Role of Adjuvant Therapy in a Population-Based Cohort of Patients With Early-Stage Small-Cell Lung Cancer

Adjuvant treatment in lung cancer

BACKGROUND

Adjuvant treatment for both small-cell and non-small-cell lung cancer is a controversial topic. There are no published results from prospective studies that either confirm or reject the benefit of adjuvant radiotherapy, although the presentation of recent studies at a number of conferences questions whether there should be a change in the paradigm of adjuvant RT for lung cancer.

AIM

The main goal of this study is to review the most relevant publications on the topic, updating the state of the matter regarding adjuvant radiotherapy following lung surgery, and analyzing the role of chemotherapy in the process.

RELEVANCE FOR PATIENTS

This review aims to assess the potential benefit of PORT in NSCLC and SCLC patients by looking at recent research. In doing so, it will be possible to determine which patients might benefit from it as adjuvant treatment after pulmonary resection.

Prophylactic cranial irradiation in SCLC

Prophylactic cranial irradiation (PCI) has well established place in therapy for patients with limited-disease small cell lung cancer who responded to treatment. The data from randomized trials document that PCI reduces brain metastases rate from approximately 60% to 30%, and increases 3-year overall survival by approximately 5%. Currently, the dose of 25 Gy in 10 fractions is considered as standard. In attempt to reduce neuropsychological sequelae attributable to PCI hippocampal sparing techniques are employed. The existing studies suggest the benefit of hippocampal sparing in limiting memory and higher neurocognitive function losses, but with a risk of failures in the spared region. Ongoing studies will further validate the role of hippocampal sparing, both in terms of toxicity reduction and metastases prevention. PCI for patients who have undergone resection for stage I small cell lung cancer (SCLC) is not recommended, PCI may be, however, associated with a favourable outcome in SCLC patients who have undergone complete surgery in stages II−III. The role of PCI in extensive-disease (ED) SCLC has been evolving. Most recent evidence indicate that PCI is controversial in ED patients with response to initial chemotherapy and absence of brain metastases confirmed by contrast-enhanced MRI. The patients who do not receive PCI, must, however, receive periodic MRI examination during follow-up, i.e., remain under active surveillance with access to radiotherapy at brain relapse. The assessment of safety and effectiveness of hippocampal-sparing PCI, with or without drug neuroprotection in consideration of diverse combinations of radiotherapy, chemotherapy and immunotherapy create a background for future directions of research.

Optimal Surgery Type and Adjuvant Therapy for T1N0M0 Lung Large Cell Neuroendocrine Carcinoma

Background

The appropriate treatment strategy for T1N0M0 lung large cell neuroendocrine carcinoma (LCNEC) was not well illustrated. We evaluated the efficacy of different surgery types and adjuvant therapy on patients with T1N0M0 LCNEC.

Methods

Patients diagnosed T1N0M0 LCNEC from 2004 to 2016 were identified in the surveillance, epidemiology, and end results (SEER) database. Clinical characteristics, treatment and survival data were collected. The efficacy of surgery type and adjuvant therapy stratified by tumor size was assessed. Overall survival(OS) was evaluated by the Kaplan-Meier method, and relevant survival variables were identified by the Cox proportional hazard model.

Results

From 2004 to 2016, 425 patients were included in this study, 253 (59.5%) patients received lobectomy, and 236 (55.5%) patients had 4 or more lymph nodes removed. Patients received lobectomy had better survival than those received sublobar resection(P=0.000). No matter tumor size less than 2 cm or 2 to 3 cm, lobectomy was significantly prolonged survival. Compared with no lymph nodes removed, lymph nodes dissection was associated with more remarkable OS(P<0.000). 4 or more regional lymph nodes dissection predicted better OS compared with 1 to 3 regional lymph nodes dissection(P=0.014). After surgery, adjuvant chemotherapy did not contribute to extended survival in patients with tumor less than 2 cm(P=0.658), and possibly for tumor 2 to 3 cm(P=0.082). Multivariate analysis showed that age and lobectomy were independent prognostic factors(P=0.000).

Conclusion

Our results suggest that lobectomy and lymph nodes dissection were associated with significantly better survival. Extensive regional lymph node dissection(4 or more) was more effective in prolonging survival than 1 to 3 lymph nodes dissection. Adjuvant chemotherapy was not associated with extended survival for tumor less than 2 cm, and possibly for tumor 2 to 3 cm.

GOECP/SEOR radiotherapy guidelines for small-cell lung cancer

Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancers. The main treatment is chemotherapy (Ch). However, the addition of radiotherapy significantly improves overall survival (OS) in patients with non-metastatic SCLC and in those with metastatic SCLC who respond to Ch. Prophylactic cranial irradiation reduces the risk of brain metastases and improves OS in both metastatic and non-metastatic patients. The 5-year OS rate in patients with limited-stage disease (non-metastatic) is slightly higher than 30%, but less than 5% in patients with extensive-stage disease (metastatic). The present clinical guidelines were developed by Spanish radiation oncologists on behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Society of Radiation Oncology to provide a current review of the diagnosis, planning, and treatment of SCLC. These guidelines emphasise treatment fields, radiation techniques, fractionation, concomitant treatment, and the optimal timing of Ch and radiotherapy. Finally, we discuss the main indications for reirradiation in local recurrence.

Small-cell lung cancer

Small-cell lung cancer (SCLC) represents about 15% of all lung cancers and is marked by an exceptionally high proliferative rate, strong predilection for early metastasis and poor prognosis. SCLC is strongly associated with exposure to tobacco carcinogens. Most patients have metastatic disease at diagnosis, with only one-third having earlier-stage disease that is amenable to potentially curative multimodality therapy. Genomic profiling of SCLC reveals extensive chromosomal rearrangements and a high mutation burden, almost always including functional inactivation of the tumour suppressor genes TP53 and RB1. Analyses of both human SCLC and murine models have defined subtypes of disease based on the relative expression of dominant transcriptional regulators and have also revealed substantial intratumoural heterogeneity. Aspects of this heterogeneity have been implicated in tumour evolution, metastasis and acquired therapeutic resistance. Although clinical progress in SCLC treatment has been notoriously slow, a better understanding of the biology of disease has uncovered novel vulnerabilities that might be amenable to targeted therapeutic approaches. The recent introduction of immune checkpoint blockade into the treatment of patients with SCLC is offering new hope, with a small subset of patients deriving prolonged benefit. Strategies to direct targeted therapies to those patients who are most likely to respond and to extend the durable benefit of effective antitumour immunity to a greater fraction of patients are urgently needed and are now being actively explored.

Association of Race, Socioeconomic Factors, and Treatment Characteristics With Overall Survival in Patients With Limited-Stage Small Cell Lung Cancer

IMPORTANCE

It has been established that disparities in race and socioeconomic status are associated with outcomes of non-small cell lung cancer. However, it remains unknown whether this extends to stage I, II, or III small cell lung cancer (SCLC), or limited-stage SCLC (L-SCLC).

OBJECTIVE

To investigate the associations of race, socioeconomic factors, and treatment characteristics with survival among patients with L-SCLC.

DESIGN, SETTING, AND PARTICIPANTS

Demographic information for patients with L-SCLC diagnosed between 2004 and 2014 was obtained from the National Cancer Database. The follow-up end point is death or last follow-up (date of last contact). Patients were divided into 5 mutually exclusive cohorts by race. Data analysis was performed in October 2019.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards models were used to calculate univariable and multivariable models. Multivariable analyses were conducted to assess the associations of race and socioeconomic factors with risk-adjusted outcomes. Overall survival between groups was depicted by Kaplan-Meier curves.

RESULTS

Of 72 409 patients analyzed (median [range] age, 67.0 [23.0-90.0] years), 40 289 (55.6%) were women. The distribution of disease stage was 10 619 patients (14.7%) with stage I disease, 7689 patients (10.6%) with stage II disease, and 54 101 patients (74.7%) with stage III disease. The median (range) duration of follow-up was 8.2 (2.4-15.8) months. Compared with White patients, the hazard of death decreased to 0.92 (95% CI, 0.89-0.95; P < .001) for African American patients and 0.83 (95% CI, 0.77-0.91; P < .001) for Asian patients. The difference in median survival among different racial groups was significant only among those with stage III SCLC. Other factors associated with better survival were female sex, high income, high education, private insurance, diagnostic confirmation by positive cytological analysis, increase in number of sampled regional lymph nodes, and earlier stage at diagnosis.

