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

Primary gastric small cell carcinoma: report of a case and review of the literature

A 52-year-old man suffering from a pure-type primary gastric small cell carcinoma was treated with surgery and combination chemotherapy. The small cell carcinoma, approximately 6.5 cm in diameter, was situated in the posterior wall of the antrum and there were no distant metastases. Total gastrectomy and regional lymph node dissection was carried out. Histological examination revealed a solid pattern of proliferation of small cells with hyperchromatic, round nuclei and scant cytoplasm. Neoplastic cells infiltrated into the subserosal layer with severe lymphatic and vascular invasion. Regional lymph node cells were mostly replaced by tumor cells that stained positive for Grimelius, neuron-specific enolase (NSE), and synaptophysin. Accumulations of electron-dense core granules in the small neoplastic cells were seen by electron microscopy. Following surgery, the patient was treated with adjuvant chemotherapy consisting of cisplatin and etoposide. The patient is alive and recurrence free 3 years after surgical operation. We review 107 published cases of primary gastric small cell carcinoma, an extremely rare disease first reported in 1976. Small cell carcinoma is an aggressive, malignant tumor. Intensive chemotherapy is essential for patient survival even when curative surgical resection is carried out.

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

BACKGROUND

To determine the changes in clinical trials and outcomes of patients with limited-stage small cell lung carcinoma (SCLC) treated on Phase III randomized trials initiated in North America between 1972 and 1992.

METHODS

Phase III trials from 1972 to 1992 for patients with limited-stage SCLC were identified. Patients with limited-stage SCLC treated during a similar time interval were also evaluated in the Surveillance, Epidemiology, and End Results (SEER) database. Trends were tested in the number of trials, in the number and gender of patients entered on trial, and in survival duration over time.

RESULTS

Thirty trials involving 6564 patients were eligible for analyses. Nineteen trials (61%) involving 3626 patients were initiated within the first half of this time period (1972-1981). The median of median survival times of all patients treated on the control arms of the Phase III trials initiated between 1972 and 1981 and between 1982 and 1992 were 12.0 months (range, 10-16 months) and 17.0 months (range, 11-20 months), respectively (P < 0.001). Of 26 studies available for survival analysis, 5 (19%) showed a statistically significant survival prolongation in the experimental arm compared with the control arm with a median prolongation of 3.4 months (range, 1-5.2 months). All five evaluated some aspect of thoracic radiation therapy. Over a similar time period, there was a 6.4-month increase in the median survival of limited-stage SCLC patients listed in the SEER database (P < 0.0001) and a more than doubling of the 5-year survival from 5.2% to 12.1% (P = 0.0001).

CONCLUSIONS

Analyses of the patients with limited-stage SCLC treated on Phase III trials in North America initiated between 1972 and 1992 and those listed in the SEER database show significant improvements in median survivals. Furthermore, the 5-year survival of patients with limited-stage SCLC listed in the SEER database has more than doubled over the last 25 years. Further research will be needed to determine the relative contribution of improved therapy, supportive care, and stage migration to this prolongation in survival.

Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide

BACKGROUND

For small-cell lung cancer confined to one hemithorax (limited small-cell lung cancer), thoracic radiotherapy improves survival, but the best ways of integrating chemotherapy and thoracic radiotherapy remain unsettled. Twice-daily accelerated thoracic radiotherapy has potential advantages over once-daily radiotherapy.

METHODS

We studied 417 patients with limited small-cell lung cancer. All the patients received four 21-day cycles of cisplatin plus etoposide. We randomly assigned these patients to receive a total of 45 Gy of concurrent thoracic radiotherapy, given either twice daily over a three-week period or once daily over a period of five weeks.

RESULTS

Twice-daily treatment beginning with the first cycle of chemotherapy significantly improved survival as compared with concurrent once-daily radiotherapy (P=0.04 by the log-rank test). After a median follow-up of almost 8 years, the median survival was 19 months for the once-daily group and 23 months for the twice-daily group. The survival rates for patients receiving once-daily radiotherapy were 41 percent at two years and 16 percent at five years. For patients receiving twice-daily radiotherapy, the survival rates were 47 percent at two years and 26 percent at five years. Grade 3 esophagitis was significantly more frequent with twice-daily thoracic radiotherapy, occurring in 27 percent of patients, as compared with 11 percent in the once-daily group (P<0.001).

