Diagnosis, treatment, and prognosis of stage IB non-small cell lung cancer with visceral pleural invasion

With the increasing implementation of early lung cancer screening and the increasing emphasis on physical examinations, the early-stage lung cancer detection rate continues to rise. Visceral pleural invasion (VPI), which denotes the tumor's breach of the elastic layer or reaching the surface of the visceral pleura, stands as a pivotal factor that impacts the prognosis of patients with non-small cell lung cancer (NSCLC) and directly influences the pathological staging of early-stage cases. According to the latest 9th edition of the TNM staging system for NSCLC, even when the tumor diameter is less than 3 cm, the final T stage remains T2a if VPI is present. There is considerable controversy within the guidelines regarding treatment options for stage IB NSCLC, especially among patients exhibiting VPI. Moreover, the precise determination of VPI is important in guiding treatment selection and prognostic evaluation in individuals with NSCLC. This article aims to provide a comprehensive review of the current status and advancements in studies pertaining to stage IB NSCLC accompanied by VPI.

Major clinical benefit from adjuvant chemotherapy for stage II-III non-small cell lung cancer patients aged 75 years or older: a propensity score-matched analysis

BACKGROUND

Data are currently insufficient to support the use of adjuvant chemotherapy (ACT) after surgical resection for stage II or III non-small cell lung cancer (NSCLC) in patients aged ≥ 75 years. In this study we evaluated efficacy and safety profile of ACT in this population.

METHODS

We retrospectively evaluated 140 patients ≥ 75 years who underwent curative surgical resection for stage II-III NSCLC from 2010 to 2018 with an indication to ACT according to current guidelines. A propensity score-matched analysis was performed to avoid cofounding biases.

RESULTS

Thirty of 140 patients (21%) received ACT. Most patients (n = 24, 80%) received carboplatin in combination with vinorelbine, while 5 patients (17%) received cisplatin plus vinorelbine and one patient (3%) carboplatin plus gemcitabine. The occurrence of adverse events led to treatment discontinuation in 8 (27%) cases, while 19 (63%) patients completed 4 chemotherapy cycles. Common reported adverse events with ACT were anemia (n = 20, 67%), neutropenia (n = 18, 60%), thrombocytopenia (n = 9, 30%), renal impairment (n = 4, 13%) and transaminase elevation (n = 4, 13%). No toxic deaths occurred. The median follow-up was 67 months (IQR: 53-87). ACT was associated with a significant benefit in both relapse-free survival (median 36 vs. 18.5 months, p = 0.049) and overall survival (median not reached [NR] vs. 33.5 months, p = 0.023) in a propensity score-matched analysis which controlled for cofounders.

CONCLUSION

ACT confers a survival benefit after curative resection of stage II-III NSCLC in selected patients aged 75 years or older with a manageable toxicity profile.

Survival Nomogram for Stage IB Non-Small-Cell Lung Cancer Patients, Based on the SEER Database and an External Validation Cohort

OBJECTIVE

This study aimed to construct a nomogram to effectively predict the overall survival (OS) of patients with stage IB non-small-cell lung cancer (NSCLC).

METHODS

In total, 5513 patients with stage IB NSCLC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and used as the training cohort. We enrolled 440 patients from the Cancer Hospital, Chinese Academy of Medical Sciences, for the external validation cohort. A nomogram was constructed based on the risk factors affecting prognosis using a Cox proportional hazards regression model. The discrimination and calibration of the nomogram were evaluated by C-indexes and calibration curves.

RESULTS

Six independent risk factors for OS were identified and integrated into the nomogram. The discrimination of the nomogram revealed good prognostic accuracy and clinical applicability as indicated by C-index values of 0.637 (95% CI 0.634-0.641) and 0.667 (95% CI 0.656-0.678) for the training cohort and the external validation cohort, respectively. Additionally, the patients were divided into two groups according to risk (sum-score > 185), and significant differences in OS were observed between the high-risk and low-risk groups in the training and external validation cohorts (P < 0.001). Finally, chemotherapy was significantly associated with OS in patients with differentiation grades II-IV (P = 0.004) and patients with adenocarcinoma (P = 0.005).

