Surgery of primary non-small cell lung cancer with oligometastasis: analysis of 172 cases

A Nomogram for Predicting Cancer-Specific Survival in Young Patients With Advanced Lung Cancer Based on Competing Risk Model

BACKGROUND

Young lung cancer is a rare subgroup accounting for 5% of lung cancer. The aim of this study was to compare the causes of death (COD) among lung cancer patients of different age groups and construct a nomogram to predict cancer-specific survival (CSS) in young patients with advanced stage.

METHODS

Lung cancer patients diagnosed between 2004 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and stratified into the young (18-45 years) and old (> 45 years) groups to compare their COD. Young patients diagnosed with advanced stage (IVa and IVb) from 2010 to 2015 were reselected and divided into training and validation cohorts (7:3). Independent prognostic factors were identified through the Fine-Gray's test and further integrated to the competing risk model. The area under the receiver operating characteristic curve (AUC), consistency index (C-index), and calibration curve were applied for validation.

RESULTS

The proportion of cancer-specific death (CSD) in young patients was higher than that in old patients with early-stage lung cancer (p < 0.001), while there was no difference in the advanced stage (p = 0.999). Through univariate and multivariate analysis, 10 variables were identified as independent prognostic factors for CSS. The AUC of the 1-, 3-, and 5-year prediction of CSS was 0.688, 0.706, and 0.791 in the training cohort and 0.747, 0.752, and 0.719 in the validation cohort. The calibration curves demonstrated great accuracy. The C-index of the competing risk model was 0.692 (95% CI: 0.636-0.747) in the young patient cohort.

CONCLUSION

Young lung cancer is a distinct entity with a different spectrum of competing risk events. The construction of our nomogram can provide new insights into the management of young patients with lung cancer.

Development of a nomogram for predicting survival in clinical T1N0M1 lung adenocarcinoma: a population-based study

OBJECTIVE

This study aimed to establish a prognostic model for clinical T1N0M1 (cT1N0M1) lung adenocarcinoma patients to evaluate the prognosis of patients in terms of overall survival (OS) rate and cancer-specific survival (CSS) rate.

METHODS

Data of patients with metastatic lung adenocarcinoma from 2010 to 2016 were collected from the Surveillance, Epidemiology and End Results database. Multivariate Cox regression analysis was conducted to identify relevant prognostic factors and used to develop nomograms. The receiver operating characteristic (ROC) curve and calibration curve are used to evaluate the predictive ability of the nomograms.

RESULTS

A total of 45610 patients were finally included in this study. The OS and CSS nomograms were constructed by same clinical indicators such as age (<60 years or ≥60 years), sex (female or male), race (white, black, or others), surgery, radiation, chemotherapy, and the number of metastatic sites, based on the results of statistical Cox analysis. From the perspective of OS and CSS, surgery contributed the most to the prognosis. The ROC curve analysis showed that the survival nomograms could accurately predict OS and CSS. According to the points obtained from the nomograms, survival was estimated by the Kaplan-Meier method, then cT1N0M1 patients were divided into three groups: low-risk group, intermediate-risk group, and high-risk group, and the OS ( P  < 0.001) and CSS ( P  < 0.001) were significantly different among the three groups.

CONCLUSION

The nomograms and risk stratification model provide a convenient and reliable tool for individualized evaluation and clinical decision-making of patients with cT1N0M1 lung adenocarcinoma.

VATS versus Open Lobectomy following Induction Therapy for Stage III NSCLC: A Propensity Score-Matched Analysis

Objectives: This study aims to evaluate the perioperative and oncologic outcomes of thoracoscopic lobectomy for advanced stage III NSCLC. Methods: We retrospectively reviewed 205 consecutive patients who underwent VATS or open lobectomy for clinical stage III lung cancer between January 2013 and December 2020. The perioperative and oncologic outcomes of the two approaches were compared. Long-term survival was assessed using the Kaplan−Meier estimator. Propensity score-matched (PSM) comparisons were used to obtain a well-balanced cohort of patients undergoing VATS and open lobectomy. Results: VATS lobectomy was performed in 77 (37.6%) patients and open lobectomy in 128 (62.4%) patients. Twelve patients (15.6%) converted from VATS to the open approach. PSM resulted in 64 cases in each group, which were well matched according to twelve potential prognostic factors, including tumor size, histology, and pTNM stage. Between the VATS and the open group, there were no significant differences in unmatched and matched analyses, respectively, of the overall postoperative complications (p = 0.138 vs. p = 0.109), chest tube duration (p = 0.311 vs. p = 0.106), or 30-day mortality (p = 1 vs. p = 1). However, VATS was associated with shorter hospital stays (p < 0.0001). The five-year overall survival (OS) and five-year Recurrence-free survival (RFS) were comparable between the VATS and the open groups. There was no significant difference in the recurrence pattern between the two groups in both the unmatched and matched analyses. Conclusion: For the advanced stage III NSCLC, VATS lobectomy achieved equivalent postoperative and oncologic outcomes when compared with open lobectomy without increasing the risk of procedure-related locoregional recurrence.