CONCLUSIONS AND RELEVANCE

This analysis highlights disparities in race and socioeconomic factors associated with outcomes of L-SCLC. Racial minorities, including African American and Asian patients, have better survival than White patients for L-SCLC after adjustment for sociodemographic factors.

Surgery for small cell lung cancer: When and how

OBJECTIVE

Since data from large retrospective observational studies and cancer registries became available, suggesting a benefit for patients undergoing surgery, the role of surgery in the treatment of small cell lung cancer (SCLC) needs to be reconsidered. The aim of this study was to evaluate outcomes and results of patients with SCLC undergoing intent-to-treat surgery.

MATERIAL AND METHODS

We retrospectively analyzed 324 patients (1998-2018) with a diagnosis of SCLC referred to our Institution. 65 patients underwent surgical resection with curative intent. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) for all patients.

RESULTS

Among the patients, 39 (60.0 %) patients had surgery upfront, whereas 24 (36.9 %) had surgery after chemotherapy (CT) alone, and 2 (3.1 %) after CT plus radiotherapy (RT). Twenty-nine (44.6 %) patients were stage I or had a complete response to induction treatment, 21 (32.3 %) had stage II, and 15 (23.1 %) stage III. Forty-four (67.7 %) patients underwent adjuvant treatment: 21 (32.3 %) had CT, 31 (47.7 %) RT, and 7 (10.8 %) both. Prophylactic cranial irradiation was administered in 15 patients (23.1 %). The median OS after initial diagnosis at 1, 5, 10 years was 1, 5, 10 years was 81.4 %, 41.4 % and 25.4 % respectively. Among patients who underwent surgical resection with curative intent, those with clinical stage I had a longer survival (5-year OS 62.9 %) p < 0.0001.

CONCLUSION

patients with stage I SCLC could be considered the best candidates for surgery, in a multidisciplinary setting. Instead, considering their worse survival, those with stage II and III should be carefully selected for the surgical approach, and alternative therapy should be considered.

Predictors of survival following surgical resection of limited-stage small cell lung cancer

BACKGROUND

Adjuvant chemotherapy, postoperative radiation (PORT), and prophylactic cranial irradiation (PCI) have been individually examined in limited-stage small cell lung cancer (SCLC). There is a paucity of data on the effectiveness of each adjuvant treatment modality when used in combination after surgical resection of SCLC.

METHODS

Data were collected from 5 cancer centers on all patients with limited-stage SCLC who underwent surgical resection between 1986 and 2019. Univariate and multivariable models were conducted to identify predictors of long-term outcomes, focusing on freedom from recurrence and survival benefit of adjuvant chemotherapy, PORT, and PCI.

RESULTS

A total of 164 patients were analyzed. Multivariable Cox regression analysis did not identify any adjuvant therapies to significantly influence recurrence in this cohort. Specifically, PORT was not associated with a significant influence on locoregional recurrence and PCI was not significantly associated with intracranial outcomes. Adjuvant chemotherapy improved survival in all stage I through III disease (hazard ratio, 0.49; 95% confidence interval, 0.29-0.81; P = .005) and even in pathologically node negative patients (hazard ratio, 0.49; 95% confidence interval, 0.27-0.91; P = .024). Although PCI was found to improve survival in univariate analysis, it was not significant in a multivariable model. PORT was not found to affect survival on either univariate or multivariable analysis.

CONCLUSIONS

This is among the largest multi-institutional studies on surgically resected limited-stage SCLC. Our results highlight survival benefit of adjuvant chemotherapy, but did not identify a statistically significant influence from mediastinal PORT or PCI in our cohort. Larger prospective studies are needed to determine the benefit of PORT or PCI in a surgically resected limited-stage SCLC population.

Surgery for limited stage small cell lung cancer

Small cell lung cancer (SCLC) is an aggressive tumor type characterized by rapid growth and overall poor prognosis. For the past several decades, chemotherapy and radiotherapy have served as the cornerstone of treatment. Recently, however, the role of surgery for early stage disease has gained considerable interest. Multiple retrospective and observational studies have shown excellent survival for early stage SCLC treated with surgical resection. We herein review the past and present evidence regarding surgical options for limited stage SCLC.

American Radium Society Appropriate Use Criteria: Radiation Therapy for Limited-Stage SCLC 2020

INTRODUCTION

Combined modality therapy with concurrent chemotherapy and radiation has long been the standard of care for limited-stage SCLC (LS-SCLC). However, there is controversy over best combined modality practices for LS-SCLC. To address these controversies, the American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) Committee have developed updated consensus guidelines for the treatment of LS-SCLC.

METHODS

The ARS AUC are evidence-based guidelines for specific clinical conditions that are reviewed by a multidisciplinary expert panel. The guidelines include a review and analysis of current evidence with application of consensus methodology (modified Delphi) to rate the appropriateness of treatments recommended by the panel for LS-SCLC. Agreement or consensus was defined as less than or equal to 3 rating points from the panel median. The consensus ratings and recommendations were then vetted by the ARS Executive Committee and subject to public comment before finalization.

RESULTS

The ARS Thoracic AUC committee developed multiple consensus recommendations for LS-SCLC. There was strong consensus that patients with unresectable LS-SCLC should receive concurrent chemotherapy with radiation delivered either once or twice daily. For medically inoperable T1-T2N0 LS-SCLC, either concurrent chemoradiation or stereotactic body radiation followed by adjuvant chemotherapy is a reasonable treatment option. The panel continues to recommend whole-brain prophylactic cranial irradiation after response to chemoradiation for LS-SCLC. There was panel agreement that prophylactic cranial irradiation with hippocampal avoidance and programmed cell death protein-1/programmed death-ligand 1-directed immune therapy should not be routinely administered outside the context of clinical trials at this time.

CONCLUSIONS

The ARS Thoracic AUC Committee provide consensus recommendations for LS-SCLC that aim to provide a groundwork for multidisciplinary care and clinical trials.

Lymphatic Metastasis of NSCLC Involves Chemotaxis Effects of Lymphatic Endothelial Cells through the CCR7-CCL21 Axis Modulated by TNF-α

Metastasis and recurrence are the main causes of lung adenocarcinoma patients’ death. Lymphatic metastasis is the main way of non-small cell lung cancer (NSCLC) metastasis. C-C chemokine receptor type 7 (CCR7) overexpression has been demonstrated to mediate occurrence and progression of NSCLC. Moreover, Chemokine ligand 21 (CCL21) was used to activate CCR7. The CCR7–CCL21 axis is one of the most common “chemokine-receptor” modes of action in the development and metastasis of multiple tumors. However, the role of the CCR7–CCL21 axis in lymphatic metastasis of NSCLC is poorly understood. The study was conducted to investigate the molecular mechanism underlying CCR7–CCL21 axis-mediated lymphatic metastasis of NSCLC A549 cells. Tumor necrosis factor α (TNF-α) could regulate the tumor microenvironment balance by promoting chemokine secretion. Our study demonstrated that TNF-α promoted CCL21 production in human lymphatic endothelial cells (HLEC). Results further showed that TNF-α significantly activated the NF-κB pathway in HLEC. NF–κB pathway inhibition with ammonium pyrrolidinedithiocarbamate (PDTC) caused a significant decrease in CCL21 secretion, suggesting that TNF-α-induced CCL21 secretion in HLEC was through NF–κB pathway. Co-culture of A549 cells and TNF-α-treated HLEC confirmed that the metastasis of A549 cells was enhanced, meanwhile, apoptosis-related proteins were hardly affected. The data proved that a co-culture system prevented cell apoptosis while inducing the lymphatic metastasis of A549 cells. However, the situation was reversed after neutralizing CCL21 expression, suggesting that TNF-α-induced CCL21 secretion in HLEC is involved in A549 cells metastasis. Collectively, our finding demonstrated that NF-κB pathway-controlled CCL21 secretion of HLEC contributing to the lymphatic metastasis of A549 cells via the CCR7–CCL21 axis, validating the CCR7–CCL21 axis as a potential target to inhibit metastasis of NSCLC.

