Prognostic factors of oligometastatic non-small-cell lung cancer following radical therapy: a multicentre analysis

Mandibular metastasis of pulmonary adenocarcinoma: How unexpected could it be?

OBJECTIVE

Metastatic tumours of bone must be considered in all patients with unexplained bone pain and particularly in patients who present with a known cancer, localised pain at multiple sites, and radiographic findings suggestive of metastasis. The purpose of this report was to present a case of a pathological fracture of the mandible as a consequence of metastatic pulmonary adenocarcinoma.

MATERIALS AND METHODS

In July 2018 a 68-year-old male patient was hospitalised because of pulmonary adenocarcinoma and attended our department for an oral maxillo-facial evaluation. He complained of pain and swelling in the right temporomandibular region resulting in a reported functional limitation. An Orthopantomogram (OPG) demonstrated a right intracapsular condylar compound fracture associated with an osteolytic lesion at the condyle base with jagged margins. Subsequently, a CT scan with contrast of the maxillo-facial complex and a fine-needle aspiration of the lesion was performed.

RESULTS

CT images showed the presence of a right mandibular condyle fracture associated with a large osteolytic lesion which confirmed the pathological nature of the fracture. Fine-needle aspiration of the lesion confirmed its metastatic nature. It was not possible to proceed with a mandibular resection due to the critical clinical condition of the patient who died in September 2018.

CONCLUSION

Lung cancer frequently produces lytic-type metastasis, sometimes even in the jaw. In patients with an established diagnosis of lung cancer, any radiolucent lesion of the jaw or an unexplained painful symptomatology to the oro-maxillo facial complex should be placed in differential diagnosis with metastasis of the primary tumour.

Surgical Outcomes in Non-Small Cell Lung Cancer with Distant Metastasis: The Prognostic Significance of Delayed Metastasis Diagnosis

BACKGROUND

The diagnosis of distant metastasis on preoperative examinations for non-small cell lung cancer (NSCLC) can be challenging, leading to surgery for some patients with uncertain metastasis. This study evaluated the prognostic impact of delayed diagnosis of metastasis on patients who underwent upfront surgery.

METHODS

The study enrolled patients who underwent lobectomy or pneumonectomy for NSCLC between June 2010 and December 2017 and evaluated the presence of distant metastasis before surgery. Overall survival (OS) for patients with stage IV cancer was compared with that for patients without metastasis, and the prognostic factors were analyzed.

RESULTS

Of 3046 patients (mean age, 63 years; 1770 men), 100 (3.3 %) had distant metastasis, diagnosed preoperatively in 1.4 % (42/3046) and postoperatively in 1.9 % (58/3046) of the patients. The two most common metastasis sites diagnosed after surgery were contralateral lung (22/58, 37.9 %) and ipsilateral pleura (16/58, 27.6 %). The OS (median, 42.7 months) for the patients with stage IV cancer diagnosed postoperatively was comparable with that for the patients with stage IIIB cancer (P = 0.865), whereas the OS (median OS, 91.7 months) for the patients with stage IV cancer diagnosed preoperatively was better than for the patients with stage IIIB cancer (P = 0.001). Among the patients with distant metastasis, squamous cell type (hazard ratio [HR], 3.15; P = 0.002) and systemic treatment for metastasis (HR, 2.42; P = 0.002) were independent predictors of worse OS.

CONCLUSIONS

Among NSCLC patients undergoing upfront surgery, the OS for the patients with stage IV cancer diagnosed postoperatively was comparable with that for the patients with stage IIIB cancer. For patients with stage IV disease, squamous cell type and systemic treatment for metastasis were prognostic factors for poorer OS.

Lung Cancer Resection after Immunochemotherapy Versus Chemotherapy in Oligometastatic Nonsmall Cell Lung Cancer

BACKGROUND

Neoadjuvant immunochemotherapy is currently being tested in pivotal trials for stage I to III nonsmall cell lung cancer (NSCLC). The impact of immunochemotherapy in patients with oligometastatic disease (OMD) remains undefined. This study aimed to compare the outcomes of radical treatment after the neoadjuvant course of immunochemotherapy versus chemotherapy.

METHODS

We retrospectively analyzed patients with OMD who were treated with immunochemotherapy or chemotherapy combined with local ablation of metastases and radical primary tumor resection between 2017 and 2021. Group A included eight patients with immunochemotherapy; Group B included seven patients with chemotherapy. Descriptive statistical analysis included the characteristics of the patients, tumors, and outcomes.

