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Salari K, Lee JS, Ye H, Seymour ZA, Lee KC, Chinnaiyan P, Grills IS. Long-term survival in patients with brain-only metastatic non-small cell lung cancer undergoing upfront intracranial stereotactic radiosurgery and definitive treatment to the thoracic primary site. Radiother Oncol 2024; 196:110262. [PMID: 38556172 DOI: 10.1016/j.radonc.2024.110262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND AND PURPOSE To evaluate modern clinical outcomes for patients with brain-only metastatic non-small cell lung cancer (NSCLC) treated with intracranial stereotactic radiosurgery (SRS) with or without definitive treatment of the primary site. MATERIALS AND METHODS Patients with synchronously diagnosed NSCLC and brain-only metastatic disease treated with intracranial SRS at a single institution were retrospectively identified. Patients were stratified based on whether they did (A) or did not (B) receive definitive primary site treatment. Patient characteristics and clinical outcomes were compared. RESULTS From 2008 to 2022, 103 patients were identified, 53 of whom received definitive primary site treatment. Median follow-up was 2.1 y (A) and 0.8 y (B) (p < 0.001). 28 (53 %) patients in Group A received immune checkpoint inhibitor (ICI) therapy versus 19 (38 %) in Group B (p = 0.13) and there were no other statistically significant baseline or treatment characteristic differences between the groups. 5-year local-PFS was 34.5 % (A) versus 0 % (B) (p < 0.001). 5-year regional-PFS was 33.0 % (A) versus 0 % (B) (p < 0.001). 5-year distant body-PFS was 34.0 % (A) versus 0 % (B) (p < 0.001). 5-year CNS-PFS was 14.7 % (A) versus 0 % (B) (p = 0.12). 5-year OS was 40.2 % (A) versus 0 % (B) (p = 0.001). 5-year CSS was 67.6 % (A) versus 0 % (B) (p = 0.002). On multivariable analysis, lack of definitive treatment to the primary site (HR = 2.40), AJCC T3-4 disease (HR = 2.73), and lack of ICI therapy (HR = 2.86) were significant predictors of death. CONCLUSION Definitive treatment to the thoracic primary site in patients with brain-only metastatic NSCLC after intracranial radiosurgery was associated with slower progression of disease and improved survival.
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Affiliation(s)
- K Salari
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, United States.
| | - J S Lee
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, United States
| | - H Ye
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, United States
| | - Z A Seymour
- Department of Radiation Oncology, Corewell Health Dearborn Hospital, Dearborn, MI, United States
| | - K C Lee
- Department of Radiation Oncology, Corewell Health Troy Hospital, Troy, MI, United States
| | - P Chinnaiyan
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, United States
| | - I S Grills
- Department of Radiation Oncology, Corewell Health East William Beaumont University Hospital, Royal Oak, MI, United States
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Goldberg M, Mondragon-Soto MG, Dieringer L, Altawalbeh G, Pöser P, Baumgart L, Wiestler B, Gempt J, Meyer B, Aftahy AK. Navigating Post-Operative Outcomes: A Comprehensive Reframing of an Original Graded Prognostic Assessment in Patients with Brain Metastases. Cancers (Basel) 2024; 16:291. [PMID: 38254781 PMCID: PMC10813622 DOI: 10.3390/cancers16020291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 12/28/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Graded Prognostic Assessment (GPA) has been proposed for various brain metastases (BMs) tailored to the primary histology and molecular profiles. However, it does not consider whether patients have been operated on or not and does not include surgical outcomes as prognostic factors. The residual tumor burden (RTB) is a strong predictor of overall survival. We validated the GPA score and introduced "volumetric GPA" in the largest cohort of operated patients and further explored the role of RTB as an additional prognostic factor. METHODS A total of 630 patients with BMs between 2007 and 2020 were included. The four GPA components were analyzed. The validity of the original score was assessed using Cox regression, and a modified index incorporating RTB was developed by comparing the accuracy, sensitivity, specificity, F1-score, and AUC parameters. RESULTS GPA categories showed an association with survival: age (p < 0.001, hazard ratio (HR) 2.9, 95% confidence interval (CI) 2.5-3.3), Karnofsky performance status (KPS) (p < 0.001, HR 1.3, 95% CI 1.2-1.5), number of BMs (p = 0.019, HR 1.4, 95% CI 1.1-1.8), and the presence of extracranial manifestation (p < 0.001, HR 3, 95% CI 1.6-2.5). The median survival for GPA 0-1 was 4 months; for GPA 1.5-2, it was 12 months; for GPA 2.5-3, it was 21 months; and for GPA 3.5-4, it was 38 months (p < 0.001). RTB was identified as an independent prognostic factor. A cut-off of 2 cm3 was used for further analysis, which showed a median survival of 6 months (95% CI 4-8) vs. 13 months (95% CI 11-14, p < 0.001) for patients with RTB > 2 cm3 and <2 cm3, respectively. RTB was added as an additional component for a modified volumetric GPA score. The survival rates with the modified GPA score were: GPA 0-1: 4 months, GPA 1.5-2: 7 months, GPA 2.5-3: 18 months, and GPA 3.5-4: 34 months. Both scores showed good stratification, with the new score showed a trend towards better discrimination in patients with more favorable prognoses. CONCLUSION The prognostic value of the original GPA was confirmed in our cohort of patients who underwent surgery for BM. The RTB was identified as a parameter of high prognostic significance and was incorporated into an updated "volumetric GPA". This score provides a novel tool for prognosis and clinical decision making in patients undergoing surgery. This method may be useful for stratification and patient selection for further treatment and in future clinical trials.
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Affiliation(s)
- Maria Goldberg
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Michel G. Mondragon-Soto
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City 14269, Mexico;
| | - Laura Dieringer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Ghaith Altawalbeh
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Paul Pöser
- Department of Neurosurgery, Charite–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
| | - Lea Baumgart
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany;
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
| | - Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum Rechts der Isar, Technical University Munich, 80333 Munich, Germany; (L.D.); (G.A.); (B.M.); (A.K.A.)
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Fiore G, Tariciotti L, Bertani GA, Gagliano D, D’Ammando A, Ampollini AM, Schisano L, Borsa S, Pluderi M, Locatelli M, Caroli M. Surgery vs. Radiosurgery for Patients with Localized Metastatic Brain Disease: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Cancers (Basel) 2023; 15:3802. [PMID: 37568618 PMCID: PMC10417431 DOI: 10.3390/cancers15153802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Purpose: To analyze the efficacy and safety of surgery compared to radiosurgery (RS), combined or not with whole brain radiotherapy (WBRT), for localized metastatic brain disease. Methods: A systematic review with meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The inclusion criteria were limited to randomized controlled trials (RCTs) that compared surgery and RS for patients with up to 3 metastases (median diameter ≤ 4 cm). The primary outcomes were represented by overall survival (OS) and local brain progression-free survival (PFS), with the rate of complications as a secondary outcome. The pooled estimates were calculated using random forest models. The risk of bias was evaluated using the RoB2 revised tool and the certainty of the evidence was assessed according to the GRADE guidelines. Results: In total, 11,256 records were identified through database and register searches. After study selection, 3 RCTs and 353 patients were included in the quantitative synthesis. Surgery and RS represented the main intervention arms in all the included RCTs. Conclusions: A low level of evidence suggests that RS alone and surgery followed by WBRT provide an equal rate of local brain PFS in patients with localized metastatic brain disease. There is a very low level of evidence that surgery and RS as main interventions offer equivalent OS in the population investigated. A reliable assessment of the complication rates among surgery and RS was not achievable. The lack of high-certainty evidence either for superiority or equivalence of these treatments emphasizes the need for further, more accurate, RCTs comparing surgery and RS as local treatment in patients with oligometastatic brain disease.
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Affiliation(s)
- Giorgio Fiore
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Leonardo Tariciotti
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Giulio Andrea Bertani
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Dario Gagliano
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Antonio D’Ammando
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Antonella Maria Ampollini
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Luigi Schisano
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Stefano Borsa
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Mauro Pluderi
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
| | - Marco Locatelli
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
- Department of Medical and Surgical Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Manuela Caroli
- Unit of Neurosurgery, IRCCS Ca’ Granda Foundation Ospedale Maggiore Policlinico, Via Francesco Sforza, 35, 20122 Milan, Italy
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Kumar A, Salama JK. Role of radiation in oligometastases and oligoprogression in metastatic non-small cell lung cancer: consensus and controversy. Expert Rev Respir Med 2023; 17:1033-1040. [PMID: 37962878 DOI: 10.1080/17476348.2023.2284362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/13/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION The oligometastatic state in non-small cell lung cancer (NSCLC) has recently become well-established. However, the specific definition of oligometastases remains unclear. Several smaller randomized studies have investigated the safety and efficacy of radiation as metastasis-directed therapy (MDT) in oligometastatic NSCLC, which have led the way to larger studies currently accruing patients globally. AREAS COVERED This review covers the definitions of 'oligometastases' and explains why the oligometastatic state is becoming increasingly relevant in metastatic NSCLC. This includes the rationale for MDT in oligometastatic NSCLC, specifically reviewing stereotactic body radiation therapy (SBRT) as a treatment strategy. This review details many randomized trials that support radiation as MDT and introduces trials that are currently accruing patients. Finally, it explores some of the controversies that warrant further investigation. EXPERT OPINION Radiation treatment, specifically SBRT, has been shown to be safe, convenient, and cost-effective as MDT. As systemic therapy, including targeted agents and immunotherapy, continues to improve, the precise role(s) and timing of radiation therapy may evolve. However, radiation therapy as MDT will continue to be an integral part of treatment in patients with oligometastatic NSCLC.
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Affiliation(s)
- Abhishek Kumar
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
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5
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Chakrabarty N, Mahajan A, Patil V, Noronha V, Prabhash K. Imaging of brain metastasis in non-small-cell lung cancer: indications, protocols, diagnosis, post-therapy imaging, and implications regarding management. Clin Radiol 2023; 78:175-186. [PMID: 36503631 DOI: 10.1016/j.crad.2022.09.134] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 09/09/2022] [Accepted: 09/29/2022] [Indexed: 12/14/2022]
Abstract
Increased survival (due to the use of targeted therapies based on genomic profiling) has resulted in the increased incidence of brain metastasis during the course of disease, and thus, made it essential to have proper imaging guidelines in place for brain metastasis from non-small-cell lung cancer (NSCLC). Brain parenchymal metastases can have varied imaging appearances, and it is pertinent to be aware of the various molecular risk factors for brain metastasis from NSCLC along with their suggestive imaging appearances, so as to identify them early. Leptomeningeal metastasis requires additional imaging of the spine and an early cerebrospinal fluid (CSF) analysis. Differentiation of post-therapy change from recurrence on imaging has a bearing on the management, hence the need for its awareness. This article will provide in-depth literature review of the epidemiology, aetiopathogenesis, screening, detection, diagnosis, post-therapy imaging, and implications regarding the management of brain metastasis from NSCLC. In addition, we will also briefly highlight the role of artificial intelligence (AI) in brain metastasis screening.
