Thoracic: Lung Cancer
Surgical management of non–small cell lung cancer with limited metastatic disease involving only the brain

Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.
https://doi.org/10.1016/j.jtcvs.2023.04.034Get rights and content

Abstract

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.

Section snippets

Data Source

The data used in this study were from the NCDB, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The NCDB is estimated to capture 80% of all newly diagnosed cases of lung cancer in the United States and Puerto Rico.9

Study Design

The Institutional Review Board of Massachusetts General Hospital approved the study protocol and publication of data (Protocol #2020P004110; approved on February 2, 2021). Data were analyzed from a de-identified NCDB

Study Cohort

Between 2010 and 2017, 1240 patients diagnosed with cT1-3, N0-1, M1b-c NSCLC presented with synchronous limited metastatic disease involving only the brain and met the study eligibility criteria. Definitive thoracic treatment included surgery as part of multimodal therapy (“Thoracic Surgery”) for 270 patients (21.8%) compared with systemic therapy with or without radiation without thoracic surgery (“No Thoracic Surgery”) in 970 patients (78.2%) (Figure 1). Patients with missing data are

Discussion

In this national analysis of patients with stage IV cM1b-c NSCLC presenting with synchronous limited metastatic disease involving only the brain and who received brain SRS or neurosurgical resection, multimodal therapy that included primary site thoracic surgical resection (“Thoracic Surgery”) was associated with better overall survival than systemic therapy with or without radiation (“No Thoracic Surgery”). Accounting for potential underlying bias in the selection of patients who underwent

Conclusions

In this national analysis, patients with stage IV cM1b-c NSCLC presenting as a primary tumor with synchronous limited metastatic disease involving only the brain who underwent metastatic treatment with SRS or neurosurgical resection had better overall survival after multimodal therapy that included primary site resection compared with systemic therapy with or without radiation without surgery. Primary site resection was associated with improved overall survival after multivariable-adjusted Cox

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