RESULTS

There was no difference in postoperative morbidity rates between the groups (p = 0.626). The 30-day mortality in both groups was 0%. The median overall survival for Group A was not reached, with a median follow-up time of 25 (range: 13-35) months; the median overall survival for Group B was 26 (range: 5-53) months. In Group A, all patients remained alive; in contrast, in Group B, four patients died (p = 0.026). There was no local thoracic recurrence in either group. In Group B, the recurrent disease was identified significantly more often (12.5 vs. 85.75%; p = 0.009). The rates of complete and major pathologic response were 37.5 and 0% in Group A and 42.85 and 14.25% in Group B, respectively.

CONCLUSION

Despite the small patient number and short-term results, the progression-free and overall survival in patients with OMD after local therapy for metastases and primary tumor resection following a neoadjuvant course of immunochemotherapy might be promising compared with chemotherapy.

The oncologic efficacy of extended resections for lung cancer

Extended lung resections for T3-T4 non-small-cell lung cancer remain challenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.

The "new" oligometastatic disease state and associated therapies in non-small cell lung cancer: A narrative review

Patients with non-small cell lung cancer (NSCLC) at stage IV have typically been considered incurable. Nonetheless, there is growing evidence that certain patient groups with fewer metastases, or so-called oligometastatic disease, which may have a more indolent biological nature than widespread metastatic diseases, may survive longer if definitive local treatment is administered to all metastatic sites. According to several retrospective investigations, this subgroup had a better prognosis than other stage IV patients, and the eighth edition of TNM staging was revised to reflect these findings. As a result of rapidly emerging systemic therapies, such as immune checkpoint inhibitors and a growing number of targeted therapies, more patients with this uncommon clinical opportunity have been identified and have received greater clinical attention. Currently, there is no established protocol for the management of oligometastatic disease, and the majority of therapeutic decisions are made through multidisciplinary discussion. In addition to systemic treatment, the two primary local therapeutic options for oligometastatic diseases are surgery and radiotherapy. A few phase 2 trials suggest that aggressive local ablative therapy may significantly improve the prognosis of patients with oligometastatic NSCLC. This review summarizes the most recent data on the management of oligometastatic NSCLC, with a focus on the prognostic significance of local ablative therapy in these patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

Local therapy treatment conditions for oligometastatic non-small cell lung cancer

Standard treatments for patients with metastatic non-small cell lung cancer (NSCLC) include palliative chemotherapy and radiotherapy, but with limited survival rates. With the development of improved immunotherapy and targeted therapy, NSCLC prognoses have significantly improved. In recent years, the concept of oligometastatic disease has been developed, with randomized trial data showing survival benefits from local ablation therapy (LAT) in patients with oligometastatic NSCLC (OM-NSCLC). LAT includes surgery, stereotactic ablation body radiation therapy, or thermal ablation, and is becoming an important treatment component for OM-NSCLC. However, controversy remains on specific management strategies for the condition. In this review, we gathered current randomized trial data to analyze prognostic factors affecting patient survival, and explored ideal treatment conditions for patients with OM-NSCLC with respect to long-term survival.

The Role of Surgery for Oligometastatic Non-Small Cell Lung Cancer

Oligometastatic non-small cell lung cancer (NSCLC) is metastatic disease that refers to a limited number of metastatic sites. It is analogous to an intermediate stage of NSCLC, between localized and widely metastatic disease, even though no staging criteria establishes this distinction. Oligometastatic NSCLC describes a patient subgroup with limited metastasis to one or a few organs. These patients seem to have a more indolent cancer than those with diffuse metastasis. For these select patients with oligometastatic disease, the use of palliative systemic therapy over local aggressive treatment may be a missed opportunity to improve survival. The clear definition of this subgroup and identification of the best treatment remains the current challenge in the management of the disease. Surgery was the early cornerstone in the treatment of limited disease; however, as modalities such as chemotherapy, stereotactic radiosurgery, and immunotherapy have matured, the role of excision is less clearly defined. There are sparse randomized controlled trials comparing the efficacy of different treatment modalities in patients with oligometastatic NSCLC. However, there is a growing body of retrospective research detailing the prognostic factors that characterize the role of surgery in the management of these patients. This article clarifies the context and definition of the term oligometastatic, as it applies to NSCLC, and reviews the current results in the use of surgery for its management.

Practical Management of Oligometastatic Non-Small-Cell Lung Cancer

Local ablative therapies, including surgery or stereotactic radiotherapy (SABR), are becoming an integral component in the treatment of oligometastatic disease in non-small-cell lung cancer. In this review, we summarize recent randomized evidence supporting progression-free survival and overall survival benefits of local ablation in these patients, as well as upcoming phase III data which should help us better understand the ideal treatment conditions and provide more insight into the oligometastatic state. Since practical management of oligometastatic disease in non-small-cell lung cancer can be challenging, we discuss a modern framework to identify patient, tumor, and treatment characteristics that can best guide management.

