Surgical treatment in non-small cell lung cancer with pulmonary oligometastasis

Hybrid Approaches to Local Management of Pulmonary Metastatic Disease

With increasingly effective systemic therapies for stage IV disease, the addition of local control strategies for a subset of patients with limited metastatic disease has contributed to improved disease control and life prolongation. While surgery has been the mainstay strategy for local control, stereotactic ablative body radiation and percutaneous ablation techniques are alternate methods that have been demonstrated to be safe and effective and offer options to those patients who are unresectable, inoperable, or who do not desire surgery. A hybrid approach combining surgery and radiotherapy can maximize the ability to treat more lesions.

Palliative surgery is effective in patients with EGFR-mutant lung adenocarcinoma with pleural metastasis

Background

Pleural metastasis is a common metastatic pattern in patients with epidermal growth factor receptor-mutant lung adenocarcinoma (EGFR-LUADm); however, the value of palliative surgery for these patients remains controversial. The purpose of the present study aims to investigate whether palliative surgery benefits in stage IVA LUADm patients with pleural metastasis, who achieved complete remission of pleural lesions following targeted therapy.

Methods

From November 2014 to November 2023, patients with stage IVA EGFR-LUADm with pleural metastasis at Shanghai Pulmonary Hospital were retrospectively included in this study. All the patients received EGFR-tyrosine kinase inhibitor (TKI) monotherapy. The patients were divided into surgical- and non-surgical treatment subgroups. To reduce any selection bias, a 1:2 propensity score matching (PSM) was performed before comparing oncological outcomes between the two groups. The Kaplan-Meier method and log-rank test were used to identify the prognostic factors of these patients.

Results

A total of 134 patients who met the inclusion and exclusion criteria were enrolled in this study. Of the 134 patients, 13 received EGFR-TKI monotherapy followed by palliative surgical treatment (the surgical group), and 121 received EGFR-TKI monotherapy alone (the non-surgical group). No significant differences in the baseline characteristics were observed between the subgroups. After PSM, the surgical and non-surgical groups comprised 13 and 26 patients, respectively. The survival analysis showed that the patients in the surgical group had significantly better progression-free survival (PFS) than those in the non-surgical group {surgical vs. non-surgical: median PFS: 43 [95% confidence interval (CI): 30-not available] vs. 11 (95% CI: 10-26, P<0.001)}.

Conclusions

Compared with EGFR-TKI monotherapy, palliative surgery combined with EGFR-TKI treatment prolonged the PFS of pleural metastatic EGFR-LUADm patients. A subset of EGFR-LUADm patients with pleural metastasis might be suitable for palliative surgery.

Oligometastatic non-small cell lung cancer: Impact of local and contemporary systemic treatment approaches on clinical outcome

Oligometastatic (OMD) non-small cell lung cancer (NSCLC) is a distinct but heterogeneous entity. Current guidelines recommend systemic therapy and consolidation with local ablative therapy (LAT). However, evidence regarding the optimal choice of multimodal treatment approaches is lacking, in particular with respect to the integration of immunotherapy. This real-world study identified 218 patients with OMD NSCLC (2004-2023, prespecified criteria: ≤5 metastases in ≤2 organ systems) from three major German comprehensive cancer centers. Most patients had one (72.5%) or two (17.4%) metastatic lesions in a single (89.9%) organ system. Overall survival (OS) was significantly longer with a single metastatic lesion (HR 0.54, p = .003), and female gender (HR 0.4, p < .001). Median OS of the full cohort was 27.8 months, with 29% survival at 5 years. Patients who had completed LAT to all NSCLC sites, typically excluding patients with early progression, had a median OS of 34.4 months (37.7% 5-year OS rate) with a median recurrence-free survival (RFS) of 10.9 months (13.3% at 5 years). In those patients, systemic treatment as part of first-line therapy was associated with doubling of RFS (12.3 vs. 6.4 months, p < .001). Despite limited follow-up of patients receiving chemo-immunotherapy (EU approval 2018/2019), RFS was greatly improved by adding checkpoint inhibitors to chemotherapy (HR 0.44, p = .008, 2-year RFS 51.4% vs. 15.1%). In conclusion, patients with OMD NSCLC benefitted from multimodality approaches integrating systemic therapy and local ablation of all cancer sites. A substantial proportion of patients achieved extended OS, suggesting a potential for cure that can be further augmented with the addition of immunotherapy.

