Prognostic factors of small cell lung cancer

Clinical and molecular characterization of long-term survivors with extensive-stage small cell lung cancer treated with first-line atezolizumab plus carboplatin and etoposide

OBJECTIVES

In the Phase I/III IMpower133 study, first-line atezolizumab plus carboplatin and etoposide (CP/ET) treatment for extensive-stage small cell lung cancer (ES-SCLC) significantly improved overall survival (OS) and progression-free survival versus placebo plus CP/ET. We explored patient and disease characteristics associated with long-term survival in IMpower133, and associations of differential gene expression and SCLC-A (ASCL1-driven), SCLC-N (NEUROD1-driven), SCLC-P (POU2F3-driven), and SCLC-inflamed (SCLC-I) transcriptional subtypes with long-term survival.

MATERIALS AND METHODS

Patients with previously untreated ES-SCLC were randomized 1:1 to four 21-day cycles of CP/ET with atezolizumab or placebo. Long-term survivors (LTS) were defined as patients who lived ≥ 18 months post randomization. A generalized linear model was used to evaluate the odds of living ≥ 18 months. Differential gene expression was analyzed using RNA-sequencing data in LTS and non-LTS. OS was assessed by T-effector and B-cell gene signature expression. Distribution of SCLC transcriptional subtypes was assessed in LTS and non-LTS.

RESULTS

More LTS were in the atezolizumab arm (34%) than in the placebo arm (20%). The odds ratio for living ≥ 18 months in the atezolizumab arm versus the placebo arm was 2.1 (P < 0.03). Enhanced immune-related signaling was seen in LTS in both arms. Exploratory OS analyses showed atezolizumab treatment benefit versus placebo across T-effector and B-cell gene signature expression subgroups. A higher proportion of LTS than non-LTS in both arms had the SCLC-I subtype; this difference was particularly pronounced in the atezolizumab arm.

CONCLUSION

These exploratory analyses suggest that long-term survival is more likely with atezolizumab than placebo in ES-SCLC, confirming the treatment benefit of the IMpower133 regimen.

CLINICALTRIAL

gov Identifier: NCT02763579.

Is Onodera's prognostic nutritional index (OPNI) a prognostic factor in small cell lung cancer (SCLC)?

INTRODUCTION

We aimed to evaluate the prognostic value of Onodera's prognostic nutritional index (OPNI) in patients with Small-cell lung cancer (SCLC).

MATERIALS AND METHODS

This study retrospectively examined 109 patients diagnosed with SCLC between January 2008 and October 2018 in our hospital. Patients were divided into two groups according to the median of OPNI values.

RESULTS

A significant difference was observed between the groups in terms of neutrophil percentage, lymphocyte count, lymphocyte percentage, C-reactive protein (CRP), albumin, lactat dehidrogenase (LDH) and neutrophil to lymphocyte ratio (NLR) (P < 0.05). LDH, CRP, neutrophil percentage and NLR (P = 0.008, P < 0.001, P = 0.001, P < 0.001, respectively) were significantly higher and albumin, lymphocyte count and lymphocyte percentage (P < 0.001, P < 0.001, P = 0.001, respectively) were significantly lower in the low OPNI group. Survival analyses have shown that mortality rates and lifespan are similar in the two groups.

CONCLUSION

The OPNI may be a helpful tool for determining the prognosis in SCLC.

The Relation between Hemogram Parameters and Survival in Extensive-Stage Small Cell Lung Cancer

PURPOSE

To determine whether hemogram parameters have prognostic effects on survival in patients with extensive-stage small cell lung cancer (ED-SCLC).

METHODS

This retrospective analysis included 113ED-SCLC patients, who were followed in an oncology clinic. The data regarding the baseline patient demographic characteristics, complete blood count (white blood cell, red blood cell, hemoglobin, hematocrit, mean platelet volume, platelet, total neutrophil, total lymphocyte, total monocyte, neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], and monocyte-to-lymphocyte ratio [MLR]), and survival were analyzed. According to the ROC curve drawn for overall survival (OS) analysis, the cutoff values were determined as follows: NLR ≥3, with 71.4% sensitivity and 63.6% specificity; PLR ≥0.150, with 68.1% sensitivity and 52.4% specificity; and MLR ≥0.367, with 64.4% sensitivity and 71.4% specificity.

