Limited disease of extra-pulmonary small cell carcinoma. Impact of local treatment and nodal status, role of cranial irradiation

Head and neck small-cell carcinoma: A multicenter study of 39 cases from 10 institutions

Objective

Basal information of head and neck small-cell carcinoma (HNSmCC) including epidemiology, primary site, treatment, and prognosis remains sparse due to its rarity. We report here a multicenter retrospective study on the diagnosis, treatment, and outcomes of patients with HNSmCC.

Materials and methods

This study involved 47 patients with HNSmCC from 10 participating institutions. Eight patients were excluded for whom no pathological specimens were available (n = 2) and for discrepant central pathological judgements (n = 6). The remaining 39 patients were processed for data analysis.

Results

As pretreatment examinations, computed tomography (CT) was performed for the brain (n = 8), neck (n = 39), and chest (n = 32), magnetic resonance imaging (MRI) for the brain (n = 4) and neck (n = 23), positron emission tomography-CT (PET-CT) in 23 patients, bone scintigraphy in 4, neck ultrasonography in 9, and tumor markers in 25. Primary sites were oral cavity (n = 1), nasal cavity/paranasal sinuses (n = 16), nasopharynx (n = 2), oropharynx (n = 4), hypopharynx (n = 2), larynx (n = 6), salivary gland (n = 3), thyroid (n = 2), and others (n = 3). Stages were II/III/IV-A/IV-B/IV-C/Not determined = 3/5/16/6/5/4; stage IV comprised 69%. No patient had brain metastases. First-line treatments were divided into 3 groups: the chemoradiotherapy (CRT) group (n = 27), non-CRT group (n = 8), and best supportive care group (n = 4). The CRT group included concurrent CRT (CCRT) (n = 17), chemotherapy (Chemo) followed by radiotherapy (RT) (n = 5), and surgery (Surg) followed by CCRT (n = 5). The non-CRT group included Surg followed by RT (n = 2), Surg followed by Chemo (n = 1), RT alone (n = 2), and Chemo alone (n = 3). The 1-year/2-year overall survival (OS) of all 39 patients was 65.3/53.3%. The 1-year OS of the CRT group (77.6%) was significantly better compared with the non-CRT group (31.3%). There were no significant differences in adverse events between the CCRT group (n = 22) and the Chemo without concurrent RT group (n = 9).

Conclusion

Neck and chest CT, neck MRI, and PET-CT would be necessary and sufficient examinations in the diagnostic set up for HNSmCC. CCRT may be recommended as the first-line treatment. The 1-year/2-year OS was 65.3%/53.3%. This study would provide basal data for a proposing the diagnostic and treatment algorithms for HNSmCC.

Small cell carcinoma of cervix: A population-based study evaluating standardized provincial treatment protocols

Objectives

To describe the patient characteristics, patterns of treatment, and outcome of patients with small cell carcinoma of Cervix (SmCC) treated with radical radiotherapy from a provincial cancer registry database.

Methods

Overall 25 patients with SmCC were treated with radical radiotherapy (with or without chemotherapy) from January 1, 1994 to December 31, 2013. Nineteen patients had pure SmCC while 6 had additional neuroendocrine component. Patients were treated with combined chemo-radiotherapy using multi-agent chemotherapy with pelvic or combined pelvic and para-aortic radiotherapy. All patients received brachytherapy. Use of prophylactic cranial irradiation was dependent on physician discretion. Survival was estimated using Kaplan-Meier method and compared using log-rank test.

Results

We report a median overall survival of 53.8 months for our cohort. After a median follow-up of 54 months for surviving patients, the overall survival (OS) and progression free survival (PFS) at 5-years were 48% and 46.4% respectively. Patients with stage I-IIA disease had superior 5-year PFS (67.3% vs. 11.1%; p = .004) and 5-year OS (62.5% vs. 22.2%; p = .006). Patients with node-negative disease had a trend towards better 5-year PFS (55.7% vs. 19%; p = .07) and OS (61.1% vs. 14.3% at 5-years; p = .06) Distant metastasis was the predominant site of disease progression (n = 12; 48%).