Randomized Phase III Study of Irinotecan Plus Cisplatin Versus Etoposide Plus Cisplatin for Completely Resected High-Grade Neuroendocrine Carcinoma of the Lung: JCOG1205/1206

PURPOSE

To verify the superiority of irinotecan plus cisplatin over etoposide plus cisplatin as postoperative adjuvant chemotherapy for patients with pathologic stage I-IIIA, completely resected, high-grade neuroendocrine carcinoma (HGNEC) of the lung.

METHODS

This was a randomized, open-label, phase III study on patients with completely resected stage I-IIIA HGNEC of the lung. They were randomly assigned to receive either etoposide (100 mg/m², days 1-3) plus cisplatin (80 mg/m², day 1) or irinotecan (60 mg/m², days 1, 8, 15) plus cisplatin (60 mg/m², day 1) up to four cycles. The primary end point was relapse-free survival (RFS) in the intention-to-treat population. This trial was registered with the Japan Registry of Clinical Trials (jRCTs031180216).

RESULTS

Between April 2013 and October 2018, 221 patients were enrolled (etoposide plus cisplatin arm, 111 patients; irinotecan plus cisplatin arm, 110 patients). In the second interim analysis, early termination of the trial was recommended because of futility. At a median follow-up of 24.1 months, the 3-year RFS was 65.4% for etoposide plus cisplatin and 69.0% for irinotecan plus cisplatin, with a hazard ratio of 1.076 (95% CI, 0.666 to 1.738; one-sided log-rank P = .619). Grade 3-4 adverse events were more frequent in the etoposide plus cisplatin arm, with febrile neutropenia (20% of 109 patients v 4% of 107 patients) and neutropenia (97% v 36%) being the most common. Meanwhile, grade 3-4 anorexia (6% v 11%) and diarrhea (1% v 8%) were more frequently observed in the irinotecan plus cisplatin arm.

CONCLUSION

Irinotecan plus cisplatin is not superior to etoposide plus cisplatin for improving RFS in patients with completely resected HGNEC; thus, etoposide plus cisplatin remains the standard treatment.

PD-L1 Predicts Poor Prognosis in Surgically Resected Limited Stage Small-Cell Lung Cancer

Purpose

Small-cell lung cancer (SCLC) is an aggressive high-grade neuroendocrine tumor with limited treatment strategies. Programmed death 1 (PD-1) and its ligand (PD-L1), delta-like ligand-3 (DLL-3), and poly ADP-ribose polymerase (PARP) inhibitors have shed light on the treatment of extensive stage-SCLC. However, the expression and prognostic role of PD-L1, DLL-3, and PARP are barely explored in surgically resected limited stage-SCLC (LS-SCLC).

Methods

We retrospectively reviewed 404 SCLC patients from 2011 to 2018 in the First Affiliated Hospital of Xi’an Jiaotong University and collected 43 surgically resected LS-SCLC samples with adequate materials and histological specimens containing abundant tumor cells. Immunohistochemistry staining of PD-L1, DLL-3, and PAPR1 was performed by anti-PD-L1 (22C3/Dako), anti-DLL-3, and anti-PAPR1 antibodies, respectively. Positive expression of PD-L1 was characterized as >5% tumor cells and/or tumor-infiltrating immune cells expressing PD-L1. The correlation between PD-L1, DLL-3, PARP1, and clinicopathological characteristics of surgically resected LS-SCLC patients was performed by χ² test. The survival curves were calculated by the Kaplan–Meier method and analyzed by the Log rank test and Cox proportional hazards model.

Results and Conclusion

63.04% patients were positive for PD-L1, 65.12% were positive for DLL-3, and 20.93% were positive for PARP1. DLL-3 was significantly overexpressed in SCLC tissues, compared with matched para-noncancerous tissues. Male, elder than 60 years old, advanced TNM stage, smoking, and positive PD-L1 expression predicted shorter DFS, while patients received adjuvant therapy performed better DFS. Further multivariate analysis revealed that TNM stage (HR=2.51, 95% CI=1.31–4.78, P=0.005) was an individual prognostic factor for DFS in LS-SCLC. Moreover, advanced TNM stage and positive PD-L1 expression also indicated worse OS, but adjuvant therapy improved OS in LS-SCLC. Multivariate analysis demonstrated that PD-L1 and TNM stage were independent and significant negative predictive factors for OS (HR=2.89, 95% CI=1.21–6.93, P=0.017; HR=2.49, 95% CI=1.25–4.94, P=0.009 for PD-L1 and TNM stage, respectively), while adjuvant treatment was an independent positive prognostic factor for OS (HR=0.37, 95% CI=0.17–0.81, P=0.012).

Analysis of Factors Affecting Brain Metastasis in Limited-Stage Small-Cell Lung Cancer Treated With Definitive Thoracic Irradiation

Background

Small-cell lung cancer (SCLC) is the most lethal cancer. With the development of chemotherapy and radiotherapy, brain metastasis (BM) emerged as one most predominant treatment failure. However, the factors affecting BM have not been identified completely. The purpose of this study was to investigate the risk factors involved in the development of BM in patients with limited-stage small-cell lung cancer (LS-SCLC) following definitive thoracic radiotherapy (TRT) and to provide a reference for the planning of a clinical treatment strategy.

Methods

The clinical data of patients with LS-SCLC treated with neoadjuvant chemotherapy (NAC) followed by TRT were collected and retrospectively reviewed. The factors affecting BM, BM-free survival (BMFS) and overall survival (OS) rates were analyzed statistically.

Results

A total of 152 patients with LS-SCLC fulfilled the inclusion criteria were reviewed. Following TRT, 31 (20.4%) patients achieved CR, 90 (59.2%) patients reached PR, 31 (20.4%) patients maintained SD, and no patients developed PD. The OS at 1, 3, and 5 years was 80.6, 34.2, and 19.4%, respectively. Multivariate analyses indicated that the greatest dimension of primary tumor (Dmax-T) and short-term response to TRT were risk factors affecting BM. The clinical N stage (cN), greatest dimension of metastatic nodes (Dmax-N), short-term response to TRT, and adjuvant chemotherapy (AC) were identified as independent factors correlated with OS.

Conclusions

Poor short-term response to TRT and huger Dmax-T were risk factors for BM. AC following TRT improved patient survival, but not decreased BM. However, due to the limitations associated with the retrospective design of the present study, further prospective clinical trials are required to confirm these conclusions.

Treatments for combined small cell lung cancer patients

Background

Combined small cell lung cancer (CSCLC) is a subtype of small cell lung cancer (SCLC) which contains both components of SCLC and non-small cell lung cancer (NSCLC). The prognostic outcomes and treatment strategy of it are still unclear. A large-scale retrospective study was performed to investigate proper treatments for CSCLC.

Methods

All cases of CSCLC were identified from the SEER database during the period of 2004–2016. Clinical characteristics, first-line treatments, surgical procedures and survival data including overall survival (OS) and cancer-specific survival (CSS) were analyzed.

Results

A total of 37,639 SCLC patients were identified. CSCLC accounted for 2.1% (784/37,639). The mean age of CSCLC cohort is 67.3±9.9 years old. Male and white ethnicity patients were accounted for larger proportions (55.7% and 80.4%). The oncological characteristics of CSCLC were consistent with SCLC that most of patients were diagnosed as higher grade and advanced stages. The prognosis of CSCLC was better than SCLC but worse than NSCLC in IA-IIIA stages. No difference was observed in IIIB-IV. Surgery was beneficial in IA-IB stage CSCLC. Adjuvant chemotherapy seemed to have few effects on early stage patients. Trimodality treatment could significantly improve OS in IIA-IIIA CSCLC patients. Chemotherapy-based treatment is predominant choice in advanced stage patients.

