Small cell lung cancer: analysis of treatment factors contributing to prolonged survival

Somatostatin and Somatostatin Receptors in Tumour Biology

Somatostatin (SST), a growth hormone inhibitory peptide, is expressed in endocrine and non-endocrine tissues, immune cells and the central nervous system (CNS). Post-release from secretory or immune cells, the first most appreciated role that SST exhibits is the antiproliferative effect in target tissue that served as a potential therapeutic intervention in various tumours of different origins. The SST-mediated in vivo and/or in vitro antiproliferative effect in the tumour is considered direct via activation of five different somatostatin receptor subtypes (SSTR1-5), which are well expressed in most tumours and often more than one receptor in a single cell. Second, the indirect effect is associated with the regulation of growth factors. SSTR subtypes are crucial in tumour diagnosis and prognosis. In this review, with the recent development of new SST analogues and receptor-specific agonists with emerging functional consequences of signaling pathways are promising therapeutic avenues in tumours of different origins that are discussed.

Surgical Resection in the Treatment of Stages I-II of Small Cell Lung Carcinoma (SCLC)

From 1981 to 1986, 17 patients with resected small cell lung carcinoma (SCLC) staged as I or II according to the new TNM classification were recruited for a prospective study to evaluate the effctiveness of surgery and postoperative chemotherapy (plus locoregional radiotherapy only when a nonradical resection was accomplished) in the treatment of early stages of the disease. Six patients received full protocol chemotherapy (6 courses) and 8 a mean of 79.1% of the planned courses. Three patients received non adjuvant treatment. Locoregional radiotherapy for residual disease was administered in 2 cases. One patient died for myelosuppression due to chemotherapy and 10 for recurrences of cancer, all within the 20th postoperative month. Metastases accounted 80% of overall recurrences. Six patients were alive and tumor-free at 18, 22, 39, 44, 47 and 51 months from resection. Actuarial observed 3-year survival was 32%.

Recall Those Thrilling Days of Yesteryear …

This editorial explores Burris's examination, in this issue, of combined modality anticancer treatment and radiation recall.

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.

Time between the first day of chemotherapy and the last day of chest radiation is the most important predictor of survival in limited-disease small-cell lung cancer

PURPOSE

To identify time factors for combined chemotherapy and radiotherapy predictive for long-term survival of patients with limited-disease small-cell lung cancer (LD-SCLC).

METHODS

A systematic overview identified suitable phase III trials. Using meta-analysis methodology to compare results within trials, the influence of the timing of chest radiation and the start of any treatment until the end of radiotherapy (SER) on local tumor control, survival, and esophagitis was analyzed. For comparison between studies, the equivalent radiation dose in 2-Gy fractions, corrected for the overall treatment time of chest radiotherapy, was analyzed.

RESULTS

The SER was the most important predictor of outcome. There was a significantly higher 5-year survival rate in the shorter SER arms (relative risk [RR] = 0.62; 95% CI, 0.49 to 0.80; P = .0003), which was more than 20% when the SER was less than 30 days (upper bound of 95% CI, 90 days). A low SER was associated with a higher incidence of severe esophagitis (RR = 0.55; 95% CI, 0.42 to 073; P < .0001). Each week of extension of the SER beyond that of the study arm with the shortest SER resulted in an overall absolute decrease in the 5-year survival rate of 1.83% +/- 0.18% (95% CI).

CONCLUSION

A low time between the first day of chemotherapy and the last day of chest radiotherapy is associated with improved survival in LD-SCLC patients. The novel parameter SER, which takes into account accelerated proliferation of tumor clonogens during both radiotherapy and chemotherapy, may facilitate a more rational design of combined-modality treatment in rapidly proliferating tumors.

The pulmonary status of patients with limited-stage small cell lung cancer 15 years after treatment with chemotherapy and chest irradiation

STUDY OBJECTIVES

To describe pulmonary symptoms, signs, pulmonary function, and lung imaging studies in patients with limited-stage small cell lung cancer (SCLC) 2 to 15 years after receiving treatment with chemotherapy and chest radiotherapy.

DESIGN

Retrospective review of clinical records and radiographic studies of patients treated in three different prospective combined-modality studies.

SETTING

Federal hospital.

PATIENTS

One hundred fifty-six patients with SCLC who were enrolled between 1974 and 1994.

INTERVENTIONS

Patients with limited-stage SCLC treated on prospective therapeutic studies of combined chemotherapy and radiation therapy were identified. Pulmonary symptoms, physical findings, pulmonary function tests, arterial blood gas measurements, and chest imaging studies were assessed at baseline, and at 1 to 2 years, at 3 to 5 years, and at > 5 years following the initiation of treatment.

MEASUREMENTS AND RESULTS

Initial symptoms included cough in 84 (55%), dyspnea in 59 (39%), and sputum production in 26 (17%). Twenty-three patients lived beyond 5 years (15%) without evidence of recurrence. Seven of these 5-year survivors were without pulmonary symptoms. Pulmonary function test results showed no significant changes in percent predicted values for FVC, FEV(1), and FEV(1)/FVC ratio over the time periods reviewed. The percent predicted values for the diffusing capacity of the lung for carbon monoxide decreased from 71% before the start of treatment to 56% (p < 0.032) at 1 to 2 years. Values improved in most patients beyond 5 years after starting treatment. Radiologist interpretations of chest imaging studies were available for 17 of 23 patients surviving > 5 years. Most patients had minimal to no changes in imaging study findings beyond 5 years.