Complex situations in lung cancer: multifocal disease, oligoprogression and oligorecurrence

With the emergence of lung cancer screening programmes and newly detected localised and multifocal disease, novel treatment compounds and multimodal treatment approaches, the treatment landscape of non-small cell lung cancer is becoming increasingly complex. In parallel, in-depth molecular analyses and clonality studies are revealing more information about tumorigenesis, potential therapeutical targets and the origin of lesions. All can play an important role in cases with multifocal disease, oligoprogression and oligorecurrence. In multifocal disease, it is essential to understand the relatedness of separate lesions for treatment decisions, because this information distinguishes separate early-stage tumours from locally advanced or metastatic cancer. Clonality studies suggest that a majority of same-histology lesions represent multiple primary tumours. With the current standard of systemic treatment, oligoprogression after an initial treatment response is a common scenario. In this state of induced oligoprogressive disease, local ablative therapy by either surgery or radiotherapy is becoming increasingly important. Another scenario involves the emergence of a limited number of metastases after radical treatment of the primary tumour, referred to as oligorecurrence, for which the use of local ablative therapy holds promise in improving survival. Our review addresses these complex situations in lung cancer by discussing current evidence, knowledge gaps and treatment recommendations.

Distinguishing optimal candidates for primary tumor resection in patients with metastatic lung adenocarcinoma: A predictive model based on propensity score matching

Background

Primary tumor resection is associated with survival benefits in patients with metastatic lung adenocarcinoma (mLUAD). However, there are no established methods to determine which individuals would benefit from surgery. Therefore, we developed a model to predict the patients who are likely to benefit from surgery in terms of survival.

Methods

Data on patients with mLUAD were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Depending on whether surgery was performed on the primary tumor, patients were categorized into two groups: cancer-directed surgery (CDS) and no-cancer-directed surgery (No-CDS). Propensity Score Matching (PSM) was utilized to address bias between the CDS and No-CDS groups. The prognostic impact of CDS was assessed using Kaplan-Meier analysis and Cox proportional hazard models. Subsequently, we constructed a nomogram to predict the potential for surgical benefits based on multivariable logistic regression analysis using preoperative factors.

Results

A total of 89,039 eligible patients were identified, including 6.4% (5705) who underwent surgery. Following PSM, the CDS group demonstrated a significantly longer median overall survival (mOS) compared with the No-CDS group (23 [21-25] vs. 7 [7-8] months; P < 0.001). The nomogram showed robust performance in both the training and validation sets (area under the curve [AUC]: 0.698 and 0.717, respectively), and the calibration curves exhibited high consistency. The nomogram proved clinically valuable according to decision curve analysis (DCA). According to this nomogram, surgical patients were categorized into two groups: no-benefit candidates and benefit candidates groups. Compared with the no-benefit candidate group, the benefit candidate group was associated with longer survival (mOS: 25 vs. 6 months, P < 0.001). Furthermore, no difference in survival was observed between the no-benefit candidates and the no-surgery groups (mOS: 6 vs. 7 months, P = 0.9).

Conclusions

A practical nomogram was developed to identify optimal CDS candidates among patients with mLUAD.

Surgery for M1A Non-Small-Cell Lung Cancer With Additional Pulmonary Nodules in a Contralateral Lobe

INTRODUCTION

Limited consensus exists on the optimal treatment strategy for clinical M1a non-small-cell lung cancer (NSCLC) presenting as a primary tumor with additional intrapulmonary nodules in a contralateral lobe ("M1a-Contra"). This study sought to compare long-term survival of patients with M1a-Contra tumors receiving multimodal therapy with versus without thoracic surgery.

