Role of surgical resection for patients with limited disease-small cell lung cancer

Disparities and Underutilization of Surgery for Early Stage Small Cell Lung Cancer

BACKGROUND

The National Comprehensive Cancer Network recommends surgical resection for stage I small cell lung cancer (SCLC). Despite these recommendations and the curative potential of such surgery, many continue to underutilize surgery. Our aim is to investigate factors that contribute to underutilization of surgery for stage I SCLC.

METHODS

The National Cancer Database was queried to identify patients with SCLC stage I-IV from 2004 to 2018. Staging was defined by the American Joint Committee on Cancer guidelines. Cochran-Armitage analysis was performed to analyze trends in surgical treatment for patients diagnosed with stage I SCLC. Multivariable logistic regression assessed relationships between patient factors and surgical treatment.

RESULTS

A total of 296,583 patients were diagnosed with SCLC. Of the stage I patients (n = 13,003), only 29.4.% (n = 3823) underwent surgery. Trend analysis demonstrated increased frequency of surgical treatment for stage I SCLC over years 2004 to 2017, from 14.9% to 39.6% (P < .0001). Factors that were associated with underutilization of surgery for stage I SCLC include African American race, lower median income, nonprivate insurance or Medicare, community facility, and geographic regions other than the Northeast.

CONCLUSIONS

Surgical treatment for stage I SCLC remains underutilized and our study identifies notable associated factors. The recognition of these factors may help patients overcome barriers to receiving recommended treatments, improve guideline adherence, and overall quality of care for stage I SCLC patients.

Closing the RCT Gap-A Large Meta-Analysis on the Role of Surgery in Stage I-III Small Cell Lung Cancer Patients

INTRODUCTION

Despite clear guideline recommendations, surgery is not consistently carried out as part of multimodal therapy in stage I small cell lung cancer (SCLC) patients. The role of surgery in stages II and III is even more controversial. In the absence of current randomized control trials (RCT), we performed a meta-analysis comparing surgery versus non-surgical treatment in stage I to III SCLC patients.

METHODS

A systematic review of the literature was conducted on 1 July 2023, focusing on studies pertaining to the impact of surgery on small cell lung cancer (SCLC). These studies were evaluated using the ROBINS-I tool. Statistical analyses, including I² tests, Q-statistics, DerSimonian-Laird tests, and Egger regression, were performed to assess the data. In addition, 5-year survival rates were analyzed. The meta-analysis was conducted according to PRISMA standards.

RESULTS

Among the 6826 records identified, 10 original studies encompassing a collective cohort of 95,323 patients were incorporated into this meta-analysis. Heterogeneity was observed across the included studies, with no discernible indication of publication bias. Analysis of patient characteristics revealed no significant differences between the two groups (p-value > 0.05). The 5-year survival rates in a combined analysis of patients in stages I-III were 39.6 ± 15.3% for the 'surgery group' and 16.7 ± 12.7% for the 'non-surgery group' (p-value < 0.0001). SCLC patients in stages II and III treated outside the guideline with surgery had a significantly better 5-year survival compared to non-surgery controls (36.3 ± 20.2% vs. 20.2 ± 17.0%; p-value = 0.043).

CONCLUSIONS

In the absence of current RCTs, this meta-analysis provides robust suggestions that surgery might significantly improve survival in all SCLC stages. Non-surgical therapy could lead to a shortening of life. The feasibility of surgery in non-metastatic SCLC should always be evaluated as part of a multimodal treatment.

CD3, CD8, IFN-γ, tumor and stroma inflammatory cells as prognostic indicators for surgically resected SCLC: evidences from a 10-year retrospective study and immunohistochemical analysis

