identify patients with stage IV non–small cell lung cancer (NSCLC) who might be most amenable to curative treatment. Limited data have been available regarding the survival of patients with node‐negative oligometastatic NSCLC.

Patients and methods

Consecutive patients with advanced NSCLC who attended Kindai University Hospital between January 2007 and January 2016 were recruited to this retrospective study. Patients with regional lymph node–negative disease and a limited number of metastatic lesions (≤5) per organ site and a limited number of affected organ sites (1 or 2) were eligible.

Results

Eighteen patients were identified for analysis during the study period. The most frequent metastatic site was the central nervous system (CNS, 72%). Most patients (83%) received systemic chemotherapy, with only three (17%) undergoing surgery, for the primary lung tumor. The CNS failure sites for patients with CNS metastases were located outside of the surgery or radiosurgery field. The median overall survival for all patients was 15.9 months, with that for EGFR mutation–positive patients tending to be longer than that for EGFR mutation–negative patients.

Conclusion

Cure is difficult to achieve with current treatment strategies for NSCLC patients with synchronous oligometastases, although a few long‐term survivors and a smaller number of patients alive at last follow‐up were present among the study cohort. There is an urgent clinical need for prospective evaluation of surgical resection as a treatment for oligometastatic NSCLC, especially negative for driver mutations.

Approach for oligometastasis in non-small cell lung cancer

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

The role of stereotactic body radiation therapy in the management of oligometastatic lung cancer

A growing body of evidence has surfaced over the past 20 years that supports the use of surgery for metastasis limited in number termed ‘oligometastases’. Local therapy for oligometastases results in long progression free survival in the absence of systemic therapy, including non-small-cell lung cancer (NSCLC). Stereotactic body radiation therapy (SBRT) allows for the delivery of anatomically precise, ablative doses of radiation therapy able to achieve local control rates of approximately 80% with minimal toxicity. In NSCLC, SBRT is emerging as an effective therapy in the management of sites resistant to targeted therapy. This review summarizes the published evidence for the use of local therapy in the management of oligometsatic cancer, with a focus on SBRT and NSCLC.

Prognostic factors in patients with postoperative brain recurrence from completely resected non-small cell lung cancer

Background

Treatment strategies for brain metastasis from lung cancer have been making progress. The aim of this retrospective analysis was to investigate the post-recurrent prognostic factors in patients with brain metastasis after complete resection of non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed the medical records of 40 patients found to have postoperative brain metastasis from NSCLC in our institution from 2002 to 2008. All patients had undergone radical pulmonary resection for the lung cancer. The impact of numerous variables on survival were assessed, including gender, age, carcinoembryonic antigen (CEA), tumor size, N status, histological type, number of brain metastases, tumor size of brain metastasis, presence of symptoms from the brain tumor(s), and use of perioperative chemotherapy.

Results

The median follow-up was 20.6 months (range, 3.4–66 months). The five-year survival rate from the diagnosis of brain recurrence was 22.5%. In univariate analysis, the favorable prognostic factors after brain recurrence included a normal range of CEA, no extracranial metastasis, no symptoms from the brain metastasis, brain metastasis (less than 2 cm), and radical treatment (craniotomy or stereotactic radiosurgery [SRS]). The multivariate Cox model identified that a small brain metastasis and radical treatment were independent favorable prognostic factors.

Conclusions

This study found that the implementation of radical therapy for metastatic brain tumor(s) when the tumor is still small contributed to an increase in patients' life expectancy.

The management of non-small cell lung cancer with oligometastases

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.

Definitive primary therapy in patients presenting with oligometastatic non-small cell lung cancer

PURPOSE

Although palliative chemotherapy is the standard of care for patients with diagnoses of stage IV non-small cell lung cancer (NSCLC), patients with a small metastatic burden, "oligometastatic" disease, may benefit from more aggressive local therapy.

METHODS AND MATERIALS

We identified 186 patients (26% of stage IV patients) prospectively enrolled in our institutional database from 2002 to 2012 with oligometastatic disease, which we defined as 5 or fewer distant metastatic lesions at diagnosis. Univariate and multivariable Cox proportional hazards models were used to identify patient and disease factors associated with improved survival. Using propensity score methods, we investigated the effect of definitive local therapy to the primary tumor on overall survival.