CONCLUSION

This nomogram provides a convenient and reliable tool for individual evaluations and clinical decision-making for patients with stage IB NSCLC; among these patients, those with differentiation grades II-IV or adenocarcinoma could benefit from chemotherapy.

Recent trends in use of adjuvant chemotherapy in elderly stage II-III non-small cell lung cancer

Background

Although randomized trials demonstrated survival benefit of adjuvant chemotherapy, previous reports have suggested that its use in elderly populations for early stage non-small cell lung cancer (NSCLC) was infrequent. The current status of adjuvant chemotherapy in this population is unknown.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) database, we examined the incidence of chemotherapy in resected stage II–III NSCLC between 2004 and 2015. Staging was determined according to the American Joint Committee on Cancer (AJCC) 6th version. Cases were grouped by age (20–69, 70–79, and 80+). Trends in use of chemotherapy by age group were assessed by univariate and multivariate analyses.

Results

A total of 35,009 cases were selected as surgically resected stage II–III NSCLC. Use of chemotherapy was 66.9%, 48.2%, 25.0% in age 20–69, 70–79, 80+, respectively. Multivariate analysis demonstrated that younger age [20–69] and recent year [2010–2015] of diagnosis were associated with increased use of chemotherapy. Chemotherapy use increased from 2004 to 2015 by 11.0%, 18.3%, and 11.3% in age 20–69, 70–79, 80+, respectively. In the age 70–79 group, increased use of chemotherapy was greater in stage II (24.3%) than stage III (14.1%). Five-year overall survival in age 70–79 group mildly increased by 7.6% from 2004 to 2011.

Conclusions

This study suggests that use of adjuvant chemotherapy in the elderly population increased primarily in age 70–79. Few patients in the 80+ age group received adjuvant chemotherapy even in recent years.

Do Elderly Patients With Stage I-II Hepatocellular Carcinoma Benefit From More Radical Surgeries? A Population-Based Analysis

Background and Aims: The best treatment modalities for elderly patients with stage I–II HCC (hepatocellular carcinoma) remain controversial in an era of a shortage of liver donors.

Methods: From the SEER database (Surveillance, Epidemiology, and End Results program), 2,371 elderly patients were sampled as Cohort 1. OS (Overall Survival) and CSS (Cancer-Specific Survival) were compared between the Non-surgery and Surgery groups. A stratification analysis in a CSS Cox model was also conducted among sub-groups, and propensity score matching was performed to generate Cohort 2 (746 pairs), reducing the influences of confounders.

Results: For Cohort 1, the median follow-up times of the Non-surgery and Surgery groups were 11 months (95% CI, confidence interval: 9.74–12.26) vs. 49 months (44.80–53.21) in OS, and 14 months (12.33–15.67) vs. 74 months (64.74–83.26) in CSS, respectively. In the stratification analysis, for the elderly patients (age >= 70 years), Larger Resection was associated with a higher HR (hazard ratio) than Segmental Resection: 0.30 (95% CI, confidence interval: 0.22–0.41) vs. 0.29 (0.21–0.38) in 70–74 year-olds; 0.26 (0.18–0.38) vs. 0.23 (0.16–0.32) in 75–79 year-olds; 0.32 (0.21–0.49) vs. 0.21 (0.13–0.32) in those 80+ years old. For Cohort 2, a similar result could be seen in the CSS Cox forest plot. The HRs of Larger Resection and Segmental Resection were 0.27 (0.21–0.33) and 0.25 (0.20–0.31), respectively.

Conclusions: It is cautiously recommended that, when liver transplantation is not available, segmental or wedge liver resection is the better treatment choice for elderly patients with stage I–II HCC (AJCC edition 6), especially those over 70 years old, compared with other surgeries, based on the SEER data.

Predictors of Distant Recurrence Following Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer

OBJECTIVE

The objective of this study was to characterize patients at an increased risk of distant metastasis (DM) following stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

We identified patients undergoing SBRT for stage I NSCLC between 2005 and 2016. Patients with a prior lung cancer diagnosis, receiving a biological effective dose <100 Gy, or receiving chemotherapy were excluded. Patients underwent pretreatment staging and were classified according to the American Joint Committee for Cancer (AJCC) 8th edition staging. The primary endpoint was DM. The Kaplan-Meier method and the Cox proportional hazards model were used for survival analysis and to identify predictors of DM.

