Current status of therapy for small cell carcinoma of the lung

Intensive Alternating Combination Chemotherapy and High Dose Chest Radiotherapy in Small Cell Lung Cancer

Sixty-nine patients, 32 with limited and 37 with extensive small cell lung cancer (SCLC), were admitted to the present study. Patients with limited disease underwent alternating combination chemotherapy consisting of CAV (cyclophosphamide, adriamycin, vincristine) and PE (cisplatin and etoposide) regimens and concurrent high dose thoracic radiotherapy (6,000 cGy); prophylactic brain irradiation (3,000 cGy) was administered to complete responders. Patients with extensive disease received the same alternating chemotherapy but not radiotherapy. In the 25 evaluable patients with limited disease we obtained an objective response (OR) in 80% with a complete response (CR) in 54% and partial response (PR) in 24%, stable disease (SD) in 4% and progressive disease (PD) in 16%. Median duration of response was 9.5 months for CR and 8.5 months for PR. Median survival was 14 months for all patients with 12% long-term survivors. Toxicity was acceptable. In the 32 evaluable patients with extensive disease we observed 65.6% OR with 18.7% CR and 46.8% PR, 9.3% minimal response and 25% PD. Median duration of response was 7 months for CR and 8 months for PR. Median survival was 10 months for all patients. The treatment was well tolerated. Our study did not show a therapeutic advantage for alternating combination chemotherapy in SCLC and failed to show the use of high dose chest radiotherapy in combined modality for limited disease.

Pilot Study with Adriamycin and Ifosfamide in Small Cell Lung Cancer

Twenty-one patients with limited (12 cases) or extensive (9 cases) small cell lung cancer entered a pilot study with adriamycin (ADM) plus ifosfamide (IFX) as first line treatment for six planned cycles. ADM was administered at the dose of 60 mg/m2 iv push on day 1 and IFX at 3 g/m2/iv in 1-hour infusion on days 1 and 2. To prevent IFX-induced hemorrhagic cystitis, mercaptoethane sulfonate sodium (Mesna) was given after the admnistration of IFX at the dose of 500 mg/m2 by iv push four times (hour 0, 4, 8, 12) on days 1 and 2. In the absence of disease progression, chemotherapy was repeated every 3 weeks for 6 cycles. All patients were evaluable for analysis of response, toxicity and survival. The overall response rate clinically and radiologically assessed after four treatment cycles was 95.3% (CR 28.6%, PR 66.7%). However, by continuing the same drug treatment up to the sixth cycle, 7 of 14 partial responders showed tumor progression within the intrathoracic region. Therefore, at the end of the planned chemotherapy program the partial remission rate fell to 33.3%, for a total remission rate of 61.9% and a median total survival of 9 months (range 5 to 36+). The regimen was well tolerated with only one case presenting hemorrhagic cystitis. The results achieved with this drug combination appear comparable to those obtained with other conventional regimens. However, the high response rate achieved after four cycles and the low incidence of marrow toxicity suggest the use of this regimen for a short period with increased dose levels.

Lymph node staging by endobronchial ultrasound-guided transbronchial needle aspiration in patients with small cell lung cancer

BACKGROUND

Surgical treatment of small cell lung cancer (SCLC) is limited to stage I disease. Therefore, accurate lymph node staging is mandatory in SCLC patients. The purpose of this study was to evaluate the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the evaluation of mediastinal and hilar lymph node metastasis in patients with SCLC.

METHODS

Forty patients with untreated SCLC who underwent EBUS-TBNA for lymph node staging between November 2002 and September 2008 were retrospectively analyzed. The convex probe endobronchial ultrasonography was used for EBUS-TBNA. Lymph nodes assessed by the convex probe endobronchial ultrasonography were aspirated until EBUS-TBNA revealed malignant cells by rapid on-site cytology.

RESULTS

Endobronchial ultrasound-guided transbronchial needle aspiration was successfully performed in all patients, and revealed lymph node status as follows: N0, 13 cases; N1, 5 cases; and N2, 22 cases. Among the 13 N0 cases, 9 patients underwent surgery, whereas 4 patients did not undergo surgical intervention because of enlargement of subaortic or paraaortic lymph nodes (stations 5 and 6) that precluded EBUS-TBNA assessment (n = 3) or poor performance status (n = 1). Pathologic examination of dissected nodes confirmed an N0 diagnosis in 8 patients, whereas 1 patient had hilar lymph node metastasis (N1). The sensitivity, specificity, and diagnostic accuracy rate of EBUS-TBNA were 96.4%, 100%, and 97.2%, respectively. The overall 5-year survival rate for the 9 patients who underwent surgery was 77.8%.