Conclusions

CSCLC is a rare and special subtype of SCLC. It has better survival outcome than non-CSCLC in early stage. Surgical treatment is crucial in early stage of CSCLC. Prognostic improvement might be achieved from trimodality treatment in stage IIA-IIIA. Chemotherapy-based treatments should be considered in advanced stage. The effect of surgical treatments in advanced stage patients should be further investigated.

Current and future strategies in radiotherapy for small-cell lung cancer

Small-cell lung cancer (SCLC) accounts for 13% of all lung tumors. The standard treatment in patients with limited-stage (LS) disease is thoracic radiotherapy (TRT) combined with chemotherapy. In extensive-stage (ES) SCLC, the importance of consolidation TRT in patients with a good treatment response has become increasingly recognized. In both LS and ES disease, prophylactic cranial irradiation is recommended in patients who respond to treatment. New therapeutic approaches such as immunotherapy are being increasingly incorporated into the treatment of SCLC, although more slowly than in non-small cell lung cancer. Diverse radiation dose and fractionation schemes, administered in varying combinations with these new drugs, are being investigated. In the present article, we review and update the role of radiotherapy in the treatment of SCLC. We also discuss the main clinical trials currently underway to identify future trends.

RELEVANCE FOR PATIENTS

Radiotherapy is a critical component of multimodality treatment of SCLC. This article can help physicians to improve medical knowledge and find better ways to treat their SCLC patients.

Trends in pneumonectomy for treatment of small-cell lung cancer

BACKGROUND

According to practice guidelines, patients with clinical stage T1-2 node-negative small-cell lung cancer are candidates for surgical resection. However, the role of pneumonectomy in small-cell lung cancer patients is not well understood. The objective of this study was to assess the extent to which pneumonectomy is used and to evaluate the survival implications for small-cell lung cancer patients who underwent pneumonectomy.

METHODS

A total of 106 small-cell lung cancer patients who underwent pneumonectomy between 2006 and 2016 and met the study criteria were identified in the National Cancer Database. Demographics and treatment regimens are described, and overall survival was assessed using Kaplan-Meier and log-rank tests.

RESULTS

The most common treatment was surgery with adjuvant chemotherapy, followed by surgery only and surgery with neoadjuvant therapy. The 5-year overall survival for the entire cohort after pneumonectomy was 23%. In subgroup analysis, the 5-year overall survival was 30% for guideline-concordant clinical stage I patients and 28% for clinical stage II/III patients who underwent pneumonectomy. There was no statistical difference in survival according to pathologic N disease. Patients with a right-sided pneumonectomy had higher mortality than patients with a left-sided pneumonectomy.

CONCLUSIONS

This study suggests a role for pneumonectomy in clinical stage I and potentially some clinical stage II and III small-cell lung cancer patients. Right-sided pneumonectomy is associated with higher mortality and should be approached with caution. Despite declining trends over the past decades, pneumonectomy is still an effective treatment that is able to achieve acceptable survival outcomes.

Current Management and Progress in Radiotherapy for Small Cell Lung Cancer

Radiotherapy (RT) and chemotherapy continue to be widely utilized in small cell lung cancer (SCLC) management. In most limited stage (LS)-SCLC cases, the standard initial therapy remains concurrent chemoradiotherapy (CRT), typically with an etoposide and platinum-based regimen. Hyperfractionated twice daily (BID) RT remains the standard of care, though conventional daily (QD) RT is now a viable alternative supported by randomized evidence. In LS-SCLC patients who experienced good response to CRT, prophylactic cranial irradiation (PCI) remains the standard of care. Brain imaging, ideally with MRI, should be performed prior to PCI to screen for clinically apparent brain metastases that may require a higher dose of cranial irradiation. Platinum doublet chemotherapy alone is the historic standard initial therapy in extensive stage (ES)-SCLC. Addition of immunotherapy such as atezolizumab and durvalumab to chemotherapy is now recommended after their benefits were demonstrated in recent trials. In patients with response to chemotherapy, consolidation thoracic RT and PCI could be considered, though with caveats. Emergence of hippocampal avoidance cranial irradiation and SRS in SCLC patients may supplant whole cranial irradiation as future standards of care. Incorporation of novel systemic therapies such as immunotherapies has changed the treatment paradigm and overall outlook of patients with SCLC. This narrative review summarizes the current state, ongoing trials, and future directions of radiotherapy in management of SCLC.

Does surgically resected small-cell lung cancer without lymph node involvement benefit from prophylactic cranial irradiation?

BACKGROUND

It has previously been demonstrated that surgically resected small-cell lung cancer (SCLC) patients could benefit from prophylactic cranial irradiation (PCI). However, PCI in patients without lymph node involvement remains controversial. This study includes a larger sample size to evaluate the benefit of PCI therapy in this specific population.

METHODS

The records of surgically resected SCLC patients without lymph node involvement (N0M0) in Shanghai Chest Hospital were retrospectively reviewed.

RESULTS

Between January 2006 and May 2017, a total of 146 cases of surgically resected SCLC without lymph node involvement were included. A total of 46 patients received PCI therapy and 100 patients received no therapy. During the observation period, 12.0% (12/100) of the patients who did not receive PCI therapy developed brain metastases while 10.9% (5/46) of patients who received PCI therapy developed brain metastases. With regard to time to recurrence, no significant difference was observed among the groups (P = 0.798). Moreover, there was no significant difference in either the overall survival benefit (hazard ratio [HR] = 0.84, 95% confidence interval [CI]: 0.49-1.45, P = 0.532) or disease-free survival rate (HR = 0.95, 95% CI: 0.52-1.75, P = 0.864).

CONCLUSIONS

The evidence obtained does not support PCI therapy in the management of surgically resected SCLC with no lymph node involvement.

KEY POINTS

Prophylactic cranial irradiation (PCI) remains controversial for resected small-cell lung cancer (SCLC) without lymph node involvement. In this study, the results indicated that PCI does not reduce the risk of cerebral recurrence of resected p-T1-2N0M0 SCLC. This is the largest sample size study focused on PCI in resected p-T1-2N0M0 SCLC. Future revised versions of the guidelines should address this issue.

Comparison of treatment strategies for patients with limited-stage small cell lung cancer who received chemotherapy

Background

The standard care for limited-stage small cell lung cancer (SCLC) is unclear. The purpose of this study is to compare the outcome for patients receiving chemotherapy alone, chemotherapy plus surgery (CS), chemotherapy plus radiation (CR), or chemotherapy plus surgery and radiation (CSR) for limited-stage SCLC.

Methods

Patients with T1-4N0-2M0 SCLC who received chemotherapy from 2004 to 2014 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The overall survival (OS) of these patients, stratified by different stage, was compared in accordance to the method of receiving different treatments using Kaplan-Meier method and Cox regression analysis.

Results

A total of 7,204 patients were included, where 1,347 (18.7%) patients received chemotherapy alone, 296 (4.1%) undergone CS, 5,296 (73.5%) patients were subjected to CR and 267 (3.7%) patients were managed by the three combination of CSR. Chemotherapy alone was associated with the worst survival in comparison to the other two method of combination i.e., chemotherapy with radiation or surgery. When compared with CR, CS had no survival benefit in patients with stage in excess of T1-2N0 disease, but was associated with improved 5-year OS in patients with T1-2N0 disease, which ranged from 29.1% to 54.3% (P<0.001). For patients with T1-2N2 disease who received CSR demonstrated superior OS over those who received CR (P=0.004) or CS (P=0.036). Cox regression analysis showed CS was associated with improved OS when compared with CR in patients with N0 disease (HR, 0.54; 95% CI, 0.43–0.68; P=0.000) and CSR was associated with better OS in comparison with CR in patients with N2 disease (HR, 0.71; 95% CI, 0.55–0.93; P=0.013).

Conclusions

Patients with limited-stage SCLC can benefit from local treatment such as surgery, radiation, and surgery plus radiation. For patients with N0 disease, CS was associated with improved survival in comparison to CR. If N2 was identified after surgery, radiation may be added to improve OS.