Current clinical guidelines limit surgical intervention to patients with cT1-2N0M0 small cell lung cancer (SCLC). Our objective was to reassess the role of surgery in SCLC management, and explore novel prognostic indicators for surgically resected SCLC. We reviewed all patients diagnosed with SCLC from January 2011 to April 2021 in our institution. Survival analysis was conducted using the Kaplan-Meier method, and independent prognostic factors were assessed through the Cox proportional hazard model. In addition, immunohistochemistry (IHC) staining was performed to evaluate the predictive value of selected indicators in the prognosis of surgically resected SCLC patients. In the study, 177 SCLC patients undergoing surgical resection were ultimately included. Both univariate and multivariate Cox analysis revealed that incomplete postoperative adjuvant therapy emerged as an independent risk factor for adverse prognosis (p < 0.001, HR 2.96). Survival analysis revealed significantly superior survival among pN0-1 patients compared to pN2 patients (p < 0.0001). No significant difference in postoperative survival was observed between pN1 and pN0 patients (p = 0.062). Patients with postoperative stable disease (SD) exhibited lower levels of tumor inflammatory cells (TIC) (p = 0.0047) and IFN-γ expression in both area and intensity (p < 0.0001 and 0.0091, respectively) compared to those with postoperative progressive disease (PD). Conversely, patients with postoperative SD showed elevated levels of stromal inflammatory cells (SIC) (p = 0.0453) and increased counts of CD3+ and CD8+ cells (p = 0.0262 and 0.0330, respectively). Survival analysis indicated that high levels of SIC, along with low levels of IFN-γ+ cell area within tumor tissue, may correlate positively with improved prognosis in surgically resected SCLC (p = 0.017 and 0.012, respectively). In conclusion, the present study revealed that the patients with pT1-2N1M0 staging were a potential subgroup of SCLC patients who may benefit from surgery. Complete postoperative adjuvant therapy remains an independent factor promoting a better prognosis for SCLC patients undergoing surgical resection. Moreover, CD3, CD8, IFN-γ, TIC, and SIC may serve as potential indicators for predicting the prognosis of surgically resected SCLC.

Survival analysis of surgical versus nonsurgical treatment in stage I to III small cell lung cancer in the last 20 years: A systematic review and meta-analysis

More and more patients with small cell lung cancer (SCLC) have received surgical treatment in the last 20 years. This meta-analysis compared whether surgical treatment can bring greater survival benefits to patients with stage I-III SCLC compared with chemotherapy, radiotherapy and chemoradiotherapy. Pubmed, Embase, Web of Science, Cochrane library database, and ClinicalTrials were searched for relevant articles. The main outcomes were overall survival (OS), reported as hazard ratios (HRs), and 95% confidence intervals (CIs). A total of 19 articles containing 30 185 patients (3940 patients receiving surgical treatment and 26 245 patients receiving nonsurgical treatment) were included in this study. Surgical resection significantly improved OS when compared to nonsurgical treatment in retrospective studies (HR: 0.55, 95% CI: 0.47-0.64, p < 0.01). In the subgroup analysis for retrospective studies, surgical resection was associated with superior OS in stage I (HR: 0.42, 95% CI: 0.24-0.71, p < 0.01), stage II (HR: 0.61, 95% CI: 0.52-0.73, p < 0.01), and stage III diseases (HR: 0.66, 95% CI: 0.51-0.86, p < 0.01). Sublobar resection resulted in worse OS than a lobectomy (HR: 0.78,95% CI: 0.60-1.00, p < 0.01) for patients undergoing surgical resection. Compared with nonsurgical treatment, surgical treatment can indeed bring more significant survival benefits to patients with stage I-III SCLC, and lobectomy can bring longer survival compared with sublobectomy. More prospective studies are needed to confirm these findings.

Whole-Section Landscape Analysis of Molecular Subtypes in Curatively Resected Small Cell Lung Cancer: Clinicopathologic Features and Prognostic Significance

Despite the recognition of various molecular subtypes in small cell lung cancer (SCLC), most information has been derived from tissue microarrays or biopsy samples. Using whole-sections of curatively resected SCLCs, we aimed to elucidate the clinicopathologic relevance and prognostic significance of the molecular subtypes. Whole-section immunohistochemistry was conducted for 73 resected SCLC samples using antibodies representative of molecular subtypes: ASCL1 (SCLC-A), NEUROD1 (SCLC-N), POU2F3 (SCLC-P), and YAP1. Further, multiplexed immunofluorescence was performed to evaluate the spatial relationship of YAP1 expression with other markers. The molecular subtype was correlated with clinical and histomorphologic features, and its prognostic role was explored in this cohort and validated in a previously published surgical cohort. Overall, the molecular subtypes were SCLC-A (54.8%), SCLC-N (31.5%), SCLC-P (6.8%), and SCLC-TN (triple-negative, 6.8%). We found significant enrichment of SCLC-N (48.0%, p = 0.004) among combined SCLCs. Although a distinct subtype with high YAP1 expression was not found, YAP1 expression was reciprocal with ASCL1/NEUROD1 at the cellular level within tumors and was increased in areas with non-small cell-like morphology. Furthermore, the YAP1-positive SCLCs showed significantly increased recurrence at mediastinal lymph nodes (p = 0.047) and are an independent poor prognostic factor after surgery (adjusted hazard ratio 2.87; 95% confidence interval 1.20-6.86; p = 0.017). The poor prognostic impact of YAP1 was also validated in the external surgical cohort. Our whole-section analysis in resected SCLCs reveals the highly heterogeneous nature of the molecular subtype and its clinicopathologic relevance. Although YAP1 is not a subtype delineator, YAP1 relates to the phenotypic plasticity of SCLC and may serve as a poor prognostic factor in resected SCLC.