CONCLUSIONS

Long-term survivors with limited-stage SCLC who were treated with combined chemotherapy and chest radiotherapy have minimal changes in pulmonary symptoms or function from 5 to 15 years after the start of treatment. A concern for late toxicity from combined-modality therapy should not dissuade clinicians from offering therapy with potentially curative result with minimal to no pulmonary dysfunction.

A case of long-term survival with stage IV small cell lung cancer and early-stage central-type squamous cell lung cancer treated by photodynamic therapy

The present report is on a 67-year-old man with stage IV small cell lung cancer and early-stage centrally located squamous cell cancer of the lung. He was diagnosed as small cell lung cancer with multiple metastasis to the ipsilateral lung and was found to have a central-type early-stage squamous cell cancer by bronchoscope. After obtaining a complete response to the small cell lung cancer with chemotherapy and radiotherapy, photodynamic therapy was applied to the squamous cell carcinoma, resulting in complete disappearance of the tumor. Recurrence of small cell cancer occurred at the ipsilateral lung and this patient died of small cell cancer 8 years after initiation of treatment. Post mortem examination confirmed complete disappearance of squamous cell cancer treated by photodynamic therapy. This is a rare case of long-term survival with stage IV small cell lung cancer and early-stage central-type squamous cell lung cancer successfully treated by photodynamic therapy.

Outcome of patients with small-cell lung cancer during 20 years of clinical research at the US National Cancer Institute

OBJECTIVE

To determine the outcome of all patients with small-cell lung cancer (SCLC) treated at the US National Cancer Institute between April 1973 and April 1993.

DESIGN

We retrospectively analyzed a series of 594 consecutive patients with SCLC treated at a single institution during a 20-year period to assess changes in duration of survival and toxicity related to various treatment regimens.

MATERIAL AND METHODS

For analysis, patients were grouped by decade, and the duration of survival of patients with limited- and extensive-stage SCLC was examined to assess whether patients treated during the first decade of the study (1973 through 1983), when cyclophosphamide-based regimens were used, had different outcomes than those treated during the second decade (1983 through 1993), when cisplatin-based regimens were used. Patients had a minimal follow-up of 2 years.

RESULTS

No significant difference was found in the survival of patients with limited- or extensive-stage SCLC treated during the second decade in comparison with during the first decade of the study. Among patients with extensive-stage SCLC, performance status 3 or 4 and metastatic lesions of the liver and central nervous system had a significant adverse effect on survival in both the first and the second decade. Among patients with limited-stage disease, performance status 3 or 4 had the most significant adverse influence on survival during the overall study period. In addition, in a multivariate analysis, etoposide-cisplatin plus twice-daily chest radiotherapy was significantly associated with prolonged survival (P = 0.003).

CONCLUSION

We noted no significant change in the duration of survival of patients with either limited-or extensive-stage SCLC treated at our institution during a 20-year period. A multivariate analysis showed that patients with limited-stage SCLC given a cisplatin-based regimen plus chest radiotherapy lived modestly longer than similar patients given cyclophosphamide regimens at our institution. No evidence was found of changes in pretreatment factors that would affect survival.

Retreatment of patients surviving cancer-free 2 or more years after initial treatment of small cell lung cancer

STUDY OBJECTIVE

To assess the outcome after retreatment of patients with small cell lung cancer (SCLC) who redevelop small cell cancer (SCC) 2 or more years after initial therapy.

DESIGN

Retrospective analysis.

SETTING

Single government institution: the National Cancer Institute.

PATIENTS

Twenty patients who redeveloped SCC among 65 patients who survived 2 or more years after starting treatment for their initial cancer.

MEASUREMENTS

The response rate of patients after retreatment, the survival duration from the time of redevelopment of SCC, and the toxicities of retreatment.

RESULTS

Twenty patients redeveloped SCC: 18 with a relapse and 2 with a second primary cancer. Sixteen received treatment after they redeveloped SCLC while four did not. Eleven patients were retreated with chemotherapy alone, two patients received chemotherapy plus chest radiotherapy, one patient received radiotherapy alone, one patient underwent lobectomy, and one patient was treated with a monoclonal antibody followed by chemotherapy. Nine of 16 patients (56%) treated after they redeveloped SCLC had an objective response (3 complete and 6 partial). The median survival of all 20 patients after they redeveloped SCC was 3.9 months (range, 0 to 46 months). The median survival of the patients who were retreated was 6.5 months (range, 1 to 46 months).

CONCLUSIONS

Patients who suffer relapses with SCLC 2 or more years from diagnosis are candidates for retreatment.

[Evaluation of tumor response during chemotherapy of bronchial cancer]

Chemotherapy of lung cancer is still an experimental approach requiring careful evaluation. Tumour response (marker of anticancer activity) is not perfectly correlated to survival (marker of chemotherapy efficacy), but its evaluation remains a milestone inasmuch as reporting a wrong tumour response rate might lead to the rejection of active new treatments. This review deals with the method of tumour response measurements and its use during a chemotherapy protocol. Recommendations drawn from the analysis of the literature are: 1) to assess and classify all lesions which can be identified at the beginning of the treatment; 2) to define the target lesions, mainly the ones which can be bidimensionally measured; 3) to use the World Health Organization recommendations for reporting the overall response; 4) to confirm complete response by negative rebiopsies; 5) to avoid second fiberoptic bronchoscopy to patients with stable or progressive disease on CT-scan, and finally; 6) to assess response quality by evaluating response duration and improvement of quality of life.