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Affiliation(s)
- N Chakrabarty
- Department of Radiodiagnosis, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 400 012, Maharashtra, India
| | - A Mahajan
- Department of Radiodiagnosis, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 400 012, Maharashtra, India.
| | - V Patil
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 400 012, Maharashtra, India
| | - V Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 400 012, Maharashtra, India
| | - K Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, 400 012, Maharashtra, India
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6
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Leblanc D, Cantin G, Desnoyers A, Dufresne J, Masucci GL, Panet-Raymond V, Poirier É, Soldera S, Gingras I. Management of Oligometastatic Breast Cancer: An Expert Committee's Opinion. Curr Oncol 2023; 30:1416-1425. [PMID: 36826069 PMCID: PMC9954938 DOI: 10.3390/curroncol30020108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Patients with oligometastatic breast cancer (BC) are candidates of choice for metastasis-directed therapy (MDT). This paper summarizes the opinions of an expert committee about the management of oligometastatic BC. The experts could complete the questionnaire from 13 September 2021, to 10 October 2021, followed by a discussion. The experts were physicians working in the Province of Quebec (Canada) and specialized in BC care, including surgical oncologists, medical oncologists, and radiation oncologists. The experts provided their opinions about the context of the disease and therapeutic approach, local and systemic therapies, and the prognosis of oligometastatic BC. In addition to the expert panel's opinions about the management of oligometastatic disease per se, the experts stated that a prospective data registry should be implemented to collect data about oligometastatic BC to improve knowledge about oligometastatic BC and implement data-driven MDT. These data could also allow for the design of treatment algorithms. In conclusion, this paper presents the expert panel's opinions about the management of oligometastatic BC and highlights the needs to be met to improve the care of this condition.
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Affiliation(s)
- Dominique Leblanc
- Centre Hospitalier Universitaire de Québec—Université Laval, Québec, QC G1V 0A6, Canada
- Correspondence:
| | - Guy Cantin
- Centre Hospitalier Universitaire de Québec—Université Laval, Québec, QC G1V 0A6, Canada
| | - Alexandra Desnoyers
- Centre Hospitalier Universitaire de Québec—Université Laval, Québec, QC G1V 0A6, Canada
| | - Jean Dufresne
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
| | | | | | - Éric Poirier
- Centre Hospitalier Universitaire de Québec—Université Laval, Québec, QC G1V 0A6, Canada
| | - Sara Soldera
- Hôpital Charles-Le Moyne, Greenfield Park, QC J4V 2H1, Canada
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Bowley TY, Lagutina IV, Francis C, Sivakumar S, Selwyn RG, Taylor E, Guo Y, Fahy BN, Tawfik B, Marchetti D. The RPL/RPS gene signature of melanoma CTCs associates with brain metastasis. CANCER RESEARCH COMMUNICATIONS 2022; 2:1436-1448. [PMID: 36407834 PMCID: PMC9668078 DOI: 10.1158/2767-9764.crc-22-0337] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Melanoma brain metastasis (MBM) is linked to poor prognosis and low overall survival. We hypothesized that melanoma circulating tumor cells (CTCs) possess a gene signature significantly expressed and associated with MBM. Employing a multi-pronged approach, we provide first-time evidence identifying a common CTC gene signature for ribosomal protein large/small subunits (RPL/RPS) which associate with MBM onset and progression. Experimental strategies involved capturing, transcriptional profiling and interrogating CTCs, either directly isolated from blood of melanoma patients at distinct stages of MBM progression or from CTC-driven MBM in experimental animals. Second, we developed the first Magnetic Resonance Imaging (MRI) CTC-derived MBM xenograft model (MRI-MBM CDX) to discriminate MBM spatial and temporal growth, recreating MBM clinical presentation and progression. Third, we performed the comprehensive transcriptional profiling of MRI-MBM CDXs, along with longitudinal monitoring of CTCs from CDXs possessing/not possessing MBM. Our findings suggest that enhanced ribosomal protein content/ribogenesis may contribute to MBM onset. Since ribosome modifications drive tumor progression and metastatic development by remodeling CTC translational events, overexpression of the CTC RPL/RPS gene signature could be implicated in MBM development. Collectively, this study provides important insights for relevance of the CTC RPL/RPS gene signature in MBM, and identify potential targets for therapeutic intervention to improve patient care for melanoma patients diagnosed with or at high-risk of developing MBM.
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Affiliation(s)
- Tetiana Y. Bowley
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Irina V. Lagutina
- Animal Models Shared Resource, The University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Carol Francis
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Sinduja Sivakumar
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Reed G. Selwyn
- Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Erik Taylor
- Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Yan Guo
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Bridget N. Fahy
- Division of Surgical Oncology and Palliative Medicine, University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Bernard Tawfik
- Division of Hematology and Oncology, Department of Internal Medicine, University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
| | - Dario Marchetti
- Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Corresponding Author: Dario Marchetti, University of New Mexico Health Sciences Center, CRF, 915 Camino de Salud, Albuquerque, NM, 87131. Phone: 505-272-7937; E-mail:
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Li M, Hou X, Sai K, Wu L, Chen J, Zhang B, Wang N, Wu L, Zheng H, Zhang J, Mou Y, Chen L. Immune suppressive microenvironment in brain metastatic non-small cell lung cancer: comprehensive immune microenvironment profiling of brain metastases versus paired primary lung tumors (GASTO 1060). Oncoimmunology 2022; 11:2059874. [PMID: 35402080 PMCID: PMC8986255 DOI: 10.1080/2162402x.2022.2059874] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Lung cancer is one of the most common causes of brain metastases and is always associated with poor prognosis. We investigated the immunophenotypes of primary lung tumors and paired brain metastases, as well as immunophenotypes in the synchronous group (patients with brain metastases upon initial diagnosis) and metachronous group (patients developed brain metastases during the course of their disease). RNA sequencing of eighty-six samples from primary lung tumors and paired brain metastases of 43 patients was conducted to analyze the tumor immune microenvironment. Our data revealed that matched brain metastases compared with primary lung tumors exhibited reduced tumor infiltrating lymphocytes (TILs), a higher fraction of neutrophils infiltration, decreased scores of immune-related signatures, and a lower proportion of tumor microenvironment immune type I (high PD-L1/high CD8A) tumors. Additionally, we found a poor correlation of PD-L1 expression between paired brain metastases and primary lung tumors. In addition, gene set enrichment analysis (GSEA) showed that some gene sets associated with the immune response were enriched in the metachronous group, while other gene sets associated with differentiation and metastasis were enriched in the synchronous group in the primary lung tumors. Moreover, the tumor immune microenvironment between paired brain metastases and primary lung tumors displayed more differences in the metachronous group than in the synchronous group. Our work illustrates that brain metastatic tumors are more immunosuppressed than primary lung tumors, which may help guide immunotherapeutic strategies for NSCLC brain metastases.
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Affiliation(s)
- Meichen Li
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Xue Hou
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Ke Sai
- Department of Neurosurgery, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Lihong Wu
- Genecast Biotechnology Co., Ltd, Wuxi, P.R. China
| | - Jing Chen
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Baishen Zhang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Na Wang
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Lijia Wu
- Genecast Biotechnology Co., Ltd, Wuxi, P.R. China
| | - Hongbo Zheng
- Genecast Biotechnology Co., Ltd, Wuxi, P.R. China
| | - Jiao Zhang
- Genecast Biotechnology Co., Ltd, Wuxi, P.R. China
| | - Yonggao Mou
- Department of Neurosurgery, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Likun Chen
- Department of Medical Oncology, Sun Yat-Sen University Cancer Center; State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
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Yang K, Gutierrez E, Landry AP, Kalyvas A, Millesi M, Leite M, Jablonska PA, Weiss J, Millar BA, Conrad T, Laperriere N, Bernstein M, Zadeh G, Shultz D, Kongkham PN. Multiplicity does not significantly affect outcomes in brain metastasis patients treated with surgery. Neurooncol Adv 2022; 4:vdac022. [PMID: 35386569 PMCID: PMC8982197 DOI: 10.1093/noajnl/vdac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Brain metastasis quantity may be a negative prognostic factor for patients requiring resection of at least one lesion.
Methods
We retrospectively reviewed patients who underwent surgical resection of brain metastases from July 2018 to June 2019 at our institution, and examined outcomes including overall survival (OS), progression free survival (PFS) and rates of local failure (LF). Patients were grouped according to the number of metastases at the time of surgery (single vs multiple).
Results
We identified 130 patients who underwent surgical resection as the initial treatment modality. At the time of surgery, 87 patients had only one lesion (control) and 43 had multiple (>1). Two-year OS for the entire cohort was 46%, with equal rates in both the multiple metastases group and the control group (p=0.335). 2-year PFS was 27%; 21% in the multiple metastases group and 31% in the control group (p=0.766). The rate of LF at 2-years was 32%, with equal rates in both the multiple lesion group and control group (p=0.889). On univariate analysis, multiplicity was not significantly correlated to OS (HR=0.80, 95% CI: 0.51-1.26, p=0.336), PFS (HR=1.06, 95% CI: 0.71-1.59, p=0.766) or LF (HR=1.06, 95% CI: 0.57-1.97, p=0.840). Multivariate analysis revealed preoperative tumor volume of the resected lesion to be the single correlate for OS (p=0.0032) and PFS (p=0.0081).
Conclusions
Having more than one metastasis does not negatively impact outcomes in patients treated with surgery. In carefully selected patients, especially those with large tumors, surgery should be considered regardless of the total number of lesions.