RESULTS

A total of 174 patients were included, with a median age 75 years (range, 49 to 96 y) and a median follow-up of 24 months (range, 3 to 123 mo). The 2- and 4-year cumulative incidences of DM were 14.2% and 19.1%, respectively. Patients who developed DM had worse overall survival versus patients developing a locoregional recurrence (P=0.023). On multivariable analysis, having stage IB disease (hazard ratio: 2.95; 95% confidence interval: 1.06-8.23; P=0.039) or a lower/middle lobe tumor (hazard ratio: 2.67; 95% confidence interval: 1.07-6.69; P=0.036) was associated with increased risk of DM. The 2-year cumulative incidences of DM were 10.9% and 35.7% (P=0.002) for patients with stage IA versus IB tumors, respectively, and 11.3% and 19.7% (P=0.049) for patients with upper lobe versus lower/middle lobe tumors, respectively.

CONCLUSIONS

Patients with stage IB disease or lower/middle lobe tumors may have an increased risk of DM following SBRT. Randomized controlled trials are needed to further identify patients who may benefit from adjuvant systemic therapy after SBRT for stage I NSCLC.

Comparing the benefits of postoperative adjuvant chemotherapy vs. observation for stage IB non-small cell lung cancer: a meta-analysis

Background

The aim of this meta-analysis was to compare the benefits of postoperative adjuvant chemotherapy vs. observation for stage IB non-small cell lung cancer (NSCLC).

Methods

A literature search was performed in PubMed, Embase, and Cochrane Library databases, and stage IB NSCLC patients were assigned to the postoperative adjuvant chemotherapy and observation groups. The 5-year overall survival (OS), 5-year disease-free survival (DFS), local recurrence, and distant metastasis were then assessed. In addition, statistical analysis was conducted using Review Manager 5.3 software.

Results

The meta-analysis involved nine articles and included 1,645 stage IB patients. There was no significance in the 5-year OS [relative risk (RR) =1.05; 95% confidence interval (CI): 0.98-1.13; P=0.14] and 5-year DFS (RR =1.29; 95% CI: 0.97-1.72; P=0.08) between the postoperative adjuvant chemotherapy and observation groups. However, there was a significant difference in local recurrence (RR =0.43; 95% CI: 0.23-0.80; P=0.007) and distant metastasis (RR =0.68; 95% CI: 0.48-0.97; P=0.03) between the two groups.

Conclusions

Adjuvant chemotherapy might not be recommended for stage IB NSCLC.

Robotic-Assisted Lobectomy for Non-Small Cell Lung Cancer: A Comprehensive Institutional Experience

BACKGROUND

It is unclear whether the enhanced dexterity and visualization of the surgical robot lessens morbidity and influences staging or survival. We compared outcomes of robotic-assisted lobectomy (RAL) with thoracoscopic video-assisted lobectomy (VAL) or open lobectomy (OL) of non-small cell lung cancer.

METHODS

Using a prospective surgical database, perioperative and cancer-related outcomes of patients who received a lobectomy for non-small cell lung cancer from 2011 to 2017 were analyzed. Outcomes between each surgical approach were compared using inverse probability of treatment weighting generated from the inverse of the propensity score.

RESULTS

There were 831 patients: 106 RAL, 301 VAL, and 424 OL. More RAL patients than VAL received neoadjuvant therapy (16% vs 6%, P = .001), but less than OL (28% vs 16%, P = .014). After adjustment, RAL was associated with longer operative times, less blood loss, and improved nodal harvest (all P < .02). There were no differences in morbidity, nodal upstaging, or mortality between surgical approaches. Length of stay was shorter with RAL vs OL (P < .01). Unadjusted cost was higher after RAL vs VAL (P = .003), but after adjustment, cost differences disappeared.