Early alternating chemotherapy and radiotherapy schedule in limited disease stage small cell lung cancer

44 patients with limited small cell lung cancer were treated with six cycles of chemotherapy (cisplatinum 60 mg/m2 day 1, doxorubicin 40 mg/m2 day 1, etoposide 100 mg/m2 days 1-3) alternating with three courses of mediastinal irradiation, the first one starting 7 days after the first day of chemotherapy. A total dose of 55 Gy was delivered. Prophylactic cranial irradiation (30 Gy after the third cycle of chemotherapy) was left to the physician's discretion. 4 patients had radical surgery before combined modality treatment. 29 patients finished the scheduled program. The complete response rate (bronchoscopically confirmed) was 25.6% after two cycles of chemotherapy and 41% at the end of treatment. Median survival time was 17.2 months, with an estimated survival of 32% at 2 years. Main toxicity was haematological with one early toxic death and six premature interruptions of treatment. We conclude that this treatment modality is feasible and efficacious. Prospective studies comparing chemotherapy with alternating or concurrent early radiotherapy schedules in limited disease small cell lung cancer are needed to determine the best treatment modality.

Small cell lung cancer: etiology, biology, clinical features, staging, and treatment

Lung cancer is the leading cause of cancer death in the United States. Small cell lung cancer (SCLC) accounts for 20% to 25% of all bronchogenic carcinoma and is associated with the poorest 5-year survival of all histologic types. SCLC differs in its etiologic, pathologic, biologic, and clinical features from non-SCLC, and these differences have translated to distinct approaches to its prevention and treatment. Compared with other histologic types of lung cancer, exposures to tobacco smoke, ionizing radiation, and chloromethyl ethers pose a substantially greater risk for development of SCLC. The histologic classification of SCLC has been revised to include three categories: (1) small cell carcinoma, (2) mixed small cell/large cell, and (3) combined small cell carcinoma. Ultrastructurally, SCLC displays a number of neuroendocrine features in common with pulmonary neuroendocrine cells, including dense core vesicles or neurosecretory granules. These dense core vesicles are associated with a variety of secretory products, cell surface antigens, and enzymes. The biology of SCLC is complex. The activation of a number of dominant proto-oncogenes and the inactivation of tumor suppressor genes in SCLC have been described. Dominant proto-oncogenes that have been found to be amplified or overexpressed in SCLC include the myc family, c-myb, c-kit, c-jun, and c-src. Altered expression of two tumor suppressor genes in SCLC, p53 and the retinoblastoma gene product, has been demonstrated. Cytogenetic and molecular evidence for chromosomal loss of 3p, 5q, 9p, 11p, 13q, and 17p in SCLC has intensified the search for other tumor suppressor genes with potential import in this malignancy. Bombesin/gastrin-releasing peptide, insulin-like growth factor I, and transferrin have been identified as autocrine growth factors in SCLC, with a number of other peptides under active investigation. Several mechanisms of drug resistance in SCLC have been described, including gene amplification, the recently described overexpression of multi-drug resistance-related protein (MRP), and the expression of P-glycoprotein. The classic SCLC staging system has been supplanted by a revised TNM staging system where limited disease and extensive disease are equivalent to the TNM stages I through III and stage IV, respectively. Therapeutically, recent strategies have attained small improvements in survival but significant reductions in the toxicities of chemotherapeutic regimens. Presently, the overall 5-year survival for SCLC is 5% to 10%, with limited disease associated with a significantly higher survival rate.(ABSTRACT TRUNCATED AT 400 WORDS)

Pretreatment staging evaluation in small cell lung carcinoma. A new approach to medical decision making

The real need for extensive staging at the time of diagnosis is discussed in regard to small cell lung carcinoma. We performed a decisional retrospective analysis on a series of 182 patients, based on three staging steps: the first step included physical examination and routine biologic tests. The second step consisted of liver ultrasonography and needle aspiration of any clinically detectable tumor mass, and the third step included bone marrow examination, radionuclide bone scan, thoracic, abdominal, and brain CT scan. A stepwise multivariate logistic regression performed on 11 variables considered in the first step shows that a four-parameter model can predict the spread of the disease (limited or extensive): weight loss, performance status, and elevated LDH or alkaline phosphatase levels. Limited disease can be predicted in two ways: (1) elevated LDH with normal alkaline phosphatases, no weight loss, and good performance status, or (2) normal LDH and alkaline phosphatases. In this series, 28 percent of patients can be predicted as having extensive disease and can be treated with chemotherapy alone without chest irradiation. After the second step, the probability of disease being extensive is only 25 percent, and only 84 (46.15 percent) patients would need to undergo the third step of staging procedures (brain CT scan, bone marrow aspiration and biopsy, radionuclide bone scan) with this method. We conclude that a multistep approach represents a simple staging method and offers the advantage of harmlessness and lower costs for patients not to be evaluated in prospective clinical trials.