RESULTS

Of the 113 patients with ED-SCLC, 92 (81.4%) were men and 21 (18.6%) were women. The median age was 65 years (range, 35-81 years). NLR was <3 in 40 (65.4%) patients. Patients with NLR <3 had significantly higher OS than those with NLR ≥3 (15 vs. 5 months, respectively, p < 0.001). Patients with PLR <150 had significantly higher median OS than those with PLR ≥150 (14 vs. 6 months, respectively, p = 0.014). The median OS was significantly greater in patients with MLR <0.367 compared to that in patients with MLR ≥0.367 (11 vs. 6 months, respectively, p = 0.016). In multivariate analysis, NLR was the only factor associated with OS (HR = 2.26, 95% Cl 1.24-4.10).

CONCLUSION

NLR was determined as an independent negative prognostic factor for OS in ED-SCLC patients at diagnosis, thus may help determine disease prognosis as a useful prognostic marker.

Serum lactate dehydrogenase predicts survival in small-cell lung cancer patients with brain metastases that were treated with whole-brain radiotherapy

This study aimed to identify factors that predict prognosis after radiotherapy for brain metastases (BMs) from small-cell lung cancer (SCLC). This study retrospectively evaluated 48 consecutive patients who underwent whole-brain radiotherapy (WBRT) for BMs from SCLC between February 2008 and December 2017. WBRT was delivered at a median dose of 30 Gy (range: 30-40 Gy) in 10 fractions (range: 10-16 fractions). Clinical factors were tested for associations with overall survival after WBRT. The median survival and 1-year overall survival rate after WBRT treatment were 232 days and 34.4%, respectively. Univariate analyses revealed that longer survival was associated with Eastern Cooperative Oncology Group performance status of 0-1, asymptomatic BMs, lactate dehydrogenase (LDH) in the normal range, Radiation Therapy Oncology Group-recursive partitioning analysis class 2, and a graded prognostic assessment score of ≥1.5 (P < 0.01, P < 0.01, P < 0.01, P < 0.01 and P < 0.05, respectively). In the multivariate analyses, longer survival was independently associated with asymptomatic BMs [hazard ratio for death (HR), 0.32; 95% confidence interval (CI), 0.12-0.79; P < 0.05] and LDH in the normal range (HR, 0.42; 95% CI, 0.21-0.83; P < 0.05). The presence of symptoms due to BMs and LDH values independently predicted prognosis after WBRT for BMs from SCLC. Elevated LDH may provide valuable information for identifying patients with BMs who could have poor survival outcomes.

High neutrophil-to-lymphocyte ratios confer poor prognoses in patients with small cell lung cancer

Background

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are easily obtained from routine blood tests. We investigated the associations of the NLR and PLR with the clinical parameters and prognoses of small cell lung cancer (SCLC) patients.

Methods

Pre-treatment clinical and laboratory data from 139 patients with SCLC were retrospectively studied with univariate analyses. The NLR and PLR values were divided into two separate groups: high NLR (>4.55, n = 32) vs low NLR (≤4.55, n = 107) and high PLR (>148, n = 63) vs low PLR (≤148, n = 76). Kaplan-Meier survival analyses and Cox proportional hazard models were used to examine the effects of NLR and PLR on overall survival.

Results

Chi-square analyses revealed significant associations of high NLR with tumour stage, hepatic metastasis, radiotherapy and chemotherapy and significant associations of high PLR with tumour stage, bone and hepatic metastases, exposure to cooking oil fumes, and chemotherapy. Mann-Whitney U tests demonstrated an association of high NLR with smoking exposure, and high NLR and high PLR were correlated with several laboratory parameters. Kaplan-Meier analyses revealed that high NLR and high PLR conferred poor prognoses for SCLC patients. Moreover, multivariate analysis demonstrated that NLR, tumour stage, and hepatic metastasis were independent prognostic factors for survival. In this study, we found that NLR and PLR were associated with several factors that reflect the inflammatory (white blood cell count, WBC; lactate dehydrogenase, LDH) and nutritional (albumin, ALB; haemoglobin, HB; and cholesterol) status of SCLC patients at diagnosis.

Conclusions

NLR is an independent prognostic factor and can be used to predict the mortality risk of SCLC patients.

Syndrome of Inappropriate Antidiuretic Hormone Secretion: A Poor Prognosis in Small-cell Lung Cancer

BACKGROUND AND AIMS

Small cell lung cancer (SCLC) is frequently associated with syndrome of inappropriate antidiuretic hormone (SIADH) secretion. In this study we investigated the prognostic value of SIADH in Chinese patients with SCLC.

