Does surgery or radiation therapy impact survival for patients with extrapulmonary small cell cancers?

Clinical characteristics and prognosis of primary small cell carcinoma of the breast: a propensity score-matched, population-based study

OBJECTIVE

The purpose of this study was to describe the clinicopathological characteristics and prognosis of primary small cell carcinoma of the breast (PSCCB) and compare PSCCB with breast invasive ductal carcinoma (IDC).

DESIGN

A retrospective cohort study.

SETTING

Data of patients with PSCCB and breast IDC were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2016.

PARTICIPANTS

Eighty-three patients with PSCCB and 410 699 patients with breast IDC were enrolled in the present cohort study.

MATERIALS AND METHODS

Patients with PSCCB and breast IDC were identified from the SEER database between 2004 and 2016. The clinicopathological characteristics and survival of patients with PSCCB and IDC were compared. Propensity score matching (PSM) analysis was performed to adjust for differences in baseline characteristics when comparing overall survival (OS) and cancer-specific survival (CSS). Moreover, OS-/CSS-specific nomograms were established to predict the prognosis of PSCCB.

RESULTS

Compared with IDC, PSCCB was significantly correlated with older age, male, higher pathological grade, higher TNM (tumour, node, metastases) stage, a higher proportion of triple-negative breast cancer, a lower proportion of ER/PR positivity and significantly worse clinical outcome. The median OS and CSS of patients with PSCCB were 23.0 m (95%CI 13.0 to 56.0) and 28.0 m (95%CI 18.0 to 66.0), respectively. The 5-year OS and CSS rates in the PSCCB group were 36.1% and 42.4%, respectively. In the matched cohort after PSM analysis, patients with PSCCB had significantly worse OS and CSS than IDC patients. Multivariate Cox regression analysis demonstrated that T stage and administration of chemotherapy were independent prognostic factors for both OS and CSS in patients with PSCCB. The C-index for OS-/CSS-specific nomogram was 0.75 (95%CI 0.66 to 0.85)/0.79 (95%CI 0.69 to 0.89), respectively. The calibration curve in the ROC analysis indicated that the predicted value was consistent with the actual observation value. Decision curve analysis suggested that the nomogram model has a significant positive net benefit from the risk of death and are better than the traditional TNM staging system.

CONCLUSION

PSCCB has distinct clinicopathological characteristics, and patients with PSCCB have significantly worse clinical outcomes than those with IDC.

Localized Colonic Small-Cell Carcinoma with Pathological Complete Response after Neoadjuvant Cisplatin and Etoposide: A Case Report

Extrapulmonary small-cell carcinoma (SCC) is a rare neoplasm that shares certain features with its pulmonary counterpart and occurs predominantly in the gastrointestinal tract (GIT). It is a high-grade and poorly differentiated neuroendocrine tumor, usually diagnosed in advanced stages, with a poor prognosis and few therapeutic options in that setting. This is a case report of a 77-year-old Spanish male patient with localized SCC of the colon, who presented a pathological complete response in the surgical specimen after neoadjuvant chemotherapy with cisplatin and etoposide. To date, 5 years after surgery, the patient remains without evidence of tumor recurrence. As clinical guidelines for the management of this entity are lacking, and therefore its management has not been standardized, an attempt to summarize the current evidence in the literature was made.

Epidemiology, Treatment and Prognosis Analysis of Small Cell Breast Carcinoma: A Population-Based Study

BACKGROUND

Primary small cell breast carcinoma (SCBC) is an uncommon malignancy with highly invasive behavior. The aim of this study was to find out more about the incidence, clinicopathologic characteristics and identify potential prognostic factors of SCBC.

METHODS

Data of patients with primary diagnosis of SCBC between 1975 and 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The incidence after adjustment for age and percentage change per year in incidence were calculated. Disease-specific survival (DSS) and overall survival (OS) were analyzed among these SCBC patients identified from the SEER database. The whole cohorts were randomized into training and validation cohorts as ratio of 7: 3. Cox regression analysis was performed to determine predictors of survival with the training cohorts. Predictive models were constructed with training cohorts, and nomogram validation was performed using receiver operating characteristic curves, concordance indices and calibration curves in both training and validation cohorts.

