Twenty-five years of clinical research for patients with limited-stage small cell lung carcinoma in North America

Predictive value of BRCA1, ERCC1, ATP7B, PKM2, TOPOI, TOPΟ-IIA, TOPOIIB and C-MYC genes in patients with small cell lung cancer (SCLC) who received first line therapy with cisplatin and etoposide

BACKGROUND

The aim of the study was to evaluate the predictive value of genes involved in the action of cisplatin-etoposide in Small Cell Lung Cancer (SCLC).

METHODS

184 SCLC patients' primary tumour samples were analyzed for ERCCI, BRCA1, ATP7B, PKM2 TOPOI, TOPOIIA, TOPOIIB and C-MYC mRNA expression. All patients were treated with cisplatin-etoposide.

RESULTS

The patients' median age was 63 years and 120 (65%) had extended stage, 75 (41%) had increased LDH serum levels and 131 (71%) an ECOG performance status was 0-1. Patients with limited stage, whose tumours expressed high ERCC1 (p=0.028), PKM2 (p=0.046), TOPOI (p=0.008), TOPOIIA (p=0.002) and TOPOIIB (p<0.001) mRNA had a shorter Progression Free Survival (PFS). In limited stage patients, high expression of ERCC1 (p=0.014), PKM2 (p=0.026), TOPOIIA (p=0.021) and TOPOIIB (p=0.019) was correlated with decreased median overall survival (mOS) while in patients with extended stage, only high TOPOIIB expression had a negative impact on Os (p=0.035). The favorable expression signature expression signature (low expression of ERCC1, PKM2, TOPOIIA and TOPOIIB) was correlated with significantly better PFS and Os in both LS-SCLC (p<0.001 and p=0.007, respectively) and ES-SCLC (p=0.007 and (p=0.011, respectively) group. The unfavorable expression signature was an independent predictor for poor PFS (HR: 3.18; p=0.002 and HR: 3.14; p=0.021) and Os (HR: 4.35; p=0.001and HR: 3.32; p=0.019) in both limited and extended stage, respectively.

CONCLUSIONS

Single gene's expression analysis as well as the integrated analysis of ERCC1, PKM2, TOPOIIA and TOPOIIB may predict treatment outcome in patients with SCLC. These findings should be further validated in a prospective study.

Cancer stem cells in lung cancer: Evidence and controversies

The cancer stem cell (CSC) model is based on a myriad of experimental and clinical observations suggesting that the malignant phenotype is sustained by a subset of cells characterized by the capacity for self-renewal, differentiation and innate resistance to chemotherapy and radiation. CSC may be responsible for disease recurrence after definitive therapy and may therefore be functionally synonymous with minimal residual disease. Similar to other solid tumours, several putative surface markers for lung CSC have been identified, including CD133 and CD44. In addition, expression and/or activity of the cytoplasmic enzyme aldehyde dehydrogenase ALDH and capacity of cells to exclude membrane permeable dyes (known as the 'side population') correlate with stem-like function in vitro and in vivo. Embryonic stem cell pathways such as Hedgehog, Notch and WNT may also be active in lung cancers stem cells and therefore may be therapeutically targetable for maintenance therapy in patients achieving a complete response to surgery, radiotherapy or chemotherapy. This paper will review the evidence regarding the existence and function of lung CSC in the context of the experimental and clinical evidence and discuss some ongoing controversies regarding this model.

Lung cancer stigma, anxiety, depression and symptom severity

OBJECTIVES

Compared to other cancers, lung cancer patients report the highest levels of psychological distress and stigma. Few studies have examined the relationship between lung cancer stigma (LCS) and symptom burden. This study was designed to investigate the relationship between LCS, anxiety, depression and physical symptom severity.

METHODS

This study employed a cross-sectional, correlational design to recruit patients online from lung cancer websites. LCS, anxiety, depression and physical symptoms were measured by patient self-report using validated scales via the Internet. Hierarchical multiple regression was performed to investigate the individual contributions of LCS, anxiety and depression to symptom severity.

RESULTS

Patients had a mean age of 57 years; 93% were Caucasian, 79% were current or former smokers, and 74% were female. There were strong positive relationships between LCS and anxiety (r = 0.413, p < 0.001), depression (r = 0.559, p < 0.001) and total lung cancer symptom severity (r = 0.483, p < 0.001). Although its contribution was small, LCS provided a unique and significant explanation of the variance in symptom severity beyond that of age, anxiety and depression, by 1.3% (p < 0.05).

CONCLUSIONS

Because LCS is associated with psychosocial and physical health outcomes, research is needed to develop interventions to assist patients to manage LCS and to enhance their ability to communicate effectively with clinicians.

Surgical treatment of early stage small cell lung cancer

BACKGROUND

Chemotherapy with radiation has to be considered the standard therapy for limited-stage small cell lung cancer but surgical resection is possible in a small subgroup in which it may improve survival. Surgery is not recommended as the standard treatment, but a few small studies have demonstrated a benefit of surgery in highly selected cases of limited-stage small cell lung cancer.

METHODS

We conducted a retrospective study of 29 patients with limited-stage small cell lung cancer undergoing surgical resection in our department. There were 7 (24%) women and 22 (76%) men with a median age of 62 years (range, 46-82 years). Medical history, histology and survival status were extracted from the medical database of the University Medical Center Freiburg.