CONCLUSIONS

Robotic-assisted lobectomy was associated with improved nodal harvest and less blood loss as compared with VAL or OL. Length of stay was shorter with RAL as opposed to OL. Unexpectedly, cost was not higher with RAL. The profile of patients who received RAL more closely approximated OL, suggesting RAL may allow typical thoracotomy patients to receive minimally invasive surgery after adequate training and experience.

Oral fluorouracil vs vinorelbine plus cisplatin as adjuvant chemotherapy for stage II-IIIA non-small cell lung cancer: Propensity score-matched and instrumental variable analyses

BACKGROUND

Adjuvant chemotherapy with vinorelbine plus cisplatin (VNR/CDDP) is a standard regimen for treatment of postoperative stage II-IIIA non-small cell lung cancer (NSCLC). However, oral fluorouracil offers a feasible alternative adjuvant chemotherapeutic regimen. We compared the prognoses of patients with NSCLC treated with adjuvant chemotherapy with either VNR/CDDP or oral fluorouracil.

METHODS

We identified patients with stage II-IIIA NSCLC who underwent lung surgery followed by adjuvant chemotherapy with VNR/CDDP (n = 384) or oral fluorouracil (n = 268) between July 2010 and March 2015, using the national Japanese inpatient and outpatient Diagnosis Procedure Combination database. We compared recurrence-free survival between the groups by multivariable Cox regression analysis for one-to-one propensity score-matched patients and by instrumental variable analysis.

RESULTS

Younger patients and patients with positive N2 nodes were more likely to receive VNR/CDDP, while older patients and those with T3N0 classification were more likely to receive oral fluorouracil. Among 172 pairs of propensity-matched patients, time to adjuvant chemotherapy was shorter for oral fluorouracil compared with VNR/CDDP. Oral fluorouracil was also significantly associated with improved recurrence-free survival compared with VNR/CDDP, according to multivariable Cox regression analysis (hazard ratio, 0.41; 95% confidence interval, 0.26-0.64). Instrumental variable analysis showed a similar relationship (hazard ratio, 0.19; 95% confidence interval, 0.038-0.92).

CONCLUSIONS

On a large nationwide cohort, adjuvant chemotherapy with oral fluorouracil prolonged recurrence-free survival in patients with postoperative stage II-IIIA NSCLC, compared with VNR/CDDP. Oral fluorouracil may thus be a useful alternative to VNR/CDDP for the adjuvant treatment of these patients.

Spread through air spaces predicts a worse survival in patients with stage I adenocarcinomas >2 cm after radical lobectomy

Background

The aim of this study was to evaluate the significance of spread through air spaces (STAS) in early lung adenocarcinomas after radical lobectomy and lymphadenectomy.

Methods

A total of 242 patients with lung adenocarcinomas less than 4 cm (8th pStage I) were selected from the lung cancer patients surgically treated from January, 2009 to September, 2011. Pathological review focused on STAS as well as histological subtypes, blood vessel & neural invasion, pathological tumor size etc. Recurrence or disease-free survival (DFS) and overall survival (OS) were compared between patients as stratified by STAS and tumor size.

Results

STAS was observed in 33.47% (81/242) patients, which was significantly correlated with histological predominant subtype (χ²=25.903, P=0.093×10^-3) and differentiation grade (χ²=23.986, P=0.025×10^-3). Patients with STAS (+) showed a comparable PFS (P=0.268) and OS rates (P=0.100) in all stage I cases, but a significant lower PFS (P=0.029) and OS (P=0.013) in tumors within 2< tumors ≤4 cm. Multivariate analysis revealed STAS to be an independent worse prognostic factor in lung adenocarcinomas within 2< tumors ≤4 cm, both for PFS (P=0.004) and OS (P=0.002), while no significant difference was found in patients with tumors ≤2 cm (PFS, P=0.537; OS, P=0.448), after adjusting by other clinicopathological parameters as age, gender, smoking etc.

Conclusions

Presence of STAS was a significant worse predictor for pStage I patients with lung adenocarcinoma >2 cm who underwent radical lobectomy, while it is not significant in patients with tumor ≤2 cm. These findings may be helpful in assessing postoperative therapy stratified by tumor size and STAS status.