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

Simple Summary

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

Abstract

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

[Mediastinal Staging]

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice ("needle first"). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Outcomes of salvage lung resections in advanced EGFR-mutant lung adenocarcinomas under EGFR TKIs

Background

Studies regarding the outcomes of salvage lung resections of epidermal growth factor receptor (EGFR)‐mutant advanced lung adenocarcinomas (ALAs) following treatment with EGFR tyrosine kinase inhibitors (TKIs) are limited, hence the objective of this study was to investigate such outcomes.

Methods

A total of 29 patients with EGFR‐mutant ALA who underwent salvage surgery after EGFR‐TKI treatment from October 2013 through January 2019 were enrolled. The patients were divided into two groups according to the surgical indications. Their perioperative parameters and surgical outcomes, including progression‐free survival (PFS) and overall survival (OS), were then analyzed.

Results

The initial stages of the patients were stage IIIB (seven patients), IVA (17 patients), and IVB (five patients). Their surgical indications included residual tumor (25 patients) and progressive disease (PD) (four patients). They all underwent surgery via minimally invasive approaches and the median follow‐up was 33.9 months. Within that follow‐up duration, the median PFS after surgery was 36.4 months, and the median OS was still not reached. There were no significant differences in PFS or OS according to the different EGFR‐TKIs used, the different durations of EGFR‐TKI treatment before surgery, or the different surgical indications. However, the patients presenting with pleural seeding before EGFR‐TKI treatment had significantly poorer PFS and OS than the other patients (P < 0.001).

Conclusions

Salvage surgery following EGFR‐TKI treatment of ALAs is a safe procedure with acceptable intra‐ and postoperative results. However, studies involving more cases and longer follow‐up periods are needed to clarify its benefits.

Key points

Salvage surgery following EGFR‐TKI treatment of ALAs is a safe procedure with acceptable intra‐ and postoperative results.

Our results support the use of surgery following treatment with EGFR‐TKIs such as afatinib in advanced lung cancer.

Mediastinales Staging

Thorough mediastinal staging is pivotal for prognostic assessment and treatment planning in patients with non-small-cell lung cancer (NSCLC) without distant metastasis. It aims to answer the question of whether a technically and functionally feasible operation also makes sense from an oncological point of view. In case of a nodal-free mediastinum, primary surgical therapy can be considered. If the ipsilateral mediastinal lymph nodes are affected, multimodal therapy should be sought. Operating is usually no longer the first step, especially with extensive lymph node infestation. Surgery is recommended, if neoadjuvant (radio-)chemotherapy has achieved downstaging or major response. If the contralateral mediastinal lymph nodes are involved, curative surgery is no longer part of the therapeutic concept. The therapy of choice in this situation is definitive chemo-radiotherapy.Guidelines for mediastinal staging consistently require to combine radiological, nuclear medicine and minimally invasive methods. Imaging with CT and PET allows an initial assessment of the mediastinal status. In most cases it has to be complemented with tissue confirmation. Echoendoscopic assessment of the mediastinum with needle biopsy is the minimally invasive method of first choice ("needle first"). Surgical staging methods are reserved for situations, that cannot be satisfactorily clarified by echoendoscopy.Technique and outcome of the different methods are described and algorithms are presented for different oncological situations.

Epidemiology of oligometastatic non-small cell lung cancer: results from a systematic review and pooled analysis

Background

To describe the incidence and the clinical characteristics of oligometastatic non-small cell lung cancer (NSCLC) patients. Oligometastatic NSCLC is gaining recognition as a clinical condition with a different prognosis compared to multi metastatic disease. Usually, four different scenarios of oligometastatic disease can be described but not epidemiological data are available. To date, it is difficult to delineate an exhaustive epidemiological scenario because no uniform or shared definition of oligometastatic status exists, even though a recent consensus defined synchronous oligometastatic disease as having a maximum of 5 metastases in 3 different organs.

Methods

A systematic review and a pooled analysis of literature were performed. Article selection was based on the following characteristics: focus on lung cancers; dealing with oligometastatic settings and providing a definition of oligometastatic disease; number of metastatic lesions with or without the number of organs involved; providing some incidence or clinical characteristics of oligometastatic NSCLC patients. Series focusing on a specific single metastatic organ were excluded. The research was launched in MEDLINE (OvidSP) in March 2020. Full articles were individually and collectively read by the authors according to the previous criteria. Each author inspected the reference list included in the eligible articles. If the selection criteria were recognized, the article was reviewed by all authors and then included. Data on patient clinical features were pooled together from 31 articles selected.