Clinical significance of MYC family protein expression in surgically resected high-grade neuroendocrine carcinoma of the lung

OBJECTIVES

MYC family genes including MYC, MYCN, and MYCL are amplified and overexpressed as oncogenic drivers in high-grade neuroendocrine carcinoma of the lung (HGNEC), but little is known about their clinical significance. This study evaluated the prognostic impact of MYC family protein expression in patients with surgically resected HGNEC.

METHODS

Immunohistochemical analyses were performed on 83 resected specimens of HGNEC using antibodies against MYC family proteins (c-MYC, n-MYC, and l-MYC). When nuclear staining of any intensity in ≥10% of tumor cells showed immunoreactivity with any one or more of c-MYC, n-MYC, or l-MYC, the specimens were defined as MYC family-positive.

RESULTS

A total of 83 patients were analyzed. MYC family-positive status was observed in 33.7% (28 of 83 cases) and was not correlated with clinicopathological factors. The protein expression was mutually exclusive and no duplicate cases were observed. A log-rank test showed that MYC family-positive status was significantly associated with shorter overall survival (OS) (p = 0.003) and recurrence-free survival (RFS) (p = 0.039). According to Cox multivariate analysis, MYC family-positive status had a significant effect on shorter OS (hazard ratio [HR] = 2.217, 95% confidence interval [CI] 1.179-4.169, p = 0.014) and RFS (HR = 1.802, 95% CI 1.014-3.202, p = 0.045). In patients with pathological stage I, MYC family-positive status also showed significantly poor OS (HR = 2.847, 95% CI 1.236-6.557, p = 0.014) and RFS (HR = 2.088, 95% CI 1.006-4.332, p = 0.048) in the multivariate analysis.

CONCLUSIONS

MYC family protein expression could be an independent unfavorable prognostic factor in patients with surgically resected HGNEC.

Excellent survival of pathological N0 small cell lung cancer patients following surgery

BACKGROUND

Current clinical guidelines recommend surgery only for cT1-2N0M0 small cell lung cancer (SCLC) patients. In light of recent studies, the role of surgery in the treatment of SCLC needs to be reconsidered.

METHODS

We reviewed all SCLC patients who underwent surgery from November 2006 to April 2021. Clinicopathological characteristics were retrospectively collected from medical records. Survival analysis was performed by the Kaplan-Meier method. Independent prognostic factors were evaluated by Cox proportional hazard model.

RESULTS

196 SCLC patients undergoing surgical resection were enrolled. The 5-year overall survival for the entire cohort was 49.0% (95% CI: 40.1-58.5%). PN0 patients had significantly superior survival to pN1-2 patients (p < 0.001). The 5-year survival rate of pN0 and pN1-2 patients were 65.5% (95% CI: 54.0-80.8%) and 35.1% (95% CI: 23.3-46.6%), respectively. Multivariate analysis revealed that smoking, older age, and advanced pathological T and N stages were independently associated with poor prognosis. Subgroup analyses demonstrated similar survival among pN0 SCLC patients regardless of pathological T stages (p = 0.416). Furthermore, multivariate analysis showed factors, including age, smoking history, type of surgery, and range of resection, were not independently prognostic factors for the pN0 SCLC patients.

CONCLUSION

Pathological N0 stage SCLC patients have significantly superior survival to pN1-2 patients, regardless of features, including T stage. Thorough preoperative evaluation should be applied to estimate the status of lymph node involvement to achieve better selection of patients who might be candidate for surgery. Studies with larger cohort might help verify the benefit of surgery, especially for T3/4 patients.

Long-term results of postoperative unsuspected small cell lung cancer on real-world data

BACKGROUND

In traditional opinion, solid pulmonary nodule suspected lung cancer should be confirmed by pathology before the operation to exclude small cell lung cancer (SCLC), considering SCLC tends to be aggressive and surgical effect in the management of SCLC remains controversial. The aim of this study was to evaluate the survival result and risk factors of postoperative unsuspected SCLC.

METHODS

A total of 120 patients with postoperative unsuspected SCLC who were confirmed by pathology and referred to Chinese PLA General Hospital between 2000 and 2021 were retrospectively analyzed (surgery group). Additionally, 120 patients with limited-stage SCLC who underwent chemotherapy and radiotherapy in the same period were enrolled in the chemoradiotherapy group.. Kaplan-Meier method was used to estimate survival; the Log-Rank test was used to compare survival rates between different groups; a COX stepwise regression model was used for multivariate analysis.