METHODS

We prospectively studied a total of 385 patients with SCLC diagnosed in our institution. The relationship between the SIADH and treatment outcomes including progression-free survival (PFS) and overall survival (OS) were analyzed. Univariate analysis and Cox multivariate analyses were used for statistical analyses. PFS and OS curves were drawn using Kaplan-Meier method.

RESULTS

The median PFS and OS in patients with SIADH was 6.7 months (95% confidence interval [CI]: 4.3-9.1) and 11.6 months (95% CI: 7.4-15.7), respectively. The corresponding PFS and OS in SCLC without SIADH was 9.2 months (95% CI: 8.6-9.8) and 19.2 months (95% CI: 16.5-21.9), respectively; the difference between groups was statistically significant (p = 0.007 and p = 0.000, respectively). The association of SIADH with poor PFS (p = 0.000) and OS (p = 0.002) retained its statistical significance after adjusting for potential confounding variables. In addition, PFS (p = 0.000) and OS (p = 0.000) of SIAHD patients with plasma sodium <125 mmol/L or without plasma sodium recovery to normal level are both shorter than in patients without SIADH. OS in SIAHD patients with plasma sodium recovery time to normal level is also shorter than patients without SIADH (p = 0.03).

CONCLUSIONS

SIADH is a common occurrence in patients with SCLC and is associated with poor prognosis for SCLC in Chinese patients.

Efficacy and safety of ifosfamide in combination with carboplatin and etoposide in small cell lung cancer

PURPOSE

Ifosfamide, a potent alkylating agent, is rarely incorporated into small cell lung cancer (SCLC) treatment. The aim of this study was to assess the efficacy and safety of ifosfamide in combination with carboplatin and etoposide (ICE) in previously untreated patients with SCLC.

METHODS

From January 2002 to January 2014, we consecutively enrolled 69 patients with SCLC who were treated with ICE as initial chemotherapy at Kangbuk Samsung Hospital. The modified ICE regimen consists of ifosfamide 1200 mg/m(2)/day on days 1, 2, and 3 with mesna, etoposide 80 mg/m(2)/day on days 1, 2, and 3, and carboplatin AUC 6 on day 1. Treatment was repeated every 3 weeks and continued for up to nine cycles. Response assessments were performed every three cycles with computed tomography.

RESULTS

Among 69 patients with SCLC, the median age was 69 years (range 51-88 years). Sixteen (23 %) patients had limited disease (LD), and 53 (77 %) had extensive disease (ED). The overall response rate was 73 %. Stable disease rate was 20 %. The median overall survival was 11.3 months [95 % confidence interval (CI) 8.9-14.1] in the overall population, 20.6 months (95 % CI 14.2-21.2) for LD and 9.1 months (95 % CI 7.8-11.6) for ED. The median number of administered cycles was 6 (range 1-9). Grade ≥3 hematological toxicities included neutropenia (34 %), anemia (59 %), and thrombocytopenia (31 %). Grade ≥3 non-hematological toxicities included peripheral neuropathy in 2 %.

CONCLUSION

In chemonaïve patients with SCLC, modified ICE is well tolerated and shows favorable efficacy.

Clinical significance of plasma fibrinogen and D-dimer in predicting the chemotherapy efficacy and prognosis for small cell lung cancer patients

PURPOSE

Elevated plasma fibrinogen and D-dimer levels indicate activation of hemostasis and fibrinolysis, and this activation is required for tumor angiogenesis, metastasis, and invasion. Previous studies demonstrated that the plasma fibrinogen and D-dimer levels correlate with patient's prognosis in several solid tumors. The aim of this study is to examine the relationship between plasma fibrinogen and D-dimer levels before and during chemotherapy and treatment response and survival in patients with small cell lung cancer (SCLC).

METHODS

Plasma fibrinogen and D-dimer levels before and during chemotherapy were prospectively measured in 74 SCLC patients who received first-line therapy. The results were analyzed for correlation between fibrinogen and D-dimer levels and treatment response, as well as progressive-free survival (PFS) and overall survival (OS).

RESULTS

The levels of fibrinogen and D-dimer in SCLC patients before (C0) and after two cycles (C2) of chemotherapy were significantly higher than those in controls. Fibrinogen and D-dimer levels decreased during chemotherapy, and changes in fibrinogen and D-dimer levels between at C0 and at C2 were associated with treatment response. No matter which disease stage, patients with fibrinogen or D-dimer positivities at C0 and C2 time points had worse PFS and OS than those with fibrinogen or D-dimer negativities. Multivariate analyses revealed that fibrinogen and D-dimer positivities after two chemotherapy cycles were independently unfavorable factors for PFS and OS.