RESULTS

The median overall survival was 20.7 months. In 15 patients who received neoadjuvant treatment, the median survival was 89.4 months. Karnofsky performance status and neoadjuvant chemotherapy had a significant influence on median survival (p <0.0004).

CONCLUSIONS

We concluded that surgical resection can be beneficial in a highly selected group of patients as a part of a multidisciplinary approach. In addition, surgical resection is safe with acceptable mortality and morbidity.

A phase I study of amrubicin and fixed dose of irinotecan (CPT-11) in relapsed small cell lung cancer: Japan multinational trial organization LC0303

PURPOSE

To determine the maximum tolerated dose of amrubicin (AMR) with a fixed dose of irinotecan (CPT-11).

METHODS

Patients having pathologically proven small cell lung cancer (SCLC) relapsed after one or two chemotherapies, and Eastern Cooperative Oncology Group performance status of 0 to 2 were eligible for the study. CPT-11 was delivered as 50 mg/m2 on days 1 and 8, every 21 days. AMR was delivered on day 1. Doses of AMR were level 1: 80 mg/m2, level 2: 90 mg/m2, and level 3: 100 mg/m2. Dose elevation was determined using the modified continuous reassessment method. Tolerability was assessed after the first cycle. Another two cycles were conducted when disease progression or unacceptable toxicities were not observed.

RESULTS

Eighteen patients (mean age: 66.3 years) were enrolled. A total of 40 courses were conducted. Grade 3/4 toxicities of the first cycle were leukocytopenia: 11 (61%, grade 3/4: 8/3); neutropenia: 15 (83%, grade 3/4: 6/9); and thrombocytopenia: three (17%, grade 3/4: 2/1). Other grade 3 toxicities observed were febrile neutropenia, one; infection, three; diarrhea, one; and dyspnea, one. Dose-limiting toxicity was observed in two of six patients at level 2 (neutropenia and febrile neutropenia) and in one of six at level 3 (thrombocytopenia and infection). The maximum tolerated dose was level 3, and so, the recommended dose for phase II trials was judged to be 90 mg/m2. Objective response was obtained in four of eight patients who were able to evaluate responses. Median survival time was 13 months, with 68% at 1-year survival rate.

CONCLUSIONS

This combination was well tolerated and showed encouraging activities in SCLC. Randomized phase II trials are being planned in chemonaive SCLC.

A study of elderly patients with limited-stage small-cell lung cancer after combined chemoradiotherapy

In this study, we evaluated the effect of chemotherapy (CT) and thoracic radiotherapy (RT) integration and the timing of RT on survival of elderly patients with limited-stage small-cell lung cancer. Eighty patients were retrospectively analyzed. All the patients revived thoracic RT and 70 patients received ≥2 cycles of CT. Twenty-two patients received RT sequentially to CT, 19 with RT consolidated with CT, and 29 with RT concurrent with CT. Early chest irradiation was defined as beginning RT after 1-3 cycles of CT (n = 44), and late chest irradiation was defined as occurring after ≥4 cycles of CT (n = 26). Twenty-six patients (32.5%) achieved complete response, 37 (46.2%) partial response, 10 (12.5%) stable disease, and 7 (8.7%) progressive disease. The median survival time for all patients was 19 months. The 1-, 2-, and 3-year overall survival (OS) rates were 68.9%, 41.3%, and 31.7%, respectively. In univariate analyses, the volume of the primary tumor, CT, treatment modality, timing of RT, target volume, and RT dose were significantly associated with OS. At 3 years, concomitant chemoradiotherapy was superior to consolidated and sequential chemoradiotherapy (40.0% vs. 36.9% vs. 40.0%, respectively). The rate of OS at 3 years was 37.1% for patients receiving early-RT and 27.8% for those receiving late-RT (P = 0.006). Multivariate analysis showed that CT and RT dose were independent factors influencing OS. Concurrent chemoradiotherapy resulted in a high survival rate. A radiation dose-response relationship was observed, and a dose of at least 60-Gy daily radiation demonstrated improved survival.

Combination of HDAC and topoisomerase inhibitors in small cell lung cancer

Histone deacetylase (HDAC) inhibitors, including MGCD0103 and vorinostat, have led to tumor growth inhibition and apoptosis in vivo. However, with limited single-agent activity demonstrated in solid tumor trials, we examined the potential for enhanced effects in combination with topoisomerase I and II inhibitors, a staple for treatment in refractory small cell lung cancer (SCLC). SCLC cell lines were exposed to increasing concentrations of single-agent HDAC inhibitors and topoisomerase inhibitors, in various combinations, to assess for cell viability, additivity or synergy, and apoptosis. We found that MGCD0103 and vorinostat decreased cell viability by at least 60% and 80%, respectively. In the majority of cell lines, the strongest synergism was seen when vorinostat was followed by either etoposide or topotecan; concurrent therapy led to antagonism in most cell lines. Synergistic effects were seen when MGCD0103 was given concurrently or sequentially with both amrubicin and epirubicin. Enhanced additive effects leading to caspase activation were noted for the combination of MGCD0103 or vorinostat with a topoisomerase inhibitor vs. either agent alone. Thus, the combination of HDAC inhibitors and topoisomerase inhibitors showed enhanced cytotoxic effects in SCLC cell lines. Further evaluation in a clinical setting may be warranted.

