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• W2898127643 abstract "Historically, surgery was reserved for palliation in patients with stage IV NSCLC, but since the 1980s there have been reports of prolonged survival following complete resection of primary tumors and metastatic lesions in select patients with low volume metastatic disease. Hellman and Wechselbaum introduced the term “oligometastasis” to describe an intermediate spread of disease, prior to widely metastatic disease and recognized it as a subset where aggressive local treatments were warranted. Surgery for metastatic NSCLC is increasing in frequency. An analysis from the National Inpatient Sample uncovered a 5.8% average annual percent increase resections of NSCLC metastases between 2000 and 2011.1This increase is attributed to several factors, including more efficacious and better tolerated chemotherapies including targeted agents, which have slowed the progression of metastatic spread and altered patterns of resistance. Simultaneously, there have been significant improvements in surgical techniques, with increased minimally invasive approaches, making resection better tolerated and negating long interruption from systemic treatments. The majority of patients considered for resection of oligometastatic NSCLC fall into three categories, isolated metastasis to the brain, adrenal glands, or contralateral lung. Patients who have previously undergone resection of early stage NSCLC and subsequently develope isolated oligometastasis and good performance status should be considered for curative intent resection. Similarly patients with oliogometastsis de novo should be evaluated for curative resection in addition to systemic therapy. Isolated Brain Metastasis: Some of the oldest series on surgical treatment of oligometastatic NSLC relate to treatment of isolated brain metastasis.2,3 Up to one quarter of all patients with stage IV NSCLC harbor brain metastasis. Adenocarcinomas are associated with higher rates of brain metastasis, but in 10% of patients with metastatic adenocarcinoma the brain is the only site of involvement.4 Aggressive curative intent treatment of the primary and metastatic site is encouraged in those with good performance status and in whom both sites are amenable to complete resection or ablation. Curative intent local treatments can only be considered after a thorough search for disease at other sites. Mediastinal lymph node involvement portends poor prognosis and therefore invasive mediastinal staging is recommended prior to starting treatment. Brain MRI is recommended in addition to PET/ CT because of increased sensitivity. Multiple brain metastasis are not an absolute contraindication to this aggressive treatment approach, but most recommend three or fewer lesions.5 Treatment of the brain lesion can be by resection or radiosurgery ablation. Five year survival following definitive treatment of isolated brain metastasis and primary NSCLC is 15%, and not significantly impacted by synchronous or metachronous presentation. Prognosis is improved in patients who are younger, female, have lower t-stage, and good performance status. Adjuvant whole brain radiation therapy (WBRT) following resection or radiosurgery is recommended. Randomized data on WBRT in this setting is limited, but the sole trial demonstrated a significant decrease brain recurrence.6 There is also no randomized data specifically addressing the use of adjuvant chemotherapy following complete resection of stage IV disease, but with strong evidence supporting adjuvant chemotherapy for completely resected stage II and III, it is recommended. Isolated Adrenal Metastasis: In well-selected patients with isolated adrenal metastasis from NSCLC, survival following complete resection is 25%.7 Similar to those with isolated brain metastasis, mediastinal lymph node involvement portend poor prognosis so invasive staging is recommended. Histology and laterality appear to have no impact on survival and adjuvant chemotherapy is recommended. Synchronous and metachronous tumors have similar long-term survival rates, despite younger age distribution in patients with synchronous presentation.7 Operative mortality is extremely low in reported series and the majority of patients die of disease progression. M1a Disease: The appearance of bilateral NSCLC lesions with the same histology is a staging challenge. In the absence of other disease it is difficult to distinguish bilateral primary tumors from stage IVa disease. Analysis of mutational status and genetic clonality difference are being investigated, but not clinically reliable at this time.The clinical judgement of an experienced multi-modality team is essential, 4 and the criteria described by Martini and Melamed in 1975 remains relevant.8 As with isolated brain and adrenal metastasis, an exhaustive search for additional metastatic disease and invasive mediastinal staging are recommended prior to considering resection. Parenchymal sparing resections are typically recommended when possible in this setting. Most agree that favorable biology is the primary driver of prognosis in the setting of oligometastasis and the true impact of local interventions on prognosis is unclear. But in an era when local treatments carry minimal morbidity and mortality, the lack of clarity should not translate into a denial of intervention in well-selected patients , but rather another treatment option to prolong survival." @default.
• W2898127643 created "2018-11-02" @default.
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• W2898127643 date "2018-10-01" @default.
• W2898127643 modified "2023-09-30" @default.
• W2898127643 title "ES06.04 Surgical Considerations in OMD" @default.
• W2898127643 doi "https://doi.org/10.1016/j.jtho.2018.08.038" @default.
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