RESULTS

Among 120 patients in the surgery group, 28 were with central type and other 92 with peripheral type. The median survival (OS) was 44.85 months, and the 5-year survival rate was 46%. The 5-year survival rates for stage I, II, and III were 52.1%, 45.4%, and 27.8%, respectively. The mean disease-free survival time (DFS) was 30.63 ± 4.38 months, and the 5-year DFS rate was 31.5%. In the chemoradiotherapy group, the mean OS was 21.4 ± 4.26 months, and the 5-year survival rate was 28.3%. The 5-year survival rates for clinical stage I, II, and III were 42.5%, 39.8%, and 20.5%, respectively. The mean progression-free survival (PFS) was 10.63 ± 3.6 months. In the surgery group, one-way ANOVA revealed that the gender, symptoms, smoking history, tumor location, and postoperative radiotherapy were not associated with OS (P ≥ 0.05), while age, surgical approach, surgical method, N stage, TNM stage, and vascular tumor thrombus were related to OS (P < 0.05). Multivariate analysis indicated that the N stage was associated with OS (HR = 1.86 P = 0.042).

CONCLUSION

Surgery and adjuvant therapy were found to have encouraging outcomes in postoperative unsuspected SCLC. Patients with stage I, stage II and part of stage IIIA SCLC could benefit from surgery and the standard lobectomy, and systematic lymph node dissection, is also recommended for these patients.

Safety and effectiveness of neoadjuvant immunotherapy combined with chemotherapy followed by surgical resection in patients with stage I-IIIA small-cell lung cancer: a retrospective single-arm clinical trial

BACKGROUND

Immunotherapy, chemotherapy and surgery all have significant roles in the management of small-cell lung cancer (SCLC). Neoadjuvant immunotherapy combined with chemotherapy followed by surgery has shown encouraging efficacy for resectable SCLC with a good tolerability and considerable survival benefit. However, there are still few data on whether surgery for stage I-IIIA SCLC can be performed after immunotherapy with chemotherapy. Therefore, we investigated the safety and effectiveness of neoadjuvant immunotherapy combined with chemotherapy followed by surgery in patients with stage I-IIIA SCLC in the hope of adding new ideas to the treatment of SCLC.

METHODS

The study group comprised 19 patients with stage I-IIIA SCLC who received neoadjuvant immunotherapy and chemotherapy between 2019 and 2021. Patients received 2-4 cycles of immunotherapy combined with platinum-containing dual-drug chemotherapy (platinum + paclitaxel) before surgery. Imaging evaluation was performed every two cycles until surgery. Tumor response to neoadjuvant therapy, neoadjuvant treatment related adverse events, perioperative and postoperative complications, surgical resection rate, and degree of tumor regression were evaluated. We obtained follow-up data from the patients' regular examination or treatment in hospital. If we can't complete it, contacting patients by telephone or WeChat would be adopted by us. The follow-up was not terminated until 3 months after surgery.

RESULTS

The objective response rate (ORR) was 84.2% (16/19), and no patients had progressive disease (PD). Of the 10 patients who underwent surgery, and approximately 9 (90.0%) had R0 resection. There were no perioperative deaths, and 1 case of pyothorax. The rate of pathological complete remission (pCR) and major pathological response (MPR) was 30.0% (3/10), and 40.0% (4/10) respectively. Grade 3-4 adverse reactions comprised 1 case of anemia and 1 case of constipation.

CONCLUSIONS

Neoadjuvant immunotherapy combined with chemotherapy followed by surgical resection for patients with stage I-IIIA SCLC is effective and safe with a high ORR and MPR rate, as well as a high R0 resection rate and a tolerable toxicity profile. Whether this regimen gives a survival benefit should be confirmed by further follow-up and larger, randomized controlled trials are required to confirm our findings.

Redefining the role of surgery in early small-cell lung cancer

PURPOSE

Resection is guideline recommended in stage I small-cell lung cancer (SCLC) but not in stage II. In this stage, patients are treated with a non-surgical approach. The aim of this meta-analysis was to assess the role of surgery in both SCLC stages. Surgically treated patients were compared to non-surgical controls. Five-year survival rates were analysed.