Effect of cigarette smoking on quality of life in small cell lung cancer patients

BACKGROUND

Continued cigarette smoking after small cell lung cancer (SCLC) diagnosis has been shown to shorten patients' survival, but little is known about the impact of smoking and cessation on quality of life (QOL) profile (e.g., overall QOL, pain, fatigue, cough, dyspnea, appetite change, and performance status) in SCLC survivors (who survived at least 6 months post initial diagnosis). In this study, we sought to evaluate the relationship between cigarette smoking and QOL profiles in SCLC patients.

METHODS

A total of 223 survivors were classified into five groups: never smokers, former smokers (quit more than 1 year prior to diagnosis), recent quitters (quit within 1 year surrounding diagnosis), late quitters (quit after 1 year post diagnosis) and never quitters. One hundred and sixty-eight of these survivors were matched with 334 lung-cancer-free controls on age, gender, and smoking status for comparative analysis. QOL scales were scored from 0 (worse) to 100 (best). Conditional logistic regression, linear mixed-effect models, and Wilcoxon signed rank tests were used.

RESULTS

SCLC survivors consistently showed a significant deficit in QOL profile; e.g., mean overall QOL in patients was 17.5 points worse than the controls (p<0.0001). Among all smokers, former smokers reported the best QOL profile, while late or never quitters reported the worst. The recent quitters showed an improving trend in QOL profile and lower percent of reduced appetite (an average of 43%) compared to the late or never quitters (58%).

CONCLUSIONS

Our study confirmed the negative impact of smoking on SCLC survivors' QOL and found that smoking cessation surrounding the time of diagnosis could improve overall QOL and symptoms. The findings of this study provide evidence for oncologists to recommend smoking cessation to their SCLC patients.

Notch signaling in lung cancer

Lung cancer is the leading cause of cancer-related deaths in the Western world. The lungs can be affected by a number of histologically diverse malignancies. Nonetheless, the vast majority of lung cancers are classified as non-small-cell lung cancer (NSCLC). Despite extensive research on different therapeutic regimens, the overall 5-year survival of patients diagnosed with NSCLC (all stages) is a dismal 15%. Although strongly correlated with tobacco smoke, there is an increasing NSCLC morbidity in individuals who have never smoked. The pattern of genetic lesions found in NSCLC derived from smokers and never-smokers appears to be different. This fact led to the hypothesis that different, still unidentified carcinogens are responsible for lung cancer onset in never-smokers. All the aforementioned considerations compel the scientific community to find novel therapeutic targets to fight such a deadly disease. In recent years critical pathways governing embryonic development have been increasingly linked to cancer. Here we will focus on the role of Notch signaling in lung cancer. Notch receptors' activity can be blocked through the use of different strategies, thus representing a promising alternative/complement to the arsenal of therapeutic strategies currently used to treat lung cancer.

Lung cancer stigma, depression, and quality of life among ever and never smokers

PURPOSE

In 2010, lung cancer is expected to be the leading cause of cancer death in both men and women. Because survival rates are increasing, an evaluation of the effects of treatment on quality of life (QOL) is an important outcome measure. In other diseases, stigma is known to have a negative impact on health status and QOL and be amenable to intervention. This is the first study to compare levels of lung cancer stigma (LCS) and relationships between LCS, depression, and QOL in ever and never smokers.

METHOD

A total of 192 participants with a self-report diagnosis of lung cancer completed questionnaires online.

RESULTS

Strong associations in the expected directions, were found between LCS and depression (r = 0.68, p < 0.001) and QOL (r = -0.65, p < 0.001). No significant differences were found in demographic characteristics or study variables between ever smokers and never smokers. A simultaneous multiple regression with 5 independent variables revealed an overall model that explained 62.5% of the total variance of QOL (F5,168 = 56.015, P < 0.001).

CONCLUSIONS

After removing age, gender, and smoking status, depression explained 22.5% of the total variance of QOL (F4,168 = 100.661, p < 0.001). It is expected that depression and LCS would share some of the explanation of the variance of QOL, the correlation between LCS and depression is 0.629 (p < 0.001), however, LCS provides a unique and significant explanation of the variance of QOL over and above that of depression, age, gender, and smoking status, by 2.1% (p < 0.001).

Update on new drugs in small cell lung cancer

INTRODUCTION

Small cell lung cancer (SCLC) will account for 25,000 to 32,000 new lung cancer cases in the USA in 2010. Current treatmenta pproaches include platinum-based chemotherapy and etoposide with or without radiation therapy depending on stage and performance status. Five-year survival is approximately 25% for patients with limited stage disease and 1 -- 2% for patients with extensive stage disease and has noti mproved in almost two decades.

AREAS COVERED

This article reviews the results of recent clinical trials that have evaluated targeted agents and novel cytotoxic agents alone or in combination with standard chemotherapy in the treatment of patients with SCLC.

EXPERT OPINION

The lack of a targeted approach to the treatment of patients with SCLC has led investigators to evaluate a multitude of agents with overwhelmingly negative results. A more systematic approach to clinical trials in patients is needed to improve outcomes for patients with this disease.

Novel strategies for the treatment of small-cell lung carcinoma

Small-cell lung cancer (SCLC) is a disease with a poor prognosis and limited treatment options. Over the past 30 years, basic and clinical research have translated to little innovation in the treatment of this disease. The Study of Picoplatin Efficacy After Relapse (SPEAR) evaluated best supportive care with or without picoplatin for second-line SCLC treatment and failed to meet its primary end point of overall survival. As the largest second-line, randomized study in patients with SCLC, SPEAR provides an opportunity to critically examine the drug development model in this disease. In this Review, we discuss the current standard approach for the management of SCLC that progresses after first-line therapy, analyze the preliminary data that supported the evaluation of picoplatin in this setting, and critically evaluate the SPEAR trial design and results. Lastly, we present advances in the understanding of the molecular biology of SCLC that could potentially inform future clinical trials and hopefully lead to the successful development of molecular targeted agents for the treatment of this disease.