Somatostatin and analogues in the treatment of cancer. A review

Somatostatin is a naturally occurring cyclic tetradecapeptide that inhibits release of growth hormone and all gastrointestinal hormones. The beneficial effect of somatostatin in the treatment of certain hypersecretory disorders of hormone excess in well recognized; however its clinical usefulness has been limited in the past by its extremely short plasma half-life. The development of long-acting somatostatin analogues has provided clinically useful agents for treatment of hormone-producing tumors. In addition to well-known inhibiting effects on hormone release and actions, recent studies using experimental tumor models have demonstrated an antiproliferative effect of somatostatin and its analogues on growth of a variety of neoplasms. The exact role of somatostatin analogues in cancer therapy has yet to be established; however studies suggest that these agents could provide a useful and relatively nontoxic adjuvant therapy in the treatment of certain tumors. In this review, the oncologic application of somatostatin and possible mechanism of action are examined and current clinical and experimental studies are summarized.

Alternating radiotherapy and chemotherapy schedules in limited small cell lung cancer: analysis of local chest recurrences

An analysis of the chest recurrences was conducted in 72 consecutive patients with limited small cell lung cancer treated in two successive phase II trials alternating six induction chemotherapy courses and three series of thoracic radiotherapy, followed by maintenance chemotherapy. The total radiation dose was 45 Gy (3 series of 15 Gy) in the first trial, and 55 (20, 20 and 15 Gy) in the second. The effect of the irradiated volume was investigated by comparing the local relapse rates in the group of patients treated by radiation fields encompassing the initial tumor volume to another group in which the initial target volume was not fully covered by radiation fields. The definition of these two groups was performed retrospectively by examination of radiological, fiberoptic bronchoscopy initial findings, technical radiation charts and check films. The local recurrence rate were 33 and 36% in each group (no significant difference). This finding could suggest that tumor shrinkage after chemotherapy might allow the use of "reduced" radiation volumes. However, the limited number of patients does not permit a definite conclusion. The effect of radiation dose was investigated by comparing the local control rates in the two consecutive trials which delivered 45 and 55 Gy, respectively. No difference in long-term local control was found: the addition of 10 Gy in the second trial only seemed to delay the appearance of local recurrences by 6 months. Twenty percent of patients died from a local relapse without evidence of distant metastases.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic radiotherapy variables: influence on local control in small cell lung cancer limited disease

In limited small cell lung cancer (LSCLC), the high local failure rate of chemotherapy by itself (60-100%) and with the addition of external beam radiotherapy (approximately 30%) has led to investigation of methods to improve local control. To that end, we integrated Platinum 60 mg/m2, d. 1, 22 and Etoposide 120 mg/m2, d. 4, 6, & 8; 25, 27 & 29 with concurrent twice-daily 150 cGy (total dose: 4500 cGy). Of 32 consecutively referred patients, 4 with variant histology, 31 were evaluable for toxicity, response, and survival. Two of 4 variant histology patients responded, and 27 of 27 pure small cell responded, p = 0.005. CT scans were inaccurate at forecasting survival. Of 17/32 patients considered "positive," 59% of these were survivors; of those considered "negative," 47% were survivors, p = N.S. Radiation portals were volumetrically conservative; the supraclavicular fossa was included infrequently and the contralateral hilum not at all. Local failure occurred in only 1/27 patients (4%). All four variant patients failed locally, p = 0.001. With a median follow-up of 43 months, the actuarial disease-free survival remains nearly 50%. Variant histology is more predictive of local control than the physical factors of dose or volume.

Long-term outcome of small cell lung cancer

Long-term survival (greater than or equal to 3 years) is possible in a small proportion of patients with SCLC, particularly if the disease is limited in extent. The influence of thoracic irradiation on the long-term outcome of limited stage patients is controversial, although there is a suggestion of benefit. Despite the use of irradiation, thoracic recurrence is the single most important site of treatment failure. Further experience will be necessary to determine if radiotherapeutic strategies to enhance thoracic control can improve long-term survival. Prophylactic cranial irradiation (PCI) may influence long-term survival of limited stage patients who achieve a complete response to therapy and remain controlled in the chest. However, this is not clearly established and must be considered in the light of the contribution of PCI to neurotoxicity occurring in survivors. Reduction in the radiation fraction size and the omission of chemotherapeutic agents which cause neurotoxicity, either alone or by synergism with PCI, are reasonable approaches to pursue in an attempt to prevent this complication. A small proportion of NSCLC occurring after treatment of SCLC may be preventable by attempts to eradicate NSCLC components present in the original SCLC. Leukemogenic chemotherapy agents may contribute to the development of secondary ANL, and should probably not be used in view of the availability of alternative equally effective agents.

Etoposide compared with the combination of vincristine, doxorubicin, and cyclophosphamide in the treatment of small cell lung cancer

One hundred and three patients with small cell lung carcinoma were stratified according to stage of disease (47 limited disease, 56 extensive disease) and then randomised to receive etoposide 300 mg/m2 alone for two days or a combination (VAC) of vincristine 1 mg/m2, doxorubicin (Adriamycin) 50 mg/m2, and cyclophosphamide 1000 mg/m2. The drugs were given at three week intervals. Patients were assessed after three cycles of treatment and continued with the same regimen if in complete remission and with the alternative regimen if in partial remission; they were withdrawn if the disease had progressed. Twenty four patients (23%) achieved complete remission and this occurred more often when patients were receiving VAC (19 of 82) than etoposide (5 of 75). There was no difference, however, in overall survival between those initially treated with etoposide and those having combination chemotherapy, whether for limited disease (both 8 months) or extensive disease (7 and 5.5 months). Toxicity was less with etoposide. Survival was disappointing, especially with limited disease, even in patients who showed a complete response to treatment.