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Affiliation(s)
- Kaiyun Yang
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Enrique Gutierrez
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alexander P Landry
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Matthias Millesi
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Matheuss Leite
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Tatiana Conrad
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Normand Laperriere
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Mark Bernstein
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - David Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Paul N Kongkham
- Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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10
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Radiographic markers of breast cancer brain metastases: relation to clinical characteristics and postoperative outcome. Acta Neurochir (Wien) 2022; 164:439-449. [PMID: 34677686 PMCID: PMC8854251 DOI: 10.1007/s00701-021-05026-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/09/2021] [Indexed: 12/24/2022]
Abstract
Objective Occurrence of brain metastases BM is associated with poor prognosis in patients with breast cancer (BC). Magnetic resonance imaging (MRI) is the standard of care in the diagnosis of BM and determines further treatment strategy. The aim of the present study was to evaluate the association between the radiographic markers of BCBM on MRI with other patients’ characteristics and overall survival (OS). Methods We included 88 female patients who underwent BCBM surgery in our institution from 2008 to 2019. Data on demographic, clinical, and histopathological characteristics of the patients and postoperative survival were collected from the electronic health records. Radiographic features of BM were assessed upon the preoperative MRI. Univariable and multivariable analyses were performed. Results The median OS was 17 months. Of all evaluated radiographic markers of BCBM, only the presence of necrosis was independently associated with OS (14.5 vs 22.5 months, p = 0.027). In turn, intra-tumoral necrosis was more often in individuals with shorter time interval between BC and BM diagnosis (< 3 years, p = 0.035) and preoperative leukocytosis (p = 0.022). Moreover, dural affection of BM was more common in individuals with positive human epidermal growth factor receptor 2 status (p = 0.015) and supratentorial BM location (p = 0.024). Conclusion Intra-tumoral necrosis demonstrated significant association with OS after BM surgery in patients with BC. The radiographic pattern of BM on the preoperative MRI depends on certain tumor and clinical characteristics of patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05026-4.
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11
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Hanke B, Jünger ST, Kirches E, Waldt N, Schreiber J, Lücke E, Franke S, Sandalcioglu IE, Warnke JP, Meisel HJ, Prell J, Scheller C, Braunsdorf WEK, Preusser M, Schildhaus HU, Mawrin C. Frequency of actionable molecular drivers in lung cancer patients with precocious brain metastases. Clin Neurol Neurosurg 2021; 208:106841. [PMID: 34343913 DOI: 10.1016/j.clineuro.2021.106841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022]
Abstract
Brain metastases frequently occur during the course of disease in patients suffering from lung cancer. Occasionally, neurological symptoms caused by brain metastases (BM) might represent the first sign of systemic tumor disease (so called precocious metastases), leading to the detection of the primary lung tumor. The biological basis of precocious BM is largely unknown, and treatment options are not well established for this subgroup of patients. Therefore, we retrospectively analyzed 33 patients (24 non-small cell lung cancer (NSCLC)), 9 small cell lung cancer (SCLC)) presenting with precocious BM focusing on molecular alterations potentially relevant for the tumor's biology and treatment. We found five FGFR1 amplifications (4 adenocarcinoma, 1 SCLC) among 31 analyzed patients (16.1%), eight MET amplifications among 30 analyzed tumors (7 NSCLC, 1 SCLC; 26.7%), three EGFR mutations within 33 patients (all adenocarcinomas, 9.1%), and five KRAS mutations among 32 patients (all adenocarcinomas; 15.6%). No ALK, ROS1 or RET gene rearrangements were detected. Our findings suggest that patients with precocious BM of lung cancer harbor EGFR mutations, MET amplifications or FGFR1 amplifications as potential targeted treatment options.
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Affiliation(s)
- Benjamin Hanke
- Department of Neuropathology, Otto-von-Guericke University Magdeburg, Germany
| | - Stephanie T Jünger
- Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Elmar Kirches
- Department of Neuropathology, Otto-von-Guericke University Magdeburg, Germany
| | - Natalie Waldt
- Department of Neuropathology, Otto-von-Guericke University Magdeburg, Germany
| | - Jens Schreiber
- Department of Pneumonology, Otto-von-Guericke University Magdeburg, Germany
| | - Eva Lücke
- Department of Pneumonology, Otto-von-Guericke University Magdeburg, Germany
| | - Sabine Franke
- Department of Pathology, Otto-von-Guericke University Magdeburg, Germany
| | | | - Jan-Peter Warnke
- Department of Neurosurgery, Paracelsus Hospital Zwickau, Germany
| | - Hans-Jörg Meisel
- Department of Neurosurgery, Bergmannstrost Hospital Halle/Saale, Germany
| | - Julian Prell
- Department of Neurosurgery, University Hospital Halle/Saale, Germany
| | | | | | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Austria
| | | | - Christian Mawrin
- Department of Neuropathology, Otto-von-Guericke University Magdeburg, Germany.
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12
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Fuchs J, Früh M, Papachristofilou A, Bubendorf L, Häuptle P, Jost L, Zippelius A, Rothschild SI. Resection of isolated brain metastases in non-small cell lung cancer (NSCLC) patients - evaluation of outcome and prognostic factors: A retrospective multicenter study. PLoS One 2021; 16:e0253601. [PMID: 34181677 PMCID: PMC8238224 DOI: 10.1371/journal.pone.0253601] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Brain metastases occur in about 30% of all patients with non-small cell lung cancer (NSCLC). In selected patients, long-term survival can be achieved by resection of brain metastases. In this retrospective study, we investigate the prognosis of NSCLC patients with resected brain metastases and possible prognostic factors. METHODS In 119 patients with NSCLC and resected brain metastases, we report the following parameters: extent of resection, resection status, postoperative complications and overall survival (OS). We used the log-rank test to compare unadjusted survival probabilities and multivariable Cox regression to investigate potential prognostic factors with respect to OS. RESULTS A total of 146 brain metastases were resected in 119 patients. The median survival was 18.0 months. Postoperative cerebral radiotherapy was performed in 86% of patients. Patients with postoperative radiotherapy had significantly longer survival (median OS 20.2 vs. 9.0 months, p = 0.002). The presence of multiple brain metastases was a negative prognostic factor (median OS 13.5 vs. 19.5 months, p = 0.006). Survival of patients with extracerebral metastases of NSCLC was significantly shorter than in patients who had exclusively brain metastases (median OS 14.0 vs. 23.1 months, p = 0.005). Both of the latter factors were independent prognostic factors for worse outcome in multivariate analysis. CONCLUSIONS Based on these data, resection of solitary brain metastases in patients with NSCLC and controlled extracerebral tumor disease is safe and leads to an overall favorable outcome. Postoperative radiotherapy is recommended to improve prognosis.
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Affiliation(s)
- Julia Fuchs
- Medical Oncology, Department Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Martin Früh
- Department of Medical Oncology and Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Medical Oncology, University Hospital Bern, Bern, Switzerland
| | - Alexandros Papachristofilou
- Lung Cancer Center Basel, Comprehensive Cancer Center, University Hospital Basel, Basel, Switzerland
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - Lukas Bubendorf
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
| | - Pirmin Häuptle
- Department Oncology, Hematology and Transfusion Medicine, Cantonal Hospital Baselland, Liestal, Switzerland
| | - Lorenz Jost
- Medical Oncology, Cantonal Hospital Baselland, Bruderholz, Basel, Switzerland
| | - Alfred Zippelius
- Medical Oncology, Department Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sacha I. Rothschild
- Medical Oncology, Department Internal Medicine, University Hospital Basel, Basel, Switzerland
- Lung Cancer Center Basel, Comprehensive Cancer Center, University Hospital Basel, Basel, Switzerland
- * E-mail:
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13
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Commentary: Why do we operate in metastatic lung cancer? J Thorac Cardiovasc Surg 2021; 163:826-827. [PMID: 34088499 DOI: 10.1016/j.jtcvs.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/21/2022]
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14
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Local Ablative Therapies for Oligometastatic and Oligoprogressive Non-Small Cell Lung Cancer. ACTA ACUST UNITED AC 2021; 26:129-136. [PMID: 32205537 DOI: 10.1097/ppo.0000000000000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
More than half of all patients with non-small cell lung cancer (NSCLC) have metastatic disease at the time of diagnosis. A subset of these patients has oligometastatic disease, which exists in an intermediary state between locoregional and disseminated metastatic disease. In addition, some metastatic patients on systemic therapy may have limited disease progression, or oligoprogression. Historically, treatment of metastatic NSCLC was palliative in nature, with little expectation of long-term survival. However, an accumulation of evidence over the past 3 decades now demonstrates that local ablative therapy to sites of limited metastases or progression can improve patient outcomes for this complex disease. This review examines the evidence behind local ablative therapy in oligometastatic and oligoprogressive NSCLC, with a focus on surgery, stereotactic radiotherapy, and radiofrequency ablation.
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Proescholdt MA, Schödel P, Doenitz C, Pukrop T, Höhne J, Schmidt NO, Schebesch KM. The Management of Brain Metastases-Systematic Review of Neurosurgical Aspects. Cancers (Basel) 2021; 13:1616. [PMID: 33807384 PMCID: PMC8036330 DOI: 10.3390/cancers13071616] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/07/2023] Open
Abstract
The multidisciplinary management of patients with brain metastases (BM) consists of surgical resection, different radiation treatment modalities, cytotoxic chemotherapy, and targeted molecular treatment. This review presents the current state of neurosurgical technology applied to achieve maximal resection with minimal morbidity as a treatment paradigm in patients with BM. In addition, we discuss the contribution of neurosurgical resection on functional outcome, advanced systemic treatment strategies, and enhanced understanding of the tumor biology.
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Affiliation(s)
- Martin A. Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Petra Schödel
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Tobias Pukrop
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
- Department of Medical Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julius Höhne
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
| | - Karl-Michael Schebesch
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (M.A.P.); (P.S.); (C.D.); (J.H.); (N.O.S.)
- Wilhelm Sander Neuro-Oncology Unit, University Hospital Regensburg, 93053 Regensbur, Germany;
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16
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Jünger ST, Pennig L, Schödel P, Goldbrunner R, Friker L, Kocher M, Proescholdt M, Grau S. The Debatable Benefit of Gross-Total Resection of Brain Metastases in a Comprehensive Treatment Setting. Cancers (Basel) 2021; 13:cancers13061435. [PMID: 33801110 PMCID: PMC8004079 DOI: 10.3390/cancers13061435] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Stephanie T. Jünger
- Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany; (S.T.J.); (R.G.); (L.F.)
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | - Lenhard Pennig
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany;
| | - Petra Schödel
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (P.S.); (M.P.)
- Wilhelm Sander Neuro-Oncology Unit and Department of Neurology, University of Regensburg, 93053 Regensburg, Germany
| | - Roland Goldbrunner
- Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany; (S.T.J.); (R.G.); (L.F.)
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
| | - Lea Friker
- Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany; (S.T.J.); (R.G.); (L.F.)
| | - Martin Kocher
- Centre for Neurosurgery, Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany;
| | - Martin Proescholdt
- Department of Neurosurgery, University Hospital Regensburg, 93053 Regensburg, Germany; (P.S.); (M.P.)
- Wilhelm Sander Neuro-Oncology Unit and Department of Neurology, University of Regensburg, 93053 Regensburg, Germany
| | - Stefan Grau
- Centre for Neurosurgery, Department of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany; (S.T.J.); (R.G.); (L.F.)
