Lung Cancer with Unexpected Localized Pleural Dissemination Detected during Surgery: Should We Stop Surgery or Should We Go On?

Therapeutic decisions are made after clinical staging procedures. Surgical resection is the preferred treatment of choice for patients with non–small cell lung cancer (NSCLC) at early stages and in case of resectable extensions (e.g., chest wall, proximal airway, mediastinum; cT3–4, cN0–1).[1] In general, systemic chemotherapy is considered standard of care for metastatic stage IV disease. However, limited and resectable metastatic pleural extension (stage IVa) might be found at the time of surgery despite the presurgical diagnostic imaging studies.

Should one carry on when everyone else stops at stage IVa NSCLC?

This contrary practice could be driven by the feeling of a need to “do something.” However, there is no evidence-based consensus about the treatment of lung cancer with unexpected localized pleural dissemination detected during surgery due to the lack of prospective randomized trials in multicenter settings.

Yun and colleagues “did something.”[2]

This article presents a single-institution, retrospective study of perioperative outcomes in NSCLC patients with unexpected localized pleural dissemination detected during surgery. Pulmonary resection and pleurectomy were associated with prolonged overall survival and progression-free survival compared with patients undergoing exploratory thoracotomy only. One interesting finding is the prolonged 5-year survival rate. Patients undergoing resection had 5-year survival of 42.7%. Five-year survival was as high as only 15.2% in the exploration group. At stage IVa NSCLC, median survival and 5-year survival rates are reported to be 5 to 8 months and 2 to 4%, respectively.[3] [4] In general, the results of the study underscore the improvements in standard of care due to safe surgery with low morbidity and mortality, different effective chemotherapy regimens, epidermal growth factor receptor (EGFR) - tyrosine kinase inhibitors (TKIs) therapy in patients with activating EGFR mutations, crizotinib therapy for patients with anaplastic lymphoma kinase (ALK) rearrangement and different maintenance treatment options, respectively.[5]

Do exceptions confirm the rule here? This does not seem to be the case. More and more studies have reported similar results.[6] [7] [8] Thus, the take-home message of this study could be that macroscopic complete resection might be a treatment option in lung cancer patients with unexpected localized pleural dissemination detected during surgery in carefully selected cases. However, we would need prospective randomized trials to confirm this theory. It is time for evidence!

• References

• 1 Ettinger DS, Wood DE, Akerley W. , et al. Non-small cell lung cancer, version 6.2015. J Natl Compr Canc Netw 2015; 13 (05) 515-524
• 2 Yun JK, Kim HR, Kim MA. , et al. Surgical outcomes after pulmonary resection for non-small cell lung cancer with localized pleural seeding first detected during surgery. Thorac Cardiovasc Surg 2018; 66 (02) 142-149
• 3 Postmus PE, Brambilla E, Chansky K. , et al; International Association for the Study of Lung Cancer International Staging Committee; Cancer Research and Biostatistics; Observers to the Committee; Participating Institutions. The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer. J Thorac Oncol 2007; 2 (08) 686-693
• 4 Ou SH, Zell JA. Validation study of the proposed IASLC staging revisions of the T4 and M non-small cell lung cancer descriptors using data from 23,583 patients in the California Cancer Registry. J Thorac Oncol 2008; 3 (03) 216-227
• 5 Reck M, Popat S, Reinmuth N, De Ruysscher D, Kerr KM, Peters S. ; ESMO Guidelines Working Group. Metastatic non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 (Suppl. 03) iii27-iii39
• 6 Okamoto T, Iwata T, Mizobuchi T. , et al. Pulmonary resection for lung cancer with malignant pleural disease first detected at thoracotomy. Eur J Cardiothorac Surg 2012; 41 (01) 25-30
• 7 Liu T, Liu H, Wang G, Zhang C, Liu B. Survival of M1a non-small cell lung cancer treated surgically: a retrospective single-center study. Thorac Cardiovasc Surg 2015; (e-pub ahead of print). DOI: doi:10.1055/s-0034-1396666.
• 8 Iida T, Shiba M, Yoshino I. , et al; Japanese Joint Committee of Lung Cancer Registry. Surgical intervention for non-small-cell lung cancer patients with pleural carcinomatosis: results from the Japanese Lung Cancer Registry in 2004. J Thorac Oncol 2015; 10 (07) 1076-1082