CONCLUSIONS

Four cycles of cisplatin plus etoposide and a course of radiotherapy (45 Gy, given either once or twice daily) beginning with cycle 1 of the chemotherapy resulted in overall two- and five-year survival rates of 44 percent and 23 percent, a considerable improvement in survival rates over previous results in patients with limited small-cell lung cancer.

Risk of late recurrence and/or second lung cancer after treatment of patients with small cell lung cancer (SCLC)

The aim of this study was to illustrate some difficulties in distinguishing late recurrence of small cell lung cancer (SCLC), from second primary lung cancer. Three-hundred fourteen SCLC patients were observed at the Institute of Tuberculosis and Chest Diseases in Warsaw, during the period 1976-1985. All patients were treated with chemotherapy and 125 were also treated with radiotherapy on the tumour and mediastinum. Nineteen patients (6%) survived 3 years. This group consisted of eight females (9%) and 11 males (5%). In all of them a complete remission was obtained. In six patients from this group no progression of lung cancer was observed. Four of them are still living, 7.9-16.2 years after the start of treatment. Two patients died of heart infarct. In the remaining 13 patients, progression of SCLC or development of new cancer was noted in the course of observation. In seven of them, histological proof of the character of progression was obtained. In four cases non-small cell lung cancer (NSCLC) was diagnosed after 3-11 years of observation. In one of them SCLC metastases in the liver were unexpectedly found in the autopsy, although adenocarcinoma in the lung diagnosed during bronchoscopy was also confirmed in the autopsy. In three cases SCLC was diagnosed. In one case, 2.7 years from the beginning of treatment, only SCLC metastases were found during laparoscopy. SCLC was found in two other cases after a 7-year cancer-free period. In one of those patients, a new lesion was found in the other lung while the second patient developed a new lesion exactly in the place of the former cancer. In six other patients no histological proof of the character of progression was obtained. Two of the six are still living, 8.2 and 15.1 years later. In the first of these two, a new lesion developed very early in the course of treatment in the same place as the primary tumour and it was regarded as the progression of SCLC. In the second patient, who probably had NSCLC the lesion developed in the contralateral lung after 12.5 years of remission and disappeared after radiotherapy. Four patients died of cancer after 3.2-6.4 years of observation. The cumulative risk of a second primary lung cancer after a 3-year survival period oscillated in our SCLC patients between 4% and 6% for every patient/year of observation. It was concluded that prognosis in SCLC patients is still doubtful, nevertheless, some patients made a complete recovery.

Incorporation of radiotherapy fractionation in the combined-modality treatment of limited small-cell lung cancer

Although systemic failure continues to plague patients receiving combined-modality treatment for limited small-cell lung cancer (SCLC), improvements in chemotherapy, including use of cisplatin/etoposide-based regimens, and radiotherapy have produced increases in median, 2-year, and 5-year survival over the last decade. Employing more conservative volumes of radiotherapy in more aggressive ways, today about 50% of SCLC patients will survive 2 years and 30%, 5 years. Moreover, integrating radiotherapy with chemotherapy early in the course of treatment can potentially eliminate resistant clones. The various factors in radiotherapy, including dose, volume, fractionation, and timing, therefore deserve scrutiny in the reporting and design of clinical trials.

Urokinase combination chemotherapy in small cell lung cancer. A phase II study

BACKGROUND AND METHODS

Fifty-one patients with small cell lung cancer (SCLC) were treated with alternating urokinase (UK)-cyclophosphamide-doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH)-vincristine and cisplatin-etoposide-vincristine. UK was given as a loading dose of 3000 micrograms/kg body weight, followed by 3000 micrograms/kg/h for 6 hours. Thoracic irradiation with split technique (46 Gy) and prophylactic cranial irradiation (25 Gy) were administered to responding patients. A second staging was performed in patients exhibiting a clinical complete response (CR) after 1 year.