Long-term Surgical Outcomes in Oligometastatic Non-small Cell Lung Cancer: A Single-Center Study

Background

We reviewed the clinical outcomes of patients with oligometastatic (OM) non-small cell lung cancer (NSCLC) who received multimodal therapy including lung surgery.

Methods

We retrospectively analyzed 117 patients with OM NSCLC who underwent complete resection of the primary tumor from 2014 to 2017.

Results

The median follow-up duration was 2.91 years (95% confidence interval, 1.48-5.84 years). The patients included 73 men (62.4%), and 76 patients (64.9%) were under the age of 65 years. Based on histology, 97 adenocarcinomas and 14 squamous cell carcinomas were included. Biomarker analysis revealed that 53 patients tested positive for epidermal growth factor receptor, anaplastic lymphoma kinase, or ROS1 mutations, while 36 patients tested negative. Metastases were detected in the brain in 74 patients, the adrenal glands in 12 patients, bone in 5 patients, vertebrae in 4 patients, and other locations in 12 patients. Radiation therapy for organ metastasis was performed in 81 patients and surgical resection in 27 patients. The 1-year overall survival (OS) rate in these patients was 82.8%, and the 3- and 5-year OS rates were 52.6% and 37.2%, respectively. Patients with positive biomarker test results had 1-, 3-, and 5-year OS rates of 98%, 64%, and 42.7%, respectively. These patients had better OS than those with negative biomarker test results (p=0.031). Patients aged ≤65 years and those with pT1-2 cancers also showed better survival (both p=0.008).

Conclusion

Surgical resection of primary lung cancer is a viable treatment option for selected patients with OM NSCLC in the context of multimodal therapy.

Patient Selection for Local Aggressive Treatment in Oligometastatic Non-Small Cell Lung Cancer

Simple Summary

Since the first introduction of the oligometastatic state with a low burden of metastases in non-small cell lung cancer, accumulating evidence from retrospective and prospective studies has shown that a local aggressive, multimodality treatment may significantly improve the prognosis in these patients. Local aggressive treatment includes a systemic therapy of micrometastatic disease, as well as a radical resection of the primary tumor and surgical resection and/or radiation therapy of distant metastases. However, patient selection and treatment allocation remain a central challenge in oligometastatic disease. In this review, we aimed to address the current evidence on criteria for patient selection for local aggressive treatment in non-small cell lung cancer.

Abstract

One-fourth of all patients with metastatic non-small cell lung cancer presents with a limited number of metastases and relatively low systemic tumor burden. This oligometastatic state with limited systemic tumor burden may be associated with remarkably improved overall and progression-free survival if both primary tumor and metastases are treated radically combined with systemic therapy. This local aggressive therapy (LAT) requires a multidisciplinary approach including medical oncologists, radiation therapists, and thoracic surgeons. A surgical resection of the often advanced primary tumor should be part of the radical treatment whenever feasible. However, patient selection, timing, and a correct treatment allocation for LAT appear to be essential. In this review, we aimed to summarize and discuss the current evidence on patient selection criteria such as characteristics of the primary tumor and metastases, response to neoadjuvant or first-line treatment, molecular characteristics, mediastinal lymph node involvement, and other factors for LAT in oligometastatic NSCLC.

Surgical Survival Benefits With Different Metastatic Patterns for Stage IV Extrathoracic Metastatic Non-Small Cell Lung Cancer: A SEER-Based Study

Background:

With the knowledge of oligometastases, primary surgery plays an increasingly vital role in metastatic non-small cell lung cancer. We aimed to evaluate the survival benefit of primary surgery based on metastatic patterns.

Materials and Methods:

The selected patients with stage IV extrathoracic metastatic (m1b) non-small cell lung cancer between 2010 and 2015 were included in a retrospective cohort study from the Surveillance, Epidemiology, and End Results (SEER) database. Multiple imputation was used for the missing data. Patients were divided into 2 groups depending on whether surgery was performed. After covariate balancing propensity score (CBPS) weighting, multivariate Cox regression models and Kaplan-Meier survival curve were built to identify the survival benefit of different metastatic patterns.