Treatment of small cell lung cancer. Two-drug versus four-drug chemotherapy and loco-regional irradiation with or without prophylactic cranial irradiation

Fifty-five patients with untreated small cell lung cancer were allocated randomly to receive either a standard 2-drug or a 4-drug chemotherapy regimen. The patients were further randomized to receive or not to receive prophylactic cranial irradiation (PCI) 40 Gy/20 fractions/4 weeks. Each patient also received split-course irradiation against the primary tumour (55 Gy/25 fractions/8 weeks), the mediastinum, and the supraclavicular areas. The standard 2-drug regimen consisted of cyclophosphamide 10 mg/kg i.v. days 1-4 and vincristine 1 mg i.v. days 1 + 4; every 4 weeks. The 4-drug regimen comprised cyclophosphamide 10 mg/kg i.v. days 1-3, vincristine 2 mg i.v. day 1 and 1 mg i.v. day 5, methotrexate 30 mg i.v. days 3 and 5, CCNU 80 mg/m2 i.v. day 2; every 7 weeks. The total treatment time for both protocols was 9 to 12 months. Objective response after 2 cycles of chemotherapy was seen in 46% of patients with the 2-drug regimen and in 56% with the 4-drug regimen. Local radiotherapy increased the response rates to 58% and 90% respectively. The median survival time was 12 months with the 2-drug regimen and 14 months with the 4-drug regimen. The 2-year and 3-year survival rates were 11% and 0% in the 2-drug group and 19% and 15% in the 4-drug group respectively. Toxicity was more severe in the 4-drug group with 4 deaths due to myelosuppression. Altogether, 25 patients received PCI. This did not in any subgroup increase median survival significantly but a reduction of relapses in the central nervous system was seen. Median survival was 13 months with versus 10 months without PCI; 2-year survival rates were 15% and 6% respectively. Morbidity due to PCI did not occur. Although no statistically significant survival advantage could be documented, there was obviously a higher rate of complete responses with multidrug therapy, and longer median duration of remission, median survival and maximal survival.

A preliminary report: concurrent twice-daily radiotherapy plus platinum-etoposide chemotherapy for limited small cell lung cancer

From July 1984 through March 1987 23 patients with small cell lung cancer have entered a trial at the University of Pennsylvania. Concurrent Platinum (DDP) Etoposide (VP-16) chemotherapy and twice-daily, 150 cGy radiotherapy to a total dose of 4500 cGy in 3 weeks was used. Besides the twice-daily radiotherapy, multiple field arrangements attempted to minimize normal tissue exposure while concentrating on the target volume. Sophisticated CT-assisted treatment planning employing beams-eye-view technology was used. Esophagitis occurred in 73% (13% severe); hematologic toxicity occurred in 65% (17% WBC less than 1000). Response--100% in pure small cell carcinoma, 91% overall. Median follow-up is 22 months with an actuarial projection of 56% 2-year survival. Median survival is not yet reached. This is a highly effective therapy with substantive but tolerable toxicity. Accrual and follow-up continues. This is a preliminary report. We expect 30 patients before closing the study. A parallel study is underway in the Eastern Cooperative Oncology Group, with a randomized prospective trial in the design stage.

Altered metastatic behavior of small cell carcinoma of the lung after chemotherapy and radiation

Heterogeneity of malignant neoplasms is a recognized phenomenon now, but the implications of this with respect to the responsiveness of carcinomas to different modes of therapy are not known. To examine this question, we reviewed the clinical and pathologic features of 85 autopsied patients with small cell carcinoma of the lung. Patients who were treated with chemotherapy plus radiation survived significantly longer than all other patients (P less than 0.005), but there were no significant differences in the mean number of metastatic sites or overall tumor burden at autopsy. Patients who were treated with chemotherapy only had significantly more frequent (P less than 0.05) and more extensive (P less than 0.005) metastases to the leptomeninges, more frequent metastases to other sites within the lungs (P less than 0.05), and less frequent metastases to the adrenal glands (P less than 0.01) and pancreas (P less than 0.05). The patients who were treated with radiation only had more extensive metastases to the adrenal glands (P less than 0.005), and more frequent metastases to the pancreas (P less than 0.001), colon (P less than 0.01), and cerebral white matter (P less than 0.05). The patients who were treated with both chemotherapy and radiation had more frequent and more extensive metastases to the gastrointestinal tract (P less than 0.05) and serosal surfaces (P less than 0.01), but not to any site within the central nervous system (CNS). The latter suggests that prophylactic treatment of the CNS may not be necessary to prolong survival when patients are treated with both chemotherapy and radiation. The results also suggest that although chemotherapy and radiation may prolong survival in patients with small cell carcinoma of the lung, these forms of treatment change the biologic behavior of the tumors by eliminating certain clones that are distinguishable by their metastatic patterns.