RESULTS

323 SCBC patients were enrolled finally during the research period. The overall incidence after adjustment for age between 1990 and 2018 was 0.14 per million per year, and the prevalence of the incidence has plateaued. Most of these tumors were poorly differentiated or undifferentiated. The most prevalent presenting stage was Stage II. Patients identified in this study were randomly divided into training (n = 226) and testing (n = 97) cohorts. Multivariate Cox proportional hazards model showed that chemotherapy, surgery and stage were important predictors of DSS and OS.

CONCLUSION

SCBC is considered an infrequent breast neoplasm with aggressive characteristics. Tumor stage is associated with poor prognosis. Combination of surgery and chemotherapy is the main treatment for SCBC.

High grade neuroendocrine carcinoma of the breast, first line and maintenance immunotherapy

Small cell carcinomas (SCCs) are poorly differentiated neuroendocrine tumors that arise predominantly in the lung and gastrointestinal tract (GIT). Neuroendocrine carcinomas can occur in a variety of extrapulmonary sites throughout the body, including breast, larynx, GIT, prostate, urinary bladder, ovary and cervix. This is a case report of a 55-year-old Asian female patient with metastatic high-grade neuroendocrine carcinoma of unknown origin that responded notably to off-label nivolumab maintenance treatment after first-line carboplatin - etoposide chemotherapy and radiation. After 2 years of nivolumab after platinum-based chemotherapy results from PET-CT showed no residual disease and we proceeded to mastectomy.

Clinical characteristics and survival of extrapulmonary small cell carcinoma in 11 different primary tumor sites in the United States, 1975-2016

OBJECTIVE

Few studies have investigated extrapulmonary small cell carcinoma (EPSCC) in a systematic way. This study is to analyze EPSCC in 11 tumor sites from different aspects in the United States (1975-2016).

METHODS

In total 4397 patients diagnosed with EPSCC in 11 primary tumor locations were selected from the Surveillance, Epidemiology and End Results (SEER) database. The incidence of EPSCC in the last decade, and the 1, 3 and 5 year survival rates of each tumor site were also roughly calculated. Prognostic factors of EPSCC were investigated by Cox regression analysis.

RESULTS

Statistically, the incidence of EPSCC was on the rise over the past 30 years. Of its 11 primary tumor sites, bladder was the most frequently affected while the stomach and kidney were rarely affected. Males were more susceptible to EPSCC than females. Married patients were more commonly afflicted by EPSCC, but had longer survival. Cases were most intensive in California and an increased trend had been observed. The 5 year overall survival (OS) rate ranged from 2.0% to 42.5% in patients with EPSCC in 11 tumor sites (p < .001). The OS was better for EPSCC in the breast and cervix. However, tumor sites in the colon, esophagus, pancreas, rectum and stomach were all associated with worse survival. Characteristics and prognosis of EPSCC in different tumor sites were statistically significant (p < .001). Age, gender, marital status, stage, surgery, radiotherapy and chemotherapy were equally significant factors of survival of EPSCC patients (p < .05).

CONCLUSION

There was an increasing trend of EPSCC incidence. The survival of EPSCC in different tumor sites was significantly different. Tumor locations, age, gender, marital status, stage, surgery, radiotherapy and chemotherapy were all important factors of survival. This study has implications for EPSCC prevention and treatment.

Small-cell neuroendocrine carcinoma of the rectum - a rare tumor type with poor prognosis: A case report and review of literature

BACKGROUND

Small-cell neuroendocrine carcinoma (SNEC) of the rectum is a rare tumor associated with poor prognosis.

CASE SUMMARY

We report a case of a 77-year-old male who came into our hospital because of blood with his stool. An endoscopy revealed a cauliflower-like neoplasm in his rectum. Imaging examination showed that the lesion in the upper rectum was likely rectal cancer, and there was no evidence of metastasis. The patient was treated with surgery. Pathological examination confirmed SNEC of the rectum and an R0 resection was achieved. However, 1 mo after the operation, the patient developed intestinal and ureteral obstructions due to peritoneal metastases. Finally, the patient died from renal failure.

CONCLUSION

SNEC of the rectum is a high-grade carcinoma with an aggressive phenotype, and surgery should be cautiously considered.

