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

Relapse of Stage I Small Cell Lung Cancer Ten or More Years after the Start of Treatment

Most patients with small cell lung cancer (SCLC) usually show relapse within 1 or 2 years. Relapses after a 5-year disease-free survival are extremely rare. This report describes two patients with stage I SCLC in whom the disease recurred 10 or more years after the start of initial therapy. Because the recurrence of SCLC was noted in the mediastinal lymph nodes of the same side, we concluded that the patients had a late relapse of SCLC rather than a metachronous lung cancer.

Lung cancer

This synthesis of the literature on radiotherapy for lung cancer is based on 80 scientific articles, including 2 meta-analyses, 29 randomized studies, 19 prospective studies, and 21 retrospective studies. These studies involve 28172 patients. Basic treatment for limited-stage small cell lung cancer (SCLC), is chemotherapy. Addition of radiotherapy to the primary tumor and mediastinum reduces local recurrence, prolongs long-term survival, and is often indicated. Current, and future, studies can be expected to show successive improvements in results for SCLC by optimizing the combination of radiotherapy and chemotherapy. Should these treatments be given simultaneously or sequentially, and in which order? Which fractionation is best? Probably, no change in resource requirements for radiotherapy will be necessary, with the possible exception of changes in fractionation. Surgery constitutes primary treatment for nonsmall cell lung cancer (NSCLC) stages I and II. Radiotherapy may provide an alternative for patients who are inoperable for medical reasons. The value of radiotherapy following radical surgery for NSCLC remains to be shown. It is not indicated based on current knowledge. For NSCLC stage III, radiotherapy shrinks tumors and prolongs survival at 2 and 3 years. Whether it influences long-term survival after 5 years has not been shown. Considering the side effects of treatment, one must question whether limited improvements in survival motivate routine radiotherapy in these patients. Earlier attempts to add chemotherapy to radiotherapy to improve treatment results of NSCLC have not yielded convincing results. Several studies are currently on-going. Prophylactic cranial irradiation (PCI) greatly reduces the risk for brain metastases from SCLC. However, it has little influence on survival. Many treatment centers give PCI to SCLC patients who have achieved complete remission. This practice may be questioned since PCI is associated with serious complications. PCI is not indicated in patients with NSCLC. In SCLC, where the disease is extensive, only palliative radiotherapy is appropriate. Radiotherapy is an important treatment alternative in special palliative situations involving severe cough, severe bleeding, pain, pulmonary obstructions, and vena cava superior syndrome. In these situations, good results may be achieved with few fractions.

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.

An audit of survival in small cell lung cancer

A total of 351 previously untreated patients presented to this department with limited small cell bronchogenic carcinoma between 1974 and 1985. They were treated with either radical or palliative radiotherapy (152), chemotherapy alone (63), or combined chemoradiotherapy (136). Their 5-year survival rates were 2.6%, 0%, and 5.1% with median survival being 25.7, 29.0 and 47.4 weeks, respectively. Forty-seven patients were given radical radiotherapy, 30 of these received chemotherapy as initial treatment (20), as adjuvant (3) or at relapse (7). Their 5-year survival rate was 12.8%, with a median of 58 weeks, compared with 2.1% and 31.5 weeks for 241 patients who had palliative radiotherapy (P < 0.001). Seventeen of the 47 patients (36%) and 135 of the 241 patients (56%) were given radiotherapy alone. Univariate analysis showed that gender and age had no significant influence on survival but lymph node status did. The median survival for patients who had no lymph node metastases was 37 weeks compared with 24.5 for those who had (P < 0.01). The median and long-term survival rates for patients in this report contradict previous reports that radiotherapy has no influence on survival. Only patients who received radiotherapy, either alone, or with chemotherapy, have survived 5 years.

Tumor-cell killing by MAbs against fucosyl GM1, a ganglioside antigen associated with small-cell lung carcinoma

Monoclonal antibodies (MAbs) reactive with the ganglioside fucosyl GM1 (Fuc-GM1), an antigen associated with small-cell carcinoma of the lung (SCLC), were tested for their ability to mediate tumor-cell killing in vitro in conjunction with humoral and cellular effectors and to inhibit tumor engraftment in nude mice in vivo. MAbs F12 and F15, both IgG3k, induced human complement-mediated cytolysis of 3 Fuc-GM1-expressing tumor cell lines: one rat hepatoma cell line, H4-II-E, and 2 human SCLC cell lines, NC1 H69 and NC1 H128. F12 and F15 also induced ADCC of these cell lines in the presence of either murine or human effector cells. Addition of sub-cytolytic amounts of fresh human serum as complement source resulted in enhanced ADCC induced by MAb F12 (IgG3). Also a Fuc-GM1-reactive MAb of IgM isotype, F9, was able to induce such complement-aided ADCC (CADCC). F12 and F15 both proved to effectively inhibit engraftment of H4-II-E tumors in nude mice. A single dose of a modest amount (40 micrograms) of MAb conferred 65 to 100% protection against development of tumors. Our results demonstrate that Fuc-GM1 can act as a target antigen on tumor cells for specific immunotherapy in vitro and in a mouse model in vivo. Complement and murine and human mononuclear effector cells were effective mediators of tumor cytolysis in vitro in the presence of murine Fuc-GM1-reactive MAbs. Our results also suggest that humoral and cellular effectors may co-operate in specific tumoricidal reactions and that these may be induced by antibodies of both IgG and IgM isotypes.