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50923 Cologne, Germany
- Correspondence: ; Tel.: +49-221-478-82764; Fax: +49-221-478-82825
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17
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Kaba E, Yardımcı EH, Kakuturu J, Toker A. In Spite of Curative Radical Pulmonary Procedures, Lesser Pulmonary Resection Shows More Favorable Prognosis in Surgically Treated NSCLC With Synchronous Isolated Cranial Oligometastases. Front Surg 2021; 8:645870. [PMID: 33718430 PMCID: PMC7947805 DOI: 10.3389/fsurg.2021.645870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/03/2021] [Indexed: 12/25/2022] Open
Abstract
Oligometastatic disease in lung cancer is not a rare condition as previously thought. Among 812 non-small cell lung cancer patients treated surgically with lung resection between October 2011 and October 2018 at the Department of Thoracic Surgery, Florence Nightingale Hospitals, Turkey, 28 patients (3.4%) had synchronous cranial metastases. We analyzed synchronous isolated cranial metastases patients treated by locally ablative treatments (surgery, radiotherapy, or both). Metastases existing at the diagnosis of primary cancer were considered as synchronous, and their treatment was performed before (at least 1 month) or after (for maximum 1 month) surgery of the primary lung lesion. Prognostic factors affecting survival are evaluated retrospectively to identify clinical factors predicting survival in an effort to better select patients for surgery. Patients having T1-T2 primary lung tumors, no mediastinal lymph node metastasis, receiving minor anatomical lung resection, receiving neoadjuvant chemotherapy, having single cranial metastasis, and receiving surgical cranial metastasectomy were found to have better survival. According to tumor histology, having adenocarcinoma, and not having lymphovascular or visceral pleura invasion correlated with better survival. Average survival time was 52.1 months and median survival was 32 months. The last mortality during the follow-up was at 24 months; cumulative survival was 48.3% at that time. Our study was designed to define the criteria for patients with oligometastatic disease who may benefit from lung resection.
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Affiliation(s)
- Erkan Kaba
- Department of Thoracic Surgery, Group Florence Nightingale Hospitals, Demiroglu Bilim University, Istanbul, Turkey
| | - Eyüp Halit Yardımcı
- Department of Thoracic Surgery, Group Florence Nightingale Hospitals, Demiroglu Bilim University, Istanbul, Turkey
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart & Vascular Institute, Morgantown, WV, United States
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart & Vascular Institute, Morgantown, WV, United States
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18
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Jünger ST, Schödel P, Ruess D, Ruge M, Brand JS, Wittersheim M, Eich ML, Schmidt NO, Goldbrunner R, Grau S, Proescholdt M. Timing of Development of Symptomatic Brain Metastases from Non-Small Cell Lung Cancer: Impact on Symptoms, Treatment, and Survival in the Era of Molecular Treatments. Cancers (Basel) 2020; 12:cancers12123618. [PMID: 33287226 PMCID: PMC7761690 DOI: 10.3390/cancers12123618] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 11/17/2022] Open
Abstract
Simple Summary In order to clarify whether an early development of brain metastases from non-small cell lung cancer represents a poor prognostic factor for further survival we analyzed 377 patients with brain metastases, treated by radiosurgery or surgery at two German institutions. Our results show that an early appearance of brain metastasis does not influence further survival in a comprehensive treatment setting. Abstract Objective: We attempted to analyze whether early presentation with brain metastases (BM) represents a poor prognostic factor in patients with non-small cell lung cancer (NSCLC), which should guide the treatment team towards less intensified therapy. Patients and methods: In a retrospective bi-centric analysis, we identified patients receiving surgical treatment for NSCLC BM. We collected demographic-, tumor-, and treatment-related parameters and analyzed their influence on further survival. Results: We included 377 patients. Development of BM was precocious in 99 (26.3%), synchronous in 152 (40.3%), and metachronous in 126 (33.4%) patients. The groups were comparable in terms of age (p = 0.76) and number of metastases (p = 0.11), and histology (p = 0.1); however, mutational status significantly differed (p = 0.002). The precocious group showed the worst clinical status as assessed by Karnofsky performance score (KPS) upon presentation (p < 0.0001). Resection followed by postoperative radiotherapy was the predominant treatment modality for precocious BM, while in syn- and metachronous BM surgical and radio-surgical treatment was balanced. Overall survival (OS) did not differ between the groups (p = 0.76). A good postoperative clinical status (KPS ≥ 70) and the application of any kind of adjuvant systemic therapy were independent predictive factors for OS. Conclusion: Early BM presentation was not associated with worse OS in NSCLC BM patients.
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Affiliation(s)
- Stephanie T. Jünger
- Centre for Neurosurgery, Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (R.G.); (S.G.)
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (D.R.); (M.R.)
- Correspondence: ; Tel.: +49-221-478-4550; Fax: +49-221-478-82825
| | - Petra Schödel
- Department of Neurosurgery, University Medical Centre Regensburg, 93053 Regensburg, Germany; (P.S.); (N.-O.S.); (M.P.)
- Wilhelm Sander Neuro-Oncology Unit, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Daniel Ruess
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (D.R.); (M.R.)
- Centre for Neurosurgery, Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany;
| | - Maximilian Ruge
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (D.R.); (M.R.)
- Centre for Neurosurgery, Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany;
| | - Julia-Sarita Brand
- Centre for Neurosurgery, Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany;
| | - Maike Wittersheim
- Department of Pathology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (M.W.); (M.-L.E.)
| | - Marie-Lisa Eich
- Department of Pathology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (M.W.); (M.-L.E.)
| | - Nils-Ole Schmidt
- Department of Neurosurgery, University Medical Centre Regensburg, 93053 Regensburg, Germany; (P.S.); (N.-O.S.); (M.P.)
- Wilhelm Sander Neuro-Oncology Unit, University Medical Centre Regensburg, 93053 Regensburg, Germany
| | - Roland Goldbrunner
- Centre for Neurosurgery, Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (R.G.); (S.G.)
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (D.R.); (M.R.)
| | - Stefan Grau
- Centre for Neurosurgery, Department of Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (R.G.); (S.G.)
- Centre for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne, 50931 Cologne, Germany; (D.R.); (M.R.)
| | - Martin Proescholdt
- Department of Neurosurgery, University Medical Centre Regensburg, 93053 Regensburg, Germany; (P.S.); (N.-O.S.); (M.P.)
- Wilhelm Sander Neuro-Oncology Unit, University Medical Centre Regensburg, 93053 Regensburg, Germany
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Schanne DH, Heitmann J, Guckenberger M, Andratschke NHJ. Evolution of treatment strategies for oligometastatic NSCLC patients - A systematic review of the literature. Cancer Treat Rev 2019; 80:101892. [PMID: 31522079 DOI: 10.1016/j.ctrv.2019.101892] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND The concept of oligometastatic disease (OMD) has expanded the scope of potentially curative therapy for metastatic NSCLC. However, large uncertainties remain regarding its definition and optimal management strategies. We therefore conducted a systematic review to investigate the value of various multimodality treatment concepts. METHODS We searched the available literature in Pubmed, Medline and EMBASE using the terms "oligomet*", "synchron*", "oligorec*", "metachr*" "NSCLC", "lung cancer" and "stage IV" and included studies reporting treatment regimens and outcomes on radically treated patients with either "synchronous", "metachronous" or "mixed" OMD. Only de-novo diagnosis of OMD was considered. The impact of patient and treatment characteristics on overall survival (OS) and time trends in patterns of care were investigated. RESULTS 54 studies published between 1987 and 2018 were included. Despite a wide range of OMD definitions, 90.1% of patients were treated for a single metastasis. Systemic therapy was used as backbone treatment for most patients. Although surgery was the preferred local treatment in earlier studies, the use of stereotactic radiotherapy increased rapidly after 2011. No OS difference was observed between surgery or radiotherapy as the treatment of primary tumor or metastases, respectively. A time trend towards improved OS after 2011 could be detected. CONCLUSIONS While evidence in favor of radical treatment is emerging, most studies remain retrospective and mainly evaluate patients with singular metastases. While surgery, stereotactic radiotherapy and chemotherapy are the cornerstones of current treatment strategies, future clinical trials need to address the high risk of distant metastases by integrating targeted or immunotherapy.
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Affiliation(s)
- Daniel H Schanne
- University Hospital Zurich, Department of Radiation Oncology, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Jana Heitmann
- University Hospital Zurich, Department of Radiation Oncology, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Matthias Guckenberger
- University Hospital Zurich, Department of Radiation Oncology, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Nicolaus H J Andratschke
- University Hospital Zurich, Department of Radiation Oncology, Rämistrasse 100, 8091 Zurich, Switzerland.
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Amichetti M, Lay G, Dessì M, Orrù S, Farigu R, Orrù P, Farci D, Melis S. Results of Whole Brain Radiation Therapy in Patients with Brain Metastases from Colorectal Carcinoma. TUMORI JOURNAL 2019; 91:163-7. [PMID: 15948545 DOI: 10.1177/030089160509100211] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Carcinoma of the colon-rectum is an infrequent cause of brain metastases, constituting 1-5% of all metastatic lesions to the brain. We reviewed our experience in the treatment of brain metastases from colorectal cancer to define the efficacy of whole brain radiation therapy as a palliative measure in this setting of patients. Methods Twenty-three consecutive cases of brain metastasis from colorectal cancer treated between 1999 and 2004 were identified in the files of the Division of Radiotherapy of the A Businco Regional Oncological Hospital, Cagliari. Their records were reviewed for patient and tumor characteristics and categorized according to the RTOG RPA classes. Results Fifteen patients (65%) had multiple metastases. Twenty-one patients (91%) showed extracranial metastases. Fourteen patients were classified as RTOG RPA class II and 9 class III. The median radiation dose delivered was 2000 cGy in 5 fractions in one week (range, 20-36 Gy). In 14 of 20 assessable patients (70%), symptomatic improvement was observed. The median follow-up and survival time for all the patients, 12 females and 11 males, was 3 months. In 3 patients only the cause of death was the brain metastasis. Conclusions Despite the disappointing survival time, external radiation therapy to the whole brain proved to be an efficacious palliative treatment for patients with multiple or inoperable brain metastasis from colorectal cancer.
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Affiliation(s)
- Maurizio Amichetti
- Department of Radiation Oncology, "A Businco" Regional Oncological Hospital, Cagliari, Italy.