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

Background

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

Methods

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

Results

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

Conclusions

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

A rare rarity: Neuroendocrine tumor of the esophagus

Esophageal Neuroendocrine tumors (NETs) are rare, aggressive and lacking specific symptoms. This causes a diagnostic delay, worsening the prognosis. Numerous cases are reported in literature, without a consensus on the management. Our aim was to clarify epidemiology, clinical presentation, diagnostic, therapeutic management of esophageal NETs. Extensive literature search identified a total of 226 articles. One hundred twenty-five articles (n = 1676) met the inclusion criteria, showing that: the incidence of esophageal NET varies geographically; men (60-70 years) are more affected; smoking and alcohol abuse are the major risk factors; dysphagia, weight loss, appetite loss are the most common clinical features. The histotypes include high-grade small and large cell esophageal carcinomas and low-grade carcinoid tumors. Mixed neuroendocrine/non-neuroendocrine neoplasms are the most common. Often the diagnosis occurs randomly on endoscopic examination. Circulating markers, functional combined with conventional imaging contributes to the diagnosis and management. Treatment depends on type, grade and stage of the tumor.

Primary Small Cell Carcinoma of the Hypopharynx: A Report of Two Cases and Review of Nine Additional Cases

Objective

Two patients with primary small cell carcinoma (SmCC) of the hypopharynx, an extremely rare site for the occurrence of SmCC, are reported and nine additional well-documented cases are reviewed.

Methods

Case report and review of the literature concerning primary SmCC of the hypopharynx.

Results

On the final analysis, we reviewed eleven cases of primary SmCC of the hypopharynx. The tumors contained mixed elements of SmCC and squamous cell carcinoma (SCC) in six (55%) of eleven patients. Out of eleven patients, two patients had distant metastasis at the initial presentation. Even though nine patients presented with locoregional disease, development of distant metastasis after treatment was seen in five patients (56%), whereas there was no report of treatment failure on the primary site. To achieve more than two-year survival, patients should have received more than 4 cycles of chemotherapy.

Conclusion

We report two cases of primary SmCC of the hypopharynx with a review of the literature. In more than half of the cases, combined carcinomas with SCC are seen. Because this tumor has a strong propensity for distant metastasis even in patients with clinically localized tumor, new powerful systemic agents should be explored.

Extrapulmonary small cell carcinoma in head and neck

PURPOSE

The management of extrapulmonary small cell carcinoma has not been standardised to date. This study reviewed the clinical course, management and survival outcomes of patients with extrapulmonary small cell carcinoma in the head and neck region.

METHODS

Nine patients with extrapulmonary small cell carcinoma in the head and neck were included in this study.

RESULTS

Five patients received radical surgery followed by adjuvant chemotherapy or radiotherapy or both. Two other patients were treated with chemotherapy consisting of CPT11 plus cisplatin or CPT11 plus cisplatin plus VP-16 three times. Two other patients received chemoradiotherapy consisting of S-1 or CPT11 plus cisplatin. The median overall survival was 14.5 months, with a three-year survival rate of 23.7 per cent.

CONCLUSIONS

The prognosis of extrapulmonary small cell carcinoma is generally poor. Further prospective multicentre studies are required for better understanding of disease entities and response to treatment modalities.

Neuroendocrine Carcinomas of the Gastroenteropancreatic System: A Comprehensive Review

To date, empirical literature has generally been considered lacking in relation to neuroendocrine carcinomas (NECs), the highly malignant subgroup of neuroendocrine neoplasms. NECs are often found in the lungs or the gastroenteropancreatic (GEP) system and can be of small or large cell type. Concentrating on GEP-NECs, we can conclude that survival times are poor, with a median of only 4–16 months depending on disease stage and primary site. Further, this aggressive disease appears to be on the rise, with incidence numbers increasing while survival times are stagnant. Treatment strategies concerning surgery are often undecided and second-line chemotherapy is not yet established. After an analysis of over 2600 articles, we can conclude that there is indeed more empirical literature concerning GEP-NECs available than previously assumed. This unique review is based on 333 selected articles and contains detailed information concerning all aspects of GEP-NECs. Namely, the classification, histology, genetic abnormalities, epidemiology, origin, biochemistry, imaging, treatment and survival of GEP-NECs are described. Also, organ-specific summaries with more detail in relation to disease presentation, diagnosis, treatment and survival are presented. Finally, key points are discussed with directions for future research priorities.

A population-based study of incidence and patient survival of small cell carcinoma in the United States, 1992-2010

BACKGROUND

In contrast to the well-described epidemiology and behavior of small cell lung carcinoma (SCLC), little is known about extrapulmonary small cell carcinoma (EPSCC).