Klotho predicts good clinical outcome in patients with limited-disease small cell lung cancer who received surgery

BACKGROUND

The important role of surgery in early-stage small cell lung cancer (SCLC) has been recognized, and curative surgical resection is recommended. However, the role of adjuvant chemotherapy for stage I SCLC has not yet been evaluated, and novel approaches focusing on the specific genomic characteristics of SCLC may be invaluable for customized therapy. In this study, we focused on the Klotho gene, which is an anti-aging gene known to be a potential tumor suppressor. We investigated whether the expression of Klotho, assessed by immunohistochemistry, can predict survival in patients with resected SCLC.

METHODS

The medical records of patients diagnosed as having limited-disease (LD) SCLC and treated by surgical resection (n=30) at Tokyo Medical University Hospital were retrospectively reviewed. The expression status of Klotho, and of the ATP-binding cassette (ABC) transporters MRP1, MDR and breast cancer resistant protein (BCRP), which can cause resistance to anticancer drugs, including irinotecan, was assessed by immunohistochemical analysis in resected surgical specimens of patients with early-stage SCLC.

RESULTS

Of the 30 patients, Klotho expression was seen in the specimens from 18 patients (60.0%), but not in those of the remaining 12 patients (40.0%). The immunostaining for Klotho was mostly localized in the cytoplasm. The expression of Klotho was significantly associated with the overall survival (OS) (ratio 0.088; 95% confidence interval 0.019-0.409; P=0.002). The administration of perioperative chemotherapy had no significant effect in improving the survival, as assessed by the Kaplan-Meier method. However, the patients showing Klotho expression in the resected specimens in p-stage I and II, may have benefited from perioperative chemotherapy. A multivariate analysis revealed no significant association between the expression status of MRP1, MDR or BCRP and the OS.

CONCLUSION

Expression of Klotho was predictive of a favorable outcome following resection in limited-disease SCLC patients, and the Klotho expression status may serve as a new biomarker for the need of additional therapies to be developed in the future.

Neoplastic pericardial disease in lung cancer: impact on outcomes of different treatment strategies. A multicenter study

BACKGROUND

Local (intrapericardial) chemotherapy has been reported to be useful for the treatment of neoplastic pericardial disease, but it has never been compared to systemic chemotherapy, a combination of the two and simple pericardial drainage or sclerosis.

METHODS

We analyzed the clinical and echocardiographic data of 119 patients, suffering of neoplastic pericarditis due to lung cancer (97 with non-small-cell), comparing the outcomes of four different treatment strategies (extended catheter drainage/sclerosis, systemic chemotherapy, local chemotherapy, and combined - local plus systemic - chemotherapy) at the last available follow-up or at the change of therapy after a treatment failure. The outcomes (based on semiquantitative evaluation of pericardial disease) were classified as complete, partial, no response and progressing disease.

RESULTS

A complete response was achieved in 37/53 of patients with combined, in 12/22 with local, in 5/27 with systemic chemotherapy, respectively, and in 4/17 after drainage/sclerosis (p<0.001). Overall response was achieved in 51/53 with combined, 18/22 and 16/27 with local or systemic chemotherapy, respectively, and in 5/17 with drainage/sclerosis only (p<0.001). Survival was significantly better after combined chemotherapy (p<0.001) and 12/53 patients (23%) in this subgroup survived more than 1 year. The overall response rate was higher with intrapericardial cisplatinum than with other agents (98% vs 80%, χ(2)=7.69, p<0.01).

CONCLUSIONS

Local chemotherapy, alone or with systemic chemotherapy, is effective in treating pericardial metastases from lung carcinoma, leading to a good control of pericardial effusion in 92% of cases, and to complete disappearance of effusion and masses in 65%. Combined therapy is significantly better than any other treatment. Pericardiocentesis and intrapericardial chemotherapy should be used whenever possible in lung cancer neoplastic pericardial disease, not only in case of tamponade.

Features of potentially predictive biomarkers of chemotherapeutic efficacy in small cell lung cancer

INTRODUCTION

One-size-fits-all chemotherapy does not improve survival in patients with small cell lung cancer (SCLC). Excision repair cross-complementing group 1 (ERCC1), ribonucleotide reductase 1 (RRM1), thymidylate synthase (TS), and topoisomerase 2alpha (Topo2alpha) expression levels are predictive of chemotherapeutic efficacy in some malignancies. Our aim was to determine the expression levels of these proteins to assess their potential clinical utility in SCLC.

METHODS

We used an immunofluorescence-based automated quantitative technique to score RRM1, ERCC1, TS, and Topo2alpha levels in tumor specimens from 100 patients with SCLC and immunohistochemistry to semiquantitatively score levels of TS, 5-phosphoribosyl-glycinamide formyl-transferase, and folyl-polyglutamate synthase expression. Confocal microscopy was used for subcellular localization in SCLC cells.