CONCLUSIONS

Endobronchial ultrasound-guided transbronchial needle aspiration has a high diagnostic yield for the evaluation of mediastinal and hilar lymph node metastasis in SCLC and has a high impact on patient management.

Role of topoisomerase I inhibitors in small-cell lung cancer

Lung cancer continues to be the leading cause of cancer-related death in the United States. Small-cell lung cancer constitutes 15%-20% of all cases of lung cancer. It is a chemosensitive disease with an overall response rate of 70%-90% in first-line treatment. However, the majority of patients relapse, and further treatment at that time is unlikely to achieve a durable response. Among the new drugs studied in this disease, topoisomerase I inhibitors are emerging as active agents with significant activity in both untreated and relapsed disease. This paper reviews the current status of irinotecan and topotecan in the treatment of small-cell lung cancer.

Carboplatin plus paclitaxel in extensive small cell lung cancer: a multicentre phase 2 study

A multicentre phase 2 trial (single-stage design) was undertaken to test the efficacy and toxicity of carboplatin (AUC 6 according to Calvert) plus paclitaxel (175 mg/m(2)3-h infusion) every 4 weeks in the first line treatment of patients affected by extensive small cell lung cancer. The primary end-point of the trial was the objective response rate. 31 objective responses among 50 patients were considered necessary to proceed to a phase 3 trial. 48 patients were enrolled (median age 59 years). Treatment was very well tolerated. 3 patients (6.2%) had a complete response and 23 (47.9%) a partial response, for an overall response rate of 54.2% (95% CI: 39.2-68.6). Median time to progression was 5.7 months (95% CI: 5.2-6.2). Median survival was 9.6 months (95% CI: 7.2-14.6), with a median follow-up time of alive patients of 12 months. At 1 year, the probability of being progression-free or alive was 0.16 and 0.43, respectively. In conclusion, carboplatin plus paclitaxel as given in the present study is very well tolerated but not sufficiently active to warrant phase 3 comparison with standard chemotherapy regimens.

Surgical results for small cell lung cancer based on the new TNM staging system. Thoracic Surgery Study Group of Osaka University, Osaka, Japan

BACKGROUND

Operation with combined chemotherapy has been recently recommended for very early stage of small cell lung cancer without lymph node metastasis.

METHODS

A retrospective study was undertaken in 91 patients who had undergone pulmonary resection for small cell lung cancer according to the new international staging system.

RESULTS

The 5-year overall probability of survival was 37.1%. The 5-year survival rate was 100% for p-stage 0, 56.1% for p-stage IA, 30.0% for p-stage IB, 57.1% for p-stage IIA, and 42.9% for p-stage IIB. In the p-stage IA-IIB patients who underwent a complete resection, the 5-year survival rate of the patients treated by operation with chemotherapy was better than that of patients treated by operation alone. In addition, the 5-year survival rate of the patients who had four or more courses of chemotherapy was 80.0%.

CONCLUSIONS

These results suggest that operation should be considered for p-stage IA-IIB patients and more than four courses of combined chemotherapy might be desirable in these resectable cases.

Surgery for small cell lung cancer

Operative management of small cell lung cancer generally yields little benefit because these tumors are known for their propensity to disseminate early to regional lymph nodes and distant sites. Primary surgery followed by chemotherapy is however indicated in very early stage tumors where survival approximates that of resected non small cell lung tumors. Surgery as an adjuvant to combination chemotherapy is also advocated by some authors to downstage the tumor and render it resectable. Candidates for salvage procedures include patients who have achieved complete response with chemotherapy, but subsequently relapsed within the chest at the site of the primary tumor.

A pilot phase 2 study of surgical treatment after induction chemotherapy for resectable stage I to IIIA small cell lung cancer

BACKGROUND

To evaluate the feasibility and efficacy of surgical resection of the primary tumor and regional lymph nodes in patients with resectable stage I to IIIA small cell lung cancer (SCLC) who had responded to induction chemotherapy.

