Stage IV lung cancer: Is cure possible?

Flausino L, Iyer G, Balkrishnan R. Effectiveness of immunological agents in non-small cell lung cancer

BACKGROUND AND AIM

Non-small cell lung cancer (NSCLC) continues to claim millions of lives worldwide. Although its poor prognosis is largely attributed to the lack of adequate and precise detection technologies, cancer cells' suppression of the immune system adds on to the difficulty of identifying abnormal NSCLC tumors in their early stages. Therefore, cancer immunotherapy, which activates the immune system and helps it fight tumors, has recently become the most sought-after technique, especially in the advanced stages of NSCLC, where surgery or chemotherapy may or may not bring about the desired survival benefits in patients.

METHODS

This review focuses on the various immunotherapeutic interventions and their efficacy in advanced NSCLC clinical trials. Monoclonal antibodies like anti-PD-1/PD-L1 agents and anti-CTLA-4 antibodies, cancer vaccines, oncolytic viruses and adoptive T cell therapy have been discussed in brief. Furthermore, the effects of gender, age, and race on the efficacy of immune checkpoint inhibitors and suggest plausible future approaches in the realm of immuno-oncology.

RESULTS

Immunotherapy is used alone or in combination either with other immunological agents or with chemotherapy. However, the efficacy of these strategies depends extensively on various demographic variables, as some patients respond perfectly well to immunotherapy, while others do not benefit at all or experience disease progression. By targeting a "hallmark" of cancer (immune evasion), immunotherapy has transformed NSCLC management, though several barriers prevent its complete effectiveness.

CONCLUSIONS

All these immunological strategies should be interpreted in the current setting of synergistic treatment, in which these agents can be combined with chemotherapy, radiotherapy, and, or surgery following patient and tumor characteristics to proportionate the best-individualized treatment and achieve superior results. To better pursue this goal, further investigations on cost-effectiveness and sex-gender, race, and age differences in immunotherapy are needed.

Lung Cancer Management in Low and Middle-Income Countries

Lung cancer is an increasing problem in the developing world due to rising trends in smoking, high incidence of air pollution, lack of awareness and screening, delayed presentation, and diagnosis at the advanced stage. Even after diagnosis, there are disparities in access to health care facilities and inequitable distribution of resources and treatment options. In addition, the shortage of trained personnel and infrastructure adds to the challenges faced by patients with lung cancer in these regions. A multi-pronged effort targeting tobacco cessation, health promotion and awareness, capacity building, and value-based care are the need of the hour.

Percutaneous cryoablation of adrenal metastases: technical feasibility and safety

PURPOSE

To assess the technical feasibility and outcomes of adrenal metastases cryoablation.

MATERIALS AND METHODS

This is an IRB approved retrospective review of adrenal metastases cryoablation between April 2003 and October 2018. Forty percutaneous cryoablation procedures were performed on 40 adrenal metastases in 34 patients. Histology, tumor size, ablation zone size, major vessel proximity, local recurrences, complications, and anesthesia-managed hypertension monitoring was collected. Complications were graded according to the Common Terminology of Complications and Adverse Events (CTCAE).

RESULTS

Mean tumor and ablation size was 3.2 cm and 5.2 cm, respectively. Local recurrence rate was 10.0% (N = 4/40) for a mean follow-up time of 1.8 years. Recurrences for tumors > 3 cm (21.0%, N = 4/19) was greater than for tumors ≤ 3 cm (0.0%, N = 0/21) (p = 0.027). Proximity of major vasculature (i.e., IVC & aorta) did not statistically effect recurrence rates (p = 0.52), however, those that recurred near vasculature were > 4 cm. Major complication (≥ grade 3) rate was 5.0% (N = 2/40), with one major complication attributable to the procedure. Immediate escalation of blood pressure during the passive stick phase (between freeze cycles) or post procedure thaw phase was greater in patients with residual adrenal tissue (N = 21/38) versus masses replacing the entire adrenal gland (N = 17/38), (p = 0.0020). Lower blood pressure elevation was noted in patients with residual adrenal tissue who were pre-treated with alpha blockade (p = 0.015).

CONCLUSIONS

CT-guided percutaneous cryoablation is a safe, effective and low morbidity alternative for patients with adrenal metastases. Transient hypertension is related only to residual viable adrenal tissue but can be safely managed and prophylactically treated.