Results:

Surgery can potentially increase the overall survival (OS) (adjusted HR: 0.68, P < 0.001) of non-small cell lung cancer. The weighted 3-year OS in the surgical group was 16.9%, compared with 7.8% in the nonsurgical group. For single organ metastasis, surgery could improve the survival of metastatic non-small cell lung cancer. Meanwhile, no significant survival improvements in surgical group were observed in patients with multiple organ metastases.

Conclusion:

The surgical survival benefits for extrathoracic metastatic non-small cell lung cancer could be divided by metastatic pattern.

Clinical prognostic factors in surgically treated oligometastatic non-small cell lung cancer: a systematic review

Background

Since the concept of oligometastatic (OM) disease was introduced in the oncological scenario of non-small cell lung cancer (NSCLC), these patients progressively became a new category of stage IV NSCLC in whom the multimodality approach, including surgery, may improve prognosis. This systematic review aimed to investigate the clinical prognostic factors in OM-NSCLC surgically treated with radical intent.

Methods

This systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Cochrane’s Collaboration Tool was used to determine the risk of bias for the included studies’ primary outcome. A search strategy using a combination of free-text words, relevant MeSH headings and appropriate restrictions (time limit: from January 1997 to March 2020, language: English) was designed. Potentially qualified papers were subjected to an in-depth full-text examination after preliminary title/abstract screening to identify studies for inclusion in the systematic review. Data extracted included: study characteristics, baseline patient characteristics, primary and secondary outcomes. The Cochrane’s Collaboration Tool was used to determine the risk of bias for included studies’ primary outcome. The risk of bias due to incomplete outcome data was evaluated at an outcome level. However, at the study stage, the possibility of bias due to sequence generation, allocation concealment, blinding, selective reporting, or funding was assessed. Two independent observers calculated the probability of bias, and differences were resolved through dialogue and consensus.

Results

Nine studies were selected. Overall survival (OS) was 51.8 months and varied from 21.1 to 60 months, but results were not statistically significant. Positive prognostic factors for survival were cessation of smoking, age <60, a histologic grade of G1/G2, pN0. The presence of extra-brain OM and multiple metastases negatively affected survival.

Discussion

For otherwise stable patients with a single organ site with synchronous (or metachronous) extrathoracic M1 disease and no intrathoracic lymph node involvement, aggressive treatment should be used in the absence of randomized evidence to help determine the effective management of OM-NSCLC.

Lobectomy Can Improve the Survival of Patients With Non-small Cell Lung Cancer With Lung Oligometastatic

Background: This study was to evaluate the value of lobectomy in the prognosis of Non-small cell lung cancer (NSCLC) patients with primary metastasis based on the Surveillance Epidemiology and End Results (SEER) database. Methods: This was a population-based retrospective study and the clinical data were collected from the National Cancer Institute's SEER database between 2010 and 2015. The effects of pulmonary surgery and surgical procedures on lung cancer-specific survival (LCSS) and overall survival (OS) were assessed, and the COX regression models were employed to evaluate the survival of primary surgery in patients with primary metastatic NSCLC (pmNSCLC) and the survival of surgical procedure in pmNSCLC patients. Results: A total of 55,717 patients diagnosed with pmNSCLC between 2010 and 2015 were enrolled, and pulmonary surgery was indicated in 1,575 (2.83%) patients. Surgery was an independent risk factor for LCSS (P < 0.001, HR 0.658, 95%CI: 0.637-0.680) and OS (P < 0.001, HR 0.665, 95%CI: 0.644-0.686) of pmNSCLC patients. The surgery was associated with better OS (P < 0.001, HR 0.678, 95%CI: 0.657-0.699). The site of metastasis was also related to the survival after primary tumor surgery (P = 0.001). As compared to the sublobectomy and pneumonectomy, lobectomy improved the LCSS for NSCLC patients with single-organ metastasis, rather than multiple metastases (P < 0.001). In patients receiving sublobectomy, lobectomy, and pneumonectomy, the median LCSS was 12, 28, and 13 months, respectively, and the 5-year LCSS rate was 14.39, 32.06, and 17.24%, respectively. Conclusion: The effect of locoregional surgery on the survival of pmNSCLC patients with single-organ metastasis has been underestimated, and lobectomy may be a preferred treatment for patients with single-lung metastasis.