METHODS AND RESULTS

Twenty-two patients (age, 39 to 70 years; median, 60.5 years) with resectable stage I to IIIA SCLC were identified as candidates for induction chemotherapy. All patients received two to four cycles of preoperative chemotherapy IV every 3 weeks (CAV II: cisplatin, 80 mg/m2, day 1; doxorubicin hydrochloride (Adriamycin), 30 mg/m2, day 1; etoposide (VePesid), 60 mg/m2 day 1 to 5). The overall response rate to induction chemotherapy was 95.5% (complete response, 5 of 22; and partial response, 16 of 22). After induction chemotherapy, 21 patients (95.5%) underwent a surgical resection (one pneumonectomy, 19 lobectomies, one segmentectomy). The postoperative pathologic study revealed only SCLC in 15 patients, only adenocarcinoma in one patient, and no residual tumor in five patients. The median survival time was 61.9 months for both the 21 surgical patients and all 22 patients, while their actuarial 3-year survival rates were 66.7% and 63.6%, respectively, for a follow-up period from 41.1 to 107.6 months (median, 59.8 months). Patients with clinical stages I and II disease had significantly longer survival times than did those with stage IIIA disease (3-year survival rates, 73.3% and 42.9%, respectively; p=0.018). The major adverse reaction was an operation-related death for one patient with N2 disease, but no other serious side effects were observed.

CONCLUSION

This induction chemotherapy followed by surgery is feasible and may be beneficial for the treatment of resectable stage I to IIIA SCLC.

Comparison of oral etoposide and standard intravenous multidrug chemotherapy for small-cell lung cancer: a stopped multicentre randomised trial. Medical Research Council Lung Cancer Working Party

BACKGROUND

Single-drug oral etoposide daily for 5 days or more in 3-week cycles is commonly used as palliative chemotherapy for small-cell lung cancer (SCLC). However, there have been no randomised trials to compare this treatment with standard intravenous multidrug chemotherapy. Our objective was such a comparison in patients with poor performance status. However, before the planned intake of 450 patients had been completed the trial was stopped on the recommendation of an independent data monitoring committee, because of the inferiority of oral etoposide. We report the interim findings of the trial.

METHODS

Patients of either sex and any age were entered into the trial if they had: previously untreated, microscopically confirmed SCLC; WHO grade performance status 2-4; no contraindications to either treatment regimen; normal renal function; and plasma bilirubin concentrations of less than 35 mumol/L. Patients with grade 4 performance status were likely to benefit from chemotherapy. Between September, 1992, and August, 1995, 339 patients were randomly allocated four cycles of 50 mg oral etoposide twice daily for 10 days (171 patients) or a standard intravenous regimen of etoposide and vincristine (EV), or cyclophosphamide, doxorubicin, and vincristine (CAV, 168 controls). The intake was stopped in September, 1995. Patients were assessed by clinicians before the start of treatment, at each attendance for treatment, at 3 months after randomisation, every month to 6 months, every 2 months to 1 year, then every 3 months thereafter. The primary endpoint was the palliation of major symptoms at 3 months after randomisation-ie, a reduction in cough, pain, anorexia, and shortness of breath scores. Secondary endpoints were quality of life, clinical and radiographic tumour response, and survival.

FINDINGS

The palliative effects of treatment were similar in the etoposide group and control group (41% vs 46%). Grade 2 or worse haematological toxicity occurred in 35 (29%) etoposide-treated patients and 26 (21%) controls. Controls had a higher overall response rate than etoposide-treated patients (51% vs 45%). There was a small disadvantage in survival associated with oral etoposide (hazard ratio 1.35 [95% CI 1.03-1.79], p = 0.03). Median survival was 130 days in the etoposide group and 183 days in the controls; survival rates were 35% and 49% at 6 months and 11% and 13% at 12 months, respectively.

INTERPRETATION

Oral etoposide 50 mg twice daily for 10 days every 3 weeks for four cycles is inferior to standard intravenous multidrug chemotherapy in the palliative treatment of patients with SCLC and poor performance status. Oral etoposide alone should no longer be used in the treatment of such patients.

Cisplatin-VP16 alternating with cyclophosphamide-epirubicin versus cyclophosphamide-epirubicin-vincristine in small cell lung cancer

In the hope of increasing the incidence of objective remissions and the survival time of patients with small cell lung cancer, we conducted a randomized study designed to compare a treatment scheme of alternating chemotherapy featuring cisplatin+etoposide followed by cyclophosphamide+epirubicin versus conventional chemotherapy with cyclophosphamide+epirubicin+vincristine, in a total of 113 patients (56 treated with the alternating regime and 57 treated conventionally). Patients receiving the alternating drug regimen showed some increase in objective remission rates, and above all increased mean survival time (297 days versus 232). The higher incidence of side effects encountered was effectively controlled by the usual medical therapy.

