Prognostic molecular assay might improve identification of patients at risk for recurrence in early-stage non-small-cell lung cancer.

INTRODUCTION: Adjuvant chemotherapy improves survival for some patients with NSCLC and is recommended in NCCN guidelines for stage Ib to IIa patients with certain "high-risk" characteristics. An internationally validated, 14-gene expression assay has been shown to better stratify mortality risk in nonsquamous NSCLC than either conventional staging or these high risk clinicopathologic features. PATIENTS AND METHODS: A blinded chart review of 52 patients with prospective molecular risk stratification using the 14-gene test compared recurrence outcomes with a mean follow-up of 15.2 ± 11.7 months of patients with high- or low-risk determined according to either NCCN criteria or the molecular assay. RESULTS: Molecular risk assessment was discordant from NCCN criteria in 14 of 23 patients in stages Ib and IIa (61%). Recurrence was not observed among any of 31 molecular intermediate- or low-risk patients, including 10 NCCN high-risk patients, whereas 2 of 6 recurrences (33%) occurred among NCCN low-risk patients. Recurrences in stages I or IIa were seen in 2 of 18 NCCN high-risk patients (11%; both were stage IIa and both received a high-risk molecular designation), and in 4 of 18 patients (22%) with a high-risk molecular score, including 1 stage Ia and 1 stage Ib patient. CONCLUSION: This small cohort study suggests that a 14-gene prognostic assay more accurately stratifies risk among early-stage NSCLC patients than current NCCN criteria. NCCN guidelines already advocate risk stratification within tumor, node, metastases stages. This molecular assay has clinical utility in better identifying high-risk patients and might improve NCCN adjuvant chemotherapy recommendations.

Divergent management strategies for typical versus atypical carcinoid tumors of the thoracic cavity.

OBJECTIVES: At our institution, limited surgical techniques are reserved only for suspected typical carcinoids, and nodal dissection and multimodality therapy are frequently used for atypical carcinoids. We describe the results of these differing management strategies based on initial clinicopathologic characteristics. METHODS: Retrospective review of patients treated for thoracic carcinoid from 1995 to 2009. Information was abstracted concerning surgical and nonsurgical treatments, pathology results, and outcomes. Event-free and survival endpoints were compared. RESULTS: The median follow-up was 5.0 years (range, 0.5 to 17.4 y). Fifty-two patients underwent resection. The 5-year event-free survival for typical carcinoid patients was 88.2%. Atypical carcinoids had a tendency for nodal involvement (50% vs. 15%) and greater likelihood for disease recurrence, with a 5-year event-free survival of 50%. CONCLUSIONS: These data support the appropriateness of divergent management strategies for typical versus atypical bronchial carcinoids. We propose the following: (1) nonanatomic resection is acceptable only for peripheral typical carcinoids; (2) extended mediastinal dissection should be limited to central presentations, clinically aggressive, or atypical carcinoids; (3) atypical histology, especially with nodal involvement, is prognostic for recurrence and metastasis; (4) nonsurgical therapies only rarely achieve long-term freedom from disease.