treatment of stage 4 NSCLC with solitary mets can be curative intent
- related: lung mass and cancer
- tags: #literature #pulmonology
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With the testing described, this patient presents with a T1bN0M1b, stage IVA adenocarcinoma of the lung, based on a single metastatic site in the left adrenal gland. With a single metastasis to the brain or adrenal gland, curative intent resection followed by adjuvant chemotherapy should be considered. This treatment paradigm applies only when there is no evidence of regional metastases to the mediastinal lymph nodes. Despite the absence of regional spread on imaging tests, it is recommended that staging with invasive endobronchial ultrasound (EBUS) guided bronchoscopic or mediastinoscopy of the mediastinum be performed prior to deciding on a treatment plan. Curative intent resection would not be recommended if hilar or mediastinal lymph node involvement is proven. Platinum doublet chemotherapy plus an immune checkpoint inhibitor would be considered standard of care for those with multiple metastases, no targetable driver mutations, and PDL-1 staining in <50% of cancer cells. Alectinib is appropriate first-line treatment for lung cancer with an identified anaplastic lymphoma kinase mutation.
A minority of patients with stage IV non-small cell lung cancer present with a solitary metastasis. These patients have an overall better survival than patients with multiple metastases in one or several organs, and similar survival to those with metastases within the thorax. For this reason, the current staging classification has separated M descriptors to include M1a (metastases within the thorax), M1b (a single metastasis in a single organ), and M1c (multiple metastases in one or several organs). Those with M1a or M1b are grouped as a stage IVA and those with M1c are stage IVB. The improved survival and smaller metastatic burden suggest the pathobiology of these tumors is less aggressive than that of those presenting with multiple metastases, and aggressive treatment, with curative intent, could be considered in select patients. Both synchronous and metachronous presentations may be treated with curative intent.
The evidence to support curative intent treatment in otherwise healthy individuals with lung cancer and a single site of metastasis is weak, consisting mainly of case series. The largest pool of evidence exists for isolated brain or adrenal metastases. It is critical that definitive treatment of the lung and metastatic site is feasible. For brain metastases, most reports favor no more than three brain lesions. The outcome may be better with supratentorial lesions that are <3 cm in diameter. Long-term survival of around 15% has been reported. Adjuvant whole brain radiation and adjuvant chemotherapy are suggested. Similarly, case series suggest up to 25% 5-year survival in select individuals who undergo resection of an isolated adrenal metastasis. Outcomes are poor in those with nodal involvement, and similar between those with synchronous or metachronous presentations. Adjuvant chemotherapy is suggested.
Fewer case series exist that describe curative intent treatment of synchronous or metachronous solitary metastasis to other sites. A systematic review of 62 patients, 20 with synchronous presentations, and 29 with a visceral metastasis, reported a 5-year survival of 50% overall, 0% in those with N2 or N3 disease. The paucity of data for any specific site has limited the ability to make recommendations for curative intent treatment for solitary metastases at sites other than the brain or adrenal glands.1