Intracerebral and subcutaneous xenografts of human SCLC in the nude rat: comparison of monoclonal antibody localization and tumor infiltrating lymphocytes

In the WAG/Rij nude rat, subcutaneous (s.c.) and intracerebral (i.c.) xenografts of the human SCLC cell line GLC-28 were evaluated for their growth behavior, in vivo monoclonal antibody binding and presence of tumor infiltrating lymphocytes. For the i.c. xenografts, two models of cerebral tumor growth were studied, one in the cerebral cortex and one in the lateral ventricle of the brain. In the s.c. and both i.c. xenografts models, in vivo localization of anti-carcinoma moab MOC-31 occurred within 4 hours after i.p. injection, with a maximal binding at 24 h after injection. A pronounced tumor infiltration of predominantly NK cells was observed for s.c. and intraventricular xenografts, but not for the GLC-28 tumors xenografted in the cerebral cortex. The presented nude rat/GLC-28 xenograft models may be used for the in vivo testing of experimental imaging techniques or alternative treatment strategies relevant to brain metastases of human SCLC.

High-dose combined alkylating agent therapy with autologous stem cell support and chest radiotherapy for limited small-cell lung cancer

Although initially responsive to chemotherapy, patients with small-cell lung cancer (SCLC) almost invariably suffer relapse. Recurrent SCLC responds poorly to treatment. Previous trials using high-dose chemotherapy with bone marrow support have commonly used single agents or combined alkylating agents without chest radiotherapy. Among patients with limited disease receiving dose-intensive chemotherapy, locoregional relapse remained the predominant site of first failure. Recent phase II trials using intensive locoregional therapy (aggressive concurrent chemoradiotherapy) have resulted in promising survival. Our trial used combined alkylating agents with autologous marrow support and chest radiotherapy in patients with limited disease in response to conventional-dose induction chemotherapy. Of 19 patients treated, the actuarial survival was 56% with a median follow-up of 18 months following high-dose therapy. Patients who achieved complete or near-complete response prior to high-dose therapy enjoyed the best prognosis. Continued evaluation of intensive systemic and local therapy for SCLC is indicated.

Surgical resection in the management of small-cell carcinoma of the lung

Surgery has had little impact on long-term survival in patients with small-cell lung cancer (SCLC). With the evolution of modern techniques, however, surgery may play an increasingly valuable role in SCLC. Surgery may potentially cure a select minority of SCLC patients. Patients with peripheral nodules and those with regional disease achieving a complete response to chemotherapy may benefit from adjuvant surgical resection for removal of residual disease. In some cases, surgery may also be preferred over adjuvant radiotherapy, since the latter necessitates lowering the total chemotherapy dose administered to SCLC patients.

Alternating chemotherapy for small-cell lung cancer. A twelve-week schedule of six drugs

We have treated sixty-two patients (21 with limited disease, 41 with extensive disease), on an outpatient-basis schedule of six drugs administered weekly for twelve weeks. Cyclophosphamide, 400 mg/m2, adriamycin, 20 mg/m2 and vincristine, 2 mg, full dose, were administered during weeks 1, 5 and 9; cisplatin, 50 mg/m2 and etoposide, 100 mg/m2 during weeks 2, 6 and 10; adriamycin and vincristine at the same doses during weeks 3, 7 and 11; methotrexate 30 mg/m2, during weeks 4, 8 and 12. After the first 28 patients vincristine was replaced by teniposide (VM-26) due to neurotoxicity. The overall response rate was 64.5% (complete remission 13 p., partial remission 27 p.). Toxicity grade 3-4, mainly nausea and vomiting or neutropenia, was recorded in 17 patients. Alopecia grade 1-2 was universal. One toxic death occurred from sepsis. The overall survival was 8 months (range 1-40), (95% CL: 53-77%); 8 months in limited disease (range 1-40), and 7 months in extensive disease (range 1-23). Time to treatment failure was 6 months (7 limited disease, 5 extensive disease). In conclusion, the results of this alternating schedule are poorer than those attained with standard, high-dose treatments, mainly in limited disease, but could be a less toxic option for patients with extensive disease.