Results of a Combined Chemo-Radiotherapeutic Program in 61 Patients Affected by Small Cell Lung Cancer

Sixty-one patients affected by small cell lung cancer (SCLC) entered in the study. Eighteen had limited disease and 43 extensive disease. Treatment consisted of: induction chemotherapy with 3 courses of CAV (cyclophosphamide, adriamycin, vincristine) in limited disease patients or 2 courses of CAV plus 2 courses of DDP-VP16 (cisplatin, etoposide) in extensive disease patients, followed by chest radiotherapy and CNS prophylaxis in responsive patients. Subsequently, responders and stable patients received maintenance chemotherapy by the alternation of cycles of CAV, DDP-VP16 and C'MP (CCNU, methotrexate, procarbazine), which lasted 1 year or until relapse. Four of 17 limited disease patients (23%) obtained a CR and 11 (65%) a PR; their median survival was 11 months (range, 2 + - 36 +). One of the 7 extensive disease patients (3%) achieved a CR and 19 (51%) a PR; their median survival was 6 months (range, 1-22). Median duration of response was 12 months for CR and 5 months for PR. Responders (CR and PR) survived 11.5 months versus 3.5 months for failures (P < 0.05); 3/61 (5%) showed long-term survival, in the absence of disease. The overall median survival was 7 months (range, 1-36 +). The main toxic effects were myelosuppression and vomiting (WHO grade 3). From our results, this program does not offer further substantial gains in patients with SCLC.

A 10-year experience with combined modality therapy for stage III small cell lung carcinoma

During the past 10 years, 240 patients with Stage III small cell lung carcinoma (SCLC) were treated with one of five chemotherapy programs plus thoracic irradiation. In addition, prophylactic cranial irradiation was administered concurrently with thoracic irradiation to 194 patients receiving CAML-HC, VCAM, or MOCA. Seventy-two patients had disease confined to the chest (Stage IIIM0), 30 patients had disease in the chest plus ipsilateral supraclavicular nodal involvement (Stage IIIM0SCN+), and 138 patients had distant metastatic disease (Stage IIIM1); the median survivals were 15.2 months, 12.6 months, and 8.4 months, respectively. The overall complete response rate was 30% and the overall response rate (complete and partial) was 76%. The overall response rates by stage were 86% for Stage IIIM0, 90% for Stage IIIM0SCN+, and 67% for Stage IIIM1. Eight patients (3%) were alive and free of disease at 24 months. Due to continued disease relapse in this group (four of eight patients), long-term survivors should not be identified for a minimum of 3.5 years from the time of initial therapy. Prophylactic cranial irradiation (PCI) effectively reduced the incidence of central nervous system (CNS) relapse in patients with a complete response to therapy (44% relapse without PCI versus 13% relapse with PCI, P less than 0.01). More effective chemotherapy is required for the successful treatment and improved long-term survival of patients with SCLC.

Chemotherapy versus chemotherapy plus irradiation in limited small cell lung cancer. Results of a controlled trial with 5 years follow-up

One hundred and forty-five patients with limited stage small cell lung cancer were included in a randomized trial to evaluate the effect of chemotherapy with or without chest irradiation. Seventy-six patients were allotted chemotherapy alone while 69 patients received the same chemotherapy plus radiotherapy, 40 Gy in split-course, administered in weeks 6 and 10 after the initiation of chemotherapy. The chemotherapy consisted of lomustine, cyclophosphamide, vincristine and methotrexate. Patients treated with chemotherapy alone survived for a median of 52 weeks compared to 44 weeks in patients receiving the combined regimen (P = 0.055). After exclusion of five early deaths and one patient refusing the irradiation plus 14 completely resected patients, the remaining 65 patients receiving chemotherapy alone and the 60 patients treated with chemotherapy plus radiotherapy were included in a new analysis. The difference in survival duration which could be ascribed to treatment with or without chest irradiation thereby diminished (P = 0.24). Eighteen months' disease-free survival was obtained in 9.2% of the 65 patients and in 9.8% of the 60 patients. The complete remission rates were 37% and 46%, respectively, (P = 0.33) and the median durations of complete remission were 40 weeks and 52 weeks (P = 0.67). Treatment failure of the primary tumour occurred in 85% of patients treated with chemotherapy alone in contrast to 61% of patients receiving the combined regimen (P = 0.005). Seventy-nine of these patients underwent autopsy at which no residual chest disease was observed in 17% and 37%, respectively (P = 0.045). The combined regimen was more toxic than chemotherapy alone resulting in significantly greater dose reductions and more pronounced thrombocytopenia. Lung and pericardial fibrosis was responsible for four deaths among the complete responders in the radiotherapy group. The combined regimen thus tended to be more efficacious with respect to tumour control at the expense, however, of increased toxicity which per se, eliminated a potential improvement of the overall therapeutical results.

Non-small-cell lung cancer. Major cause of late mortality in patients with small cell lung cancer

Among 360 patients with small cell lung cancer treated in National Cancer Institute therapeutic trials from 1973 to 1982, 40 were two-year cancer-free survivors. Of these 40 patients, six had later development of non-small-cell lung cancer at 3.5 to 8.0 years (median 5.1) after the diagnosis of small cell lung cancer. Three had the second malignant tumor in the contralateral lung, one in a different lobe, and two in the same lobe as the initial small cell lung cancer. Ten patients had relapses of small cell lung cancer at 2.1 to 6.2 years (median 3.2) from diagnosis. Three recurrences were in the same site or lobe as the initial lesion, four in the same lobe and in sites outside the thorax, and three solely in sites outside the thorax. It is concluded that these non-small-cell lung cancers usually represent second primary lung tumors and that most late small cell lung cancers represent relapses occurring up to 6.2 years from diagnosis. In this study, the risk of development of non-small-cell lung cancer after two years of disease-free survival following small cell lung cancer is 4.4 percent per person-year, approximately 10 times higher than the rate of 0.5 percent previously determined in screening studies of men at high risk for lung cancer. Non-small-cell lung cancer represents more than a third of lung cancer deaths in patients with small cell lung cancer surviving beyond two years from diagnosis and more than half of lung cancer deaths beyond three years. It is recommended that all patients treated for small cell lung cancer discontinue smoking.