The role of the surgeon in the management of oligometastatic non-small cell lung cancer: a literature review

OBJECTIVE

In this review, we aim to summarize the most recent data on the surgical management of oligometastatic non-small cell lung cancer (NSCLC).

BACKGROUND

Approximately 60-70% of all patients with NSCLC initially present with advanced stages of cancer at time of diagnosis. These patients are generally treated with chemotherapy, radiation therapy, or a combination of these modalities. Patients with late-stage disease are usually not considered to be amenable for curative-intent treatments due to poor prognoses. Despite advances in systemic therapies, 5-year overall survival rates in these patients remain poor. However, technological advances in imaging modalities and new imaging strategies have substantially increased tumor detection rates and have resulted in a shift towards earlier diagnosis of NSCLC, possibly in stages in which metastatic disease is limited and still treatable. Studies in recent years have shown that there is a distinct group of patients with metastatic lesions at one or a few sites, often referred to as oligometastatic disease, that may have better survival outcomes compared to patients with more disseminated diseases. Furthermore, it is suggested that these patients may benefit from a combination of systemic treatment and local treatment aimed at the metastatic site(s). However, the role of surgery in this setting remains a controversial subject, with many unanswered questions.

METHODS

The PubMed/MEDLINE database and the Cochrane database were searched to find relevant articles regarding oligometastatic NSCLC. Specifically, articles regarding definitions of oligometastatic disease, oligometastatic tumor biology, diagnosis, and the treatment of oligometastatic disease were identified.

CONCLUSIONS

Oligometastatic NSCLC represents a wide spectrum of diseases and encompasses a heterogeneous patient population. Current data suggests that local ablative treatment of oligometastatic lesions with surgery or stereotactic body radiation therapy may result in improved overall survival and progression-free survival rates. However, more data from multi-center prospective trials are necessary to shed light on which therapeutic modalities are most suitable for the treatment of oligometastatic NSCLC. Integration of clinical and molecular staging data is necessary to allow for more personalized treatment approaches.

A risk stratification scheme for synchronous oligometastatic non-small cell lung cancer developed by a multicentre analysis

BACKGROUNDS

Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC.

METHODS

The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan - Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses.

RESULTS

281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29-53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00-1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45-1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 - 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21-3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme.

CONCLUSIONS

Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.

Role of Surgical Intervention in Unresectable Non-Small Cell Lung Cancer

With the development of systemic treatments with high response rates, including tyrosine kinase inhibitors and immune checkpoint inhibitors, some patients with unresectable lung cancer now have a chance to undergo radical resection after primary treatment. Although there is no general consensus regarding the definition of “unresectable” in lung cancer, the term “resectable” refers to technically resectable and indicates that resection can provide a favorable prognosis to some extent. Unresectable lung cancer is typically represented by stage III and IV disease. Stage III lung cancer is a heterogeneous disease, and in some patients with technically resectable non-small cell lung cancer (NSCLC), multimodality treatments, including induction chemoradiotherapy followed by surgery, are the treatments of choice. The representative surgical intervention for unresectable stage III/IV NSCLC is salvage surgery, which refers to surgical treatment for local residual/recurrent lesions after definitive non-surgical treatment. Surgical intervention is also used for an oligometastatic stage IV NSCLC. In this review, we highlight the role of surgical intervention in patients with unresectable NSCLC, for whom an initial complete resection is technically difficult. We further describe the history of and new findings on salvage surgery for unresectable NSCLC and surgery for oligometastatic NSCLC.

New concepts in the surgical treatment of actual and impending pathological fractures in metastatic disease

INTRODUCTION

Long bone metastases are a disease of high social importance. The goals of surgical treatment are to relieve pain, maintain or restore joint function, and prevent or treat pathological fractures. "Oligometastases" is a disease with a limited number (3-5) of metastatic lesions in the same body district, where an aggressive treatment can be carried out with "curative" intent. This study aimed to evaluate patients with bone metastases surgically treated to determine how surgical treatment can influence prognosis and quality of life, comparing solitary metastasis, oligometastases, and multiple metastases.

PATIENTS AND METHODS

This is a retrospective analysis of 130 patients with long bone metastases surgically treated between October 2015 and August 2019: 40 patients had solitary metastasis; 38 had less than three metastases (oligometastases), and 52 had multiple metastases. Surgery was resection and reconstruction with a cemented prosthesis (95) or nailing (35).