RESULTS

Median age at diagnosis was 61 years of age; 51% of patients were female; 12% had squamous histology; and 33% had N0-1 disease. On multivariable analysis, Eastern Cooperate Oncology Group performance status ≥ 2 (hazard ratio [HR], 2.43), nodal status, N2-3 (HR, 2.16), squamous pathology, and metastases to multiple organs (HR, 2.11) were associated with a greater hazard of death (all P<.01). The number of metastatic lesions and radiologic size of the primary tumor were not significantly associated with overall survival. Definitive local therapy to the primary tumor was associated with prolonged survival (HR, 0.65, P=.043).

CONCLUSIONS

Definitive local therapy to the primary tumor appears to be associated with improved survival in patients with oligometastatic NSCLC. Select patient and tumor characteristics, including good performance status, nonsquamous histology, and limited nodal disease, may predict for improved survival in these patients.

An individual patient data metaanalysis of outcomes and prognostic factors after treatment of oligometastatic non-small-cell lung cancer

INTRODUCTION/BACKGROUND

An individual patient data metaanalysis was performed to determine clinical outcomes, and to propose a risk stratification system, related to the comprehensive treatment of patients with oligometastatic NSCLC.

MATERIALS AND METHODS

After a systematic review of the literature, data were obtained on 757 NSCLC patients with 1 to 5 synchronous or metachronous metastases treated with surgical metastectomy, stereotactic radiotherapy/radiosurgery, or radical external-beam radiotherapy, and curative treatment of the primary lung cancer, from hospitals worldwide. Factors predictive of overall survival (OS) and progression-free survival were evaluated using Cox regression. Risk groups were defined using recursive partitioning analysis (RPA). Analyses were conducted on training and validating sets (two-thirds and one-third of patients, respectively).

RESULTS

Median OS was 26 months, 1-year OS 70.2%, and 5-year OS 29.4%. Surgery was the most commonly used treatment for the primary tumor (635 patients [83.9%]) and metastases (339 patients [62.3%]). Factors predictive of OS were: synchronous versus metachronous metastases (P < .001), N-stage (P = .002), and adenocarcinoma histology (P = .036); the model remained predictive in the validation set (c-statistic = 0.682). In RPA, 3 risk groups were identified: low-risk, metachronous metastases (5-year OS, 47.8%); intermediate risk, synchronous metastases and N0 disease (5-year OS, 36.2%); and high risk, synchronous metastases and N1/N2 disease (5-year OS, 13.8%).

CONCLUSION

Significant OS differences were observed in oligometastatic patients stratified according to type of metastatic presentation, and N status. Long-term survival is common in selected patients with metachronous oligometastases. We propose this risk classification scheme be used in guiding selection of patients for clinical trials of ablative treatment.

Recursive partitioning analysis classification and graded prognostic assessment for non-small cell lung cancer patients with brain metastasis: a retrospective cohort study

OBJECTIVE

To assess prognostic factors and validate the effectiveness of recursive partitioning analysis (RPA) classes and graded prognostic assessment (GPA) in 290 non-small cell lung cancer (NSCLC) patients with brain metastasis (BM).

METHODS

From Jan 2008 to Dec 2009, the clinical data of 290 NSCLC cases with BM treated with multiple modalities including brain irradiation, systemic chemotherapy and tyrosine kinase inhibitors (TKIs) in two institutes were analyzed. Survival was estimated by Kaplan-Meier method. The differences of survival rates in subgroups were assayed using log-rank test. Multivariate Cox's regression method was used to analyze the impact of prognostic factors on survival. Two prognostic indexes models (RPA and GPA) were validated respectively.

RESULTS

All patients were followed up for 1-44 months, the median survival time after brain irradiation and its corresponding 95% confidence interval (95% CI) was 14 (12.3-15.8) months. 1-, 2- and 3-year survival rates in the whole group were 56.0%, 28.3%, and 12.0%, respectively. The survival curves of subgroups, stratified by both RPA and GPA, were significantly different (P<0.001). In the multivariate analysis as RPA and GPA entered Cox's regression model, Karnofsky performance status (KPS) ≥ 70, adenocarcinoma subtype, longer administration of TKIs remained their prognostic significance, RPA classes and GPA also appeared in the prognostic model.

CONCLUSION

KPS ≥70, adenocarcinoma subtype, longer treatment of molecular targeted drug, and RPA classes and GPA are the independent prognostic factors affecting the survival rates of NSCLC patients with BM.