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Outcome after surgery in supratentorial and infratentorial solitary brain metastasis. Acta Neurochir (Wien) 2019; 161:1047-1053. [PMID: 30859322 DOI: 10.1007/s00701-019-03865-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/03/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND The aim of this retrospective study was to investigate and compare the outcome after surgery in patients with a supratentorial solitary metastasis (SSM) and an infratentorial solitary metastasis (ISM). A worse prognosis has been reported in ISM. METHODS Fifty-two patients with a newly diagnosed solitary brain metastasis on MRI were included to identify risk factors affecting the outcome. Key variables included tumor size, staging of the primary tumor, time span of presurgical work-up, and surgical technique. Outcome variables included postoperative complications, tumor recurrence, and mortality. Kaplan-Meier survival analysis was applied. RESULTS Thirty patients with a SSM and 22 patients with an ISM underwent gross total resection. The tumor size did not have a statistical significant effect on survival. Presurgical work-up time was similar in SSM and ISM. Postoperative complications were more frequently encountered in ISM. Recurrence rate was comparable in SSM and ISM. Carcinomatous meningitis (CM) was more frequently seen in ISM, and CM was seen more often with the piecemeal resection technique. There was no statistical difference in overall survival between SSM and ISM. CONCLUSIONS This study identified factors that play a role in the outcome after surgery in patients with ISM and SSM on MRI. Postoperative complications seemed to be higher in ISM and CM was more often seen in ISM, but the worse prognosis in patients with ISM compared with SSM could not be confirmed.
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22
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Stephens SJ, Moravan MJ, Salama JK. Managing Patients With Oligometastatic Non-Small-Cell Lung Cancer. J Oncol Pract 2019; 14:23-31. [PMID: 29324212 DOI: 10.1200/jop.2017.026500] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Metastatic lung cancer has long been considered incurable, with the goal of treatment being palliation. However, a clinically meaningful number of these patients with limited metastases (approximately 25%) are living long term after definitive treatment to all sites of active disease. These patients with so-called oligometastatic disease likely represent a distinct clinical group who may possess a more indolent biology compared with their more widely metastatic counterparts. Hellman and Weichselbaum proposed the existence of the oligometastatic state, on the basis of the spectrum theory of cancer spread. The literature suggests that an oligometastatic state exists in patients with non-small-cell lung cancer (NSCLC). This observation in the setting of rapidly evolving systemic therapies, including immune checkpoint inhibitors and an increasing number of targeted therapies, represents a unique clinical opportunity. Metastasis-directed therapies to address sites of disease include surgery (metastasectomy) and/or radiation therapy. Available evidence suggests that treating patients with limited or oligometastases may improve outcomes in a meaningful way; however, the majority of the randomized data includes patients with intracranial metastatic disease, and there are limited robust, randomized data available in the setting of NSCLC with only extracranial sites of metastatic disease. Ongoing randomized trials, including NRG-LU002 and the UK Conventional Care Versus Radioablation (Stereotactic Body Radiotherapy) for Extracranial Oligometastases trial, are aimed at evaluating this question further. One of the current limitations of aggressive treatment of oligometastatic NSCLC is the inability to accurately identify these patients before therapy, yet molecular markers, including microRNA profiles, are being investigated as a promising way to identify these patients.
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Otake S, Goto T. Stereotactic Radiotherapy for Oligometastasis. Cancers (Basel) 2019; 11:cancers11020133. [PMID: 30678111 PMCID: PMC6407034 DOI: 10.3390/cancers11020133] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 12/22/2022] Open
Abstract
Oligometastatic disease is defined as “a condition with a few metastases arising from tumors that have not acquired a potential for widespread metastases.” Its behavior suggests a transitional malignant state somewhere between localized and metastatic cancer. Treatment of oligometastatic disease is expected to achieve long-term local control and to improve survival. Historically, patients with oligometastases have often undergone surgical resection since it was anecdotally believed that surgical resection could result in progression-free or overall survival benefits. To date, no prospective randomized trials have demonstrated surgery-related survival benefits. Short courses of highly focused, extremely high-dose radiotherapies (e.g., stereotactic radiosurgery and stereotactic ablative body radiotherapy (SABR)) have frequently been used as alternatives to surgery for treatment of oligometastasis. A randomized study has demonstrated the overall survival benefits of stereotactic radiosurgery for solitary brain metastasis. Following the success of stereotactic radiosurgery, SABR has been widely accepted for treating extracranial metastases, considering its efficacy and minimum invasiveness. In this review, we discuss the history of and rationale for the local treatment of oligometastases and probe into the implementation of SABR for oligometastatic disease.
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Affiliation(s)
- Sotaro Otake
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital, Kofu 400-8506, Japan.
| | - Taichiro Goto
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital, Kofu 400-8506, Japan.
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24
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Calluaud G, Terrier LM, Mathon B, Destrieux C, Velut S, François P, Zemmoura I, Amelot A. Peritumoral Edema/Tumor Volume Ratio: A Strong Survival Predictor for Posterior Fossa Metastases. Neurosurgery 2018; 85:117-125. [DOI: 10.1093/neuros/nyy222] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 06/04/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
| | - Louis-Marie Terrier
- CHRU de Tours, Department of Neurosurgery, Tours, France
- Université François-Rabelais de Tours, Inserm, iBrain, UMR U1253, Tours, France
| | - Bertrand Mathon
- CHU La Pitié-Salpétrière, Department of Neurosurgery, Paris, France
| | - Christophe Destrieux
- CHRU de Tours, Department of Neurosurgery, Tours, France
- Université François-Rabelais de Tours, Inserm, iBrain, UMR U1253, Tours, France
| | - Stéphane Velut
- CHRU de Tours, Department of Neurosurgery, Tours, France
- Université François-Rabelais de Tours, Inserm, iBrain, UMR U1253, Tours, France
| | | | - Ilyess Zemmoura
- CHRU de Tours, Department of Neurosurgery, Tours, France
- Université François-Rabelais de Tours, Inserm, iBrain, UMR U1253, Tours, France
| | - Aymeric Amelot
- CHRU de Tours, Department of Neurosurgery, Tours, France
- CHU La Pitié-Salpétrière, Department of Neurosurgery, Paris, France
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25
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Shibahara I, Kanamori M, Watanabe T, Utsunomiya A, Suzuki H, Saito R, Sonoda Y, Jokura H, Uenohara H, Tominaga T. Clinical Features of Precocious, Synchronous, and Metachronous Brain Metastases and the Role of Tumor Resection. World Neurosurg 2018; 113:e1-e9. [DOI: 10.1016/j.wneu.2017.10.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 01/10/2023]
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Divisi D, Barone M, Zaccagna G, Gabriele F, Crisci R. Surgical approach in the oligometastatic patient. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:94. [PMID: 29666817 DOI: 10.21037/atm.2018.01.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the setting of a stage IV non-small cell lung cancer (NSCLC), oligometastatic patients represent a heterogeneous group whose incidence is increasing as far as with the adoption of new therapeutic regimens, the improvement of the molecular characterization assays and the increasing number of long-survivor patients. The oligometastatic state undergone a major revision with the introduction of the new TNM lung cancer staging system, being characterized by a different prognosis compared to multi-metastatic patients. Furthermore, the presence of a limited number of metastases imposes a local control especially when clonal selections occur during adjuvant therapy. In this regard, the review seeks to clarify the indications for surgical treatment by organ according to recent guidelines, by analyzing prognostic factors and outcome of patients. Although accurate patient stratification is mandatory, aggressive local control strategies represent a valid therapeutic approach in patients with oligometastatic NSCLC. At the same time, persevering with ablative strategies raises both medical and ethical issues about limits and reiteration, which certainly requires a deep reflection, being, on the other hand, in front of a metastatic disease.
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Affiliation(s)
- Duilio Divisi
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Mirko Barone
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Gino Zaccagna
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Francesca Gabriele
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
| | - Roberto Crisci
- Thoracic Surgery Unit, University of L'Aquila, "G. Mazzini" Hospital, Teramo, Italy
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Patrini D, Panagiotopoulos N, Bedetti B, Mitsos S, Crisci R, Solli P, Bertolaccini L, Scarci M. Surgical approach in oligometastatic non-small cell lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:93. [PMID: 29666816 DOI: 10.21037/atm.2018.02.16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The vast majority of lung cancer (80%) are non-small cell lung cancer (NSCLC) presenting in huge proportion of patients in a metastatic stage at the time of diagnosis with an overall survival (OS) of only 6 months. Standard treatment at this stage involves systemic platinum based chemotherapy improving the OS for only few months. For the vast majority of patients disease progression occurs and cure cannot achieved. An exception to this general rule is represented by patients with a limited number of metastasis (approximately 7% of patients with metastatic NSCLC): in 1995 Hellman and Weichselbaum introduced the term "oligometastatic" for a selected group of patients with metastatic disease. Several retrospective studies have been published and documented an improved outcome in patients managed surgically. The purpose of this narrative review is to gather all relevant information and present the various clinicopathological and generic aspects of diagnosis, management strategies and prognostic factors in patients with oligometastatic NSCLC. The key for long term survival includes radical treatment of the primary NSCLC, single organ site with either synchronous or metachronous presentation, a disease free interval to be as long as possible and the absence of intrathoracic lymph node spread (N0). A more accurate staging with combination of FDG-PET and CT scan can have on impact on the survival rates due to an increased accuracy in mediastinal staging and in the diagnosis of distant metastasis. No randomized data but only retrospective series are available to date to address this topic: in the future, additional prospective studies will be necessary to provide robust evidence to support the surgical resection as treatment of oligometastatic NSCLC.
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Affiliation(s)
- Davide Patrini
- Thoracic Surgery Department, University College London Hospitals (UCLH), London, UK
| | | | | | - Sofoklis Mitsos
- Thoracic Surgery Department, University College London Hospitals (UCLH), London, UK
| | - Roberto Crisci
- Thoracic Surgery Department, Mazzini Hospital, University of l'Aquila, Teramo, Italy
| | - Piergiorgio Solli
- Thoracic Surgery Department, Bellaria and Maggiore Hospitals, Bologna, Italy
| | - Luca Bertolaccini
- Thoracic Surgery Department, Bellaria and Maggiore Hospitals, Bologna, Italy
| | - Marco Scarci
- Thoracic Surgery Department, San Gerardo Hospital, Monza, Italy
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Sato J, Horinouchi H, Goto Y, Kanda S, Fujiwara Y, Nokihara H, Yamamoto N, Ohe Y. Long-term survival without surgery in NSCLC patients with synchronous brain oligometastasis: systemic chemotherapy revisited. J Thorac Dis 2018; 10:1696-1702. [PMID: 29707323 DOI: 10.21037/jtd.2018.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jun Sato
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan.,Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hidehito Horinouchi
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasushi Goto
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Shintaro Kanda
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Fujiwara
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Nokihara
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Noboru Yamamoto
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichiro Ohe
- Division of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan.,Course of Advanced Clinical Research of Cancer, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Frati A, Pesce A, D'Andrea G, Fraschetti F, Salvati M, Cimatti M, Esposito V, Raco A. A purely functional Imaging based approach for transcortical resection of lesion involving the dominant atrium: Towards safer, imaging-guided, tailored cortico-leucotomies. J Clin Neurosci 2018; 50:252-261. [PMID: 29429789 DOI: 10.1016/j.jocn.2018.01.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND STUDY OBJECT The Dominant Atrium (DA) is a crossroad of eloquent white matter bundles difficult to preserve with a standard "anatomical" approach. The aim of this work is to evaluate the results of a cohort of patients who underwent surgery with the aid of a purely functional MRI and DTI-based approach. MATERIALS AND METHODS 43 patients suffering from lesions involving the DA have been included in the final cohort and studied in regards to quality of life (KPS); a special attention was lent on the incidence of new or worsening of preexisting neurological deficits, with a focus on motor, visual and speech disturbances after the surgical treatment. Patient, surgery and lesion-related data were recorded to identify the relationships with outcome. Eloquent areas fMRI and the course of Arcuate Fasciculus (AF), Inferior frontooccipital fasciculus (IFOF), Optic radiation (OR) and corticospinal tract (CST) have been investigated with preoperative MRI sequences and DTI reconstruction. RESULTS The final cohort consisted of 43 patients, 19 males and 24 females; average age was 56.8 years. We recorded 9 transient and 3 permanent postoperative deficits, only one of those was caused by an edema interference with DTI reconstruction. Preoperative functional status, histology and volume of the lesion proved to be independent factors affecting results. CONCLUSIONS A purely functional surgical approach to the DA provided promising preliminary results. A direct DTI-fMRI visualization of the eloquent structures proximal to DA allows surgeon to conceive an ultra-precise and "tailored" cortico-leucotomy for an optimal exposure of the lesion.