RESULTS

RRM1, ERCC1, and Topo2alpha staining was predominantly nuclear and TS mainly cytoplasmic. Using immunohistochemistry, we found that TS (antibody 106) and TS (antibody 4H4) scores were strongly correlated (r = 0.82, p < 0.0001). By automated quantitative technique, RRM1 and Topo2alpha levels were highly correlated (r = 0.56, p < 0.0001). ERCC1 and TS levels had a narrow and low range of expression. There was no correlation between any of these biomarkers and patients' age or sex.

CONCLUSION

Considering this clinical evidence, expression levels of RRM1 and Topo2alpha may have utility for chemotherapy customization. Clinical validation of their predictive power is desirable in a prospective clinical trial.

The IASLC Lung Cancer Staging Project: proposals regarding the relevance of TNM in the pathologic staging of small cell lung cancer in the forthcoming (seventh) edition of the TNM classification for lung cancer

INTRODUCTION

For more than 50 years, small cell lung cancer (SCLC) has been staged mainly as either limited or extensive stage disease. Small published series of resected SCLC have suggested that the tumor, node, metastases (TNM) pathologic staging correlates with the survival of resected patients. Recent analysis of the 8088 cases of SCLC in the International Association for the Study of Lung Cancer (IASLC) database demonstrated the usefulness of clinical TNM staging in this malignancy. The IASLC data bank contains an unprecedented number of resected SCLC cases with pathologic staging information. This analysis was undertaken to examine the impact of the TNM system on the pathologic staging of SCLC and to assess the new IASLC proposals in this subtype of lung cancer.

METHODS

Using the IASLC database, survival analyses were performed for resected patients with SCLC. Prognostic groups were compared, and the new IASLC TNM proposals were applied to this population and to the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

The IASLC database contained 349 cases of resected SCLC where pathologic TNM staging was available. Survival after resection correlated with both T and N category with nodal status having a stronger influence on survival. Stage groupings using the 6th edition of TNM clearly identify patient subgroups with different prognoses. The IASLC proposals for the 7th edition of TNM classification also apply to this population and to the SEER database.

CONCLUSION

This analysis further strengthens our previous recommendation to use TNM staging for all SCLC cases.

Accelerated hyperfractionated radiotherapy and concomitant chemotherapy in small cell lung cancer limited-disease. Dose response, feasibility and outcome for patients treated in western Sweden, 1998-2004

Addition of thoracic radiation therapy (TRT) to chemotherapy (CHT) can increase overall survival in patients with small cell lung cancer limited-disease (SCLC-LD). Accelerated fractionation and early concurrent platinum-based CHT, in combination with prophylactic cranial irradiation, represent up-front treatment for this group of patients. Optimised and tailored local and systemic treatment is important. These concepts were applied when a new regional treatment programme was designed at Sahlgrenska University Hospital in 1997. The planned treatment consisted of six courses of CHT (carboplatin/etoposide) + TRT +/- prophylactic cranial irradiation (PCI). Standard TRT was prescribed at 1.5 Gy BID to a total of 60 Gy during 4 weeks, starting concomitantly with the second or third course of CHT. However, patients with large tumour burdens, poor general condition and/or poor lung function received 45 Gy, 1.5 Gy BID, during 3 weeks. PCI in 15 fractions to a total dose of 30 Gy was administered to all patients with complete remission (CR) and "good" partial remission (PR) at response evaluation. Eighty consecutive patients were treated between January 1998 and December 2004. Forty-six patients were given 60 Gy and 34 patients 45 Gy. Acute toxicity occurred as esophagitis grade III (RTOG/EORTC) in 16% and as pneumonitis grade I-II in 10%. There were no differences in toxicity between the two groups. Three- and five-year overall survival was 25% and 16%, respectively. Medica survival was 20.8 months with no significant difference between the two groups. In conclusion, TRT with a total dose of 60 to 45 Gy is feasible with comparable toxicity and no difference in local control or survival. Distant metastasis is the main cause of death in this disease; the future challenge is thus further improvement of the systemic therapy combines with optimised local TRT.

Prognostic factors for limited-stage small cell lung cancer: a study of 284 patients

Combined modality therapy is the standard care for limited stage-small cell lung cancer (LS-SCLC) and has led to a significant improvement in patients' survival. This study sought to investigate and define the importance of prognostic effects of known and controversial factors especially the impact of smoking status and treatment strategies. A total of 284 patients with LS-SCLC were diagnosed and prospectively followed from 1997 to 2008 at Mayo Clinic; their characteristics and survival outcome were assessed on the basis of age, gender, smoking history, performance status (PS), tumor recurrence or progression, and treatment using Cox proportional hazards models. Our main results are as follows: (1) Although neither smoking status (former or current smokers) nor intensity (pack-years smoked) at the time of SCLC diagnosis were significant survival predictors, compared to continued smokers (who never quit smoking), patients who quit at or after diagnosis cut the risk of death by 45% (HR=0.55, 95% CI 0.38-0.79); patients who quit before lung cancer diagnosis also experienced survival benefit (HR=0.72, 95% CI 0.52-1.00). (2) Thoracic radiotherapy and platinum-based chemotherapy could significantly improve survival but the timing (within or after one month of diagnosis) of starting chemotherapy or radiation therapy did not. (3) After adjusting for other known factors, a lower PS did not predict poorer survival, suggesting that PS should not be the only factor for making treatment decisions. In conclusion, this study demonstrated the negative impact of continued cigarette smoking on survival; therefore, clinicians and all care providers should strongly encourage smoking cessation at diagnosis of LS-SCLC.