Results

A total number of 31 articles have been selected for the analysis. The following variables were extracted from the publications: (I) number of metastases, (II) number of organs involved, (III) number of patients, (IV) number and percentage of males and females, (V) number and percentage of squamous and non-squamous histology, (VI) T and N status and/or stage of primary disease for oligometastatic setting. The data collected have been analyzed according to the oligometastatic setting.

Conclusions

Oligometastatic status is globally identified as a different clinical condition from multi metastatic NSCLC, although the clinical characteristics were consistent in the general metastatic population, even with a lower-than-expected TN status. The brain and bones were the most frequent organs involved. Lacking consensus definition, these results must be interpreted cautiously and a prospective evaluation is urgently needed.

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

Background

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

Methods

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

Results

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

Discussion

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

Narrative review: molecular and genetic profiling of oligometastatic non-small cell lung cancer

Objective

The objectives of this review are to discuss: the definition, clinical and biologic features of oligometastatic non-small cell lung cancer (NSCLC), as well as the concept of treating oligoprogression in oligometastatic NSCLC.

Background

A substantial proportion of patients diagnosed with lung cancer present with metastatic disease, and a large portion of patients who present with localized disease later develop metastases. Oligometastatic NSCLC is defined as an intermediate state between localized and widespread metastatic disease, where there may be a role for curative localized therapy approach by treating the primary tumor and all metastases with radiotherapy or surgery. Despite the increasing application of this approach in patients with lung cancer, the identification of patients who might benefit from this approach is yet to be well characterized.

Methods

After a systematic review of the literature, a PubMed search was performed using the English language and the key terms: oligometastatic, non-small cell lung cancer (NSCLC), localized consolidative treatment (LCT), biomarkers, biologic features, clinical features. Over 500 articles were retrieved between 1889–2021. A total of 178 papers discussing the definition, clinical and biologic factors leading to oligometastatic NSCLC were reviewed and included in the discussion of this paper.

Conclusions

Oligometastatic NSCLC is a unique entity. Identifying patients who have oligometastatic NSCLC accurately using a combination of clinical and biologic features and treating them with localized consolidative approach appropriately results in improvement of outcome. Further understanding of the molecular mechanisms driving the formation of oligometastatic NSCLC is an important area of focus for future studies.

Management of Synchronous Extrathoracic Oligometastatic Non-Small Cell Lung Cancer

Stage IV non-small cell lung cancer (NSCLC) accounts for 35 to 40% of newly diagnosed cases of NSCLC. The oligometastatic state-≤5 extrathoracic metastatic lesions in ≤3 organs-is present in ~25% of patients with stage IV disease and is associated with markedly improved outcomes. We retrospectively identified patients with extrathoracic oligometastatic NSCLC who underwent primary tumor resection at our institution from 2000 to 2018. Event-free survival (EFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Factors associated with EFS and OS were determined using Cox regression. In total, 111 patients with oligometastatic NSCLC underwent primary tumor resection; 87 (78%) had a single metastatic lesion. Local consolidative therapy for metastases was performed in 93 patients (84%). Seventy-seven patients experienced recurrence or progression. The five-year EFS was 19% (95% confidence interval (CI), 12-29%), and the five-year OS was 36% (95% CI, 27-50%). Factors independently associated with EFS were primary tumor size (hazard ratio (HR), 1.15 (95% CI, 1.03-1.29); p = 0.014) and lymphovascular invasion (HR, 1.73 (95% CI, 1.06-2.84); p = 0.029). Factors independently associated with OS were neoadjuvant therapy (HR, 0.43 (95% CI, 0.24-0.77); p = 0.004), primary tumor size (HR, 1.18 (95% CI, 1.02-1.35); p = 0.023), pathologic nodal disease (HR, 1.83 (95% CI, 1.05-3.20); p = 0.033), and visceral-pleural invasion (HR, 1.93 (95% CI, 1.10-3.40); p = 0.022). Primary tumor resection represents an important treatment option in the multimodal management of extrathoracic oligometastatic NSCLC. Encouraging long-term survival can be achieved in carefully selected patients, including those who received neoadjuvant therapy and those with limited intrathoracic disease.

In Spite of Curative Radical Pulmonary Procedures, Lesser Pulmonary Resection Shows More Favorable Prognosis in Surgically Treated NSCLC With Synchronous Isolated Cranial Oligometastases

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.

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

BACKGROUNDS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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