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Affiliation(s)
- Alessandro Frati
- IRCCS "Neuromed" - Neurosurgery - "Sapienza" Univesity, Pozzilli (IS), Italy
| | - Alessandro Pesce
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy
| | | | - Flavia Fraschetti
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy.
| | - Maurizio Salvati
- IRCCS "Neuromed" - Neurosurgery - "Sapienza" Univesity, Pozzilli (IS), Italy
| | - Marco Cimatti
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy
| | - Vincenzo Esposito
- IRCCS "Neuromed" - Neurosurgery - "Sapienza" Univesity, Pozzilli (IS), Italy
| | - Antonino Raco
- NESMOS Department Neurosurgery Department "Sapienza" University, Roma, Italy; Azienda Ospedaliera Sant'Andrea, Roma, Italy
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Karagkiouzis G, Spartalis E, Moris D, Patsouras D, Athanasiou A, Karathanasis I, Verveniotis A, Konstantinou F, Kouerinis IA, Potaris K, Dimitroulis D, Tomos P. Surgical Management of Non-small Cell Lung Cancer with Solitary Hematogenous Metastases. ACTA ACUST UNITED AC 2018; 31:451-454. [PMID: 28438878 DOI: 10.21873/invivo.11082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
| | - Eleftherios Spartalis
- Second Department of Propedeutic Surgery, Laikon Hospital, Athens School of Medicine, Athens, Greece
| | - Demetrios Moris
- Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, U.S.A.
| | - Demetrios Patsouras
- Second Department of Propedeutic Surgery, Laikon Hospital, Athens School of Medicine, Athens, Greece
| | | | - Ioannis Karathanasis
- Department of Thoracic Surgery, Sotiria Hospital for Chest Diseases, Athens, Greece
| | - Alexios Verveniotis
- Department of Thoracic Surgery, Sotiria Hospital for Chest Diseases, Athens, Greece
| | - Froso Konstantinou
- Department of Internal Medicine, Sotiria Hospital for Chest Diseases, Athens, Greece
| | - Ilias A Kouerinis
- First Department of Cardiothoracic Surgery, Hippokration Hospital, Athens, Greece
| | - Konstantinos Potaris
- Department of Thoracic Surgery, Sotiria Hospital for Chest Diseases, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Department of Propedeutic Surgery, Laikon Hospital, Athens School of Medicine, Athens, Greece
| | - Periklis Tomos
- Second Department of Propedeutic Surgery, Laikon Hospital, Athens School of Medicine, Athens, Greece
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Yang CFJ, Gu L, Shah SA, Yerokun BA, D'Amico TA, Hartwig MG, Berry MF. Long-term outcomes of surgical resection for stage IV non-small-cell lung cancer: A national analysis. Lung Cancer 2017; 115:75-83. [PMID: 29290266 DOI: 10.1016/j.lungcan.2017.11.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Treatment guidelines recommend surgical resection in select cases of stage IV non-small-cell lung cancer (NSCLC) but are based on limited evidence. This study evaluated outcomes associated with surgery in stage IV disease. METHODS Factors associated with survival of stage IV NSCLC patients treated with surgery in the National Cancer Date Base (2004-2013) were evaluated using multivariable Cox proportional hazards analyses. Outcomes of the subset of patients with cT1-2, N0-1, M1 and cT3, N0, M1 disease treated with surgery or chemoradiation were evaluated using Kaplan-Meier analyses. RESULTS The five-year survival of all stage IV NSCLC patients who underwent surgical resection (n=3098) was 21.1%. Outcomes were related to the locoregional extent of the primary tumor, as both increasing T status (T2 HR 1.30 [p<0.001], T3 HR 1.28 [p<0.001], and T4 HR 1.28 [p<0.001], respectively, compared to T1) and nodal involvement (N1 HR 1.34 [p<0.001], N2 HR 1.50 [p<0.001], and N3 HR 1.49 [p<0.001], respectively, compared to N0) were associated with worse survival. Outcomes were also related to the extent of surgical resection, as pneumonectomy (HR 1.58, p<0.001), segmentectomy (HR 1.36, p=0.009), and wedge resection (HR 1.70, p<0.001) were all associated with decreased survival when compared to lobectomy. The five-year survival of cT1-2, N0-1, M1 and cT3, N0, M1 patients was 25.1% (95% CI: 22.8-27.5) after surgical resection (n=1761) and 5.8% (95% CI: 5.2-6.5) after chemoradiation (n=8180). CONCLUSIONS Surgery for cT1-2, N0-1, M1 or cT3, N0, M1 disease is associated with a 5-year survival of 25% and does not appear to compromise outcomes when compared to non-operative therapy, supporting guidelines that recommend surgery for very select patients with stage IV disease. However, surgery provides less benefit and should be considered much less often for stage IV patients with mediastinal nodal disease or more locally advanced tumors.
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Affiliation(s)
- Chi-Fu Jeffrey Yang
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, 3496 DUMC, Durham, NC, United States
| | - Lin Gu
- Department of Biostatistics, Duke University, United States
| | - Shivani A Shah
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, 3496 DUMC, Durham, NC, United States
| | - Babatunde A Yerokun
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, 3496 DUMC, Durham, NC, United States
| | - Thomas A D'Amico
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, 3496 DUMC, Durham, NC, United States
| | - Matthew G Hartwig
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, 3496 DUMC, Durham, NC, United States
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, 300 Pasteur Drive, Falk Building 2nd Floor, Stanford, CA 94305-5407, United States.
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Pojskic M, Bopp MHA, Schymalla M, Nimsky C, Carl B. Retrospective study of 229 surgically treated patients with brain metastases: Prognostic factors, outcome and comparison of recursive partitioning analysis and diagnosis-specific graded prognostic assessment. Surg Neurol Int 2017; 8:259. [PMID: 29184710 PMCID: PMC5680662 DOI: 10.4103/sni.sni_228_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/26/2017] [Indexed: 01/18/2023] Open
Abstract
Background: Metastases are the most frequent tumors in the brain. Most often used scoring systems to predict the outcome are the RPA (Recursive Partitioning Analysis) classification and the DS-GPA (Diagnosis-Specific Graded Prognostic Assessment) score. The goal of our study was to determine prognostic factors which influence outcome in patients who undergo surgery for brain metastases and to compare different outcome scores. Methods: Two hundred and twenty-nine patients who underwent surgery for brain metastases in our institution between January 2005 and December 2014 were included in the study. Patient data were evaluated retrospectively. Results: The mean survival time was 19.2 months (median survival time, MST: 8 months), for patients with a single metastasis (n = 149) 17.6 months (MST: 8 months), and for patients with multiple metastases (n = 80) 17.9 months (MST: 6 months). Significant influence on MST had age <65 years (9 vs. 5 months, P = 0.002), female sex (10 vs. 6 months, P < 0.001), RPA Class I and II (11 vs. 4 months, P < 0.001), Karnofsky score >70% (11 vs. 4 months, P < 0.001), and postoperative radiotherapy (8 vs. 5 months, P < 0.002). To evaluate the diagnostic power of DS-GPA and RPA score in respect of survival, two Cox regressions were modeled, where the RPA classification showed a better predictive power. Conclusion: Favorable factors for prolonged survival were KPS >70%, RPA Class I and II, age <65 years, female sex, a DS-GPA Score of 2.5–3 and 3.5–4, and adjuvant radiotherapy. The RPA Classification was more accurate in predicting the outcome than the DS-GPA score.
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Affiliation(s)
- Mirza Pojskic
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Miriam H A Bopp
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Markus Schymalla
- Department of Radiotherapy and Radiation Oncology, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
| | - Barbara Carl
- Department of Neurosurgery, Philipps-University Marburg, Baldingerstraβe, Germany
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Juan O, Popat S. Ablative Therapy for Oligometastatic Non-Small Cell Lung Cancer. Clin Lung Cancer 2017; 18:595-606. [PMID: 28377206 DOI: 10.1016/j.cllc.2017.03.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/22/2017] [Accepted: 03/06/2017] [Indexed: 12/19/2022]
Abstract
The oligometastatic state represents a distinct entity among those with metastatic disease and consists of patients with metastases limited in number and location, representing an intermediate state between locally confined and widely metastatic cancer. Although similar, "oligorecurrence" (limited number of metachronous metastases under conditions of a controlled primary lesion) and "oligoprogressive" (disease progression at a limited number of sites with disease controlled at other disease sites) states are distinct entities. In non-small cell lung cancer (NSCLC), the oligometastatic state is relatively common, with 20% to 50% of patients having oligometastatic disease at diagnosis. This subgroup of patients when receiving ablative therapy, such as surgery or stereotactic body radiation radiotherapy, can obtain markedly long progression-free and overall survival. The role of radical treatment for intracranial oligometastases is well established. Fewer data exist regarding radical treatment of extracranial metastases in lung cancer; however, retrospective series using surgery or stereotactic body radiotherapy for extracranial oligometastatic disease in NSCLC have shown excellent local control, with a suggestion of improvement in progression-free survival. In the present report, we have reviewed the data on the treatment of brain metastases in oligometastatic NSCLC and the results of ablative treatment of extracranial sites. Recently, the first randomized trial comparing ablative treatment versus control in oligometastatic disease was reported, and those data are reviewed in the context of smaller series. Finally, areas of controversy are discussed and a therapeutic approach for patients with oligometastatic disease is proposed.