Prognostic Factors in Completely Resected Node-Negative Lung Adenocarcinoma of 3 cm or Smaller

INTRODUCTION

The role of adjuvant chemotherapy for patients with stage I NSCLC remains unknown. The prognostic value of histological subtypes in resected node-negative small lung adenocarcinoma has not been widely investigated. This study investigated the prognostic factors in patients with node-negative lung adenocarcinoma 3 cm or smaller to find potential candidates for adjuvant chemotherapy.

METHODS

A total of 726 patients with completely resected node-negative lung adenocarcinoma 3 cm or smaller were included in the study. Prognostic factors for overall survival or probability of freedom from recurrence (FFR) were investigated.

RESULTS

During follow-up, recurrence developed in 59 patients (8.1%). Univariate analysis showed that the micropapillary/solid predominant pattern group was associated with a significantly lower probability of FFR (p = 0.001) in node-negative lung adenocarcinoma 3 cm or smaller. Those with greater tumor size (p = 0.001) and the micropapillary/solid predominant pattern group (p = 0.035) had a significantly lower probability of FFR in multivariate analysis. For tumors 2 cm or smaller, the micropapillary/solid predominant pattern group had a trend toward a lower probability of FFR (p = 0.053) in multivariate analysis. Presence of the solid pattern was a prognostic factor for lower probability of FFR (p = 0.001) in multivariate analysis.

CONCLUSIONS

The new adenocarcinoma classification has significant impact on recurrence in node-negative lung adenocarcinoma 3 cm or smaller. Patients with the micropapillary/solid predominant pattern have a significantly higher risk for recurrence. For tumors 2 cm or smaller, presence of the solid pattern was a prognostic factor for higher probability of recurrence. This information is useful for patient stratification for adjuvant therapy.

[Current knowledge on perioperative treatments of non-small cell lung carcinomas]

Surgery is still the main treatment in early-stage of non-small cell lung cancer with 5-year survival of stage IA patients exceeding 80%, but 5-year survival of stage II patients rapidly decreasing with tumor size, N status, and visceral pleura invasion. The major metastatic risk in such patients has supported clinical research assessing systemic or loco-regional perioperative treatments. Modern phase 3 trials clearly validated adjuvant or neo-adjuvant platinum-based chemotherapy in resected stage I-III patients as a standard treatment of which value has been reassessed several independent meta-analyses, showing a 5% benefit in 5y-survival, and a decrease of the relative risk for death around from 12 to 25%. Conversely perioperative treatments were not validated for stage IA and IB patients. In more advanced stage patients, neo-adjuvant radio-chemotherapy has not been validated either. Adjuvant radiotherapy for N2 patients is currently tested in the large international phase 3 trial Lung-ART/IFCT-0503. The development of video-assisted thoracic surgery (VATS) has helped adjuvant chemotherapies for elderly patients. Perioperative targeted treatments in NSCLC with EGFR or ALK molecular alterations is currently assessed in the U.S. ALCHEMIST prospective trial. Finally, the role of immune check-points inhibitors is currently evaluated in a large international phase 3 trial testing adjuvant anti-PD-L1 monoclonal antibody, the BR31/IFCT-1401 trial, while a proof-of principle neo-adjuvant trial IONESCO/IFCT-1601, has just begun by the end of the 2016 year, with survival results of both trials expected in 5 to 7 years.

Adjuvant chemotherapy for elderly patients with non-small-cell lung cancer

Background

Adjuvant chemotherapy after complete surgical resection is currently the standard of care for patients with stage IB, II, or IIIA non-small-cell lung cancer. However, the generalizability of this treatment to elderly patients is controversial. We investigated the effects of adjuvant chemotherapy in patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer.

Methods

We retrospectively analyzed 246 consecutive patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer who underwent standard lung cancer surgery between January 2001 and December 2015. They were divided into 102 who had adjuvant chemotherapy and 144 who had none (control group). The outcomes were compared between the two groups, and prognostic factors were evaluated.