Extrapulmonary and pulmonary small-cell carcinoma: tumor biology, therapy, and outcome

Extrapulmonary small-cell cancer is a distinct clinicopathological entity from small-cell anaplastic carcinoma of the lung. Approximately 1,000 cases have been projected annually in the United States, which represents an overall incidence of between 0.1% and 0.4% of all cancer. Not surprisingly then, little information is available regarding the treatment of this disease, which presents a challenge to the clinician when it is regionally confined. The majority of patients with extrapulmonary small-cell neoplasms have only been treated with local modalities of therapy, surgery, radiation, or a combination of both. Prolonged survival is not infrequent, which is in contrast to the experience for small-cell lung cancer and surprising given our current systemic approach to patients with this disease. This report will summarize the similarities and differences in biology, natural history, and clinical characteristics of patients with extrapulmonary small-cell cancer and small-cell anaplastic carcinoma of the lung. The histogenesis of small-cell cancer is briefly reviewed. A general therapeutic approach to patients with small-cell lung cancer is reported. Lastly, recommendations for therapy of patients with regionally confined extrapulmonary small-cell cancer by primary site are outlined.

Limitations of the fast green assay for chemosensitivity testing in human lung cancer

Selection of patients with lung cancer who are most likely to benefit from chemotherapeutic treatment would be a substantial step forward. Therefore, a prospective study in predictive chemosensitivity testing in vitro using the fast green assay (FGA) as developed by Weisenthal et al was carried out. Sixty-six pretreatment tumor specimens were obtained, the majority by means of bronchoscopy (n = 42). Due to an initially insufficient yield of tumor cells (n = 19), dead cells in control samples after four-day culture (n = 15), contamination (n = 7), and laboratory failure (n = 2), only 23 (34.8 percent) samples were successfully tested. In 14 of 36 patients, a comparison between in vitro and in vivo response was possible. Taking into account the number of failures, this number of successful assays does not allow for any conclusion regarding accuracy of the FGA. We conclude that the FGA has limited usefulness for in vitro chemosensitivity testing in patients with disseminated lung cancer in whom biopsy specimens were taken without major surgical investigations. Future directions for predictive testing in vitro are discussed.

Immunohistochemical detection of two small cell lung carcinoma-associated antigens defined by MAbs F12 and 123C3 in bronchoscopy biopsy tissues

We have studied MAbs* for their ability to detect SCLC and differentiate this tumor type from the other lung tumor histotypes in cryostat sections of biopsy specimens taken at bronchoscopy from patients with suspected primary lung tumor disease. MAb F12, specific for the ganglioside fucosyl-GM1, reacted with 58% of the cases with SCLC (n = 19) and with less than 3% of those with non-SCLC (n = 38). MAb 123C3, specifically reactive with NCAM, reacted with 78% of the SCLC cases (n = 23). With this MAb no positive staining was seen in the non-SCLC cases (n = 41). None of the two MAbs reacted with tissue sections without tumor. In combined analysis with MAbs F12 and 123C3, all SCLC cases (n = 15) were positive with either and 47% with both of the MAbs. Our results show that both MAbs F12 and 123C3 are highly specific for SCLC in bronchoscopic biopsy tissue specimens, whereas the sensitivity for this histotype tends to be higher with MAb 123C3 than with F12 (P = 0.14). When used in combination, all SCLC cases could be identified. These MAbs may therefore be valuable as complements to current histopathologic characterization and differentiation of lung cancer.

Influence of surgical resection before and after chemotherapy on survival in small cell lung cancer

We attempted to define the role of surgery in the treatment of small cell lung cancer (SCLC). Of 81 patients with clinically localized SCLC, 36 underwent surgical resection: 19 underwent initial resection with postoperative chemotherapy, while the remaining 17 were treated initially with chemotherapy, then resection. The remaining 45 patients were treated with a combination of chemotherapy and radiotherapy. The 5-year survival for the 36 surgical patients was 38%; median survival time (MST) was 33 months. Nineteen patients treated with postoperative chemotherapy showed a 42% 5-year survival, while 17 patients treated with preoperative chemotherapy showed a 33% 5-year survival. This difference was not significant. However, stage III survival tended to be better in patients with preoperative chemotherapy (MST, 29 months) than in those who had had postoperative chemotherapy only (MST, 17 months). Although survival of the 45 nonsurgical patients was poor, stage I and II patients, or those with complete remission showed a 25% 5-year survival with an MST of 33 months, and a 21% 5-year survival with an MST of 25 months, respectively. We thus concluded that initial resection combined with postoperative chemotherapy is beneficial for patients with stage I, and probably stage II disease. For resectable stage III, particularly in patients with N2 disease, adjuvant resection after chemotherapy may be a favorable choice in the management of SCLC. For advanced stage III, complete remission by chemotherapy should be attempted in combination with radiotherapy.