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Affiliation(s)
- Oscar Juan
- Department of Medical Oncology, University Hospital La Fe, Valencia, Spain.
| | - Sanjay Popat
- Lung Unit, Royal Marsden Hospital, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom; and the Institute of Cancer Research, London, United Kingdom
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Iyengar P, Lau S, Donington JS, Suh RD. Local Therapy for Limited Metastatic Non-Small Cell Lung Cancer: What Are the Options and Is There a Benefit? Am Soc Clin Oncol Educ Book 2017; 35:e460-7. [PMID: 27249754 DOI: 10.1200/edbk_158734] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Distant metastasis is common in non-small cell lung cancer (NSCLC) and typically associated with poor prognosis. Aggressive local therapy including surgery and/or radiation for limited metastatic disease from colorectal cancer and sarcoma is associated with survival benefit and has become part of the standard of care. In this article, we review the literature and ongoing studies concerning surgery, radiation, and radiofrequency ablation for oligometastatic NSCLC.
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Affiliation(s)
- Puneeth Iyengar
- From the Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX; NYU School of Medicine, New York, NY; Department of Radiological Sciences, Thoracic Imaging and Intervention, and Diagnostic Radiology Education, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven Lau
- From the Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX; NYU School of Medicine, New York, NY; Department of Radiological Sciences, Thoracic Imaging and Intervention, and Diagnostic Radiology Education, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Jessica S Donington
- From the Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX; NYU School of Medicine, New York, NY; Department of Radiological Sciences, Thoracic Imaging and Intervention, and Diagnostic Radiology Education, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Robert D Suh
- From the Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX; NYU School of Medicine, New York, NY; Department of Radiological Sciences, Thoracic Imaging and Intervention, and Diagnostic Radiology Education, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Radiation Oncology, Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, TX
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Hong JC, Salama JK. The expanding role of stereotactic body radiation therapy in oligometastatic solid tumors: What do we know and where are we going? Cancer Treat Rev 2017; 52:22-32. [PMID: 27886588 DOI: 10.1016/j.ctrv.2016.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/01/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
The spectrum hypothesis posits that there are distinct clinical states of metastatic progression. Early data suggest that aggressive treatment of more biologically indolent metastatic disease, characterized by metastases limited in number and destination organ, may offer an opportunity to alter the disease course, potentially allowing for longer survival, delay of systemic therapy, or even cure. The development of stereotactic body radiation therapy (SBRT) has opened new avenues for the treatment of oligometastatic disease. Early data support the use of SBRT for treating oligometastases in a number of organs, with promising rates of treated metastasis control and overall survival. Ongoing investigation is required to definitively establish benefit, determine the appropriate treatment regimen, refine patient selection, and incorporate SBRT with systemic therapies.
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Affiliation(s)
- Julian C Hong
- Department of Radiation Oncology, Duke University, Durham, NC, United States
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, NC, United States.
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Richard PJ, Rengan R. Oligometastatic non-small-cell lung cancer: current treatment strategies. LUNG CANCER-TARGETS AND THERAPY 2016; 7:129-140. [PMID: 28210169 PMCID: PMC5310708 DOI: 10.2147/lctt.s101639] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The oligometastatic disease theory was initially described in 1995 by Heilman and Weichselbaum. Since then, much work has been performed to investigate its existence in many solid tumors. This has led to subclassifications of stage IV cancer, which could redefine our treatment approaches and the therapeutic outcomes for this historically “incurable” entity. With a high incidence of stage IV disease, non-small-cell lung cancer (NSCLC) remains a difficult cancer to treat and cure. Recent work has proven the existence of an oligometastatic state in NSCLC in terms of properly selecting patients who may benefit from aggressive therapy and experience long-term overall survival. This review discusses the current treatment approaches used in oligometastatic NSCLC and provides the evidence and rationale for each approach. The prognostic factors of many trials are discussed, which can be used to properly select patients for aggressive treatment regimens. Future advances in both molecular profiling of NSCLC to find targetable mutations and investigating patient selection may increase the number of patients diagnosed with oligometastatic NSCLC. As this disease entity increases, it is of utmost importance for oncologists treating NSCLC to be aware of the current treatment strategies that exist and the potential advantages/disadvantages of each.
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Affiliation(s)
- Patrick J Richard
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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Abstract
The diagnosis of brain metastases is associated with a poor prognosis reflecting uncontrolled primary disease that has spread to the relative sanctuary of the central nervous system. 20 % of brain metastases occur in the posterior fossa and are associated with significant morbidity. The risk of acute hydrocephalus and potential for sudden death means these metastases are often dealt with as emergency cases. This approach means a full pre-operative assessment and staging of underlying disease may be neglected and a proportion of patients undergo comparatively high risk surgery with little or no survival benefit. This study aimed to assess outcomes in patients to identify factors that may assist in case selection. We report a retrospective case series of 92 consecutive patients operated for posterior fossa metastases between 2007 and 2012. Routine demographic data was collected plus data on performance status, primary cancer site, details of surgery, adjuvant treatment and survival. The only independent positive prognostic factors identified on multivariate analysis were good performance status (if Karnofsky performance score >70, hazard ratio (HR) for death 0.36, 95 % confidence interval (CI) 0.18–0.69), adjuvant whole brain radiotherapy (HR 0.37, 95 % CI 0.21–0.65) and adjuvant chemotherapy where there was extracranial disease and non-synchronous presentation (HR 0.51, 95 % CI 0.31–0.82). Patients presenting with posterior fossa metastases may not be investigated as thoroughly as those with supratentorial tumours. Staging and assessment is essential however, and in the meantime emergencies related to tumour mass effect should be managed with steroids and cerebrospinal fluid diversion as required.
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Bai H, Xu J, Yang H, Jin B, Lou Y, Wu D, Han B. Survival prognostic factors for patients with synchronous brain oligometastatic non-small-cell lung carcinoma receiving local therapy. Onco Targets Ther 2016; 9:4207-13. [PMID: 27471395 PMCID: PMC4948689 DOI: 10.2147/ott.s106696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Clinical evidence for patients with synchronous brain oligometastatic non-small-cell lung carcinoma is limited. We aimed to summarize the clinical data of these patients to explore the survival prognostic factors for this population. Methods From September 1995 to July 2011, patients with 1–3 synchronous brain oligometastases, who were treated with stereotactic radiosurgery (SRS) or surgical resection as the primary treatment, were identified at Shanghai Chest Hospital. Results A total of 76 patients (22 patients underwent brain surgery as primary treatment and 54 patients received SRS) were available for survival analysis. The overall survival (OS) for patients treated with SRS and brain surgery as the primary treatment were 12.6 months (95% confidence interval [CI] 10.3–14.9) and 16.4 months (95% CI 8.8–24.1), respectively (adjusted hazard ratio =0.59, 95% CI 0.33–1.07, P=0.08). Among 76 patients treated with SRS or brain surgery, 21 patients who underwent primary tumor resection did not experience a significantly improved OS (16.4 months, 95% CI 9.6–23.2), compared with those who did not undergo resection (11.9 months, 95% CI 9.7–14.0; adjusted hazard ratio =0.81, 95% CI 0.46–1.44, P=0.46). Factors associated with survival benefits included stage I–II of primary lung tumor and solitary brain metastasis. Conclusion There was no significant difference in OS for patients with synchronous brain oligometastasis receiving SRS or surgical resection. Among this population, the number of brain metastases and stage of primary lung disease were the factors associated with a survival benefit.
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Affiliation(s)
| | | | | | | | | | - Dan Wu
- Central Laboratory, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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Patterns of Distant Metastases After Surgical Management of Non-Small-cell Lung Cancer. Clin Lung Cancer 2016; 18:e57-e70. [PMID: 27477488 DOI: 10.1016/j.cllc.2016.06.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 03/23/2016] [Accepted: 06/16/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with limited metastases, oligometastases (OMs), might have improved outcomes compared with patients with widespread distant metastases (DMs). The incidence and behavior of OMs from non-small-cell lung cancer (NSCLC) need further characterization. PATIENTS AND METHODS The medical records of patients who had undergone surgery for stage I-III NSCLC from 1995 to 2009 were retrospectively reviewed. All information pertaining to development of the first metastatic progression was recorded and analyzed. Patients with DMs were categorized into OMs (1-3 lesions potentially amenable to local therapy) and DM subgroups. RESULTS Of 1719 patients reviewed, 368 (21%) developed DMs with a median follow-up period of 39 months. A single lesion was diagnosed in 115 patients (31%) and 69 (19%) had 2 to 3 lesions (50% oligometastatic). The median survival from the DM diagnosis for oligometastatic and diffuse DM was 12.4 and 6.1 months, respectively (hazard ratio, 0.54; 95% confidence interval, 0.42-0.68; P < .001). Patients with a single metastasis had the longest median survival at 14.7 months. Younger age, OM, the use of chemotherapy for the primary tumor, and DM detection by surveillance imaging were independently associated with improved survival. CONCLUSION DMs and OMs are common in surgically managed NSCLC. Overall survival appears to be prolonged with OM.
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JU LIXIA, HAN MINGQUAN. Isolated brain metastasis as a late recurrence of completely resected non-small cell lung cancer. Oncol Lett 2016; 12:731-733. [PMID: 27347208 PMCID: PMC4907295 DOI: 10.3892/ol.2016.4674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/19/2016] [Indexed: 11/06/2022] Open
Abstract
The brain is one of the most common sites for non-small cell lung cancer (NSCLC) metastasis; however, late isolated brain metastasis as a recurrence of NSCLC is rare. The present study describes a case of isolated solitary brain metastasis as a late recurrence of NSCLC, which occurred >2 years following the successful resection of the primary tumor, and was identified by magnetic resonance imaging. To the best of our knowledge, this is the first report of isolated brain metastasis as a postoperative recurrence of NSCLC. The aim of the present study was to highlight that, despite its rarity, such recurrence should be considered possible, and particular attention to the treatment of such patients should be paid.