Metastasis: from dissemination to organ-specific colonization

Metastasis to distant organs is an ominous feature of most malignant tumours but the natural history of this process varies in different cancers. The cellular origin, intrinsic properties of the tumour, tissue affinities and circulation patterns determine not only the sites of tumour spread, but also the temporal course and severity of metastasis to vital organs. Striking disparities in the natural progression of different cancers raise important questions about the evolution of metastatic traits, the genetic determinants of these properties and the mechanisms that lead to the selection of metastatic cells.

Small-Cell Lung Cancer: An Unusual Therapeutic Approach with More than 10-year Overall Survival. Case Report and Review of the Literature

Small-cell lung cancer is the most aggressive lung cancer, with a dismal prognosis. The authors present a case report of a patient with limited-stage small-cell lung cancer who underwent a thoracotomy for diagnostic purposes, with the diagnosis being made after surgical excision. Combination chemotherapy remains the cornerstone of treatment for both limited and extensive disease. Radiotherapy has been established as an adjunct to chemotherapy in limited-stage disease, while in extensive-stage disease it is mostly reserved for the treatment of brain metastases. As for surgery, the potential benefits of resection are predominantly seen in patients who present with a solitary pulmonary nodule. Since small-cell lung cancer becomes highly resistant to chemotherapy, second-line chemotherapeutic schemes are used for disease progression, with topotecan being the highlighted agent. Despite the unusual therapeutic approach, where surgery was preferred over the standard diagnostic and staging procedures, the patient's more than ten years’ survival makes this case presentation a very interesting one.

The International Association for the Study of Lung Cancer lung cancer staging project: proposals regarding the clinical staging of small cell lung cancer in the forthcoming (seventh) edition of the tumor, node, metastasis classification for lung cancer

BACKGROUND

Small cell lung cancer (SCLC) is usually classified using the limited and extensive definition. The tumor, node, metastasis (TNM) classification should also be applicable to SCLC, but it has only been reported in small surgical series. The current analysis looks to the impact of the TNM system on the clinical staging of SCLC and of the new International Association for the study of Lung Cancer (IASLC) proposals.

METHODS

Using the IASLC database, survival analyses were performed for clinically staged patients. Prognostic groups were compared, and the new IASLC TNM proposals were applied to this population and to the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

The IASLC database contained 12,620 eligible cases of small cell histology. TNM staging was available for 8088 patients. Survival was directly correlated to both T and N category. Differences were more pronounced in patients without mediastinal or supraclavicular nodal involvement. Stage grouping using the sixth edition of TNM also differentiates survival except between IA and IB. Patients with pleural effusion regardless of the cytology have an intermediate prognosis between limited and extensive disease. The IASLC proposals for the seventh edition of the TNM classification also apply to this series of SCLC and to the SEER database.

CONCLUSION

TNM staging is recommended for SCLC, and stratification by stage I-III should be incorporated in clinical trials of early-stage disease. Further studies are needed to clarify the impact of pleural effusion and the extent of N3 disease.

Small cell lung cancer: have we made any progress over the last 25 years?

Twenty-five years ago, small cell lung cancer was widely considered to be the next cancer added to the list of "curable cancers." This article attempts to summarize the progress made toward that goal since then. Clinical trials have provided landmarks in the therapy of limited-stage small cell lung cancer (LS-SCLC). These are: (a) the proof that thoracic radiation therapy adds to systemic chemotherapy, (b) the superiority of twice-daily radiation therapy over daily fractionation, and (c) the need for prophylactic central nervous system radiation (prophylactic cranial irradiation). Each of these innovations adds about 5%-10% to the overall survival rate. In extensive-stage disease, irinotecan plus cisplatin may be a possible alternative to the "standard" etoposide-cisplatin chemotherapy doublet, but there has been little progress otherwise. It is imperative that, whenever possible, patients be given the opportunity to participate in future clinical trials so that the survival for these patients can continue to improve.

Limited-stage small-cell lung cancer: the current status of combined-modality therapy

Limited-stage (LS) small-cell lung cancer (SCLC) remains a therapeutic challenge to medical and radiation oncologists. The treatment of LS-SCLC has evolved significantly over the last two decades with combined-modality therapy now the standard of care. The addition of thoracic radiotherapy (TRT) to standard chemotherapy has led to improvements in long-term survival in this population. However, many questions remain about the optimal way to deliver chemoradiotherapy. In a landmark trial, twice-daily TRT to a dose of 45 Gy increased 5-year survival by 10% compared with once-daily TRT administered to the same dose. This suggests that more intensive TRT regimens may lead to further survival gains, assuming they can be delivered safely in this setting. Strategies currently under investigation include higher total daily doses delivered once daily or novel concurrent boost techniques allowing more intensive treatments over shorter periods of time. Several trials and meta-analyses have evaluated the timing of TRT with chemotherapy, with the weight of evidence suggesting that early and concurrent TRT with chemotherapy is optimal. Novel cytotoxic chemotherapy combinations have failed thus far to provide an advantage over standard etoposide-cisplatin combinations. Prophylactic cranial irradiation in near or complete responders to induction chemoradiotherapy has also been shown to improve long-term survival rates. LS-SCLC has been a model cancer in terms of the potential benefit of combined chemoradiotherapy strategies in improving patient outcomes.

