Aggressive therapy for patients with non-small cell lung carcinoma and synchronous brain-only oligometastatic disease is associated with long-term survival

Abstract

Objectives Optimal therapy for patients with non-small cell lung carcinoma (NSCLC) presenting with synchronous brain-only oligometastases (SBO) is not well defined. We sought to analyze the effect of differing therapeutic paradigms in this subpopulation. Materials and Methods We retrospectively analyzed NSCLC patients with 1-4 SBO diagnosed between 1/2000 and 1/2011 at our institution. Patients with T0 tumors or documented Karnofsky Performance Status <70 were excluded. Aggressive thoracic therapy (ATT) was defined as resection of the primary disease or chemoradiotherapy whose total radiation dose exceeded 45 Gy. Cox proportional hazards and competing risks models were used to analyze factors affecting survival and first recurrence in the brain. Results Sixty-six patients were included. Median follow-up was 31.9 months. Intrathoracic disease extent included 9 stage I, 10 stage II and 47 stage III patients. Thirty-eight patients received ATT, 28 did not. Patients receiving ATT were younger (median age 55 vs. 60.5 years, p=0.027) but were otherwise similar to those who did not. Receipt of ATT was associated with prolonged median overall survival (OS) (26.4 vs. 10.5 months; p<0.001) with actuarial 2-year rates of 54% vs. 26%. ATT remained associated with OS after controlling for age, thoracic stage, performance status and initial brain therapy (HR 0.40, p=0.009). On multivariate analysis, the risk of first failure in the brain was associated with receipt of ATT (HR 3.62, p=0.032) and initial combined modality brain therapy (HR 0.34, p=0.046). Conclusion Aggressive management of thoracic disease in NSCLC patients with SBO is associated with improved survival. Careful management of brain disease remains important, especially for those treated aggressively.

Should aggressive thoracic therapy be performed in patients with synchronous oligometastatic non-small cell lung cancer? A meta-analysis

“…All the included studies are retrospective observational cohort studies from 1999 to 2015, consisting of 668 synchronous oligometastatic NSCLC patients, among whom 227 (34.0%) received ATT. With regard to ATT regimens, Surgery only was the modality of ATT in one study (26), radiotherapy in one study (23), and surgery combined with radiotherapy or not in the five others articles (24,25,(27)(28)(29). When stratifying by oligometastatic state, single organ metastases was reported in five studies (24,(26)(27)(28)(29), of which four included only patients with brain-only metastases (24,(27)(28)(29).…”

“…For synchronous brain metastases, a recent study showed that patients with multiple metastases who received ATT had significantly improved survival vs. no-ATT, and this trend also was observed in those with a solitary metastasis (24). However, recent European guidelines did not recommend ATT for patients with more than one brain metastasis (34).…”

“…No test for funnel plot asymmetry was used, because the power of the tests was too low to distinguish chance from real asymmetry when there were only seven studies included in this meta-analysis (30). Data for successive monthly pooled estimates of survival were available from 5 studies (23,24,(26)(27)(28), consisting of 429 patients, and of whom 155 patients received ATT. The pooled survival curves of OS were displayed graphically as Figure 3.…”

Autofluorescence Imaging and Spectroscopy of Human Lung Cancer

“…The five-year survival rate of lung cancer patients is approximately 18% [2]. Eighty-five percent of lung cancer patients were non-small cell lung cancer (NSCLC), whose five-year survival rate is about 21% [3]. The common types of NSCLC are adenocarcinomas and squamous cell carcinomas with five-year survival rates of 42.8% and 43.4% [4].…”

Surgical approach in the oligometastatic patient

“…Finally, when consider prognosis in stage IV disease, another significant aspect to consider is the site of metastases. In particular, brain or adrenal gland secondary lesion seem to be associated with prolonged survival rather than bone or liver ones (21,(29)(30)(31)(32)(33)(34)(35). Referring to the above risk factors, it is possible to stratify and identify patients who are candidates for aggressive local treatment.…”