Surgical Management of Oligopersistent and Oligoprogressive ALK+ Lung Cancer
Following resistance to targeted treatment, oligoprogression can occur whereby a previously controlled site or sites of metastases progress after the majority of other sites of disease stabilize on systemic therapy. Interestingly, this patient developed MET amplification as the mechanisms of TKI resistance after being on alectinib therapy for more than two years.
Limited data exist on the optimal management of oligometastatic ALK-positive non-small cell lung cancer. This video presents an oncologically unique and complex case where both oligopersistent and oligoprogressive disease are managed surgically with excellent outcomes and prolonged survival. While radiation has traditionally been central to many treatment paradigms, this case demonstrates surgery can also play an important role.
The Patient
The patient is a fifty-two-year-old woman who initially presented with hemoptysis. Imaging demonstrated a PET-avid 6 cm left upper lobe mass with concern for malignancy along with uptake of contralateral mediastinal lymph nodes and a lesion in the right tenth rib. A biopsy confirmed non-small cell lung cancer with adenocarcinoma and squamous cell carcinoma components. An ALK mutation was also identified, and the patient was initiated on alectinib for IIIC/IV disease. Imaging through five months demonstrated disease response to targeted treatment with reduction in size of the primary lesion. However, disease progression of the left upper lobe primary lesion was noted at eight months.
Following multidisciplinary discussion, the decision was made to pursue surgical resection. The patient underwent thoracoscopic left upper lobectomy and pathology revealed a 3.6 cm squamous cell carcinoma with negative lymph nodes and no viable adenocarcinoma identified. The patient was continued on adjuvant alectinib therapy. Chest CT scans were negative for recurrence up to fourteen months postoperatively.
Eighteen months postoperatively, the patient was noted to have a PET-avid partially necrotic appearing right lower paratracheal node suspicious for metastasis. Review of prior imaging demonstrated presence of adenopathy in this region, which had initially responded to alectinib, but was now deemed oligoprogressive. Following multidisciplinary discussion, local therapy was deemed appropriate. Radiation would normally be considered the standard of care in this setting but given the central location of the lesion and proximity to the airway, surgical resection was again recommended.
The Surgery
Surgical access was debated, and a robotic-assisted approach was selected in consideration of the location of the lesion and exposure required to best visualize the node. Utilizing a standard five-port technique, the upper lobe was retracted inferiorly, exposing the paratracheal space where minimal adhesions were noted. As the pleura was incised, the node was encountered and noted to be adherent to the superior vena cava. The azygous vein was then resected to enhance exposure. A combination of blunt dissection and cautery were used to carefully identify the plane between the node and the SVC, allowing surgeons to circumferentially dissect out the lesion down to the level of the aorta. The lesion was safely removed in its entirety, and the patient was discharged on day one following an uneventful postoperative course.
Surgical pathology showed metastatic adenocarcinoma and molecular testing confirmed ALK fusion along with MET amplification. Following discussion with medical oncology, the patient continued on alectenib to be followed by surveillance. Imaging at two months demonstrated no evidence of disease.