RESULTS

In 27 patients with limited disease, there were 23 CR and 8 partial responses (PR) (CR, 85.1%; 66.2-95.8% at 95% confidence intervals); in 24 patients with extensive disease, there were 17 CR, 4 PR, and 3 cases with progression. Pathologically proven CR were observed in 59.2% patients with limited disease and 33.3% patients with extensive disease. Survival rates were as follows: in patients with limited disease, 1 year, 85.1%; 2 years, 55.5%; and 3 years, 25.9%; in patients with extensive disease, 1 year, 54.1; and 2 years, 16.9%. Median survival times were 26.3 months (patients with limited disease) and 13.3 months (patients with extensive disease). UK-related toxic effects included four episodes of mild to moderate bleeding, one allergic reaction, and one cerebrovascular accident. Myelotoxicity was severe, with a median of two episodes of Grade III-IV (World Health Organization classification) aplasia per patient.

CONCLUSIONS

These results are consistent with a potential benefit of fibrinolytic therapy in combination with chemotherapy in patients with SCLC with limited disease. Additional trials are indicated.

Twice daily thoracic irradiation for limited small cell lung cancer

Thoracic failure is a significant obstacle to the cure of limited stage small-cell lung cancer (LSCLC) patients treated with combined modality therapy. In 1985 we initiated a prospective trial to evaluate the impact of twice daily thoracic irradiation without concomitant chemotherapy on control of intrathoracic tumor in LSCLC. Twenty-nine patients treated in this fashion were compared with 36 patients treated from 1979-1982 with once daily thoracic irradiation and concomitant chemotherapy. Both groups received the same induction chemotherapy; cyclophosphamide, Adriamycin, and vincristine (CAV) alternating with cisplatin and etoposide. For consolidation, the twice daily patients received thoracic irradiation, 45 Gy in 1.5 Gy fractions given twice daily, and the once daily patients received thoracic irradiation, 45 Gy in 2.5 Gy fractions given once daily with concomitant cyclophosphamide and vincristine. After completion of radiotherapy both groups received maintenance chemotherapy. The complete response (CR) rate after thoracic irradiation was higher for twice daily patients (86% (25/29) compared to the once daily patients [61% (22/36), p = 0.02]. However, this advantage was offset by the shorter duration of thoracic control among CR patients treated with twice daily thoracic irradiation compared to once daily thoracic irradiation (32% vs 67% at 2 years, p less than 0.05). In view of the enhanced initial response of LSCLC to twice daily thoracic irradiation, this basic radiotherapeutic approach seems appropriate, but new strategies using higher doses of twice daily thoracic irradiation or concomitant chemotherapy appear to be necessary to enhance long-term thoracic control.

Single-dose and fractionated irradiation of four human lung cancer cell lines in vitro

Four established human lung cancer cell lines were exposed to single-dose irradiation. The survival curves of 2 small cell lung carcinomas (SCLC) were characterized by a limited capacity for repair with small and moderate shoulders with extrapolation numbers (n) of 1.05 and 1.60 respectively. Two non-small cell lung carcinoma (NSCLC) cell lines, one squamous cell (SQCLC) and one large cell (LCLC) had large shoulders with n-values of 73 and 15 respectively. The radiosensitivity when measured as D0 did not, however, differ as much from cell line to cell line, with values from 1.22 to 1.65. The surviving fraction after 2 Gy (SF2) was 0.24 and 0.42 respectively in the SCLC cell lines and 0.90 and 0.88 respectively in the NSCLC cell lines. Fractionated irradiation delivered according to 3 different schedules was also investigated. All the schedules delivered a total dose of 10 Gy in 5 days and were applied in 1, 2, and 5 Gy dose fractions respectively. Survival followed the pattern found after single-dose irradiation; it was lowest in the SCLC cell line with the lowest SF and highest in the two NSCLC cell lines. In the SCLC cell lines all schedules were approximately equally efficient. In the LCLC and in the SQCLC cell lines, the 5 Gy schedule killed more cells than the 1 and 2 Gy schedules. The results indicate that the size of the shoulder of the survival curve is essential when choosing the most tumoricidal fractionation schedule.

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.