Biomimetic cellular vectors for enhancing drug delivery to the lungs

Despite recent advances in drug delivery, the targeted treatment of unhealthy cells or tissues continues to remain a priority. In cancer (much like other pathologies), delivery vectors are designed to exploit physical and biological features of unhealthy tissues that are not always homogenous across the disease. In some cases, shifting the target from unhealthy tissues to the whole organ can represent an advantage. Specifically, the natural organ-specific retention of nanotherapeutics following intravenous administration as seen in the lung, liver, and spleen can be strategically exploited to enhance drug delivery. Herein, we outline the development of a cell-based delivery system using macrophages as a delivery vehicle. When loaded with a chemotherapeutic payload (i.e., doxorubicin), these cellular vectors (CELVEC) were shown to provide continued release within the lung. This study provides proof-of-concept evidence of an alternative class of biomimetic delivery vectors that capitalize on cell size to provide therapeutic advantages for pulmonary treatments.

[Role of Circular RNA in Diagnosis, Development and Durg Resistance of Lung Cancer]

肺癌在全球范围内的致死率一直居高不下。近年来针对多种分子分型的靶向药物已成为中晚期肺癌治疗的新有效手段，但是肺癌在早期诊断以及长期有效的治疗上仍然面临着严峻的挑战。环状RNA（circular RNA, circRNA）是一类具有环形结构的独特RNA分子，具有优异的稳定性以及表达特异性。越来越多的研究发现circRNA在肿瘤中表达异常，这种异常表达不仅与肿瘤的恶性相关，同时可以参与调控肿瘤进展，为肿瘤的诊断与治疗提供了新的思路。因此，本文就circRNA在肺癌中的表达、诊断、预后价值以及发生发展机制展开综述，以期为肺癌的早期诊断与治疗寻找新的靶点。

Comparison Of Long Term Results Between Matched Chemoradiotherapy And Surgery For Limited Stage Small Cell Lung Cancer

Purpose

To compare the efficacy of chemoradiotherapy or surgery for limited-stage small cell lung cancer (SCLC).

Patients and methods

A retrospective analysis was performed on 138 patients with limited-stage SCLC who received surgery (69 patients) or chemoradiotherapy (69 patients) between January 2000 and September 2016 in Zhejiang Cancer Hospital. Patients of the chemoradiotherapy group were selected by using “pair-matched case-control” methodology from a cohort of 503 patients who received chemoradiotherapy.

Results

The major prognostic factors, including T, N stage, treatment duration, age, gender, and whether or not they received prophylactic cranial irradiation were well balanced between two groups. The median overall survival (OS) time and 5-year OS rate were 37.1 months and 45.0% in the surgical group vs 45.0 months and 45.0% in the chemoradiotherapy group (P=0.846). The median progression-free survival (PFS) time and 5-year PFS rate were 27.1 months and 37.8% vs 36.2 months and 40.0%, respectively, in the two groups (P=0.610). The 5-year OS rate (62.3% vs 40.1%, P=0.038) and 5-year PFS rate (80.1% vs 40.1%, P=0.048) in the surgical group were significantly higher than those of the chemoradiotherapy group in patients with stage I disease. The 5-year OS rate (41.2% vs 50.6%, P=0.946) and 5-year PFS rate (64.7% vs 42.1%, P=0.280) of surgery for stage II SCLC were comparable to chemoradiotherapy. As for stage III SCLC, compared with the surgical group, the chemoradiotherapy group had a better 5-year OS trend (25.1% vs 47.6%, P=0.220), but the difference did not reach statistical significance.

Conclusion

Surgery could confer survival benefits in patients with p-stage I disease, but not in patients with p-stage II and III disease.

Defining the role of adjuvant therapy for early-stage large cell neuroendocrine carcinoma

INTRODUCTION

Large cell neuroendocrine carcinoma is a rare, high-grade neuroendocrine tumor. The mainstay of treatment for early, node-negative disease is surgical resection, and optimal adjuvant treatment strategies are not well defined.

METHODS

Patients with early, node-negative large cell neuroendocrine carcinoma were identified in the National Cancer Database from 2004 to 2014. Patient, tumor, treatment, and hospital characteristics were examined. Survival differences in patients receiving adjuvant chemotherapy (AC) were evaluated using Kaplan-Meier curves, and adjusted multivariate Cox models were constructed. A conditional landmark analysis was used to address immortal time bias. T-stage-specific propensity score matching was used to address covariate imbalances between groups.

RESULTS

One thousand seven hundred seventy patients were identified, of whom 463 (26.2%) received AC. Patients receiving AC were younger, less comorbid, and more likely to have T2 tumors. AC was associated with significantly longer survival, which persisted after adjustment in Cox models, for patients overall (5-year overall survival, 59.2% vs 45.3%; hazard ratio, 0.69; 95% confidence interval, 0.58-0.82; P < .0001), T2 tumors (overall survival, 59.8% vs 42.1%; hazard ratio, 0.63; 95% confidence interval, 0.50-0.81; P < .0001), and tumors 2 to 3 cm (overall survival, 60.0% vs 42.6%; hazard ratio, 0.64; 95% confidence interval, 0.46-0.8; P = .002), but not tumors smaller than 2 cm. Adjuvant chest radiotherapy was not associated with longer survival. Sublobar resection was associated with worse overall survival compared with lobectomy (hazard ratio, 1.40; 95% confidence interval, 1.20-1.64; P < .0001). Propensity score matching confirmed these findings, but the association with survival for tumors 2 to 3 cm in size was not significant.

CONCLUSIONS

In this national study of early-stage large cell neuroendocrine carcinoma, AC was associated with significantly longer survival for tumors larger than 3 cm, and possibly for tumors 2 to 3 cm. Adjuvant radiation was not associated with prolonged survival.

Survival after adjuvant radiation therapy in localized small cell lung cancer treated with complete resection

OBJECTIVES

To determine whether there is an overall survival (OS) benefit to the addition of thoracic radiation therapy (RT) following R0 resection of pathologic (p) T1 or pT2 N0 M0 small cell lung cancer.

METHODS

Using the National Cancer Database, we performed a retrospective cohort analysis. Patients who underwent R0 resection for pT1 or p2 N0 M0 small cell lung cancer, stratified by receipt of adjuvant thoracic RT, were compared on the basis of OS using hierarchical Cox Proportional hazards models.

RESULTS

Of 4969 patients diagnosed with pT1or pT2 N0 M0 SCLC from 2004 to 2014, 1617 (33%) underwent R0 resection of their primary tumor; of these resected patients, 146 (9.0%) had adjuvant thoracic RT. In unadjusted analysis, there was no significant difference in OS between groups (median survival: surgery alone, 62.2 months vs surgery+RT, 43.8 months; P = .1436). In multivariable analysis, RT was not associated with improved survival (P = .099). There was no significant difference in unadjusted or adjusted survival associated with receipt of RT in both a young and healthy cohort (P = .647 for unadjusted and P = .858 for adjusted) and a matched cohort (P = .867 and P = .954). In the matched cohort, improved OS was associated with younger patient age (adjusted hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), female sex (adjusted hazard ratio, 0.68, 95% confidence interval, 0.47-0.97; P = .035), and smaller tumors (adjusted hazard ratio, 1.02; 95% confidence interval, 1.01-1.03; P = .005). Having 2 or more comorbidities was associated with worse OS (adjusted hazard ratio, 2.16; 95% confidence interval, 1.21-3.86; P = .009).

CONCLUSIONS

Although complete resection was accomplished in a minority of patients, for these patients, survival was good. The addition of thoracic RT to complete resection does not appear to confer additional survival benefit.