A feasibility study of testing new drugs for small-cell lung cancer in patients with a poor performance status

Testing of new drugs in small-cell lung cancer is definitely necessary for the development of agents that might be effective against this tumor. However, testing such drugs in previously untreated patients with a good performance status (PS) may give rise to ethical problems. When previously treated patients are used in testing, potentially effective agents could well elude discovery. Patients who are not eligible for "standard" combination chemotherapy, e.g. untreated patients with a poor PS, may be suitable for testing of new drugs. To evaluate the potential usefulness of such patients in the testing of new agents, we evaluated an effective drug (etoposide) at a relatively nontoxic dose in a group of 14 patients with a PS of 4 (WHO). Oral etoposide resulted in a response in only 3 cases, whereas 5 subjects died of therapy-related toxicity. We conclude that previously untreated patients with a poor PS are not suitable candidates for the testing of new drugs.

Longevity in small cell lung cancer. A report to the Lung Cancer Subcommittee of the United Kingdom Coordinating Committee for Cancer Research

An analysis of the long-term results of treatment of 3,681 patients with small cell lung cancer (SCLC) is presented. The data were obtained from major centres in the UK who were conducting treatment trials during the period 1978-1986 and for whom complete computer records and follow-up were available. A total of 217 (5.9%) survived 2 years or more. Two year survival for patients presenting with limited disease (LD) was 8.5% and for extensive disease (ED) 2.2%. Death from SCLC continued until 7 years after diagnosis but not thereafter. At this point overall survival was 3% (3.6% LD, 1.1% ED). Survival after 2 years was not affected by initial disease extent, sex, thoracic radiotherapy or prophylactic cranial irradiation. Death from causes other than SCLC continued throughout the period of observation. Vascular disease, respiratory failure and second tumours were the main other causes of death. The better survival in younger patients was mainly attributable to few deaths from these other causes. These results indicate that only a small proportion of patients with SCLC are cured by current treatment. Although shorter term improvement in survival has been obtained with current treatment, the poor overall long-term results support studies exploring new approaches to cure and to palliation.

Accelerated chemotherapy with or without GM-CSF for small cell lung cancer: a non-randomised pilot study

Two series of five consecutive patients with small cell lung cancer were treated with an "accelerated" chemotherapy regimen of cyclophosphamide-doxorubicin-vincristine (CAV) and cisplatin-etoposide (PE) alternated possibly every week. In the first group of patients (median age 49 years, range 46-52) recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) was given as soon as grade IV leukopenia occurred, while in the second group (median age 59 years, 55-68) no growth factor was administered. The mean interval between chemotherapy courses and the mean duration of chemotherapy were 10 and 57 days, respectively, in the patients supported with GM-CSF compared with 13 and 72 days in the control group. One GM-CSF treated patient was withdrawn after the third cycle because of severe toxicity. The mean white blood cell and platelet nadirs were 600 and 46,000/microliters in the first group vs. 840 and 105,000/microliters in the controls. Overall chemotherapy dose-intensity was increased by two fold in the patients given GM-CSF compared with a 1.5 fold increase in the control patients. In all cases, irrespective of their treatment, there was an impaired colony forming capacity of circulating and marrow haemopoietic progenitor cells when grade IV leukopenia occurred, with recovery after the end of leukopenia. This pilot study suggests that accelerated CAV/PE chemotherapy is feasible both with and without GM-CSF. Different GM-CSF schedules as well as combinations of different haemopoietic growth factors may further improve dose-intensity.