Conclusion

Distant metastasis is the predominant pattern of failure for patients with SmCC treated with radical chemo-radiotherapy. With modern chemo-radiotherapy protocols we can expect a 5 year survival of around 50%. Early stage and node-negative status appear to be favorable prognostic factors with survival rates at 5-year over 60%.

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Multi-agent chemotherapy with radiotherapy results in 50% overall survival at 5-years in small cell carcinoma of cervix

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Distant metastasis remains the predominant site of disease progression

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Stage and node-involvement bears significant association with survival

Extrapulmonary small cell carcinoma of lymph node: Pooled analysis of all reported cases

AIM

To study clinical outcomes and management of lymph nodes extrapulmonary small cell carcinoma (LNEPSCC).

METHODS

Herein, we perform a systematic search of published literature in the PubMed and EMBASE databases for studies describing LNEPSCC. For uniformity of reporting, LNEPSCC was staged as limited if it involved either single lymph node station or if surgery with curative intent had been undertaken. The disease was staged extensive if it involved two or more lymph node regions.

RESULTS

The systematic literature review yielded eight descriptions (n = 14) involving cervical, submandibular and inguinal lymph nodes. Eleven (64.7%) patients had limited disease (LD) and six (35.3%) had extensive disease (ED) at presentation. Chemotherapy (n = 6, 35.3%) or surgery (n = 4, 23.5%) were the most common form of treatment given to these patients. Complete response was achieved in 12 (70.6%) of the patients. Median (interquartile range) progression free survival and overall survival was 15 (7-42) mo and 22 (12.75-42) mo respectively. Of the three illustrative cases, two patients each had ED at presentation and achieved complete remission with platinum based combination chemotherapy.

CONCLUSION

LNEPSCC is a rare disease with less than 15 reported cases in world literature. Surgical resection with curative intent is feasible in those with LD while platinum based combination chemoradiation is associated with favorable outcomes in patients with ED. Prognosis of LNEPSCC is better than that of small cell lung cancer in general.

Controversies in small cell carcinoma of the head and neck: Prophylactic cranial irradiation (PCI) after primary complete initial remission

Small cell carcinoma of head and neck region (SmCCHN) represents a rare entity and its management remains a significant clinical challenge. Complete initial response to primary therapy poses a difficult and controversial scenario for radiation oncologists. Prophylactic cranial irradiation (PCI) has long been established in the management of small cell lung cancer; however, its role in SmCCHN is still called into question. The rationale behind PCI lies in the eradication of possible micro-metastatic brain disease, which is often documented in this type of cancer. No randomized trials on this topic are available. This review, based on 20 retrospective studies, addresses the controversies in the use of PCI in SmCCHN management.

Gynecologic Cancer InterGroup (GCIG) consensus review for small cell carcinoma of the cervix

Small cell carcinoma of the cervix (SCCC) is a rare histological entity of uterine cervical cancer. Compared with other common histological types, squamous cell carcinoma or adenocarcinoma, the outcome of SCCC is poor because of the high incidence of nodal or distant metastasis even with early stage. In this review, current consensus of epidemiology, pathology, and initial treatment for SCCC will be discussed.

Current approaches for prophylactic cranial irradiation in extrapulmonary small cell carcinoma

BACKGROUND

Small cell lung cancer (SCLC) patients, who have achieved complete or partial response after chemotherapy, should be followed with prophylactic cranial irradiation (PCI). PCI for extrapulmonary small cell carcinoma (EPSCC) is not routinely recommended. The purpose of this review is to discuss all aspects of PCI in management of EPSCC.