METHODS

Overall survival of patients with cT1-4, N0-3, M1a NSCLC with contralateral intrapulmonary nodules who received surgery as part of multimodal therapy ("Thoracic Surgery") versus systemic therapy with or without radiation ("No Thoracic Surgery") in the National Cancer Database from 2010 to 2015 was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching.

RESULTS

Of the 5042 patients who satisfied study inclusion criteria, 357 (7.1%) received multimodal therapy including surgery. In multivariable-adjusted analysis, the Thoracic Surgery cohort had better overall survival than the No Thoracic Surgery cohort (HR: 0.66, 95% CI: 0.56-0.79, P < 0.001). In a propensity score-matched analysis of 386 patients, well-balanced on 12 common prognostic covariates, the Thoracic Surgery group had better 5-year overall survival than the No Thoracic Surgery group (P = 0.020). In propensity score-matched analyses stratified by clinical N status, Thoracic Surgery was associated with better overall survival than No Thoracic Surgery for patients with cN0 disease and cN1-2 disease.

CONCLUSIONS

In this national analysis, multimodal treatment including surgery was associated with better overall survival than systemic therapy with or without radiation without surgery for patients with M1a-Contra tumors. These preliminary findings highlight the importance of further evaluation of surgery in a multidisciplinary treatment setting for M1a-Contra tumors.

Local thermal ablative therapies for extracranial oligometastatic disease of non-small-cell lung cancer

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. Clinically, 40-50% of patients with NSCLC are found to have systemic metastasis at the initial diagnosis. Meanwhile, 30-75% of patients with lung cancer who have undergone radical surgical resection have local recurrence and distant metastases. However, not all distant metastases are multiple, and some are potentially curable. In this study, among the patients with NSCLC having distant organ metastasis, approximately 7% showed extrapulmonary solitary metastasis and remained in this relatively stable state for a long time. This form of metastasis is known as NSCLC oligometastases. This review describes the concept and classification of oligometastases, as well as the local treatment and prognosis of extracranial oligometastases.

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.

Role of Local Treatment for Oligometastasis: A Comparability-Based Meta-Analysis

PURPOSE

We intend to investigate the oncological efficacy and feasibility of local consolidative therapy (LCT) through a meta-analysis method.

MATERIALS AND METHODS

Four databases including PubMed, MEDLINE, Embase, and Cochrane library were searched. Target studies are controlled trials comparing outcomes of LCT versus a control group. Primary endpoints are overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 54 studies involving 7,242 patients were included. Pooled analyses showed that the LCT arm could achieve improved OS with pooled odds ratio of 2.896 (95% confidence interval [CI], 2.377 to 3.528; p < 0.001). Regarding PFS, pooled analyses showed pooled odds ratio of 3.045 (95% CI, 2.356 to 3.937; p < 0.001) in favor of the LCT arm. In the subgroup analyses including the studies with reliable comparability (e.g. randomized studies or intentionally matched studies without significant favorable prognosticator in LCT arms), pooled odds ratio was 2.548 (95% CI, 1.808 to 3.591; p < 0.001) favoring the LCT arm regarding OS. Regarding PFS, pooled OR was 2.656 (95% CI, 1.713 to 4.120; p < 0.001) which also favored the LCT arm. Subgroup analyses limited to the randomized controlled trials (RCT) were also performed and pooled odds ratios on OS and PFS were 1.535 (95% CI, 1.082 to 2.177; p=0.016) and 1.668 (95% CI, 1.187 to 2.344; p=0.003). The rates of grade ≥ 3 complications related to LCT was mostly low (< 10%) and not significantly higher compared to the control arm.

CONCLUSION

Pooled analyses results of all included studies, selected studies with reliable comparability, and RCT's demonstrated the survival benefit of LCT. These consistent results suggest that LCT was beneficial to the patients with oligometastasis.

Survival after recurrence following surgical resected non-small cell lung cancer: A multicenter, prospective cohort study

Objectives

The optimal treatment for recurrent non–small cell lung cancer (NSCLC) has not been standardized. In this prospective cohort study, we evaluated post-recurrence survival (PRS) after treatment of recurrent NSCLC and identified prognostic factors after recurrence.