Induction chemo-radiotherapy and maintenance alternating chemotherapy for small cell lung cancer

Seventy-four patients with small cell lung cancer (SCLC) entered a program consisting of induction with three courses of CAV (cyclophosphamide, doxorubicin and vincristine) in limited disease or two courses of CAV plus two courses of DDP-VP16 (cisplatin, etoposide) in extensive disease, followed by chest radiotherapy (45 Gy) and prophylactic brain irradiation (30 Gy) in responsive patients. Subsequently, patients with response or stable disease received maintenance therapy by alternating courses of CAV, DDP-VP16 and C'MP (CCNU, methotrexate, procarbazine) during 1 year or until relapse. Sixty-seven patients were evaluable. Among 24 patients with limited disease 7/23 (30%) showed complete response, 15/23 (65%) partial response and 1/23 (5%) stable disease. Among 50 patients with extensive disease 1/44 (2%) showed complete response, 21/44 (48%) partial response, 13/44 (30%) stable disease and 9/44 (20%) progressive disease. Actuarial median survival in all patients was 8 months, in responders 11 months, and in failures (stable plus progressive patients) 4 months. Median survival was 11 months in limited disease patients and 7 months in extensive disease patients. Six patients became long-term survivors (8%). Despite the maintenance therapy with three different alternating chemotherapy regimens, our results were not superior to those obtained by more conventional chemotherapy.

Multimodality therapy for small cell carcinoma of the lung--the role of surgical treatment

Reviewing the outcome of 70 cases of clinically localized small cell lung cancer (SCLC) treated with combined modality treatment, we attempted to define the role of resection in this disease. The survival rate for all cases was 37 per cent at 2 years and 23 per cent at 3 years with a median survival time (MST) of 14 months. For 25 resected cases the overall 5-year survival rate was 37 per cent with an MST of 26 months. According to clinical staging, 5-year survival was 64 per cent for stage I and 20 per cent for stage II. However, none of the stage III cases achieved long-term survival, of over 3 years. In 45 non-resected cases, the overall response rate was 84 per cent with a 44 per cent complete response. The overall survival rate was 27 per cent at 2 years and 14 per cent at 3 years with an MST of 11 months. The 20 cases who achieved complete response had an MST of 26 months with 51 per cent alive at 2 years and 19 per cent at 5 years. Thus, we consider that lung resection is definitely indicated in cases with stage I and probably stage II SCLC. For stage III, however, particularly in cases with N2 disease, resection seems to offer no special benefit in favor of survival compared to combination chemotherapy and radiotherapy.

Prophylactic cranial irradiation for small-cell lung cancer: long-term results

Over a six-year period, 72 patients with small-cell lung cancer received prophylactic cranial irradiation, as well as combination chemotherapy. There were 58 patients with limited-stage disease. With a minimum of four years follow-up, there are only four survivors, one of whom is affected by a crippling treatment-induced neurological deficit, and another has moderate impairment of cognitive functions. Despite cranial prophylaxis, 14 patients died from cerebral metastases, and four others of undiagnosed neurological problems. One other patient, who died apparently in remission, also had severe iatrogenic brain damage. These results cast doubt upon the value of this form of treatment in a disease that remains incurable for the vast majority of sufferers.

A phase II study of oral etoposide in elderly patients with small cell lung cancer

Thirty five previously untreated patients with small cell lung cancer older than 70 years were treated with oral etoposide (800 mg/m2 over five consecutive days) every four weeks. Twenty two patients had extensive disease and 13 limited disease. The overall response rate was 71%. The median survival for patients with limited diseases was 16 (range 6-32) months and for patients with extensive disease nine (range 4-17) months. There was mild haematological toxicity and alopecia but no major toxicity. It is concluded that etoposide in this dose regimen is an effective and well tolerated treatment for elderly patients with small cell lung cancer.

Quantitative distribution of cluster 1 small cell lung cancer antigen in cancerous and non-cancerous tissues, cultured cells and sera

Three monoclonal antibodies (mAbs), NCC-LU-243, -244 and -246, detected three different epitopes on a 145-kDa cell membrane antigen, which had been designated as the cluster 1 antigen at the First International Workshop on Small Cell Lung Cancer (SCLC) Antigens. The distribution of the antigen in various tissues, cultured cells and sera was examined by immunohistochemistry and sandwich radioimmunoassay using these mAbs. The antigen is a normal differentiation antigen and is present in neuronal, neuroendocrine and cardiac muscle cells. The level of the antigen was highest in central nervous tissues, while it was undetectable in the liver, kidney and peripheral lung. Among tumor tissues, the antigen was detected only in SCLC, carcinoid tumor and neuroblastoma, indicating its usefulness as a marker for discriminating SCLC from non-SCLC. The level of the antigen varied among SCLC tissues and tended to be lower in variant-type cultured SCLC cells. Although an increase in the antigen level was observed in sera of some patients with advanced SCLC, the antigen did not possess any additional value over neuron-specific enolase as a serum tumor marker for monitoring SCLC patients.