Results

Relapse-free survival and overall survival were significantly shorter in the control group than the chemotherapy group ( p = 0.006 and p = 0.008, respectively). In multivariable analyses, adjuvant chemotherapy was found to be an independent prognostic factor for relapse-free survival and overall survival (hazard ratio = 0.594, 95% confidence interval: 0.396–0.893, p = 0.012; and hazard ratio = 0.616, 95% confidence interval: 0.397–0.957, p = 0.031, respectively). After inverse-probability-of-treatment weighting adjustment using the propensity score for baseline characteristics, chemotherapy almost improved relapse-free survival and overall survival (hazard ratio = 0.652, 95% confidence interval: 0.433–0.981, p = 0.040; and hazard ratio = 0.657, 95% confidence interval: 0.429–1.004, p = 0.052, respectively).

Conclusions

Adjuvant chemotherapy improved the prognosis after standard lung cancer surgery in patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer.

Tumor Spread through Air Spaces Affects the Recurrence and Overall Survival in Patients with Lung Adenocarcinoma >2 to 3 cm

OBJECTIVES

Tumor spread through air spaces (STAS) is a novel invasive pattern in lung adenocarcinoma (ADC). The effects of the combination of STAS and tumor size on survival have not been well studied.

METHODS

A total of 383 patients with ADC 3 cm or smaller (stage IA) and 161 patients with stage IB ADC were identified from 2009 to 2010. Recurrence-free survival (RFS) and overall survival (OS) were compared between patients as stratified by STAS and tumor size. A validation cohort was included in this study.

RESULTS

STAS was observed in 116 ADCs 3 cm or smaller (30.3%). In cases involving ADCs 3 cm or smaller, patients with STAS had worse RFS (p = 0.006) and OS rates (p < 0.001) than those without STAS. Furthermore, comparable RFS (p = 0.091) and OS (p = 0.443) rates were observed in patients with ADCs 3 cm or smaller with STAS present and those with stage IB ADC. Multivariate analysis revealed STAS to be an independent prognostic factor in ADCs 3 cm or smaller (RFS, p = 0.043; OS, p = 0.009). Among patients with ADCs larger than 2 to 3 cm, STAS still stratified the prognosis. Moreover, the unfavorable prognosis of patients with ADCs larger than 2 to 3 cm with STAS present was similar to that of patients with stage IB ADC. Among patients with ADCs 2 cm or smaller, STAS failed to stratify the prognosis significantly. Similar results were obtained in the validation cohort.

CONCLUSIONS

These results provide preliminary evidence that STAS could be considered as a factor in a staging system to predict prognosis more precisely, especially in ADCs larger than 2 to 3 cm.

Use of Stereotactic Ablative Radiotherapy (SABR) in Non-Small Cell Lung Cancer Measuring More Than 5 cm

INTRODUCTION

Stereotactic ablative radiotherapy (SABR) is currently not the guideline-recommended treatment for lung tumors measuring more than 5 cm. However, improvements in radiotherapy techniques have led to increasing use of SABR for larger tumors.

METHODS

We analyzed the clinical outcomes in patients with a primary or recurrent NSCLC measuring more than 5 cm and treated with five or eight fractions of SABR at our center. Patients who had prior thoracic radiotherapy were excluded.

RESULTS

A total of 63 consecutive patients with a median tumor diameter of 5.8 cm (range 5.1-10.4) were identified; 81% had T2N0 disease and 18% had T3N0 disease. The median Charlson comorbidity index was 2 (range 0-6). After a median follow-up of 54.7 months, median survival was 28.3 months. Disease-free survival at 2 years was 82.1%, and the local, regional, and distant control rates at 2 years were 95.8%, 93.7%, and 83.6%, respectively. An out-of-field distant recurrence at one or more sites was the most common pattern of failure (10%). Grade 3 or higher toxicity was recorded in 30% of patients, with radiation pneumonitis being the most common toxicity (19%). A likely (n = 4) or possible (n = 8) treatment-related death was scored in 19% of patients. There was preexisting interstitial lung disease in eight patients (13%), with fatal toxicity developing in five of them (63%).

CONCLUSIONS

Lung SABR in tumors larger than 5 cm resulted in high local control rates and acceptable survival outcomes in a patient population with appreciable comorbidity. Patients with interstitial lung disease should be considered a very high-risk population for SABR.