Methods

This multicenter prospective cohort study was conducted in 14 hospitals. The inclusion criteria for this study were patients with recurrence after radical resection for NSCLC. Information about the patient characteristics at recurrence, tumor-related variables, primary surgery, and treatment for recurrence was collected. After registration, follow-up data, such as treatment and survival outcomes, were obtained every 3 months.

Results

From 2010 to 2015, 505 cases were enrolled, and 495 cases were analyzed. As initial treatment for recurrence, 263 patients (53%) received chemotherapy, 46 (9%) received chemoradiotherapy, 98 (20%) had definitive radiotherapy, 14 (3%) received palliative radiotherapy, and 31 (6%) underwent surgical resection. The remaining 43 patients (9%) received supportive care. The median PRS and 5-year survival rates for all cases were 30 months and 31.9%, respectively. The median PRS according to the initial treatment was as follows: supportive care, 8 months; palliative radiotherapy, 16 months; definitive radiotherapy, 30 months; chemotherapy, 31 months; chemoradiotherapy, 35 months; and surgery, not reached. A multivariate analysis showed that the age, gender, performance status, histology presence of symptoms, duration from primary surgery to recurrence, and number of recurrent foci were independent prognostic factors for PRS.

Conclusions

The PRS of patients with recurrent NSCLC was different depending on the patient's background characteristics and initial treatment for recurrence.

Benefits of local consolidative treatment in oligometastases of solid cancers: a stepwise-hierarchical pooled analysis and systematic review

We conducted a meta-analysis of articles published in PubMed, MEDLINE, EMBASE, and Cochrane library to investigate the effectiveness of local consolidative therapy (LCT) against oligometastases. Data from randomized controlled trials (RCTs), balanced studies, and all studies combined were analyzed in a hierarchical manner. Pooled analyses of 31 studies (including seven randomized trials) investigating the effectiveness of LCT on overall survival revealed odds ratios of 3.04, 2.56, and 1.41 for all studies, balanced studies, and RCTs, respectively (all p < 0.05). The benefit of LCT was more prominent in patients with non-small cell lung and colorectal cancers than in those with prostate and small cell lung cancers. Moreover, the benefit of LCT was smaller in patients with high metastatic burdens (p = 0.054). In four of 12 studies with available information, additional grade ≥3 toxicities due to LCTs were reported. Overall, LCT is beneficial for patients with oligometastases, although such benefits are less evident in RCTs than in observational studies. Appropriate LCTs should be carefully selected considering their feasibility, disease type, and metastatic burden.

How to handle oligometastatic disease in nonsmall cell lung cancer

Patients with nonsmall cell lung cancer and limited metastatic disease have been defined as oligometastatic if local ablative therapy of all lesions is amenable. Evidence from different clinical retrospective series suggests that this subgroup harbours better prognosis than other stage IV patients. However, most reports have included patients with inconsistent numbers of metastases in different locations treated by a variety of invasive and noninvasive therapies. As long as further results from randomised clinical trials are awaited, treatment decision follows an interdisciplinary debate in each individual case. Surgery and radiotherapy should capture a dominant role in the treatment course offering the option of a curative-intended local therapy in combination with a systemic therapy based on an interdisciplinary decision. This review summarises the current treatment standard in oligometastatic lung cancer with focus on an ablative therapy for both lung primary and distant metastases in prognostically favourable locations.

Outcomes of local thoracic surgery in patients with stage IV non-small-cell lung cancer: A SEER-based analysis

BACKGROUND

The outcomes of thoracic surgery for patients with stage IV non-small-cell lung cancer (NSCLC) are controversial and uncertain.

PATIENTS AND METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results was queried for patients with stage IV NSCLC, including those treated with surgery-participated therapy modalities. Overall survival (OS) was evaluated using a variety of statistical analyses.