Teniposide (VM26): an effective treatment for brain metastases of small cell carcinoma of the lung

Despite good results of chemotherapy in small cell lung cancer (SCLC), occurrence of brain metastases is frequent and unaffected by commonly employed antineoplastic drugs, mainly because they do not cross the blood-brain barrier. We treated eight patients with SCLC and cerebral metastases with VM26 at 120 mg/m2 given on days 1, 3 and 5 and repeated every 3 weeks. Two patients achieved complete response and one had partial response. Mean response duration was 8.2 months and survival was more than 9 months in responding patients. Toxicity was manageable. VM26 is an active drug in SCLC with brain metastases.

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.

In vitro chemosensitivity of human lung cancer for vindesine

Firstly, the effect of Vindesine was studied on four different human lung carcinoma cell lines (two small cell, one adeno and one squamous cell) with the Fast Green dye exclusion assay (FGA) and the clonogenic assay. Both methods demonstrate a clear dose response relationship and the estimated drug efficacy is similar for both assays. In the cell lines with the longest doubling time a plateau was reached in the FGA, most probably due to the short culture time in this assay. Secondly, the effect of Vindesine on human lung carcinoma specimens (n = 64), mainly bronchoscopy biopsies (n = 48), was evaluated with the FGA. The FGA has merits as predictive test in the clinic in the situation that only a small number of cells can be obtained. In this study, due to the high number of bronchoscopy biopsies only in a minority of cases a conclusion could be obtained (37.5%).

Isolated intrathoracic relapse in small-cell lung cancer: incidence and implications

Between 1978 and 1983, 56 patients with limited-stage small-cell lung cancer (SCLC) were treated by combination chemotherapy and moderate-dose thoracic irradiation (30 Gy). There are four survivors beyond 4 years; other patients were followed up until death, and sites of relapse documented, with five exceptions. Nine patients died with disease apparently confined to the chest. This suggests that treatments aimed at achieving better local control warrant prospective evaluation.

The 'grey area' between small cell and non-small cell lung carcinomas. Light and electron microscopy versus clinical data in 14 cases

We studied 14 lung tumours which on light microscopy had posed difficulties on classification as either small cell or non-small cell carcinomas. The light and electron microscopical features were compared with patient follow-up data. Electron microscopy showed neuroendocrine granules in 12 cases, and adeno- and squamous cell differentiation but no neuroendocrine granules in the remaining two cases. The latter two cases showed prolonged patient survival (both patients alive after 2 1/2 and 2 years, respectively). Ten of the cases with neuroendocrine granules showed a rapid course of disease (death between 2 1/2 weeks and 15 months after diagnosis) and marked initial response to multiagent chemotherapy. Thus, the clinical impression of these cases was that of small cell carcinoma. The remaining two cases with neuroendocrine granules showed a more protracted course, with death after 1 1/2 and 2 1/2 years. These two tumours did not show the light microscopical features of atypical carcinoid. The results illustrate the value of electron microscopy in predicting clinical behaviour of carcinomas difficult to place into small cell or non-small cell carcinoma groups. They also point to the existence of neuroendocrine carcinomas other than carcinoids with a more protracted course than small cell carcinomas.

Prevalence of neuroendocrine granules in small cell lung carcinoma. Usefulness of electron microscopy in lung cancer classification

Fifty-four lung carcinomas submitted for routine electron microscopy under the light microscopical diagnosis of small cell carcinoma were investigated. In 42 or of 45 evaluable cases, neuroendocrine granules were considered definitely or probably present, the modification 'probably' being necessary in suboptimal material. In three cases, squamous cell differentiation was seen, but no neuroendocrine granules were found. On revision of these three cases, the light microscopical diagnosis was changed to squamous cell carcinoma in one instance, and neither of the other two cases was considered classical for small cell carcinoma. Patient follow-up of these three cases showed tumour behaviour indicative of non-small cell carcinoma in two evaluable cases, the third case yielding no significant data. These results indicate that neuroendocrine granules can generally be found in small cell lung carcinomas, provided the material is sufficient for evaluation. When these granules are absent, and other differentiation is found on electron microscopy, the final classification of the tumour should incorporate this finding, to warn the clinician that the tumour will not necessarily behave as a small cell carcinoma.

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.