METHODS

Using data from the Surveillance, Epidemiology and End Results (SEER) Program (1992-2010), we calculated age-adjusted incidence rates (IRs), IR ratios (IRRs), annual percent change (APC), relative survival (RS), RS ratios (RSRs), and the respective 95% confidence intervals (95% CI) of SCLC and EPSCC according to primary site. We used the SEER historic stage variable that includes localized (confined to the organ of origin), regional (direct extension to adjacent organ/tissue or regional lymph nodes), and distant (discontinuous metastases) stages and combined localized and regional stages into "limited" stage.

RESULTS

The incidence of SCLC (IR = 76.3/million person-years; n = 51,959) was 22-times that of EPSCC (IR = 3.5; n = 2,438). Of the EPSCC sites, urinary bladder, prostate, and uterine cervix had the highest incidence (IRs = 0.7-0.8); urinary bladder (IRR = 4.91) and stomach (IRR = 3.46) had the greatest male/female disparities. Distant-to-limited stage site-specific IRRs of EPSCC were significantly elevated for pancreas (IRR = 6.87; P < 0.05), stomach, colon/rectum, ovary, and prostate (IRRs = 1.62-2.42; P < 0.05) and significantly decreased for salivary glands, female breast, uterine cervix, and urinary bladder (IRRs = 0.32-0.46). During 1992-2010, significant changes in IRs were observed for EPSCC overall (APC = 1.58), small cell carcinoma of the urinary bladder (APC = 6.75), SCLC (APC = -2.74) and small cell carcinoma of unknown primary site (APC = -4.34). Three-year RS was significantly more favorable for patients with EPSCC than SCLC for both limited (RSR = 2.06; 95% CI 1.88, 2.26) and distant stages (RSR = 1.55; 95% CI 1.16, 2.07). Among limited stage small cell carcinoma, RS was most favorable for salivary glands, female breast, and uterine cervix (RS = 52-68%), whereas RS for nearly all sites with distant stage disease was <10%.

CONCLUSION

EPSCC comprises a heterogeneous group of diseases that appears, at least in part, etiologically distinct from SCLC and is associated with more favorable stage-specific patient survival.

A population-based analysis of outcomes for small cell carcinoma of the breast by tumor stage and the use of radiation therapy

Purpose

Primary small cell carcinomas of the breast (SCCB) are rare tumors with limited data on outcomes and treatment strategies. Using a population based approach, we aimed to study outcomes of SCCB and determine whether the use of radiation therapy is associated with better survival among patients with SCCB.

Methods

Using the Surveillance, Epidemiology and End Results (SEER) registry, we identified patients with SCCB between1973 and 2010. We examined the stage specific survival of these patients and compared it to the stage specific survival of small cell lung cancer (SCLC) from the SEER database over the same accrual period. We further analyzed the impact of radiation therapy on overall survival for SCCB patients using a univariate and multivariate approach.

Results

A total of 199 patients with primary SCCB with staging were identified during the study period. Eighty-four patients (42%) had localized disease, 77 (39%) had regional disease and 38 (19%) had distant disease. For comparison, 81,933 patients with SCLC were identified. Outcomes were superior for patients with SCCB with localized (150 vs. 16 months, p < 0.01) and regional disease (56 vs. 13 months, p < 0.01), but not distant disease (7 vs. 7 months, p = 0.43). Use of radiation therapy was not associated with a significant difference in OS for patients with either localized (202 vs. 147 months, p = 0.48) or regional (52 vs. 75 months, p = 0.650) disease.

Conclusions

SCCB has a more favorable prognosis by stage for localized and regional disease than SCLC. Adjuvant radiation is not associated with an improvement in survival for patients with localized or regional SCCB in this dataset.

Should patients with extrapulmonary small-cell carcinoma receive prophylactic cranial irradiation?

INTRODUCTION

Extrapulmonary small-cell carcinoma (EPSCC) is a rare disease. Management is based on small-cell lung carcinoma. Prophylactic cranial irradiation (PCI) is not routinely administered in EPSCC. This study investigates the role of PCI in EPSCC, by analyzing the incidence, treatment, and survival of patients with brain metastases in a national cohort. Disease biology and epidemiology are also investigated.