RESULTS

The analysis was carried out for 90,982 patients from 1975 to 2016 who had been diagnosed as stage IV NSCLC. Propensity score-matched (PSM) analyses that were well-balanced with all the important confounding covariates revealed improved OS (median survival time [MST]) with patients receiving surgery versus non-surgery (MST: 15 versus 8 months, P < 0.001); undergoing surgery plus chemotherapy versus chemotherapy (MST: 19 versus 11 months, P < 0.001); and having surgery plus chemoradiation versus chemoradiation (MST: 18 versus 11 months, P < 0.001). Sequential landmark analyses for long-term survivors of ≥1 and ≥3 years all indicated improved OS (P < 0.001) on univariate and multivariate analyses for the patients receiving the three surgery-related treatment patterns listed earlier, relative to the corresponding surgery-absent treatment modalities. For synchronous presentations of varied treatment paradigms, surgical intervention significantly led to increased OS (MST, months) benefits following treatment paradigms: surgery plus chemotherapy (22), surgery plus chemoradiation (18), chemotherapy (10), surgery only (9), chemoradiation (9), surgery plus radiation (6) and radiation alone (2). The subgroup analysis demonstrated that the elevated OS associated with local thoracic surgery in addition to chemotherapy (versus chemotherapy) or chemoradiation (versus chemoradiation) fell in the subcategories of T0-3, N0-2 and 0-1 (metastatic sites) tumours. The comparison of the aforementioned two types of treatment patterns indicated that the optimal patients for the surgery were those with any combination of T1-4, N0-3, Msite0-1 and adeno- or squamous carcinoma.

CONCLUSIONS

The patients with T1-4, N0-3, Msite0-1 and adeno- or squamous carcinoma of stage IV NSCLC had a longer OS with local thoracic surgery in combination with chemotherapy or chemoradiation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

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

Background

Previous studies have demonstrated that survival of patients with non-small cell lung cancer (NSCLC) with oligometastasis may benefit from local treatment. The purpose of this study was to compare the efficacy of local surgical treatment with systematic chemoradiotherapy in NSCLC with oligometastasis.

Methods

Data from a total of 172 patients with NSCLC with oligometastasis were collected at our Cancer Hospital from January 2006 to December 2016. The patients were divided into two groups: group A (82 cases) underwent primary surgical treatment and adjuvant chemotherapy was performed after operation, while group B (90 cases) received systematic chemotherapy and local radiotherapy. The median survival time (MST) and the 5-year survival rate of the two groups were compared and analyzed. The effects of various pathological types, surgical methods of the primary tumors and the site of oligometastasis were also analyzed.

Results

The MSTs in groups A and group B were 48 months and 18 months, respectively, and the 5-year survival rates were 21.1% and 7.6%, respectively (P<0.05). In group A, the survival rates were higher in patients with adrenal metastasis than patients with metastasis in the brain, bone, the liver or in other oligometastatic patients (P<0.05). There was no significant difference in the survival rate among the various pathological types or surgical methods of primary tumors (P>0.05).

Conclusions

Local surgical treatment of primary lesions in NSCLC significantly prolonged overall survival and 5-year survival rates of patients with NSCLC with oligometastasis.

Efficacy of Local Consolidative Therapy for Oligometastatic Lung Adenocarcinoma Patients Harboring Epidermal Growth Factor Receptor Mutations

BACKGROUND

For oligometastatic lung adenocarcinoma patients with sensitive epidermal growth factor receptor (EGFR) mutations, the role of local consolidative therapy (LCT) remains debatable. The purpose of this study was to investigate the efficacy of LCT in oligometastatic lung adenocarcinoma patients.

PATIENTS AND METHODS

We conducted a retrospective study to assess the effects of LCT on progression-free survival (PFS) and overall survival (OS). Patients with advanced-stage oligometastatic lung adenocarcinoma harboring sensitive mutation of epidermal growth factor receptor (EGFR) who received EGFR-tyrosine kinase inhibitor (TKI) or EGFR-TKI plus LCT were admitted to Shanghai Chest Hospital from January 2010 to December 2016. The PFS and OS of the 2 groups were accordingly analyzed.