Predictors of 5-year survival and curability in small cell lung cancer

A retrospective analysis of various characteristics in 81 small cell lung cancer patients treated at the Mount Sinai Medical Center, New York, from 1974 to 1982 was carried out to identify factors which had prognostic significance for long-term survival, defined as actual disease-free survival for at least 5 years from initiation of therapy. Six patients, five female patients (16.7%) and one male patient (2%), including four limited disease (9.7%) and two extensive disease patients (5%) were long-term survivors (73 to 96+ months from onset of therapy), and among them three remain alive and disease-free at 84, 84, and 96 months from first treatment, respectively. Although several factors, including sex, stage of disease (limited versus extensive), and occurrence of herpes zoster predicted overall survival duration, female sex and an occurrence of herpes zoster were the only variables which were statistically significantly related to 5-year survival. Herpes zoster was a relatively late occurrence whereas female sex was an independent positive prognostic factor.

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.

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.

Radical radiotherapy for bronchogenic carcinoma: five year survival rates

A total of 443 patients with bronchogenic carcinoma were treated by radical radiotherapy. Their 5-year survival rate was 10.5%, median survival 57 weeks. Of these patients 42 (9.5%) had postoperative residual or recurrent tumour. Their 5-year survival rate was 14.3%, median 80 weeks. The corresponding figures for the 401 patients who had had no previous therapy were 10.2% and 54 weeks. The tumour was histologically confirmed in 277 patients; their 5-year survival rate was 6.9%, median 54 weeks. The corresponding figures for the 166 patients who had no positive histology were 16.9% and 61 weeks. The 5-year survival rate of 235 patients with positive histology who had no surgery was 5.5%, median 51 weeks. Age and sex had no significant influence on survival. Tumour size and regional lymph node status had a marked influence on survival. The 5-year survival rate was 27.5% for patients who had T1 tumours and 8.2% for those with T2/3 tumours (P less than 0.001), median 125 and 51.5 weeks, respectively. The lymph node status was recorded in 72% of patients. The 5-year survival rate of patients who had nodal involvement was 7.4% (median 44 weeks) and 18.6% for those who had no apparent lymph node involvement (median 71 weeks), P less than 0.001. Histological type and grade had no influence on survival; in particular the survival of patients who had small cell carcinoma was similar to those of other carcinomas. Dose had no influence on survival in this series.

Three-year disease-free survivors of small cell lung cancer treated with combination chemotherapy with or without chest irradiation

One hundred and seventy-four patients with small cell lung cancer (SCLC) treated with combination chemotherapy, with or without chest radiation, were analyzed. Fourteen patients (8%) survived for 3 years or more. Three-year disease-free survival continued for 12 of the 101 patients (12%) with limited disease, and one of 75 (1%) with extensive disease (P less than 0.05). Patients' sex and performance status were not important in achieving long-term survival. All disease-free survivors, except two who could not be evaluated, achieved a complete response. Although the treatment programs had some influence on the long-term survival rates (P less than 0.05), thoracic radiation did not have significant impact on long-term survival. Three of the 13 patients (23%) developed second malignancies and died, and one of these patients also suffered from a progressive neurologic deterioration with dementia. Two other patients died free of SCLC. Consequently, eight have remained alive and free of disease. The last relapse was observed at 1.5 years from beginning of treatment. The disease-free survival may offer the hope of cure of SCLC. However, the survivors are at an increased risk of developing late complications including second malignancies and neurologic abnormalities. Therefore, careful follow-up will be necessary.

The development of small cell lung cancer in the contralateral lung of a patient surviving 8 years after the original diagnosis of small cell lung cancer

The development of non-small cell lung cancer in patients successfully treated for small cell lung cancer has been previously described. Many of these non-small cell tumors appear to be second primary lung tumors. However, the development of second primary small cell lung cancers has not been clearly delineated. In this report, a patient with limited stage small cell lung cancer who had a complete response to chemotherapy plus chest radiotherapy and remained cancer-free for 8 years is described. Small cell lung cancer developed in this patient's contralateral lung with no evidence of recurrence at the original primary site. Clinical evidence suggests that a second primary small cell lung cancer developed in this patient.