Radiotherapy for small cell lung cancer

The role of radiation therapy in the primary management of small cell lung cancer is very much a matter of current debate. Its value in palliative treatment is unquestioned. Disappointment in the apparent inability to demonstrate improvement in survival in some randomized studies as a result of locoregional radiotherapy and prophylactic cranial irradiation may be due to the use of inappropriate study analysis. Recent studies using the end points of 2-year survival and local thoracic control do demonstrate improvements associated with locoregional thoracic radiotherapy. Factors such as total dose and radiation fraction size may be important. Large-field irradiation is also currently attracting interest, but its use should remain a research investigation.

Small cell bronchogenic carcinoma

We have attempted to highlight the most important aspects of SCBC in this review. The significant strides made in a variety of areas have been associated with increased response rates and survival as well as with a prolonged disease-free interval in a fraction of patients. The consensus is that 50% or more of patients with LD can achieve a CR, with an overall objective response rate of 80% or greater and a median overall survival of 14 months or longer. Furthermore, 15% to 20% of such patients may expect a disease-free interval of at least three years that appears to be associated with cure in at least some of these patients. Patients with ED may experience a 20% or greater CR, an 80% or greater objective response, and have a median overall survival of at least seven months. Extensive research is ongoing in a variety of areas. Further refinements in developing more effective chemotherapeutic regimens are likely, as is obtaining new information concerning the intensity, duration, and selection of chemotherapeutic agents and their role in relationship to radiotherapy. Improvement in radiotherapy techniques may lead to improved therapeutic results. Only recently has a reevaluation of the role of surgery in SCBC begun to take place. Also, several new areas of investigation are on the horizon, ranging from improved staging with thoracic and abdominal computed tomography to the role of warfarin, monoclonal tumor antibodies, and several currently investigational chemotherapeutic and biologic response modifier agents.

The effect of combined modality therapy on local control and survival

The systemic component of combined modality therapeutic programs has influenced both the selection of the approach to local control and survival in a number of tumor types. The more effective systemic therapy is against metastatic cancer by itself, the greater the impact on local control and survival. This observation is consistent with the invariable inverse relationship between curability and tumor cell number. For some common cancers, local control is good, but survival remains poor because of the inability to deal effectively with micrometastases. Improved systemic treatment is likely to have an impact on survival may shift local control measures, in some cases, to radiation therapy or lesser surgery without radiation therapy. There remains a substantial number of tumor types where both local control and survival is poor. In these tumors, improvement in local control by itself is not likely to improve survival because of the presence of micrometastases, but such improvements must occur before we can have a true evaluation of the systemic treatment of micrometastases in these tumors. The recent understanding that the metastatic process is under genetic control and the cloning of metastases genes offers a substantial opportunity to control this process and influence both local control and survival.

Small cell carcinoma of the lung

Small cell lung cancer is a common, usually fatal neoplasm. Although palliative therapy is available for the majority of patients, only a very small minority enjoy long-term survival. Ironically, this neoplasm is nearly entirely preventable and a successful antismoking program is desperately needed. Our efforts to understand the basic biology of this tumor should continue, and, hopefully, will eventually translate into improvements in therapy. In addition to following the leads provided by basic research, a concerted clinical research effort needs to continue to build upon the advances already achieved.

Increased survival with high-dose multifield radiotherapy and intensive chemotherapy in limited small cell carcinoma of the lung

From June 1979 through April 1982, we treated 35 patients with limited small cell carcinoma on an intensive chemo-radio-immunotherapy regimen, consisting of induction with cyclophosphamide, doxorubicin, and vincristine, alternately cycled with VP-16 and cisplatin. Patients were stratified by performance status and randomized to thymosin, fraction V, or no thymosin. Induction was followed by consolidation, consisting of prophylactic whole-brain radiotherapy and multifield radiotherapy to the primary and mediastinum with cyclophosphamide and vincristine. Patients who were complete responders (CRs) postconsolidation resumed maintenance immediately. Patients were followed from 1 to 3.8 years (median, 2.2 years) at the time of analysis. After induction, 35% (12/34) had become CRs; after consolidation radiotherapy, an additional 10/34 became CRs for a total CR rate of 65% (22/34). There were only 9/34 local failures (26%), of which all but one were impatients who had not become CRs. A prolonged median survival (21 months) has been obtained in patients with limited small cell carcinoma of lung treated with an intensive combined modality regimen. At 1 year, survival is 83%; at 2 years, 46%. There is a 33% long-term survival (greater than 3 years). There is no difference in survival or recurrence rate between patients treated with or without thymosin.