Benefits of surgery in the multimodality treatment of stage IIB-IIIC small cell lung cancer

Surgery combined with chemotherapy/radiotherapy is recommended for early stage small cell lung cancer (SCLC); however, the role of surgery in the multimodality treatment of advanced disease remains controversial. The clinical data of patients between 2000 and 2015 were obtained from the Surveillance, Epidemiology, and End Results database. The surgery group included 998 patients with stage IIB-IIIC. A matched non-surgery group (n = 2994) was generated by propensity score matching. The Kaplan-Meier method and log-rank tests were used for survival analyses. Univariate and multivariate analyses were used to identify significant prognostic factors. After matching, there were no significant differences between the two groups in race, age, sex, T classification, N classification, TNM stage, marital status, primary sites, and origin record NAACCR Hispanic Identification Algorithm (NHIA). The surgery group showed better overall survival and cancer-specific survival than the non-surgery group. Univariate and multivariate analyses showed that therapy methods, age, sex, T classification, and N classification were independent prognostic predictors for stage IIB-IIIC SCLC (all P < 0.05). Stratified analyses showed that survival outcomes favored surgery in any age groups, men and women, any T classification except T3, and N0-2 but not N3 compared with non-surgical treatment. The survival differences favored surgery in stage IIB and IIIA SCLC, although they were not significant in stage IIB and IIIC SCLC. Therefore, surgery was associated with improved survival in stage IIB and IIIA SCLC, but not in stage IIIB and IIIC SCLC.

Long-term Survival After Surgery Compared With Concurrent Chemoradiation for Node-negative Small Cell Lung Cancer

OBJECTIVE

To determine whether surgery with adjuvant chemotherapy offers a survival advantage over concurrent chemoradiation for patients with cT1-2N0M0 small cell lung cancer (SCLC).

BACKGROUND

Although surgery with adjuvant chemotherapy is the recommended treatment for patients with cT1-2N0M0 SCLC per international guidelines, there have been no prospective or retrospective studies evaluating the impact of surgery versus optimal medical management for cT1-2N0M0 SCLC.

METHODS

Outcomes of patients with cT1-2N0M0 SCLC who underwent surgery with adjuvant chemotherapy or concurrent chemoradiation in the National Cancer Data Base (2003-2011) were evaluated using Cox proportional hazards analyses and propensity-score-matched analyses.

RESULTS

During the study period, 681 (30%) patients underwent surgery with adjuvant chemotherapy and 1620 (70%) underwent concurrent chemoradiation. After propensity-score matching, all 14 covariates were well balanced between the surgery (n = 501) and concurrent chemoradiation (n = 501) groups. Surgery was associated with a higher overall survival (OS) than concurrent chemoradiation (5-year OS 47.6% vs 29.8%, P < 0.01). To minimize selection bias due to comorbidities, we limited the propensity-matched analysis to 492 patients with no comorbidities; surgery remained associated with a higher OS than concurrent chemoradiation (5-year OS 49.2% vs 32.5%, P < 0.01).

CONCLUSIONS

In a national analysis, surgery with adjuvant chemotherapy was used in the minority of patients for early stage SCLC. Surgery with adjuvant chemotherapy for node-negative SCLC was associated with improved long-term survival when compared to concurrent chemoradiation. These results suggest a significant underuse of surgery among patients with early stage SCLC and support an increased role of surgery in multimodality therapy for cT1-2N0M0 SCLC.

Utilization of Surgery and Its Impact on Survival in Patients With Early Stage Small-cell Lung Cancer in the United States

INTRODUCTION

For patients with T1 or T2 N0 M0 small-cell lung cancer (SCLC), lobectomy followed by chemotherapy is the standard of care. However, because of its tendency for early dissemination, patients are often treated with concurrent chemo-radiation without surgery. This study was conducted to evaluate the utilization of surgery and its impact on survival in patients with early stage SCLC.

MATERIALS AND METHODS

The National Cancer Database was queried to identify patients with T1 or T2 N0 M0 SCLC diagnosed from 2004 to 2013. Multivariate logistic regression modeling was utilized to identify factors associated with receipt of surgery. Patients were stratified into 3 groups: chemo-radiation, surgery followed by chemotherapy, and surgery followed by chemotherapy and prophylactic cranial irradiation (PCI). Kaplan-Meier estimators and Cox proportional-hazards regression were used to compare overall survival. Patients were matched on the propensity score.

RESULTS

A total of 3879 SCLC cases were identified. Of those cases, 80.7% received chemo-radiation. Surgery followed by chemotherapy with or without PCI was associated with better median overall survival (93.0 months [lower 95% confidence interval (CI), 72.5] and 61.7 months [95% CI, 51.8-76.5], respectively) compared with chemo-radiation (31.2 months [95% CI, 26.3-37.0]). PCI offered survival benefit in addition to surgery and chemotherapy (hazard ratio, 0.75).

CONCLUSIONS

Our study showed a significant survival benefit with surgery (lobectomy or more), adjuvant chemotherapy, and PCI in patients with T1-T2 N0 M0 SCLC.

Stereotactic body radiotherapy versus conventional radiotherapy for early-stage small cell lung cancer

Purpose

This study was designed to compare survival outcomes for non-surgically managed T1-T2N0M0 small cell lung cancer (SCLC) who received either stereotactic body radiation therapy (SBRT) or conventionally fractionated radiotherapy (CFRT) using the National Cancer Data Base (NCDB).

Methods

The was queried between 2004-2015 for patients with T1-T2N0M0 SCLC. Patients must have been treated with curative intent SBRT or CFRT (delivered daily or twice daily, 45-70 Gy) with or without chemotherapy. The primary outcome was overall survival (OS). A subset analysis of patient receiving chemotherapy was also performed. A propensity score matched (PSM) analysis was performed to compare OS among patients who received chemotherapy.

Results

We evaluated 1378 patients in the general cohort. Multivariable Cox regression analysis(MVA) in the general cohort revealed that SBRT was significantly associated with improved survival (HR 0.68, p<0.001) along with receipt of chemotherapy (HR 0.63, p <0.001). SBRT patients were less likely to receive chemotherapy compared to CFRT patients (p<0.01). In the chemotherapy subset, of 1096 patients, on MVA, there was a trend in favor of the SBRT group (HR 0.73; p=0.06). A 3:1 PSM analysis on the chemotherapy subset found similar results on MVA with a trend in favor of SBRT (p=0.06).

Conclusion

Patients with T1-2N0M0 SCLC treated with SBRT regimens incorporating chemotherapy had comparable outcomes to concurrent chemoradiotherapy using standard fractionation. Treatment paradigms for T1-2N0M0 SCLC incorporating SBRT warrant further exploration and should incorporate chemotherapy.

Cause-specific death assessment of patients with stage I small-cell lung cancer: a competing risk analysis

Aim: Stage I small-cell lung cancer (SCLC) is a potentially curable disease that needs timely and multidisciplinary management. The aim of this study was to evaluate the probability of cause-specific mortality for patients with stage I SCLC. Material & methods: We identified patients in the SEER database and constructed a proportional subdistribution hazard model to evaluate cancer-specific mortality. A nomogram was built based on Fine and Gray competing risk regression model. Results: A total of 864 stage I SCLC patients were identified. The 5-year cumulative incidence of SCLC-specific mortality was 56.2%, while that for other causes of death was 17.3%. The c-index for the prognostic prediction model was 0.66. Besides, the nomogram was well calibrated. Conclusion: Our nomogram might serve as a reference for clinicians when evaluating the prognosis of stage I SCLC.

Adjuvant Therapy for Patients With Early Large Cell Lung Neuroendocrine Cancer: A National Analysis

BACKGROUND

Current guidelines do not routinely recommend adjuvant therapy for resected stage I large cell lung neuroendocrine cancer (LCNEC). However, data regarding the role of adjuvant therapy in early LCNEC are limited. This National Cancer Database (NCDB) analysis was performed to improve the evidence guiding adjuvant therapy for early LCNEC.

METHODS

Overall survival (OS) of patients with pathologic T1-2a N0 M0 LCNEC who underwent resection in the NCDB from 2003 to 2015 was evaluated with Kaplan-Meier and multivariable Cox proportional hazards analyses. Patients who died within 30 days of surgery and with more than R0 resection were excluded.

RESULTS

Of 2642 patients meeting study criteria, 481 (18%) received adjuvant therapy. Adjuvant chemotherapy in stage IB patients was associated with a significant increase in OS (hazard ratio, 0.67; 95% confidence interval, 0.50 to 0.90). However, there was no significant difference in survival between adjuvant chemotherapy and no adjuvant therapy for stage IA LCNEC (hazard ratio, 0.92; 95% confidence interval, 0.75 to 1.11). Adjuvant radiotherapy, whether alone or combined with chemotherapy, was not associated with a change in OS. In subgroup analysis, patients receiving adjuvant chemotherapy after lobar resection for stage IB LCNEC had a significant survival benefit compared with patients not receiving adjuvant therapy.