SCOPE

The PubMed database and the database of online abstracts of the American Society of Oncology (ASCO), ASCO Genitourinary (GU) Cancers meetings and clinical trials were searched up to 15 October 2013 using the following search keywords: 'SCC or EPSCC of each organ site and prophylactic cranial radiotherapy'. The language of screened abstracts and manuscripts was limited to English. The papers which included the largest case series and data of cases about prophylactic cranial radiotherapy and/or were published in the last 10 years were selected.

FINDINGS

Many single center studies showed low incidence of brain metastasis in patients with esophageal small cell carcinoma (SCC). Due to the low incidence of brain metastasis, PCI is not recommended for esophageal SCC. Genitourinary, colorectal, small bowel and appendix cranial metastatic SCCs are extremely rare. Therefore, PCI is not recommended. The frequency of brain metastasis of prostate small cell carcinoma is much higher (16-19%) compared to other counterparts of EPSCC. PCI can be performed in selected cases of prostate SCC. High rates (41%) of brain metastasis develop in head and neck SCC. PCI should be considered for patients with head neck SCC.

CONCLUSION

In the literature, the brain metastasis incidence of EPSCC might vary from 1.7% up to 40%. In many patients with ESPCC, PCI is not recommended. However, we have to keep in mind that primary head and neck and prostate SCC are exceptions due to the high incidence of cranial metastasis; PCI should be recommended for these patients on an individual basis.

Ionizing radiation, ion transports, and radioresistance of cancer cells

The standard treatment of many tumor entities comprises fractionated radiation therapy which applies ionizing radiation to the tumor-bearing target volume. Ionizing radiation causes double-strand breaks in the DNA backbone that result in cell death if the number of DNA double-strand breaks exceeds the DNA repair capacity of the tumor cell. Ionizing radiation reportedly does not only act on the DNA in the nucleus but also on the plasma membrane. In particular, ionizing radiation-induced modifications of ion channels and transporters have been reported. Importantly, these altered transports seem to contribute to the survival of the irradiated tumor cells. The present review article summarizes our current knowledge on the underlying mechanisms and introduces strategies to radiosensitize tumor cells by targeting plasma membrane ion transports.

Small cell carcinoma of the head and neck: report of three cases

OBJECTIVE

Small cell carcinoma of the head and neck is rare and has unique histopathological characteristics that make it difficult to diagnose and treat. In this report, the Japanese Lung Cancer Treatment Guidelines were adapted to treat three patients with small cell carcinoma of the head and neck, and outcomes evaluated.

METHODS

There was one case each of stage I small cell carcinoma of the nasal cavity, stage IV-B small cell carcinoma of the ethmoid sinus, and stage IV-A small cell carcinoma of the submandibular gland. All patients underwent chemoradiotherapy and achieved a partial response.

RESULTS

Only case one underwent surgery after chemoradiotherapy; 31 months after treatment, this patient had suffered no recurrence. Case two died three months after treatment due to bone marrow metastasis. Case three had experienced no progression after 12 months of follow up.

CONCLUSION

In this small patient series, short-term results were equivalent to or better than usual treatment outcomes for small cell carcinoma of the lung.

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

BACKGROUND

Extrapulmonary small cell carcinoma is a distinct clinicopathological entity accounting for only 2.5-4% of small cell carcinomas. Here we present a case of primary intracranial small cell carcinoma.

CASE REPORT

A 69-year-old woman with an isolated brain lesion presented with progressive headaches, confusion, nausea, and vomiting. A magnetic resonance imaging scan of the brain revealed a 4 × 3 × 5-cm solitary cystic tumor in the right frontoparietal lobe, accompanied by a midline shift. The mass was resected and pathologically proven to be a small cell carcinoma. The patient was given adjuvant radiotherapy but refused any chemotherapy. At the 12-month follow-up the patient was alive and well.

CONCLUSION

Primary intracranial small cell carcinoma presenting as an isolated lesion is extremely rare. While there are no standard treatment guidelines for these patients, the authors believe multimodality treatment including tumorectomy and postoperative radiotherapy should be recommended.

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.