RESULTS

A total of 231 patients (143 patients who received LCT plus EGFR-TKI [combination group] and 88 patients who only received EGFR-TKI only [monotherapy group]) were included in this study. Median PFS was significantly longer in the combination group (15 months; 95% confidence interval [CI], 13.611-16.389) than in the monotherapy group (10 months; 95% CI, 8.936-11.064; hazard ratio = 0.610; 95% CI, 0.461, 0.807; P = .000). The median OS in the combination group was 34 months (95% CI, 27.889, 40.111) versus 21 months (95% CI, 18.445, 23.555) in the monotherapy group (hazard ratio = 0.593; 95% CI, 0.430-0.817; P = .001).

CONCLUSION

LCT combined with TKIs therapy was a feasible method that significantly improved PFS and OS among oligometastatic lung adenocarcinoma patients with EGFR mutations, and it thus might be considered as an important medical treatment during clinical management.

Complete resection of the primary lesion improves survival of certain patients with stage IV non-small cell lung cancer

BACKGROUND

The standard treatment for patients with stage IV non-small cell lung cancer (NSCLC) is systemic chemotherapy. However, certain patients, such as those with oligometastasis or M1a disease undergo resection of the primary lesion.

METHODS

We conducted a retrospective review of the records of 1,471 consecutive patients with NSCLC who underwent resection of the primary lesion for between June 2005 and May 2016. The present study included 38 patients with stage IV NSCLC who underwent complete resection of the primary lesion as first-line treatment.

RESULTS

The median follow-up duration for the 38 patients (27 men) was 17.7 months (range, 1-82.3 months). The T factors were T1/T2/T3/T4 in 4/16/12/6 patients, respectively. The N factors were N0/N1/N2/N3 in 16/8/12/2 patients, respectively. The M factors were M1a/M1b/M1c in 19/13/6 patients, respectively. Of the 19 M1a patients, 11 were classified as cM0. We introduced the novel classification M-better/M-worse. M-better includes cM0 patients and M1b and M1c patients in whom all lesions have been locally controlled. M-worse includes cM1a patients and M1b and M1c patients in whom lesions cannot be locally controlled. The new M-better/M-worse statuses were 24/14 patients, respectively. The histology of NSCLC was adenocarcinoma/squamous cell carcinoma/others in 30/5/3 patients, respectively. The 5-year overall survival rate was 29%, and the median survival time was 725 days. Squamous cell carcinoma and M-worse were significant factors predicting poor outcomes (P=0.0017, P=0.0007, respectively).

CONCLUSIONS

Even for stage IV NSCLC patients, resection of the primary lesion may be beneficial, especially for those with M-better status and those not diagnosed with squamous-cell carcinoma (SCC).

Local thoracic therapy improve prognosis for stage IV non-small cell lung cancer patients combined with chemotherapy: A Surveillance, Epidemiology, and End Results database analysis

Patients with stage IV non-small cell lung cancer (NSCLC) comprise a heterogeneous group, and the optimal treatment for this group of patients is complex and debatable. We aimed to assess the effect of local thoracic therapy combined with chemotherapy on cancer specific survival (CSS). To evaluate the CSS of four subgroups of patients with stage IV NSCLC according to four different treatment modalities: combined modality of Chemotherapy, Surgery, and Radiation (Chem+Sur+RT), Chemotherapy and Radiation (Chem+RT), Chemotherapy and Surgery (Chem+Sur), and Chemotherapy only (Chem Only) by analyzing the Surveillance, Epidemiology, and End Results (SEER)-registered database. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of survival outcomes and risk factors. The 3-year CSS was 33.5% in “Chem+Sur+RT” group, 9.3% in “Chem+RT” group, 42.7% in “Chem+Sur” group and 11.8% in “Chem Only” group, which had significant difference in univariate log-rank test (P<0.001) and multivariate Cox regression (P<0.001). Moreover, we observed significant survival benefits in “Chem+Sur” group in all stage of T/N categories, including stage I, stage II, stage IIIa and stage IIIb (all P<0.001). Multimodality therapy, especially combined thoracic surgery and chemotherapy is associated with dramatically improved prognosis for patients with stage IV NSCLC.