CONCLUSION

Fibrinogen and D-dimer levels after two cycles of chemotherapy are predictors for response on chemotherapy and prognosis in SCLC patients.

Prognostic significance of the lymphocyte-to-monocyte ratio in patients with small cell lung cancer

We investigated the role of the lymphocyte-to-monocyte ratio (LMR) at diagnosis in patients with small cell lung cancer (SCLC) treated with standard chemotherapy. We retrospectively reviewed all SCLC patients who received frontline platinum-based chemotherapy or chemoradiotherapy. The cut-off LMR value at diagnosis was 4.19 according to time-dependent receiver-operating characteristic analysis. A total of 188 patients were divided into two groups according to the LMR at diagnosis (low vs. high LMR). Of the 171 patients evaluated for treatment response, 14 (12.4%) in the low LMR group and 1 (1.7%) in the high LMR group were non-responders (p = 0.025). In the whole patient cohort, progression-free survival and overall survival were significantly shorter in the low LMR group (low vs. high: median 6.4 vs. 7.1 months, p = 0.001; median 10.6 vs. 13.1 months, p = 0.003, respectively). On multivariate analysis, a low LMR at diagnosis was an independent unfavourable prognostic factor for predicting survival. The LMR at diagnosis could be helpful for predicting prognosis in SCLC.

The prognostic impact of the neutrophil-to-lymphocyte ratio in patients with small-cell lung cancer

Background:

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are prognostic factors for various types of cancer. In this study, we assessed the association of NLR and PLR with the prognosis of small-cell lung cancer (SCLC) in patients who received the standard treatment.

Methods:

We retrospectively reviewed patients who were diagnosed with SCLC and treated with platinum-based chemotherapy between July 2006 and October 2013 in Gyeongsang National University Hospital Regional Cancer Center and Changwon Samsung Hospital.

Results:

In total, 187 patients were evaluated. Compared with low NLR (<4), high NLR (⩾4) at diagnosis was associated with poor performance status, advanced stage, and lower response rate. Median overall survival (OS) and progression-free survival (PFS) were worse in the high-NLR group (high vs low, 11.17 vs 9.20 months, P=0.019 and 6.90 vs 5.49 months, P=0.005, respectively). In contrast, PLR at diagnosis was not associated with OS or PFS (P=0.467 and P=0.205, respectively). In multivariate analysis, stage, lactate dehydrogenase, and NLR at diagnosis were independent prognostic factors for OS and PFS.

Conclusions:

NLR is easily measurable and reflects the SCLC prognosis. A future prospective study is warranted to confirm our results.

Elevated serum C-reactive protein as a prognostic marker in small cell lung cancer

PURPOSE

Elevated C-reactive protein (CRP) is associated with poor prognosis in several tumor types. The purpose of this study was to investigate serum CRP as a prognostic marker in small cell lung cancer (SCLC).

MATERIALS AND METHODS

The pretreatment serum CRP level was measured in 157 newly diagnosed SCLC patients, and correlation between serum CRP level and other clinical parameters was analyzed. Multivariate analyses were performed to find prognostic markers using Cox's proportional hazards model.

RESULTS

The initial CRP concentration was within the normal range in 72 (45.9%) patients and elevated in 85 (54.1%) patients. There was a significant correlation between serum CRP level and the extent of disease (p<0.001), weight loss (p=0.029) and chest radiation (p=0.001). Median overall survival (OS) in the normal CRP group was significantly longer than with the high CRP group (22.5 months vs. 11.2 months, p<0.001). Extent of disease (p<0.001), age (p=0.025), and performance status (p<0.001) were additional prognostic factors on univariate analysis. On multivariate analysis, elevated serum CRP level was an independent prognostic factor for poor survival (HR=1.8; p=0.014), regardless of the extent of disease (HR=3.7; p<0.001) and performance status (HR=2.2; p<0.001).

CONCLUSION

High level of CRP was an independent poor prognostic serum marker in addition to previously well-known prognosticators in patients with SCLC.