Survival of patients treated surgically for synchronous single-organ metastatic NSCLC and advanced pathologic TN stage

INTRODUCTION

Patients with stage IV metastatic non-small cell lung cancer (NSCLC) are generally not considered for surgery due to their poor median survival ranging from 4 to 11 months. However published results suggested that carefully selected patients with oligometastatic disease may benefit from resection of both the primary and metastatic sites in a multidisciplinary treatment approach. The aim of the study was to analyze and detect prognostic factors in surgically treated patients with synchronous single-organ metastasis from NSCLC.

METHODS

This is a retrospective single-center study including 29 patients with synchronous single-organ metastatic NSCLC who underwent lung resection and local treatment of the metastasis between 2002 and 2008. Overall survival was estimated from the date of lung surgery until last follow-up. The impact on survival of nine variables (age, pT, pN, site of metastasis, presence of solitary metastasis, R-resection status, presence of neoadjuvant or adjuvant treatment, tumor histology) were further assessed.

RESULTS

Twenty-nine patients (20 males, 69%) with a median age of 62 (from 44 to 77) were included. Site of metastatic disease was the brain in 19, the lung in 8 and the adrenal glands in 2 patients. Histology was adenocarcinoma in 21, large-cell carcinoma in 3, squamous-cell carcinoma in 2 and other in 3 patients. Type of lung resection performed for primary tumors were pneumonectomy in 3, bilobar resection in 3, lobar resection in 17 and sublobar resection in 6 patients. Survival at 1 and 5 years for the overall population reached 65% and 36%, respectively. Median survival was 20.5 months. Univariate regression model analysis identified pathologic T stage as a predictor of survival. Patients with pT1-2 behaved statistically significantly better (p=0.007) compared to patients with pT3-4 tumors. No impact on survival for the other 8 variables has been shown.

CONCLUSIONS

The 5-year survival rate of 36% confirms that multimodality treatment including surgical lung resection should be considered in the therapy of single-site metatastatic NSCLC for selected patients. Pathologic T stage appeared to have significant impact on predicting patient survival.

[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.

Surgical brain metastases: management and outcome related to prognostic indexes: a critical review of a ten-year series

Brain metastasis are the most common neoplastic lesions of the nervous system. Many cancer patients are diagnosed on the basis of a first clinical presentation of cancer on the basis of a single or multiple brain lesions. Brain metastases are manifestations of primary disease progression and often determine a poor prognosis. Not all patients with a brain metastases undergo surgery: many are submitted to alternative or palliative treatments. Management of patients with brain metastases is still controversial, and many studies have been developed to determine which is the best therapy. Furthermore, management of patients operated for a brain metastasis is often difficult. Chemotherapy, stereotactic radiosurgery, panencephalic radiation therapy, and surgery, in combination or alone, are the means most commonly used. We report our experience in the management of a ten-year series of surgical brain metastasis and discuss our results in the preoperative and postoperative management of this complex condition.

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%.

Recurrent brain metastases from lung cancer: the impact of reoperation

OBJECTIVE

The best treatment for solitary brain metastases from lung cancer is surgical resection followed by adjuvant treatment. However, about 50% of these patients develop recurrent brain metastases. There is no established treatment standard for this patient group. We therefore analyzed the survival, neurological function, and overall performance status of patients with recurrent solitary brain metastases from lung cancer after second microsurgical resection.

MATERIALS AND METHODS

Treatment outcome was analyzed in 25 patients (19 men, 6 women) with a mean age of 55.8 years (range, 38-78 years) who received a resection of recurrent solitary brain metastases. Eighty-four percent of all patients had non-small-cell lung cancer and 16% small cell lung cancer (SCLC). Eighty percent of the lesions were located supratentorially, 20% infratentorially.

RESULTS

The median overall survival after initial diagnosis was 26.9 months, 13.6 months after the first and 8.3 months after the second brain surgery, respectively. The median Karnofsky index improved significantly from 80 to 100 after the second brain surgery; 66.6% of all patients presenting with neurological impairment improved, and 50% regained normal function. No surgery-related morbidity or mortality was noted. Multivariate analysis indicated that the interval until first brain metastasis and between first and recurrent metastases was significantly predictive of survival.

