radiation versus surgery in possible "oligometastatic" disease - 1267341

Previously, surgery was the only way such patients were treated if it was felt that cure might be feasible. That's still the approach that has the greater history, but in the past few years, there has been a lot more research showing the feasibility of treating a solitary lung lesion, particularly a small one (<2-3 cm or so), with focal radiation. Surgery tends to perform a little bit better in comparable patient populations (really a rather slight difference), but it's hard to tell, because many patients who don't pursue surgery have other medical problems that are as likely to limit the survival of these patients as the lung cancer does.

However, this work has all been in patients with early stage disease, not "precocious metastatic" or "oligometastatic" disease, which is likely to be affected more by risk of distant disease and less by local disease control. In this situation, good radiation may be every bit as good as surgery at treating the local area sufficiently, with potentially fewer adverse effects.

This means that there's no clear answer and that either approach may do the job effectively.

Good luck.

-Dr. West

Previously, surgery was the only way such patients were treated if it was felt that cure might be feasible. That's still the approach that has the greater history, but in the past few years, there has been a lot more research showing the feasibility of treating a solitary lung lesion, particularly a small one (<2-3 cm or so), with focal radiation. Surgery tends to perform a little bit better in comparable patient populations (really a rather slight difference), but it's hard to tell, because many patients who don't pursue surgery have other medical problems that are as likely to limit the survival of these patients as the lung cancer does.

However, this work has all been in patients with early stage disease, not "precocious metastatic" or "oligometastatic" disease, which is likely to be affected more by risk of distant disease and less by local disease control. In this situation, good radiation may be every bit as good as surgery at treating the local area sufficiently, with potentially fewer adverse effects.

This means that there's no clear answer and that either approach may do the job effectively.

Good luck.

-Dr. West

It's not a silly question -- it's an open question, and still a somewhat controversial one, because there's really no "evidence" to inform the issue. However, I consider oligometastatic disease/precocious metastatic disease to be a situation that is really akin to a very high risk early stage NSCLC. Adjuvant therapy is really given to reduce the risk of recurrence by attempting to kill any stray cancer cells that may be circulating after surgery. We see that the higher the risk of recurrence, the greater the benefit of adjuvant chemotherapy. Therefore, I personally advocate for chemotherapy in this setting.

It's reasonable to do it prior to surgery or radiation rather than after, since this also gives time for the cancer to "declare itself" if it is actually destined to progress over the first few months. Though that's never welcome, it's better to learn this before a patient undergoes a challenging treatment that may prove to be futile if it's destined to spread more extensively.

Good luck.

-Dr. West

Hi ocean,

I think the question of whether this is a "high risk" situation has less to do with whether the lung lesion was active and more to do with the probability that the lung cancer has entered the bloodstream, as evidenced by the existence of the brain lesion. I'm not sure what his doctors mean if they are saying they're not sure if the brain and lung lesions are connected, except that without surgically removing the brain lesion there is no opportunity for pathology on that lesion to prove the relationship. But in any event that is normally not done; it is usually presumed that in the setting of a diagnosed lung cancer, a brain lesion represents a metastasis from that cancer.

Viewing it in that way, it would still be a high risk situation and as Dr. West stated earlier in this thread, he would usually advocate for adjuvant chemotherapy in an effort to eradicate any other cancer cells present in the bloodstream.

JimC
Forum moderator

I wouldn't want to be too heavy-handed in my comments, since it's fair to say that there is no good evidence to speak to this issue. It is really based on extrapolation of the evidence we do have.

As Jim suggested, my thoughts on the matter are informed by the presence of a metastasis. In my mind, it's hard to wave off a primary tumor as "not very active" and not threatening enough to warrant adjuvant chemo based on it being small -- if it were truly not that active, there wouldn't be a brain metastasis. Moreover, this situation isn't the same as a small chest tumor and no metastases -- this is technically stage IV, not stage I disease, so I wouldn't approach this focused too much on the evidence in patients with stage I resected lung cancer.

That said, I do think it is very appropriate to consider the individual features of any case, there is definitely room for debate here, and I don't have all of the details as if he were one of my patients, so I wouldn't want to force the issue by my more general considerations. I think that no further treatment is certainly a defensible recommendation.

Good luck.

-Dr. West

The studies that have proven a value for post-operative chemotherapy gave it within 5-7 weeks after surgery, so we generally feel that the opportunity to mop up any stray cancer cells before they "take hold" and become an incurable focus of visible disease on scans. There's nothing magical about a time point of 7 weeks, and I think most oncologists would be fine with starting chemo 8 or maybe even 9-10 weeks after surgery. Beyond 10-12 weeks, however, there's a real risk that the window of opportunity will be missed, at least based on the theoretical reason for why we recommend adjuvant/post-operative therapy.

-Dr. West