Management of stage I and II nonsmall cell lung cancer

The incidence of stage I and II nonsmall cell lung cancer is likely to increase with the ageing population and introduction of screening for high-risk individuals. Optimal management requires multidisciplinary collaboration. Local treatments include surgery and radiotherapy and these are currently combined with (neo)adjuvant chemotherapy in specific cases to improve long-term outcome. Targeted therapies and immunotherapy may also become important therapeutic modalities in this patient group. For resectable disease in patients with low cardiopulmonary risk, complete surgical resection with lobectomy remains the gold standard. Minimally invasive techniques, conservative and sublobar resections are suitable for a subset of patients. Data are emerging that radiotherapy, especially stereotactic body radiation therapy, is a valid alternative in compromised patients who are high-risk candidates for surgery. Whether this is also true for good surgical candidates remains to be evaluated in randomised trials. In specific subgroups adjuvant chemotherapy has been shown to prolong survival; however, patient selection remains important. Neoadjuvant chemotherapy may yield similar results as adjuvant chemotherapy. The role of targeted therapies and immunotherapy in early stage nonsmall cell lung cancer has not yet been determined and results of randomised trials are awaited.

Practice pearls in the management of lung cancer in the elderly

Lung cancer is a disease that afflicts the elderly. It is a leading cause of cancer mortality worldwide. Treatment of lung cancer which was predominantly combination chemotherapy was initially thought to be too toxic for older patients with cancer due to their frail state. However a number of recent studies have shown that this is not necessarily true and many elderly can actually tolerate combination chemotherapy and derive just as much benefit from it as younger patients with lung cancer do. More recently it has been found that a significant proportion of lung cancer patients have tumors that harbor mutations that are targetable by molecularly targeted therapy (MTT). These targeted therapies have a much better tolerated side effect profile, hence have been used in elderly patient with lung cancer with great success. A new generation of drugs called immune checkpoint inhibitors have now come into the fray with exciting results in the second line treatment of lung cancer with a low side effect profile. A key element in deciding whether an elderly patient with lung cancer can tolerate treatment involves a detailed assessment using the comprehensive geriatric assessment (CGA). A number of CGA and clinical factors have also been found to be able to predict chemotherapy associated toxicity. This review of lung cancer in the elderly was part of a lecture on "Practice pearls in the management of lung cancer in the elderly" presented at the SIOG Annual Meeting in Prague in November 2015.

Prognostic Impact of Multiple Clinicopathologic Risk Factors and c-MET Overexpression in Patients Who Have Undergone Resection of Stage IB Non-Small-Cell Lung Cancer

BACKGROUND

Several studies have suggested risk factors for poor survival in stage IB non-small-cell lung cancer (NSCLC) patients. However, these factors are not definite indicators of adjuvant chemotherapy for stage IB cancer, and most of them can be used to consider adjuvant chemotherapy. We aimed to determine the clinicopathologic factors and assess whether c-MET is a prognostic factor in stage IB NSCLC patients who have undergone surgery. Additionally, we determined the relevance of the factors and the recurrence pattern in these patients.

PATIENTS AND METHODS

This study included 115 patients who underwent resection of pathologic stage IB NSCLC between January 2005 and December 2013. We retrospectively reviewed the clinicopathologic data and performed immunohistochemical analysis for c-MET. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were evaluated according to clinicopathologic factors and c-MET expression.

RESULTS

Lymphovascular invasion (LVI) and c-MET overexpression were significantly associated with poor RFS. A large tumor with visceral pleural invasion (VPI) or LVI, moderate/poor differentiation with LVI, and VPI with LVI were negative prognostic factors for RFS and CSS. c-MET overexpression with a large tumor, VPI, or LVI was an independent prognostic factor for poor RFS and CSS, and LVI was a significant factor for distant recurrence.

CONCLUSION

LVI and c-MET overexpression might be associated with poor prognosis in stage IB NSCLC patients. Additionally, survival might be poor in stage IB patients with multiple pathologic risk factors. Moreover, there is a high possibility of distant recurrence in patients with LVI.