Curative intent therapy in oligometastatic lung cancer with an unresectable primary with N3 nodes: case report and review of the literature

Untreated NSCLC patients with brain metastases have a median survival of approximately 2 months; locally advanced stage III NSCLC patients treated with chemoradiation have a median survival of 16-19 months. Select patients with oligometastatic disease may have a prolonged survival if managed aggressively. We present the case of a 47-year-old woman with lung adenocarcinoma, cT2aN3M1a, (supraclavicular lymph node, solitary brain metastasis). She underwent brain metastasectomy, whole brain radiation, induction chemotherapy and concurrent chemoradiotherapy. She relapsed in the brain and locoregionally and was treated with brain re-irradiation, and systemic chemotherapy. Her progression-free survival was 32 months and she is alive with recurrent disease 63 months after diagnosis. Systemic therapy is an important tool in the multimodality management of patients with oligometastatic disease.

Stage IV EGFR Mutation-Negative and ALK Mutation-Negative Lung Adenocarcinoma: Long-Term Survival is Possible

Lung cancer is the leading cause of cancer death in the United States with a five-year survival of 16.8% for all stages and median survival of four months for Stage IV disease. We report a case of a 54-year-old male with a seven-year survival after being diagnosed with Stage IV epidermal growth factor receptor (EGFR) mutation-negative and anaplastic lymphoma kinase (ALK) mutation-negative adenocarcinoma of the lung, demonstrating an exceptional response to treatment. 

Patient perceptions regarding the likelihood of cure after surgical resection of lung and colorectal cancer

BACKGROUND

The objective of the current study was to characterize the prevalence of the expectation that surgical resection of lung or colorectal cancer might be curative. The authors sought to assess patient-level, tumor-level, and communication-level factors associated with the perception of cure.

METHODS

Between 2003 and 2005, a total of 3954 patients who underwent cancer-directed surgery for lung (30.3%) or colorectal (69.7%) cancer were identified from a population-based and health system-based survey of participants from multiple US regions.

RESULTS

Approximately 80.0% of patients with lung cancer and 89.7% of those with colorectal cancer responded that surgery would cure their cancer. Even 57.4% and 79.8% of patients with stage IV lung and colorectal cancer, respectively, believed surgery was likely to be curative. On multivariable analyses, the odds ratio (OR) of the perception of curative intent was found to be higher among patients with colorectal versus lung cancer (OR, 2.27). Patients who were female, with an advanced tumor stage, unmarried, and having a higher number of comorbidities were less likely to believe that surgery would cure their cancer; educational level, physical function, and insurance status were not found to be associated with perception of cure. Patients who reported optimal physician communication scores (reference score, 0-80; score of 80-100 [OR, 1.40] and score of 100 [OR, 1.89]) and a shared role in decision-making with their physician (OR, 1.16) or family (OR, 1.17) had a higher odds of perceiving surgery would be curative, whereas patients who reported physician-controlled (OR, 0.56) or family-controlled (OR, 0.72) decision-making were less likely to believe surgery would provide a cure.

CONCLUSIONS

Greater focus on patient-physician engagement, communication, and barriers to discussing goals of care with patients who are diagnosed with cancer is needed.

Patient perceptions regarding the likelihood of cure after surgical resection of lung and colorectal cancer

BACKGROUND

The objective of the current study was to characterize the prevalence of the expectation that surgical resection of lung or colorectal cancer might be curative. The authors sought to assess patient-level, tumor-level, and communication-level factors associated with the perception of cure.

METHODS

Between 2003 and 2005, a total of 3954 patients who underwent cancer-directed surgery for lung (30.3%) or colorectal (69.7%) cancer were identified from a population-based and health system-based survey of participants from multiple US regions.

RESULTS

Approximately 80.0% of patients with lung cancer and 89.7% of those with colorectal cancer responded that surgery would cure their cancer. Even 57.4% and 79.8% of patients with stage IV lung and colorectal cancer, respectively, believed surgery was likely to be curative. On multivariable analyses, the odds ratio (OR) of the perception of curative intent was found to be higher among patients with colorectal versus lung cancer (OR, 2.27). Patients who were female, with an advanced tumor stage, unmarried, and having a higher number of comorbidities were less likely to believe that surgery would cure their cancer; educational level, physical function, and insurance status were not found to be associated with perception of cure. Patients who reported optimal physician communication scores (reference score, 0-80; score of 80-100 [OR, 1.40] and score of 100 [OR, 1.89]) and a shared role in decision-making with their physician (OR, 1.16) or family (OR, 1.17) had a higher odds of perceiving surgery would be curative, whereas patients who reported physician-controlled (OR, 0.56) or family-controlled (OR, 0.72) decision-making were less likely to believe surgery would provide a cure.

CONCLUSIONS

Greater focus on patient-physician engagement, communication, and barriers to discussing goals of care with patients who are diagnosed with cancer is needed.