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C S Pramesh

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    MS11 - Addressing Challenges with Surgical Resection of Lung Cancer (ID 74)

    • Event: WCLC 2019
    • Type: Mini Symposium
    • Track: Treatment in the Real World - Support, Survivorship, Systems Research
    • Presentations: 1
    • Now Available
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      MS11.02 - Role of Surgery in Oligometastatic NSCLC (Now Available) (ID 3501)

      15:45 - 17:30  |  Presenting Author(s): C S Pramesh

      • Abstract
      • Presentation
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      Role of Surgery in Oligometastatic NSCLC

      The management of oligometastatic non-small cell lung cancer (NSCLC) is controversial. Sixty percent of patients with NSCLC present with metastatic disease; 45% of those with initially localized disease eventually develop metastatic disease. With 15% of these being oligometastatic disease, this is a significant problem. Over the last two decades, several advances have occurred which frame this question better. First, advances in imaging techniques including improved PET-CT and MRI have helped identify what is likely to be truly oligometastatic disease. Second, there have been advances in local therapy including minimally invasive and robotic approaches and perioperative management, as well as advanced radiation techniques including stereotactic ablative radiotherapy (SABR) which have made it safer. Finally, systemic therapy has undergone major changes with targeted therapy and immunotherapy making considerable progress. Most patients with metastatic NSCLC would be treated with systemic therapy with local treatment being offered only for symptomatic palliation. However, recognition of a “oligometastatic” state (where metastases are limited in number and location) has led to series of patients being treated with potentially curative intent using local treatment options, predominantly surgical.

      Randomized trials to evaluate the role of surgery in oligometastatic NSCLC have not been performed, compelling a reliance on several published case series and meta analysis of these studies. These series have included highly selected patients with oligometastases, typically 1-3 metastases, most commonly located in the brain, and long term outcomes have been highly variable. Overall median five year survival of a meta analysis of studies was 23.3 percent. Five year survivals in patients treated with surgery both for the primary and the metastases range from as low as <10% to as high as 80% - this wide range is more likely a reflection of selection criteria for patients undergoing surgery rather than true variations in care. Moreover, with the lack of a true comparator arm, these results should be interpreted with caution. Important favourable prognostic factors include definitive treatment of the primary tumour, negative mediastinal nodal status and a longer disease-free interval.

      Lack of well conducted prospective studies make conclusive recommendations on surgery for treatment of oligometastatic disease difficult. This is especially true now when better radiation techniques like SABR and improved outcomes with systemic treatment in selected patients with targeted and immunotherapy are available. Given the available evidence, it appears reasonable to consider surgical treatment in patients with oligometastatic disease fulfilling the following criteria: good performance status, accurately staged, with PET-CT and MRI brain showing no other sites of metastases, metachronous disease with relatively long disease free interval, negative mediastinal nodes on invasive staging, and controlled primary disease. With randomized trials being unlikely in this setting, further studies are required which prospectively collect real-world data systematically, enabling better selection criteria for patients for surgery in oligometastatic NSCLC.

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