Alternating radiotherapy and chemotherapy schedules in small cell lung cancer, limited disease

Sixty-three evaluable patients with limited small cell lung carcinoma were entered into two pilot studies alternating 6 cycles of combination chemotherapy (Doxorubicin 40 mg/m2 d 1; VP16213 75 mg/m2 d 1, 2, 3; Cyclophosphamide 300 mg/m2 d 3, 4, 5, 6; and Methotrexate 400 mg/m2 d 2--plus folinic acid rescue--or Cis-Platinum 100 mg/m2 d 2) with 3 courses of mediastinal radiotherapy as induction treatment. The first course of radiotherapy started 10 days after the second cycle of chemotherapy; there was a 7 day rest between chemotherapy and radiotherapy courses. This 6 month induction treatment was followed by a maintenance chemotherapy. The total mediastinal radiation dose was increased from 4500 rad in the first study to 5500 rad in the second. Both protocols obtained a complete response (CR) rate of greater than 85% (with fiberoptic bronchoscopy and histological verification). Local control at 2 years was 61% in the first study and 82% in the second. Relapse-free survival at 2 years was 32 and 37%, respectively. Toxicity was acceptable. We conclude that our results justify further clinical research in alternating radiotherapy and chemotherapy schedules.

The role of radiation therapy in the treatment of small cell lung cancer

Patients with small cell lung cancer (SCLC) are candidates for aggressive therapy because of their potential for long-term survival, especially patients with limited-stage disease. Although no treatment protocol can be considered "standard", the best results in limited-stage SCLC appear to be produced by a combination of chemotherapy and thoracic irradiation. Ongoing protocols testing the efficacy of thoracic irradiation should be able to settle question of the optimal treatment approach in limited-stage SCLC over the next 1 to 2 years. Careful attention to volume treated and the use of shrinking fields produce the best results with the minimum of toxicity. Treatment of extensive-stage SCLC has not been substantially improved to date with the addition of local or systemic irradiation. Prophylactic cranial irradiation reduces the incidence of CNS failure in SCLC and should be given, at a minimum, to patients achieving complete response status. Whether patients with partial response should also receive prophylactic cranial irradiation remains controversial. Finally, half-body radiation in SCLC is an experimental research technique that has shown some promise but remains quite toxic when combined with systemic chemotherapy.

Effect of histologically verified TNM stage on disease control in treated small cell carcinoma of the lung

Pretreatment classification of patients with small cell carcinoma of the lung into categories of "limited" and "extensive" disease is inadequate; it does not identify the few having a good prognosis for disease control. Available reports from the literature were analyzed for (1) histologically verified TNM stage; (2) adequate treatment by current standards; and (3) number and percent of patients remaining in complete remission at 30 months after the start of treatment. Long-surviving patients by histologically verified stage were as follows: Stage I, 5 of 6 patients (83%); Stage II, 3 of 4 (75%); T3 without N2 or M1, 2 of 4 (50%); and N2 with any T value but without M1, 1 of 16 (6.2%). Long survivors with most distant involvement in the supraclavicular nodes were the following: ipsilateral, 3 of 22 (13.6%); contralateral, 2 of 40 (5%). Histologically verified M1 elsewhere allowed less than 1% long survivors. Indirect evidence of M1 by abnormal bone scan allowed less than 5%. Contrary to general usage, TNM staging of patients with small cell carcinoma of the lung promises to correlate closely with the probability of long disease-free survival.

Current status of therapy for small cell carcinoma of the lung

Small cell carcinoma of the lung (SCCL) is distinguished from other types of lung cancer by its propensity for early development of distant metastases and its rapidly fatal clinical course in the absence of treatment. The introduction of chemotherapy into the management of SCCL has led to a four- to five-fold improvement in median survival and to the cure of a small proportion of patients with this disease. Employment of three- or four-drug regimens with or without chest irradiation in moderately intensive doses for periods of 12 months or less has proven to be the optimal therapeutic strategy with currently available agents. Despite these substantial gains, it is obvious that the vast majority of SCCL patients are continuing to die from their cancer, and a slowing in the pace of treatment advances has become apparent over the past 5 years. This article reviews current areas of active clinical investigation in SCCL and some information developed in the cell biology laboratory that may have eventual application in the clinic.

Morbidity in long-term survivors of small cell carcinoma of the lung

The follow-up of eight patients who were alive and disease-free for at least 12 months following completion of therapy for small cell carcinoma of the lung (SCC) is presented. One patient is alive and well. Five patients (62%), including two with acute leukemia, died of second malignancies. One patient died with late recurrence of SCC, and one patient died of an unexplained neurologic degenerative disease with dementia. It is concluded that patients with apparent cure of SCC are at high risk for serious disorders including second malignancies.

Small cell lung cancer 1973-1983: early progress and recent obstacles

The recognition that the vast majority of patients with small cell lung cancer have distant metastatic disease at the time of diagnosis led to the use of systemic chemotherapy and consequent major improvements in survival in the early to mid-1970's. In the past five years, however, the pace of therapeutic advances has slowed. Recently evaluated treatment strategies, including more intensive induction chemotherapy, "late intensive" therapy of responding patients, alternation of chemotherapeutic regimens, integration of chest irradiation with drug therapy, large field irradiation, and reappraisal of the value of surgical resection, are discussed in this review. Advances in understanding of the cell biology of small cell lung cancer which may eventually lead to new forms of treatment are summarized.