CONCLUSIONS

In early-stage LCNEC, adjuvant chemotherapy appears to confer an additional overall survival advantage only in patients with completely resected stage IB LCNEC and not for patients with completely resected stage IA LCNEC.

Heterogeneous tumor features and treatment outcome between males and females with lung cancer (LC): Do gender and sex matter?

Lung cancer (LC) is the leading cause of cancer-related death worldwide, despite a decreasing incidence rate in recent years, especially in men. Most risk factors for LC could be linked to an individual's reproductive system and secondary sex characteristics ('sex-related') and/or to some physical, behavioral and personality traits ('gender-related') peculiar to males rather than females or vice versa. An imbalance of these etiologic factors could explain why some LC features may differ between sexes. For this review, an extended literature data collection was performed, using keywords to identify 'sex/gender' and 'LC'. Differences between genders in LC epidemiology, pathological and molecular characteristics, loco-regional and/or systemic treatments outcome and prognosis were systematically analyzed. The possible predictive role of physio-pathological factors in males and females paves the way for a personalized therapeutic approach, emphasizing the need to include gender as a stratification factor in future clinical trials design.

Choice of surgical procedure - lobectomy, segmentectomy, or wedge resection - for patients with stage T1-2N0M0 small cell lung cancer: A population-based study

Background

To date, few studies have evaluated the impact of lobectomy versus sublobar resection for early small cell lung cancer (SCLC). We investigated the survival rates of patients with pathological stage T1‐2N0M0 SCLC who underwent lobectomy or sublobar resection.

Methods

We identified 548 SCLC patients in the Surveillance, Epidemiology, and End Results database who underwent lobectomy or sublobar resection. Propensity score matching (PSM) and Cox regression analysis were used to adjust for baseline characteristics.

Results

The three‐year overall survival (OS) of patients treated with lobectomy (n = 376, 60%) was significantly higher than those treated with sublobar resection (n = 172, 38%). PSM and Cox multivariable analysis further confirmed this result (hazard ratio [HR] 0.543, 95% confidence interval [CI] 0.421–0.680; P < 0.001). The three‐year OS of patients treated with segmentectomy (n = 24, 54%) and wedge resection (n = 148, 36%) was not significantly different (HR 0.639, 95% CI 0.393–1.039; P = 0.071). Based on PSM analysis, segmentectomy conferred a superior survival advantage to patients relative to wedge resection (HR 0.466, 95% CI 0.221–0.979; P = 0.040).

Conclusion

Lobectomy correlated with superior survival. For patients in which lobectomy is unsuitable, prognosis following segmentectomy appears to be better than after wedge resection.

Association of Chemoradiotherapy With Outcomes Among Patients With Stage I to II vs Stage III Small Cell Lung Cancer: Secondary Analysis of a Randomized Clinical Trial

Importance

There is limited evidence to guide stage I to II small cell lung cancer (SCLC) treatment.

Objective

To examine the characteristics and outcomes among patients with stage I to II SCLC treated with modern chemoradiotherapy.

Design, Setting, and Participants

In this post hoc secondary analysis of the Concurrent Once-Daily vs Twice-Daily Radiotherapy Trial (CONVERT), a multicenter phase 3 trial conducted in patients with limited-stage SCLC from April 7, 2008, to November 29, 2013, patients with TNM stage I to II SCLC were compared with those with stage III disease. Data analysis was performed from November 1, 2017, to February 28, 2018.

Interventions

In CONVERT, patients were randomized to receive twice-daily (45 Gy in 30 fractions) or once-daily (66 Gy in 33 fractions) chemoradiotherapy. Prophylactic cranial irradiation (PCI) was offered, if indicated.

Main Outcomes and Measures

The primary trial end point was overall survival (OS). TNM staging information was collected prospectively; this was an unplanned analysis because stratification was not performed according to TNM stage.

Results

A total of 509 (277 [54.4%] men; mean [SD] age, 61.5 [8.3] years) of 543 patients (93.7%) with TNM staging information were eligible for this subgroup analysis, and 86 of the 509 (16.9%) had TNM stage I to II disease. The median gross tumor volume was smaller in patients with stage I to II disease (38.4 cm3; range, 2.2-593.0 cm3) compared with patients with stage III disease (93 cm3; range, 0.5-513.4 cm3) (P < .001). No other significant differences were found in baseline and treatment characteristics and chemoradiotherapy adherence between the 2 groups or the number of patients with stage I to II disease (78 [90.7%]) and stage III disease (346 [81.8%]) who received PCI (P = .10). Patients with stage I to II disease achieved longer OS (median, 50 months [95% CI, 38 to not reached months] vs 25 months [95% CI, 21-29 months]; hazard ratio, 0.60 [95% CI, 0.44-0.83]; P = .001) compared with patients with stage III disease. In patients with stage I to II disease, no significant survival difference was found between the trial arms (median, 39 months in the once-daily arm vs 72 months in the twice-daily arm; P = .38). Apart from lower incidence of acute esophagitis in patients with stage I to II disease compared with patients with stage III disease (grade ≥3, 9 [11.3%] vs 82 [21.1%]; P < .001), the incidences of acute and late toxic effects were not significantly different.

Conclusions and Relevance

Patients with stage I to II SCLC in CONVERT achieved long-term survival with acceptable toxic effects after chemoradiotherapy and PCI. This study suggests that patients with stage I to II small cell lung cancer treated with modern chemoradiotherapy have better outcomes compared with patients with stage III disease, providing information that practitioners can potentially give their patients to aid clinical decisions.

Trial Registration

ClinicalTrials.gov identifier: NCT00433563.

Prophylactic cranial irradiation is associated with improved survival following resection for limited stage small cell lung cancer

Background

Brain metastases are a major cause of mortality in patients with small cell lung cancer (SCLC). Prophylactic cranial irradiation (PCI) may improve survival among patients that respond to chemotherapy. Less is known about the outcomes of PCI following surgical resection of SCLC. The purpose of this study was to determine if patients who underwent initial surgical resection of SCLC benefit from PCI.

Methods

Adult patients in the National Cancer Database (NCDB) who underwent complete resection for primary, non-metastatic SCLC between 2004 and 2015 were identified. Patients that received preoperative chemotherapy or who did not receive appropriate adjuvant chemotherapy were excluded. Patients were grouped by treatment with or without cranial radiation within 8 months of resection. Survival was estimated using Kaplan-Meier and Cox multivariable analysis, adjusting for patient and tumor characteristics.

Results

A total of 859 patients met inclusion criteria (202 received PCI and 657 did not). Kaplan-Meier analysis demonstrated that patients treated with PCI had significantly improved survival compared to no PCI (5-year survival 59% vs. 50%, logrank P=0.0038). Multivariable cox models confirmed a significantly decreased hazard of death for patients receiving PCI (HR: 0.70, 95% CI: 0.55-0.89, P=0.003). In subset analyses, PCI was associated with significantly improved survival for node positive patients, but not node negative patients.

Conclusions

PCI is associated with increased survival for patients following surgical resection of SCLC. Patients with positive lymph nodes appear to benefit the most, while it remains unclear if patients with negative lymph nodes derive a benefit. Further study is warranted to clarify which subsets of patients should be treated with PCI.

