Surgical management of non-small cell lung cancer with limited metastatic disease involving only the brain.

OBJECTIVE: The optimal primary site treatment modality for non-small cell lung cancer with brain oligometastases is not well established. This study sought to evaluate the long-term survival of patients with non-small cell lung cancer with isolated brain metastases undergoing multimodal therapy with or without thoracic surgery. METHODS: Patients with cT1-3, N0-1, M1b-c non-small cell lung cancer with synchronous limited metastatic disease involving only the brain treated with brain stereotactic radiosurgery or neurosurgical resection in the National Cancer Database (2010-2017) were included. Long-term overall survival of patients who underwent multimodal therapy including thoracic surgery ("Thoracic Surgery") versus systemic therapy with or without radiation to the lung ("No Thoracic Surgery") was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching. RESULTS: Of the 1240 patients with non-small cell lung cancer with brain-only metastases who received brain stereotactic radiosurgery or neurosurgery and met study inclusion criteria, 270 (21.8%) received primary site resection. The Thoracic Surgery group had improved overall survival compared with the No Thoracic Surgery group in Kaplan-Meier analysis (P < .001) and after multivariable-adjusted Cox proportional hazards modeling (P < .001). In a propensity score-matched analysis of 175 patients each in the Thoracic Surgery and No Thoracic Surgery groups, matching on 13 common prognostic variables, thoracic surgery was associated with better survival (P = .012). CONCLUSIONS: In this national analysis, patients with cT1-3, N0-1, M1b-c non-small cell lung cancer with isolated limited brain metastases had better overall survival after multimodal therapy including thoracic surgery compared with systemic therapy without surgery. Multimodal thoracic treatment including surgery can be considered for carefully selected patients with non-small cell lung cancer and limited brain metastases.

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.

Reconsidering the American Joint Committee on Cancer Eighth Edition TNM Staging Manual Classifications for T2b and T3 NSCLC.

INTRODUCTION: The American Joint Committee on Cancer (AJCC) eighth edition TNM staging manual for NSCLC, derived from the International Association for the Study of Lung Cancer (IASLC) Staging Project, designates tumors with additional nodule(s) in the same lobe as T3. This study sought to externally validate the results of the IASLC, which showed a trend in improved survival for such tumors, but excluded treatment-based adjustment, by assessing whether these tumors have worse survival than T2b NSCLC. METHODS: Overall survival of patients with T2b-T3, N0-3, M0 NSCLC (satisfying a single T descriptor of tumors >4 cm but ≤5 cm in greatest dimension ["T2b"], tumors >5 cm but ≤7 cm in greatest dimension ["T3-Size"], or tumors with additional nodule(s) in the same lobe ["T3-Add"]), according to the AJCC eighth edition, in the National Cancer Database (2010-2015), was evaluated using multivariable Cox proportional hazards modeling and propensity score matching. RESULTS: 31,563 patients with T2b-T3, N0-3, M0 NSCLC met the study inclusion criteria. In multivariable-adjusted analysis, T3-Add tumors had improved overall survival compared with T3-Size tumors (Hazard Ratio = 0.86, 95% Confidence Interval: 0.82-0.89, p < 0.001) and similar survival compared with T2b tumors (Hazard Ratio = 1.04, 95% Confidence Interval: 0.97-1.12, p = 0.28). A propensity score-matched analysis of 2260 T3-Add and 2,260 T2b patients, well-balanced on 16 common prognostic covariates, including treatment type (surgery, chemotherapy, or radiation), revealed similar 5-year survival (53.4% versus 52.3%, p = 0.30). CONCLUSIONS: In this national analysis, T3-Add tumors had better survival than other T3 tumors and similar survival to T2b tumors. These findings may be taken into consideration for the AJCC ninth edition staging classifications.