Local failure in patients treated with radiotherapy and multidrug chemotherapy for small cell lung cancer

Fifty-three patients with small cell carcinoma of the lung were treated with chemotherapy and radiotherapy, 40 Gy in the chest tumour. Intrathoracic failure occurred in 89% of the cases with extensive disease and in 60% of those with limited disease. Since 86% of all failures were localized within the target volume, one can conclude that in most cases the radiation dose was too low for eradication of the tumour. The treatment technique resulted in dose inhomogeneities of more than +/- 5% in 45% of the cases. The high local failure rate might indicate the need of improved radiotherapy, in the first place higher radiation dose. However, 82% of the patients with limited disease and local failure and 50% of those without local failure also developed distant metastases. This might indicate that the curative potential of improved thoracic radiotherapy probably is limited. Besides, lethal treatment toxicity affected particularly patients in whom local cure had been achieved, indicating the difficulty of increasing the treatment intensity without increasing the lethal toxicity in potentially curable cases.

A randomized study of radiation treatment in small cell bronchial carcinoma treated with two types of four-drug chemotherapy regimens

Of an unselected series of 133 patients with small cell bronchial carcinoma, 110 patients (54 with extensive disease and 56 with limited disease) were randomly allocated to receive either chemotherapy with cyclophosphamide, doxorubicin, vincristine, and methotrexate, alternating after four cycles with cyclophosphamide, lomustine, vincristine, and methotrexate, or the same chemotherapy combinations together with irradiation at 40 Gy to the primary tumor area and the adjacent mediastinum. In patients with extensive disease the total response rates were 70% and 86% and the median survival 7.6 and 9.2 months, respectively. There were no long-term survivors, and no advantage was gained from radiation combination treatment. The results confirm previously reported findings. In limited disease the complete remission rates were 68% and 64%, the partial remission rates 26% and 28%, and the median survival was 14.8 and 15.4 months, respectively. There were no statistically significant differences favoring either treatment regimen. The disease-free survival exceeding 2 years in the two respective groups was 6.5% and 25%; this difference was not statistically significant. A slight advantage of combined radiation and chemotherapy in the direction of better long-term survival was confirmed by the 4-year disease-free survival rate of 12% as compared with 0% in the nonirradiation group. This difference was statistically significant. There was considerable toxicity with both treatment regimens. The addition of radiation treatment to the chemotherapy most likely benefits patients with limited disease. The overall median survival of all the unselected 133 patients (nonrandomized included) was 10.3 months, and the cure rate was 3%.

Small cell neuroendocrine carcinoma of the colon and rectum: clinical, histologic, and ultrastructural study and immunohistochemical comparison with cloacogenic carcinoma

In an effort to provide immunocytochemical data that would be useful in distinguishing between small cell epithelial tumors of the anorectal region, 10 cases of neuroendocrine small cell colorectal carcinoma (NSCCC) and five cases of cloacogenic carcinoma (CC) were studied with antibodies to cytokeratin, epithelial membrane antigen (EMA), chromogranin, blood group isoantigens (BGI), carcinoembryonic antigen (CEA), Leu-M1, Leu-7, leukocyte common antigen (LCA), S-100 protein, neurofilaments (NF), neuron-specific enolase (NSE), serotonin, and 14 neuropeptides. The diagnoses for all 15 tumors were verified ultrastructurally. Among the antigenic determinants considered, reactivity for low- and medium-molecular-weight cytokeratin, EMA, NSE, and NF was seen in the majority of NSCCCs, whereas the CCs were positive for all cytokeratin classes, BGI, EMA, and CEA. In addition, Leu-M1, Leu-7, and chromogranin were each expressed in three cases of NSCCC. None of the other antisera yielded positive results in tumors of either type. All 10 patients with NSCCC died of their tumors within 11 months of clinical presentation, while four of the five CCs proved fatal, with an average survival of 28 months. One of the patients with CC was free of disease 31 months after diagnosis. These data suggest that an immunocytochemical panel, consisting of antibodies to high-molecular-weight cytokeratin, BGI, CEA, NSE, and NF (and possibly Leu-7 and chromogranin as well), is capable of distinguishing between NSCCC and CC in problematic cases. Although tumors of both types are aggressive, it is possible that the survival statistics for both may be improved through more accurate diagnostic classification.