RESULTS

Overall survival was significantly better in patients with solitary metastasis or oligometastases than in those with multiple metastases (p <0.0001). Patients treated with resection and prosthesis had significantly better survival than those treated with nailing (p <0.0001). Implant complications requiring surgical revision occurred in 20 patients treated with prostheses, while no complications occurred in patients treated with nailing.

DISCUSSION

Survival of cancer patients has improved in the last two decades, leading to an increase of diagnosed metastases. Patients with oligometastases have a survival similar to those with a single metastasis. Optimal implants survival curves should stay above the curves of patients survival.

CONCLUSIONS

Since there are no differences in survival, patients with oligometastases should be treated as patients with a solitary lesion, with more aggressive surgery (wide resection and reconstruction with prosthesis). Intramedullary nailing is still indicated in metaphyseal or diaphyseal metastases in patients with advanced disease or poor prognosis when the life expectancy does not overcome the expected survival of the nail, avoiding the need for further surgery.

Clinical characteristics and prognosis of pulmonary large cell carcinoma: A population-based retrospective study using SEER data

BACKGROUND

Pulmonary large cell carcinoma (LCC) is an infrequent neoplasm with a poor prognosis. This study explored the clinical characteristics and survival prognostic factors of LCC patients.

METHODS

Patient data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Chi-square tests or rank-sum tests were used to compare differences in clinical characteristics. Log-rank tests, univariate, and multivariate analyses were performed to investigate the independent factors of survival. Analyses of stage I-IV patients were performed to further explore the optimal treatment.

RESULTS

In total, 3197 LCC patients were included in this analysis. Compared with other non-small cell lung cancers (NSCLCs), there was a worse overall survival (OS) from LCC. LCC was more common in males, over age 60 and in the upper lobe. A total of 73.6% of patients were stage III/IV. The median OS of stage I-IV patients was 42 months, 22 months, 11 months, and three months, respectively. The elderly, males, later stage, and main bronchus location, or overlapping lesions were risk factors for survival prognosis. In stage I-III patients, treatment including surgery could significantly reduce the risk of death by 60% at least compared with no therapy. Surgery was still beneficial for stage IV patients, and the hazard ratio (HR) compared with no therapy was 0.462 (P = 0.001).

CONCLUSIONS

Our study concluded that LCC has unique clinical features, and that age, sex, primary site, stage, and treatment are significantly related to OS. Surgery based comprehensive treatments are effective for LCC.

KEY POINTS

Significant findings of the study In stage IV patients, chemotherapy or radiotherapy combined with surgery could further improve survival. When surgical resection involved more than one lobe, it may be beneficial for survival prognosis. What this study adds LCC patients were principally male and over age 60, with later stages and poor survival prognosis. Age, sex, stage, primary site and therapy are closely related to survival.

Oligorecurrence Non-small Cell Lung Cancer After Failure of First-Line Chemotherapy: Computed Tomography-Guided 125I Seed Implantation vs. Second-Line Chemotherapy

Purpose: To compare the efficacy and safety of computed tomography (CT)–guided ¹²⁵I seed implantation with second-line chemotherapy in treatment of oligorecurrence non–small cell lung cancer after failure of first-line chemotherapy.

Methods: Data of oligorecurrence non–small cell lung cancer patients after failure of first-line chemotherapy at two institutions were retrospectively reviewed from January 2013 to July 2018. A total of 53 patients who received the treatment of ¹²⁵I seed implantation or second-line chemotherapy were eligible for this study. In group A, 25 patients, 84 lesions, received CT-guided permanent ¹²⁵I seed implantation, whereas in group B, 28 patients, 96 lesions, received second-line chemotherapy. The outcomes were measured in terms of disease control rate, overall survival, quality of life, and complications.

Results: The median follow-up period was 13 months (range, 5–42 months). Disease control rate in group A was higher than that in group B (70.8 vs. 42.3%, P = 0.042) at 6 months after treatment. The median overall survival was 12.8 months (95% confidence interval, 10.5–15.1 months) in group A and 15.2 months (95% confidence interval, 12.2–18.2 months) in group B, with no significant difference (P = 0.847). Since the fourth month, the number of patients in group A with a non-decreasing Karnofsky Performance Scale score was more than that in group B (P < 0.05). The incidence of grade 3 or higher complications especially hematologic toxicity in group A was significantly lower than that in group B (P < 0.05).

Conclusion: Radioactive ¹²⁵I seed implantation is safe and feasible in selected non–small cell lung cancer patients with oligorecurrence after failure of first-line chemotherapy and seems to provide a better long-term quality of life in these patients compared with second-line chemotherapy.