METHODS

Patients diagnosed with primary EPSCC from the National Cancer Registry of Ireland from 1995 to 2007 were identified. The number of patients who developed brain metastases, their survival, and treatment data were documented. Patients who received PCI were investigated. Patient and disease characteristics, treatment, and survival data were stratified by stage and primary site.

RESULTS

Two hundred eighty patients were identified; 141 (50.4%) were men and 139 (49.6%) were women. One hundred eighty six patients (66.4%) had extensive-stage disease, 65 (23.2%) had limited-stage disease, and in 29 patients (10.3%) the stage was unknown. Eighteen patients (6.4%) developed brain metastases, with a median overall survival of 10.1 months. Eleven (61%) received cranial irradiation, and 12 (67%) received palliative chemotherapy. Two patients in the entire cohort (0.17%) received PCI. The most common primary sites included the esophagus (n = 43; 15.4%), cervix uteri (n = 17; 6.0%), bladder (n = 13; 4.6%), and prostate (n = 10; 3.6%). Median overall survival was 15.2 months (10.2-20.6) for limited-stage disease, 2.3 months (1.7-3.1) for extensive-stage EPSCC, and 3.7 months (1.3-8.3) for disease of unknown stage.

CONCLUSION

Brain metastases were uncommon in EPSCC compared with small-cell lung carcinoma. PCI is thus probably not warranted in this disease.

The 2002 AJCC TNM classification is a better predictor of primary small cell esophageal carcinoma outcome than the VALSG staging system

Small cell carcinoma of the esophagus (SCCE) is a rare and aggressive malignant tumor with a poor prognosis. The optimal disease staging system and treatment approaches have not yet been defined. This study aimed to evaluate the prediction of different staging systems for prognosis and treatment options of SCCE. We retrospectively accessed the clinicopathologic characteristics, treatment strategy, and prognosis of 76 patients diagnosed with primary SCCE between 2001 and 2011. The 1-, 2-, 3-, and 5-year overall survival rates were 58%, 31%, 19%, and 13%, respectively. Univariate analysis showed that the 2002 American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) classification (P = 0.002), Veterans Administration Lung Study Group (VALSG) stage (P = 0.001), predisposing factors (P < 0.001), T category (P = 0.023), and M category (P < 0.001) were prognostic factors for overall survival. Multivariate analysis showed that the 2002 AJCC TNM stage (P < 0.001) was the only independent prognostic factor for survival. The value of the area under the receiver operator characteristic (ROC) curve (AUC) of the 2002 AJCC TNM staging system was larger than that of VALSG staging system with regard to predicting overall survival (0.774 vs. 0.620). None of the single treatment regimens showed any benefit for survival by Cox regression analysis. Thus, the 2002 AJCC TMN staging system improved the prediction of SCCE prognosis; however, the optimal treatment regimen for SCCE remains unclear.

Cerebral metastases in extrapulmonary cell carcinoma. Implications for the use of prophylactic cranial irradiation

BACKGROUND AND PURPOSE

Extrapulmonary small cell carcinoma (EPSCC) is a rare disease. Standard treatment is performed in analogy to small cell lung cancer; however, due to the differences in rates of cerebral metastases (CM), prophylactic cranial irradiation (PCI) is not routinely used. Therefore, we evaluated the characteristics of all patients developing brain metastases in a population of EPSCC patients and calculated a number needed to treat (NNT) for the prevention of cerebral metastases by PCI.

PATIENTS, METHODS, AND RESULTS

Of 51 patients treated at our institution from 1999-2011 for EPSCC, 11 presented with CM, 5 at initial diagnosis, 6 in the course of their disease. Median overall survival after primary diagnosis of EPSCC was 12 months. Overall survival after diagnosis of CM was significantly in favor of primarily cerebrally metastasized patients with 9 compared to 2 months for secondary CM (p = 0.04), median survival for all patients being 4 months. The NNT calculation was based on the 6 patients with secondary brain metastases in our series and a relative risk reduction of 60% observed in the studies of PCI for small cell lung cancer (SCLC), resulting in an NNT of 13.

CONCLUSION

Although the frequency of brain metastases in EPSCC was lower than in SCLC, the NNT of 13 for the prevention of CM, as well as the poor median survival after diagnosis of secondary brain metastases of 2 months might be a reason to discuss and evaluate PCI for EPSCC patients responding to initial therapy.