Targeted therapies in small-cell lung cancer

Small-cell lung cancer is an aggressive form of lung cancer that, overall, remains the most common cause of cancer death in the US. Some advances have been made in the treatment of small-cell lung cancer using cytotoxic chemotherapeutic agents but no truly targeted therapies are available as of yet. At present, research is focused on finding therapies that can target the specific molecular mechanisms responsible for the survival, growth and metastasis of the tumor thereby improving responses to chemotherapy and minimizing toxicity. Several new agents, such as angiogenesis inhibitors and regulators of apoptosis, have reached clinical testing and multiple others are in preclinical trials. Some of these will be discussed in this review.

Belotecan, new camptothecin analogue, is active in patients with small-cell lung cancer: results of a multicenter early phase II study

BACKGROUND

Belotecan (Camtobell, Chong Keun Dang Corp, Seoul, Korea; CKD602) is a new camptothecin analogue. This study aimed to investigate the safety and efficacy of single-agent belotecan for small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Twenty-seven patients with chemotherapy-naive or chemosensitive SCLC were treated with belotecan 0.5 mg/m(2)/day on days 1-5 of a 3-week cycle. All 27 patients were assessable for toxicity, and 21 patients assessable for response.

RESULTS

Nine patients (42.9%) showed objective tumor responses including one complete response; seven (63.6%) in 11 chemotherapy-naive patients; and two (20.0%) in 10 chemosensitive patients. With a median follow-up of 5 years, median progression-free and survival time for chemotherapy-naive patients were 4.8 months and 11.9 months, respectively, while the corresponding values for chemosensitive patients were 3.3 months and 10.5 months, respectively. The most common toxicity was neutropenia.

CONCLUSION

Belotecan was active in SCLC patients as a single agent, warranting further investigations of belotecan in combination with platinum or other active agents.

Involvement of mutation-based inhibition of beta-catenin phosphorylation at Ser33 in the malignant progression of lung (pre)neoplastic lesions induced by N-nitrosobis(2-hydroxypropyl)amine in male Fischer 344 rats

In this study we investigated the Ser33 phosphorylation status of beta-catenin protein in relation to genomic mutations in lung (pre)neoplastic lesions induced by N-nitrosobis(2-hydroxypropyl)amine (BHP) in male Fischer 344 rats. Six-week-old animals received 2000 ppm of BHP in the drinking water for 8 weeks and were sacrificed 12 weeks thereafter. Histopathologically, 69 of 75 rats demonstrated multiple lung (pre)neoplastic lesions, classified into 27 slight and 33 advanced hyperplasias (preneoplasms) and 61 neoplasms, including adenomas, adenocarcinomas, and adenosquamous carcinomas. Nucleotide mutation analysis of the beta-catenin gene detected a total of 33 mutations in 12 assessed lung (pre)neoplastic lesions. The mutations tended to accumulate in positions near the phosphorylation region of the gene, between codons 33 and 45. Immunohistochemical analysis showed beta-catenin protein expression to be increased and its localization changed from the cell membrane to the cytoplasm and finally the nuclei with advancing malignancy of the lung lesions. In contrast, the expression of phosphorlyated beta-catenin protein at Ser33 was weakened in lung (pre)neoplastic lesions compared to normal lung tissues. These results suggest that BHP-induced mutation of the beta-catenin gene results in amino acid conversions in its product protein, which in turn lead to inhibition of phosphorylation of the protein and escape from protein degradation. These phenomena might contribute to the malignant progression of the lung (pre)neoplastic lesions, which start from the relatively early stage in lung carcinogenesis.

Survival of Small-cell Lung Cancer and its Determinants of Outcome in Singapore

Introduction: The survival and epidemiology of small-cell lung cancer (SCLC) in Singapore has not been described. We aim to present the characteristics as well as determine the survival outcome and important prognostic factors for SCLC patients. Materials and Methods: A retrospective analysis of SCLC patients diagnosed from 1999 to 2002 was conducted at the Outram campus, Singapore. Clinical characteristics and treatment data were obtained from case records and survival data were checked with the registry of births and deaths on 30 May 2005. Results: One hundred and eleven patients were analysed. There were 38 (34.2%) limited-disease (LD) patients and 73 (65.8%) extensive-disease (ED) patients. The majority were current or former smokers (94.7% among LD and 94.5% among ED). More patients with LD had good performance status (92% versus 63%, P = 0.0003) and were treated with combined chemo-therapy and radiotherapy (82% versus 48%, P = 0.012). The median survival time of LD patients treated with curative chemoradiotherapy was 14.2 months (95% CI, 10.96 to 17.44). Those given prophylactic cranial irradiation had a median survival time of 16.9 months (95% CI, 11.83 to 21.97). For ED patients, the median survival time was 8.17 months (95%CI, 5.44 to 10.89). None of the factors analysed were significant prognostic factors for LD patients while performance status and type of treatment given were significant among ED patients. Conclusions: We found that the characteristics and survival of SCLC patients in Singapore are fairly similar to that of other countries. Key words: Epidemiology, Prognostic factors, Survival

The association of chemotherapy induced neutropenia on treatment outcomes in small cell lung cancer

BACKGROUND

Chemotherapy induced neutropenia has been shown to be associated with improved treatment outcomes in selected solid tumours. We studied the association of chemotherapy induced neutropenia with treatment related outcomes in small cell lung cancer (SCLC).

METHODS

This is a retrospective analysis of patients receiving chemotherapy for SCLC at the Royal Marsden Hospital, UK over an 8 year period. The chemotherapy included Carboplatin AUC 5, IV and Etoposide 100mg/m(2) IV on day 1 and 100mg/m(2) PO, B.I.D. on day 2 and 3 every 21 days. Patients were stratified into two groups (A) those experiencing grades 0-2 neutropenia and group (B) those experiencing grades 3-4 neutropenia. The outcomes studied were response rate, time to progression (TTP) and overall survival (OS).