CONCLUSIONS

The majority of patients in our study group showed significant functional benefit from surgical resection of recurrent brain metastases. This contributes to a better quality of life in this patient group showing a short overall survival time.

Intracranial metastatic disease rarely involves the pituitary: retrospective analysis of 935 metastases in 155 patients and review of the literature

We present a case report of a patient recently treated at our institution for an isolated non-small cell lung cancer metastatic lesion to the sella, report the lack of involvement of the pituitary gland in a large single-institution series of treated intracranial parenchymal metastases, and review the pertinent literature. We reviewed cranial imaging studies (CT and MRI) for 935 metastases in 155 patients treated at our institution over the previous 3 years for intracranial metastatic disease. Special attention was paid to the skull base to document the presence of any metastatic disease involving the pituitary gland, infundibular stalk, sella turcica (including anterior and posterior clinoids), or diaphragm sellae. We found no other involvement of the pituitary gland or other sellar structures by metastatic disease in this series. Intracranial metastatic disease rarely involves the pituitary gland and infundibular stalk parenchyma, suggesting that this structure may be safely omitted from the treatment field during WBRT and prophylactic cranial irradiation (PCI). This treatment approach should reduce the late sequelae of treatment to this critical organ.

The Surgical Management of Lung Cancer

Since the introduction of the pneumonectomy as a technically feasible strategy for the treatment of lung cancer, surgical resection has played a pivotal role in the management of early stage non-small cell lung carcinoma (NSCLC). In the last two decades, surgical, medical, and radiation oncologists have produced a growing body of evidence to support the combination of neoadjuvant or adjuvant treatments with standard surgical resection, to improve disease-free and overall survival for specific patient subgroups. Furthermore, alternatives to aggressive surgical management have evolved for patients who are medically inoperable due to compromised pulmonary function or other comorbidities. In this review, surgical options and multimodal treatment strategies are discussed, as well as completed and ongoing clinical trials addressing the surgical management of NSCLC.

Management of brain metastases: the indispensable role of surgery

Brain metastases are the most common neurological complication of systemic cancer and carry a very poor prognosis. The management of patients with brain metastases has become more important recently because of the increased incidence of these tumors and the prolonged patient survival times that have accompanied increased control of systemic cancer. In this article, we review the current perspectives on surgical treatment of brain metastases in terms of patient selection criteria, intraoperative adjuncts, whole-brain radiation therapy (WBRT) as a postoperative adjuvant, reoperation for tumor recurrence, and resection of multiple and single metastases. Achieving the best outcome in treatment of brain metastasis requires the judicious and complementary use of surgical resection along with modalities such as whole-brain radiation therapy and stereotactic radiosurgery.

Annual abdominal ultrasonographic examination after curative NSCLC resection

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prolonged survival after resection and radiotherapy for solitary brain metastases from non-small-cell lung cancer

Selected patients with brain metastases from non-small-cell lung cancer benefit from aggressive treatment. This report describes three patients who developed solitary brain metastases after previous resection of primary adenocarcinoma of the lung. Each underwent surgical resection of their brain metastasis followed by cranial irradiation and remain disease free 10 or more years later. Two patients developed cognitive impairment approximately 8 years after treatment of their brain metastasis, which was felt to be due to their previous brain irradiation. Here we discuss the treatment of solitary brain metastasis, particularly the value of combined method approaches in selected patients and dose-volume considerations.

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

OBJECTIVES

Some investigators have reported long-term survival after surgical resection of a solitary non-small cell lung cancer recurrence in various sites. However, the role and indications of the second operation remain unclear.

METHODS

We reviewed 28 patients with a solitary recurrence after successful initial resection of primary non-small cell lung cancer who underwent resection of the recurrent lesion. The clinicopathologic factors associated with outcome were analyzed.

RESULTS

There were 17 men and 11 women. Recurrence resection was performed for the following sites: 16 in the lung, 5 in the brain, 2 in the adrenal gland, and 1 each in the chest wall, stomach, skin, pelvic lymph node, and malar bone. The median survival time was 25 months, and the 1-, 2-, and 5-year survival rates after recurrence were 89%, 59%, and 32%, respectively. Advanced p-stage (p-stage II and III, n = 14) of the primary tumor was the significant negative prognostic factor. Patients with p-stage II or III had survival equivalent to that of those who had multiple recurrences or were unfit for further surgical intervention.