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Affiliation(s)
- LIXIA JU
- Department of Integrative Medicine, Tongji University School of Medicine, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai 200092, P.R. China
| | - MINGQUAN HAN
- Department of Integrative Medicine, Tongji University School of Medicine, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai 200092, P.R. China
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42
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Suzuki H, Yoshino I. Approach for oligometastasis in non-small cell lung cancer. Gen Thorac Cardiovasc Surg 2016; 64:192-6. [PMID: 26895202 DOI: 10.1007/s11748-016-0630-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Hidemi Suzuki
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Ichiro Yoshino
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, Inohana 1-8-1, Chiba, 260-8670, Japan
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Prognostic factors and long-term survival in surgically treated brain metastases from non-small cell lung cancer. Clin Neurol Neurosurg 2016; 142:72-80. [PMID: 26816105 DOI: 10.1016/j.clineuro.2016.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/29/2015] [Accepted: 01/05/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Brain metastases (BMs) are the most common malignant brain tumors in adults. Despite multimodal treatment options such as microsurgery, radiotherapy and chemotherapy, prognosis still remains very poor. Non-small cell lung cancer (NSCLC) constitutes the most common source of brain metastases. In this study, prognostic factors in this patient population were identified through an in-depth analysis of clinical parameters of patients with BMs from NSCLC. PATIENTS AND METHODS Clinical data of 114 NSCLC cancer patients who underwent surgery for BMs at the University Hospital Heidelberg were retrospectively reviewed for age, gender, type of treatment, time course of the disease, presence of neurologic symptoms, Karnofsky Performance Status (KPS), smoking history, presence of extracranial metastases at initial diagnosis of NSCLC, number, location and size of brain metastases. Univariate and multivariate survival analyses were performed using the Log-rank test and Cox' proportional hazard model, respectively. RESULTS Median survival time from surgery for BMs was 11.2 months. 18.4% (21 of 114) patients were long-term survivors (>24 months; range 26.3-75.1 months). Age, gender, size and number of intracranial metastases were not significantly associated with patient survival. Univariate analysis identified complete resection, postoperative whole brain radiotherapy (WBRT) and a preoperative KPS of >80% as positive prognostic factors. Infratentorial location and presence of extracranial metastases were shown to be negative prognostic factors. Surgery for the primary tumor was associated with a superior patient outcome both in univariate and multivariate analyses. CONCLUSION Our data strongly suggest that surgical treatment of the primary tumor and complete resection of brain metastases in NSCLC patients followed by WBRT improve survival. Moreover, long-term survivors (>2 years) were more frequent than previously reported.
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Putora PM, Ess S, Panje C, Hundsberger T, van Leyen K, Plasswilm L, Früh M. Prognostic significance of histology after resection of brain metastases and whole brain radiotherapy in non-small cell lung cancer (NSCLC). Clin Exp Metastasis 2015; 32:143-9. [PMID: 25628027 DOI: 10.1007/s10585-015-9699-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/20/2015] [Indexed: 01/15/2023]
Abstract
Brain metastases from non-small cell lung cancer (NSCLC) are associated with a poor prognosis. In selected cases, surgical resection of brain metastases may be indicated, but the identification of patients suitable for surgery remains difficult. We collected data on patient and tumour characteristics known or suspected to be associated with survival by chart review. Data was merged with available data from the local cancer registry. We identified 64 NSCLC patients with resected brain metastases. Median overall survival after resection was 9.1 months with only two patients (3%) surviving more than 71 and 80 months. One and 2-year survival were 42 and 12.5%. Median survival for males and patients with more comorbidities was shorter (8 vs. 10 months [p = 0.11] and 6 vs. 9 months [p = 0.06]). Patients with squamous cell carcinomas (33% of the patients) had a significantly worse survival than patients with other histologies (7 vs. 10 months [p = 0.02]) with no patient living longer than 2 years. Squamous cell histology was associated with worse prognosis after resection of brain metastases in patients with non-small cell lung cancer. Histology, among other parameters, may also be taken into account when choosing the appropriate patients for resection of brain metastases.
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Affiliation(s)
- Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland,
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Qin H, Wang C, Jiang Y, Zhang X, Zhang Y, Ruan Z. Patients with single brain metastasis from non-small cell lung cancer equally benefit from stereotactic radiosurgery and surgery: a systematic review. Med Sci Monit 2015; 21:144-52. [PMID: 25579245 PMCID: PMC4299005 DOI: 10.12659/msm.892405] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The appropriate treatment of non-small cell lung cancer (NSCLC) with single brain metastasis (SBM) is still controversial. A systematic review was designed to evaluate the effectiveness of neurosurgery and stereotactic radiosurgery (SRS) in patients with SBM from NSCLC. Material/Methods PUBMED, EMBASE, the Cochrane Library, Web of Knowledge, Current Controlled Trials, Clinical Trials, and 2 conference websites were searched to select NSCLC patients with only SBM who received brain surgery or SRS. SPSS 18.0 software was used to analyze the mean median survival time (MST) and Stata 11.0 software was used to calculate the overall survival (OS). Results A total of 18 trials including 713 patients were systematically reviewed. The MST of the patients was 12.7 months in surgery group and 14.85 months in SRS group, respectively. The 1, 2, and 5 years OS of the patients were 59%, 33%, and 19% in surgery group, and 62%, 33%, and 14% in SRS group, respectively. Furthermore, in the surgery group, the 1 and 3 years OS were 68% and 15% in patients with controlled primary tumors, and 50% and 13% in the other patients with uncontrolled primary tumors, respectively. Interestingly, the 5-year OS was up to 21% in patients with controlled primary tumors. Conclusions There was no significant difference in MST or OS between patients treated with neurosurgery and SRS. Patients with resectable lung tumors and SBM may benefit from the resection of both primary lesions and metastasis.
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Affiliation(s)
- Hong Qin
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Cancan Wang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yongyuan Jiang
- Department of Respiratory, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Xiaoli Zhang
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
| | - Yao Zhang
- Department of Epidemiology, Third Military Medical University, Chongqing, China (mainland)
| | - Zhihua Ruan
- Department of Oncology, Southwest Hospital, Third Military Medical University, Chongqing, China (mainland)
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Abstract
Precisely focused radiation or surgical resection of limited metastases resulted in long-term disease control and survival in multiple studies of patients with oligometastatic breast cancer. The integration of these ablative techniques into standard systemic therapy regimens has the potential to be paradigm shifting, leaving many patients without evidence of disease. Although an attractive treatment option, the utility of these therapies have not been proven in controlled studies, and improved outcomes may be because of patient selection or favorable biology alone. Ongoing studies continue to refine radiation techniques and determine the role for ablative therapies in the management of patients with metastatic breast cancer (MBC). Additionally, patient selection for metastasis-directed therapies is based on clinical criteria, with many not benefiting from therapies that may have substantial toxicities. Recent reports are beginning to uncover the biology of oligometastatic cancer, but much work is needed. Current and developing trials that integrate both clinical and translational endpoints have the potential to transform management strategies in women with limited MBC.
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Affiliation(s)
- Joseph K Salama
- From the Department of Radiation Oncology, Duke University Medical Center, Durham, NC; The University of Chicago, Chicago, IL
| | - Steven J Chmura
- From the Department of Radiation Oncology, Duke University Medical Center, Durham, NC; The University of Chicago, Chicago, IL
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47
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Abstract
In the absence of persuasive findings from the trials outlined earlier, the available evidence supports treating patients with a solitary site of M1 disease with induction chemotherapy followed by resection of all sites of disease as long as patients understand that this multimodality approach has not been proven to be superior to either surgery alone or chemotherapy alone.
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Affiliation(s)
- Robert J Downey
- Thoracic Service, Department of Surgery, Memorial Hospital, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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48
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Abstract
The ability to deliver precise focused radiation, combined with improved surgical techniques, has led to multiple reports of long-term survivors in patients with oligometastatic breast cancer. The removal or ablation of known metastases, often present after systemic therapy regimens has the potential to be paradigm shifting rendering many patients without evidence of disease. However, the utility of these therapies has not been proven in phase III studies. Additionally, patient selection for metastasis-directed therapies is based on clinical criteria, with many patients not benefiting from these therapies. Refinements of radiation techniques are continuing, and discoveries are uncovering the biology of breast cancer in the oligometastatic state among patients. Integrated into ongoing studies, and those in development, they have the potential to alter standard management strategies in oligometastatic patients.
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Affiliation(s)
- Joseph K Salama
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC.
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL; Cancer Research Center, University of Chicago, Chicago, IL; Ludwig Center for Metastasis Research, Chicago, IL
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Sheu T, Heymach JV, Swisher SG, Rao G, Weinberg JS, Mehran R, McAleer MF, Liao Z, Aloia TA, Gomez DR. Propensity score-matched analysis of comprehensive local therapy for oligometastatic non-small cell lung cancer that did not progress after front-line chemotherapy. Int J Radiat Oncol Biol Phys 2014; 90:850-7. [PMID: 25216859 DOI: 10.1016/j.ijrobp.2014.07.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/07/2014] [Accepted: 07/11/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE To retrospectively analyze factors influencing survival in patients with non-small cell lung cancer presenting with ≤3 synchronous metastatic lesions. METHODS AND MATERIALS We identified 90 patients presenting between 1998 and 2012 with non-small cell lung cancer and ≤3 metastatic lesions who had received at least 2 cycles of chemotherapy followed by surgery or radiation therapy before disease progression. The median number of chemotherapy cycles before comprehensive local therapy (CLT) (including concurrent chemoradiation as first-line therapy) was 6. Factors potentially affecting overall (OS) or progression-free survival (PFS) were evaluated with Cox proportional hazards regression. Propensity score matching was used to assess the efficacy of CLT. RESULTS Median follow-up time was 46.6 months. Benefits in OS (27.1 vs 13.1 months) and PFS (11.3 months vs 8.0 months) were found with CLT, and the differences were statistically significant when propensity score matching was used (P ≤ .01). On adjusted analysis, CLT had a statistically significant benefit in terms of OS (hazard ratio, 0.37; 95% confidence interval, 0.20-0.70; P ≤ .01) but not PFS (P=.10). In an adjusted subgroup analysis of patients receiving CLT, favorable performance status (hazard ratio, 0.43; 95% confidence interval, 0.22-0.84; P=.01) was found to predict improved OS. CONCLUSIONS Comprehensive local therapy was associated with improved OS in an adjusted analysis and seemed to favorably influence OS and PFS when factors such as N status, number of metastatic lesions, and disease sites were controlled for with propensity score-matched analysis. Patients with favorable performance status had improved outcomes with CLT. Ultimately, prospective, randomized trials are needed to provide definitive evidence as to the optimal treatment approach for this patient population.
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Affiliation(s)
- Tommy Sheu
- University of Texas School of Public Health, Houston, Texas; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - John V Heymach
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen G Swisher
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Reza Mehran
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mary Frances McAleer
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Aloia
- Department of Gastrointestinal Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Abstract
Advances in radiotherapy planning and delivery have been used to treat patients with limited metastatic disease. With these techniques, high rates of treated metastasis control and low toxicity have been reported. Some patients have long disease-free intervals after radiotherapy similar to those seen after surgical resection. Ongoing studies will determine the benefit of these irradiation techniques to treat limited metastases, identify appropriate candidates, and assist in integrating these treatments into management strategies for specific diseases.
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Affiliation(s)
- Joseph K Salama
- Joseph K. Salama, Duke University, Durham, NC; and Michael T. Milano, University of Rochester, Rochester, NY.
| | - Michael T Milano
- Joseph K. Salama, Duke University, Durham, NC; and Michael T. Milano, University of Rochester, Rochester, NY
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