A case of small cell carcinoma in the buccal region

Small cell carcinoma (SCC) in the head and neck region is an extremely rare high-grade malignant tumor. The authors report a case of an SCC occurring in the left buccal region. An 85-year-old man exhibited left cheek swelling that rapidly increased in size. Histopathological examination revealed invasive growth of an SCC into the musculo-adipose tissue. Immunohistochemically, the tumor cells were positive for cytokeratin (AE1/AE3), neuron-specific enolase (NSE) and CD56, but negative for cytokeratin 20. The patient received chemotherapy and radiotherapy, which resulted in marked regression of the tumor. Surgical resection was performed. The serum levels of NSE and pro-gastrin-releasing peptide (pro-GRP) increased and multiple metastases of the tumor occurred 1 month after surgery. SCCs tend to exhibit aggressive invasion and metastasis so chemotherapy for the whole body is recommended to prevent dissemination of the tumor cells. Serum levels of NSE and pro-GRP are considered to be useful tumor markers for understanding the status of the tumor and the clinical symptoms.

Small-cell lung cancer: 8 years experience of a single multidisciplinary team

Aims. We have audited the changes in treatment practice for small-cell lung cancer (SCLC) presented to a single multidisciplinary team (MDT) at Doncaster and Bassetlaw Hospitals between January 1998 and December 2005. Materials and Methods. The MDT database was used to identify all patients with SCLC. Anonymised demographic, treatment, and outcome details were extracted from the database supplemented by patient records. Results. 235 patients were identified. 112 (48%) had limited disease at presentation. Chemotherapy was the initial treatment for 195 patients, 77% of whom had a documented radiological response with a complete response in 24%. Chemotherapy regimes evolved during the study period with the increasing use of platinum-based chemotherapy. Anthracycline-based chemotherapy was most used before 2004 and was given to 57% of all patients. 42% received consolidation thoracic radiotherapy and 24% prophylactic cranial irradiation. The median and 2-year survival were 8 months and 18%, respectively, for patients with limited disease and 5 months and 5%, respectively, for extensive disease. Conclusion. We have documented changes in treatment practice and service delivery of SCLC over the 8 years during which the MDT has been operating. However, there has not achieve any significant improvement in outcome for the population of patients with SCLC.

Phase III randomised trial of doxorubicin-based chemotherapy compared with platinum-based chemotherapy in small-cell lung cancer

This randomised trial compared platinum-based to anthracycline-based chemotherapy in patients with small-cell lung cancer (limited or extensive stage) and <or=2 adverse prognostic factors. Patients were randomised to receive six cycles of either ACE (doxorubicin 50 mg/m(2) i.v., cyclophosphamide 1 g/m(2) i.v. and etoposide 120 mg/m(2) i.v. on day 1, then etoposide 240 mg/m(2) orally for 2 days) or PE (cisplatin 80 mg/m(2) and etoposide 120 mg/m(2) i.v. on day 1, then etoposide 240 mg/m(2) orally for 2 days) given for every 3 weeks. For patients where cisplatin was not suitable, carboplatin (AUC6) was substituted. A total of 280 patients were included (139 ACE, 141 PE). The response rates were 72% for ACE and 77% for PE. One-year survival rates were 34 and 38% (P=0.497), respectively and 2-year survival was the same (12%) for both arms. For LD patients, the median survival was 10.9 months for ACE and 12.6 months for PE (P=0.51); for ED patients median survival was 8.3 months and 7.5 months, respectively. More grades 3 and 4 neutropenia (90 vs 57%, P<0.005) and grades 3 and 4 infections (73 vs 29%, P<0.005) occurred with ACE, resulting in more days of hospitalisation and greater i.v. antibiotic use. ACE was associated with a higher risk of neutropenic sepsis than PE and with a trend towards worse outcome in patients with LD, and should not be studied further in this group of patients.

A critical appraisal of prognostic and predictive factors for common lung cancers

The outlook for patients with lung cancer remains poor despite advances in the understanding of the pathology and biology of this disease. To optimize treatment protocols prognostic data are essential. The current era with molecular research on mRNA expression analysis and proteomics will lead to a plethora of new molecular markers, which are likely to be correlated, at least in part, with each other and with disease activity, progression and survival. However, although the number of prognostic factors analysed in published systematic reviews on lung cancer is large, the scope of these factors in individual studies is often narrow. In daily practice prognostic factors other than general TNM staging are not implemented. To assess the efficacy of new prognostic factors for the management of individual patients with non-small cell lung cancer, studies with clinically relevant modelling are required. In this review arguments are provided to use a model combining radiological and histopathological growth rate, histopathological diagnosis and molecular characteristics as markers for metastatic capacity, tumour volume doubling time and expected response to targeted therapy. This may reveal time-related predictive information useful for treatment guidance of the individual patient.