CONCLUSIONS

Resection of a solitary non-small cell lung cancer recurrence might provide long-term survival in highly selected patients. However, surgical resection might be contraindicated if the primary tumor is stage II or III.

Current treatment approaches to surgery for brain metastases

The role for surgical treatment of brain metastases continues to evolve. Data have demonstrated survival and quality-of-life benefits for surgical treatment of appropriate lesions in selected patients. With improvements in surgical technique, along with therapeutic improvements in the management of systemic cancers, more patients are now eligible for surgical resection. Selection of patients for surgical treatment depends on performance status, size, location, and number of brain lesions, as well as the status of systemic disease. Although surgery has traditionally been performed for patients with a single brain metastasis, an increasing number of patients with multiple brain metastases may also be treated surgically. Surgical techniques, such as image guidance, intraoperative ultrasound, functional neuronavigation, cortical mapping, and awake craniotomies, have expanded the scope of lesions that can be removed safely to optimize outcomes. Seizures, peritumoral edema, and venous thromboembolic disease all contribute significantly to surgical morbidity and mortality and thus require aggressive treatment around the time of the surgical procedure to improve the quality of life and maximize survival time.

Unexpected long-term survival after low-dose palliative radiotherapy for nonsmall cell lung cancer

BACKGROUND

Many experienced oncologists have encountered patients with proven non-small cell lung cancer (NCLC) who received modest doses of palliative radiotherapy (RT) and who unexpectedly survived for > 5 years; some were apparently cured. We used a very large prospective database to estimate the frequency of this phenomenon and to look for correlative prognostic factors.

METHODS

Patients with histologically or cytologically proven NSCLC, treated with palliative RT to a dose of < or = 36 Gy, were identified from a prospective database containing details of 3035 new patients registered from 1984-1990.

RESULTS

An estimated 1.1% (95% confidence interval, 0.7-1.6%) of 2337 palliative RT patients survived for 5 or more years after commencement of RT, including 18 patients who survived progression-free for 5 years. Estimated median survival was 4.6 months. Five-year survivors had significantly better Eastern Cooperative Oncology Group performance status at presentation than non-5-year survivors (P = 0.024) and were less likely to have distant metastases (P = 0.020). RT dose did not appear to be a significant prognostic factor. Patients who survived 5 years without progression had an estimated 78% probability of remaining free from progression in the next 5 years.

CONCLUSIONS

Approximately 1% of patients with proven NSCLC survived for > 5 years after palliative RT, and many of these patients appeared to have been cured by a treatment usually considered to be without curative potential. Because of the potential for long-term survival, doses to late-reacting normal tissues should be kept within tolerance when prescribing palliative RT in NSCLC.

Advances in Cytotoxic Chemotherapy for the Treatment of Metastatic or Recurrent Non-Small Cell Lung Cancer

Improvements in drug development and clinical trial design have resulted in a wider range of treatment options for patients with advanced non-small cell lung cancer (NSCLC). Combination chemotherapy is the standard of care for medically fit patients. A variety of chemotherapeutic doublets, including nonplatinum combinations, with similar clinical activity are now available, allowing oncologists to match acceptable toxicity profiles to individual patients' comorbidities and preferences. Single-agent treatment of refractory or recurrent disease has been shown to improve survival and offer improved quality of life (QOL). For special patient populations, such as the elderly and patients with limited performance status (PS), treatment with single-agent chemotherapy results in modest survival benefits and combination chemotherapy may be appropriate for some of these patients.

Non–small cell lung cancer with a solitary hematogenous metastasis

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.

A phase II trial of chemotherapy and surgery for non-small cell lung cancer patients with a synchronous solitary metastasis

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.

Results of recent therapy for non-small-cell lung cancer with brain metastasis as the initial relapse

The results of radiosurgery for treatment of patients with non-small-cell lung cancer with brain metastasis as the initial relapse were evaluated. Twenty-three patients were included in the study. The dominant pathologic type was adenocarcinoma (56.5%). In the mean interval of 13.7 months (range, 3-52 months) between the lung operation and treatment of brain metastasis, a solitary lesion developed in 9 patients and multiple lesions developed in 14 patients. The modalities used for brain metastasis were gamma-knife radiation therapy (GKS) in nine patients, GKS plus operation in six, GKS plus whole brain radiation therapy (WBR) in two, operation plus WBR in two, operation only in one, WBR only in two, and no treatment in one. The 1- and 3-year survival rates after treatment of brain were 47.3% and 7.4%, respectively. The prognostic impact of stage and number of brain metastases was not clear. Primary tumor size and adjuvant chemotherapy after the lung operation significantly affected survival after the management of brain metastasis. The low invasive radiosurgery is beneficial in terms of improving the quality of life of patients.