RESULTS

173 patients were studied. The median age 64 (range 39-83) and M/F ratio was 112:61. The response rates in groups A and B was 90% versus 90%, p=1.0. The median TTP in groups A and B was 30 and 38 weeks, p=0.05. The median OS in groups A and B was 47 weeks versus 60 weeks, p=0.008. The differences in TTP and OS were not significant in patients with extensive stage disease.

CONCLUSIONS

Occurrence of chemotherapy induced grade 3 or 4 neutropenia correlated with OS in patients with SCLC receiving carboplatin and etoposide chemotherapy. Trials exploring controlled, safe intra-patient dose escalation with the intent of achieving grade 3 or 4 neutropenia in patients with SCLC are warranted.

Long-term survivorship in lung cancer: a review

While outcome research in lung cancer has focused mainly on short-term survival and quality of life (QoL), information on long-term (ie, > 5 years postdiagnosis) lung cancer survivorship remains limited. This review addresses the epidemiologic significance of long-term lung cancer (LTLC) survivors, summarizes the current knowledge on their health and QoL, and suggests areas for further research in LTLC survivorship. Based on a small body of literature, lung cancer survivors do not experience the same quantity and QoL as their age-matched peers or as survivors of other cancers. Survival among 5-year survivors of lung cancer relative to the general US population with the same demographic characteristics is approximately 60%, and lung cancer survivors score lowest in health utility among long-term survivors of other cancers. Approximately one-quarter of long-term lung cancer (LTLC) survivors were significantly restricted in physical ability or reported significant depressive symptoms. There is a need to identify and intervene with subgroups of survivors who are at an elevated risk of premature death and diminished QoL. Lung cancer-specific survival alone does not reflect the overall illness burden in LTLC survivors. Patient care in lung cancer survivors should be continuous and comprehensive in considering multiple causes of health deterioration. Multidisciplinary research in epidemiologic, clinical, and basic science approaches is warranted to further our knowledge base for optimal long-term management and to develop the necessary intervention strategies among LTLC survivors.

Small-cell lung cancer

Small-cell lung carcinoma is an aggressive form of lung cancer that is strongly associated with cigarette smoking and has a tendency for early dissemination. Increasing evidence has implicated autocrine growth loops, proto-oncogenes, and tumour-suppressor genes in its development. At presentation, the vast majority of patients are symptomatic, and imaging typically reveals a hilar mass. Pathology, in most cases of samples obtained by bronchoscopic biopsy, should be undertaken by pathologists with pulmonary expertise, with the provision of additional tissue for immunohistochemical stains as needed. Staging should aim to identify any evidence of distant disease, by imaging of the chest, upper abdomen, head, and bones as appropriate. Limited-stage disease should be treated with etoposide and cisplatin and concurrent early chest irradiation. All patients who achieve complete remission should be considered for treatment with prophylactic cranial irradiation, owing to the high frequency of brain metastases in this disease. Extensive-stage disease should be managed by combination chemotherapy, with a regimen such as etoposide and cisplatin administered for four to six cycles. Thereafter, patients with progressive or recurrent disease should be treated with additional chemotherapy. For patients who survive long term, careful monitoring for development of a second primary tumour is necessary, with further investigation and treatment as appropriate.

Inhibition of the phosphatidylinositol 3-kinase/Akt/mammalian target of rapamycin pathway but not the MEK/ERK pathway attenuates laminin-mediated small cell lung cancer cellular survival and resistance to imatinib mesylate or chemotherapy

The fact that small cell lung cancer (SCLC) is commonly incurable despite being initially responsive to chemotherapy, combined with disappointing results from a recent SCLC clinical trial with imatinib, has intensified efforts to identify mechanisms of SCLC resistance. Adhesion to extracellular matrix (ECM) is one mechanism that can increase therapeutic resistance in SCLC cells. To address whether adhesion to ECM increases resistance through modulation of signaling pathways, a series of SCLC cell lines were plated on various ECM components, and activation of two signaling pathways that promote cellular survival, the phosphatidylinositol 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) pathway and the mitogen-activated protein kinase kinase/extracellular signal-regulated kinase (MEK/ERK) pathway, was assessed. Although differential activation was observed, adhesion to laminin increased Akt activation, increased cellular survival after serum starvation, and caused the cells to assume a flattened, epithelial morphology. Inhibitors of the PI3K/Akt/mTOR pathway (LY294002, rapamycin) but not the MEK/ERK pathway (U0126) abrogated laminin-mediated survival. SCLC cells plated on laminin were not only resistant to serum starvation-induced apoptosis but were also resistant to apoptosis caused by imatinib. Combining imatinib with LY294002 or rapamycin but not U0126 caused greater than additive increases in apoptosis compared with apoptosis caused by the inhibitor or imatinib alone. Similar results were observed when adenoviruses expressing mutant Akt were combined with imatinib, or when LY294002 was combined with cisplatin or etoposide. These studies identify laminin-mediated activation of the PI3K/Akt/mTOR pathway as a mechanism of cellular survival and therapeutic resistance in SCLC cells and suggest that inhibition of the PI3K/Akt/mTOR pathway is one strategy to overcome SCLC resistance mediated by ECM.