Prognostic Analysis of Limited Resection Versus Lobectomy in Stage IA Small Cell Lung Cancer Patients Based on the Surveillance, Epidemiology, and End Results Registry Database

Objective: The prognostic analysis of limited resection vs. lobectomy in stage IA small cell lung cancer (SCLC) remains scarce. Methods: Using the Surveillance, Epidemiology, and End Results registry (SEER) database, we identified patients who were diagnosed with pathological stage IA (T1a/bN0M0) SCLC from 2004 to 2013. The overall survival (OS) and lung cancer-specific survival (LCSS) rates of patients with different treatment schemes were compared in stratification analyses. Univariable and multivariable analyses were also performed to identify the significant predictors of OS and LCSS. Results: In total, we extracted 491 pathological stage IA SCLC patients, 106 (21.6%) of whom received lobectomy, 70 (14.3%) received sublobar resection and 315 (64.1%) received non-surgical treatment, respectively. There were significant differences among the groups based on different treatment schemes in OS (log-rank p < 0.0001) and LCSS (log-rank p < 0.0001). Furthermore, in subgroup analyses, we did not identify any differences between sublober resection group and lobectomy group in OS (log-rank p = 0.14) or LCSS (log-rank p = 0.4565). Patients with four or more lymph node dissection had better prognosis. Multivariable analyses revealed age, laterality, tumor location, and N number were still significant predictors of OS, whereas age, tumor location, and N number were significant predictors of LCSS. Conclusion: Surgery is an important component of multidisciplinary treatment for stage IA SCLC patients and sublober resection is not inferior to lobectomy for the specific patients.

The impact of prophylactic cranial irradiation for post-operative patients with limited stage small cell lung cancer

To evaluate the impact of prophylactic cranial irradiation (PCI) on the prognosis of patients who received definitive surgery for surgically resected small cell lung cancer (SCLC).A retrospective analysis was performed on post-operative SCLC patients treated in Zhejiang Cancer Hospital from January 2003 to December 2015. According to the treatment modality, patients were allocated to PCI group and non-PCI group. Univariate survival analysis was performed by the Kaplan-Meier method. Multivariate survival analysis was performed by a Cox proportional hazards model.A total of 52 patients were included for analysis, among which, 19 patients were in PCI group and 33 were in non-PCI group. Multivariate analysis revealed that PCI (HR = .330; P = .041) was an independently favorable prognostic factor for the overall survival. The median overall survival (OS) time was 32.9 months in PCI group, and 20.4 months in non-PCI group. The 2-year OS rates were 78.0% and 38.0% in PCI and non-PCI group respectively (P = .023). The brain metastasis-free survival (BMFS) rate at 2-year in PCI group was significantly higher than those of non-PCI group (89.0% vs 53.0%, respectively, P = .026).In conclusion, PCI might be suggested for limited SCLC patients who received definitive surgery.

Is prophylactic cranial irradiation necessary in individuals suffering from surgically resected pT1-2N0M0 small cell lung cancer?

Adjuvant chemotherapeutics and prophylactic cranial irradiation (PCI) are both recommended in the National Comprehensive Cancer Network (NCCN) guidelines for treating individuals suffering from surgically resected pT1-2N0M0 small cell lung cancer (SCLC). Whether adjuvant chemotherapy combined with PCI is superior to adjuvant chemotherapy alone in these patients is largely unknown. PCI may therefore be with uncertain effects in surgically resected pT1-2N0M0 SCLC.

Prophylactic cranial irradiation in small-cell lung cancer: update on patient selection, efficacy and outcomes

Over 10% of small-cell lung cancer (SCLC) patients have brain metastases (BM) at initial diagnosis; more than 50% will develop BM within 2 years. BM are detected in up to 80% of all patients at autopsy. After primary treatment, prophylactic cranial irradiation (PCI) has been established as standard of care in SCLC patients responding to initial therapy. Based on level I evidence, PCI significantly decreases the risk of intracranial relapse and shows a modest survival benefit after 3 years. However, the role of PCI in defined patient subgroups such as resected SCLC, elderly and extensive stage patients with access to magnetic resonance imaging surveillance and stereotactic radiotherapy is yet to be fully clarified. Furthermore, strategies to effective prevention of neurocognitive decline after PCI remain unclear. All these factors significantly impact treatment decision making and should be evaluated in prospective settings. New concepts such as hippocampal avoidance and drug neuroprotection prevent chronic neurocognitive effects reducing treatment-related side effects of PCI. The aim of this review is to present a summary and update of the latest evidence for patient selection, efficacy and outcome of PCI.

The role of prophylactic cranial irradiation in surgically resected combined small cell lung cancer: a retrospective study

Background

Combined small cell lung cancer (C-SCLC) is defined as small cell lung cancer (SCLC) combined with any of non-small cell lung cancer (NSCLC) histological types, such as large cell carcinoma, squamous cell carcinoma, or adenocarcinoma. Since C-SCLC is an increasingly recognized subtype of small cell carcinoma, we conducted a retrospective study in our institution to explore the value of prophylactic cranial irradiation (PCI) in patients with C-SCLC treated by surgery.

Methods

Between 2005 and 2014, the records of all consecutive patients with pathologically diagnosed C-SCLC after surgery in our institution were reviewed. Overall survival (OS), disease-free survival (DFS), and brain metastasis free survival (BMFS) were estimated by Kaplan-Meier method. Survival differences were evaluated by log-rank test, while multivariate analysis was performed by a Cox proportional hazards model.

Results

Of the total 91 patients included in this analysis, 11 patients (12.1%) were in PCI group and 80 (87.9%) in non-PCI group. The 5-year cumulative incidence of brain metastasis in the whole group was 22.2% (26.3% in non-PCI group vs. 0% in PCI group), and 5-year OS rate was 44.1%. Patients treated with PCI had significantly longer OS (P=0.011) and DFS (P=0.013), also had the trend to live a longer BMFS with marginal significance (P=0.092) than non-PCI-treated patients. The multivariate analysis showed that PCI [hazard ratio (HR) =0.102, P=0.024] was one of independent prognostic factors of the OS in surgery-treated C-SCLC patients.

Conclusions

C-SCLC patients have a relative high risk of developing brain metastases based on our study. These data showed that PCI could improve OS and DFS, as well as tend to decrease brain metastases in surgically resected C-SCLC. However, whether PCI could be part of comprehensive treatment modalities in C-SCLC should be assessed in prospective studies.

The role of prophylactic cranial irradiation for patients with small-cell lung cancer

Small-cell lung cancer (SCLC) has a particular propensity to metastasize to the brain, affecting ~10% of SCLC patients at diagnosis, but may occur in more than 50% of 2-year survivors. Most cytotoxic drugs have limited ability to cross the blood-brain barrier, and the effectiveness of chemotherapy for brain metastasis is limited. Therefore, prophylactic cranial irradiation (PCI) has been proposed to treat SCLC. A meta-analysis revealed that PCI significantly decreased the risk of brain metastasis and increased the 3-year survival rate; it has been established as a standard therapy for limited-disease SCLC. However, certain aspects of PCI remain unclarified, including the roles in resected SCLC and extensive-disease SCLC, and its neurotoxicities. In addition, information on PCI has been obtained from old clinical trials without the use of new imaging devices, such as magnetic resonance imaging. Evidence from advanced imaging techniques is needed in this era.

Comparing Treatment Strategies for Stage I Small-cell lung Cancer

INTRODUCTION

The diagnosis of stage I small-cell lung cancer (SCLC) is increasing in incidence with the advent of low-dose screening computed tomography. Surgery is considered the standard of care but there are very few data to guide clinical decision-making. The purpose of this study was to compare outcomes for patients receiving definitive surgery, stereotactic body radiation therapy (SBRT), or external beam radiation therapy (EBRT) for stage I SCLC.

PATIENTS AND METHODS

Patients with a primary diagnosis of stage I SCLC were identified in the National Cancer Database. Patients were defined as having a first course of treatment of either surgery, EBRT, or SBRT. Overall survival (OS) was determined using the Kaplan-Meier method and Cox proportional hazards regression methods were used to estimate risk of overall mortality.

RESULTS

A total of 2678 patients were included in the analysis. The 2- and 3-year OS for the whole cohort was 62% and 50%. Comparing treatment strategies in a multivariate model, surgical resection showed improved OS over EBRT (P < .001) and SBRT (P < .001), however, the OS benefit over SBRT did not persist for patients who underwent limited resection. When excluding patients who underwent surgery, SBRT showed improved OS compared with EBRT (P = .04). Additional use of chemotherapy with any treatment modality resulted in improved OS (P < .001).

CONCLUSION

In this hospital-based registry study, definitive surgical resection and use of chemotherapy resulted in improved survival for patients with early stage SCLC. For patients who are not candidates for surgery, SBRT may offer a survival benefit compared with standard EBRT.