Surgical management of brain metastases

Metastatic brain tumors are the most common intracranial tumors in adults and the most common cause of neurologic morbidity and mortality in these patients. Recent advances in the management of the primary cancer have resulted in improved prognosis, longer survival, and thus, increased identification of the presence of brain metastases. Data suggest that aggressive treatment of the metastatic brain tumor with surgical resection increases the length of survival in these patients. New techniques, including preoperative functional imaging, stereotactic surgical resection, image-guided neurosurgery, intraoperative ultrasound, and cortical mapping, have aided neurosurgeons in surgical resection and have helped to lower the associated surgical morbidity and mortality. The respective roles of surgery, patient selection, prognostic factors, and radiotherapy are addressed in this review.

Pronostic factors of synchronous brain metastases from lung cancer

BACKGROUND

The prognosis of brain metastases (BM) from lung cancer is poor. The management of lung cancer with BM is not clear. This retrospective study attempts to determine their prognostic factors, and to better define the role of different treatments.

METHODS

We reviewed the clinical characteristics of 271 consecutive patients with synchronous brain metastases (SBM) from lung cancer (small-cell lung cancers and non-small-cell lung cancers), collected between January 1985 and May 1993. Data were available for all patients as well as follow-up information on all patients through to death. Patients had all undergone heterogeneous treatments. Each physician had chosen the appropriate treatment after collegiate discussion. Survival curves were compared using the log-rank test in univariate analysis, and Cox's Regression model in multivariate analysis. Statistical significance was defined as P<0.05.

RESULTS

249 patients were assessable. Treatments included: neurosurgical resection in 56 cases, brain irradiation in 87 cases, and chemotherapy in 126 cases. Median overall survival time from the date of histological diagnosis of SBM was 103 days (range, 1-1699). In multivariate analysis, prognostic factors for longer overall survival times were: absence of adrenal metastases (P=0.007), neurosurgical resection (P=0.028), chemotherapy (P=0.032) and brain irradiation (P=0.008). Moreover, risk factors of intracranial hypertension as cause of death were number of SBM and absence of neurosurgical resection.

CONCLUSIONS

These results and others suggest that patients with SBM from lung cancer be considered for carcinologic treatment, and not only for best supportive care. However, further studies are necessary to evaluate quality of life with or without carcinologic treatment.

Nucleus of the tractus solitarius metastasis: relationship to respiratory arrest?

BACKGROUND

A 52-year-old woman with metastases in brain and bone had clinical and radiological response to therapy but died about 10 weeks after diagnosis. General autopsy failed to identify a primary neoplasm or an anatomic cause of death. Investigation of sudden respiratory cessation was a consideration when undertaking an anatomic study of the brain.

METHODS

Review of patient records and careful examination of the brain following autopsy were carried out.

RESULTS

The patient had terminal episodes of hypersomnia but episodes of sleep apnea were not observed. She received no respiratory support and no respiratory difficulties were recorded until she was pronounced dead at 7 a.m. Autopsy revealed metastatic adenocarcinoma in a pattern suggestive of a primary pulmonary neoplasm, including multiple cerebral metastases, although no significant pulmonary lesions of any type were found. A 0.2 cm metastatic adenocarcinoma was found in the nucleus of the tractus solitarius (NTS). No other tumor was present in the brain stem.

CONCLUSIONS

Unilateral destruction of the NTS in the medulla would have severely disturbed the most critical point of convergence of autonomic and voluntary respiratory control and of cardiocirculatory reflexes in the central autonomic network. It is postulated that this caused respiratory arrest during a state transition from sleeping to waking. Few metastases to the medulla are reported, most are relatively large, and several have caused respiratory symptoms before death. The very small metastasis in our patient could be the direct anatomic cause of death, and as such it is an unusual complication of metastatic disease of which clinicians should be aware. It is speculated that dysfunction of direct NTS connections to the pons or of connections passing close to the metastatic deposit resulted in terminal hypersomnia.