METHODS

A systematic literature search was performed on December 01, 2021 in Medline, Embase and Cochrane Library. Studies published since 2004 on the effect of surgery in SCLC were considered and assessed using ROBINS-I. We preformed I²-tests, Q-statistics, DerSimonian-Laird tests and Egger-regression. The meta-analysis was conducted according to PRISMA.

RESULTS

Out of 6826 records, we identified seven original studies with a total of 15,170 patients that met our inclusion criteria. We found heterogeneity between these studies and ruled out any publication bias. Patient characteristics did not significantly differ between the two groups (p-value > 0.05). The 5-year survival rates in stage I were 47.4 ± 11.6% for the 'surgery group' and 21.7 ± 11.3% for the 'non-surgery group' (p-value = 0.0006). Our analysis of stage II SCLC revealed a significant survival benefit after surgery (40.2 ± 21.6% versus 21.2 ± 17.3%; p-value = 0.0474).

CONCLUSION

Based on our data, the role of surgery in stage I and II SCLC is robust, since it improves the long-term survival in both stages significantly. Hence, feasibility of surgery as a priority treatment should always be evaluated not only in stage I SCLC but also in stage II, for which guideline recommendations might have to be reassessed.

A systematic literature review of real-world treatment outcomes of small cell lung cancer

BACKGROUND

Robust evidence from real-world studies is needed to aid decision-makers and other stakeholders in choosing the best treatment options for patients. The objective of this work was to assess real-world outcomes of treatment strategies for limited- and extensive-stage small cell lung cancer (SCLC) prior to the global introduction of immunotherapies for this disease.

METHODS

Searches were conducted in MEDLINE and Embase to identify articles published in English from October 1, 2015, through May 20, 2020. Searches were designed using a combination of Medical Subject Heading (Medline), Emtree (Embase subject headings), and free-text terms such as SCLC. Observational studies reporting data on outcomes of initial treatment strategies in patients with limited- and extensive-stage SCLC were included. Studies with limited sample sizes (<100 patients), enrolled all patients prior to 2010, or did not report outcomes for limited- and extensive-stage SCLC separately were excluded. Data were extracted into a predesigned template by a single researcher. All extractions were validated by a second researcher, with disagreements resolved via consensus.

RESULTS

Forty articles were included in this review. Most enrolled patients from the United States (n = 18 articles) or China (n = 12 articles). Most examined limited-stage (n = 27 articles) SCLC. All studies examined overall survival as the primary outcome. Articles investigating limited-stage SCLC reported outcomes for surgery, chemotherapy and/or radiotherapy, and adjuvant prophylactic cranial irradiation. In studies examining multiple treatment strategies, chemoradiotherapy was the most commonly utilized therapy (56%-82%), with chemotherapy used in 18% to 44% of patients. Across studies, median overall survival was generally higher for chemoradiotherapy (15-45 months) compared with chemotherapy alone (6.0-15.6 months). Studies of extensive-stage SCLC primarily reported on chemotherapy alone, consolidative thoracic radiotherapy, and radiotherapy for patients presenting with brain metastases. Overall survival was generally lower for patients receiving chemotherapy alone (median: 6.4-16.5 months; 3 years, 5%-14.9%) compared with chemotherapy in combination with consolidative thoracic radiotherapy (median: 12.1-18.0 months; 3 years, 15.0%-18.1%). Studies examining whole-brain radiotherapy for brain metastases reported lower median overall survival (5.6-8.7 months) compared with stereotactic radiosurgery (10.0-14.5 months).

CONCLUSIONS

Under current standard of care, which has remained relatively unchanged over the past few decades, prognosis remains poor for patients with SCLC.

New perspectives in the management of small cell lung cancer

The treatment of small cell lung cancer (SCLC) is a challenge for all specialists involved. New treatments have been added to the therapeutic armamentarium in recent months, but efforts must continue to improve both survival and quality of life. Advances in surgery and radiotherapy have resulted in prolonged survival times and fewer complications, while more careful patient selection has led to increased staging accuracy. Developments in the field of systemic therapy have resulted in changes to clinical guidelines and the management of patients with advanced disease, mainly with the introduction of immunotherapy. In this article, we describe recent improvements in the management of patients with SCLC, review current treatments, and discuss future lines of research.

Clinicopathological Difference and Survival Impact of Patients with c-SCLC and SCLC

Background

Combined small cell lung cancer (c-SCLC) distinguishes itself from small cell lung cancer (SCLC) due to its inclusion of both SCLC and non-small cell lung cancer (NSCLC) components. Few studies have compared clinicopathological characteristics, prognosis and factors affecting survival. We therefore addressed the issues in this study.

Patients and Methods

A total of 400 c-SCLC and 20,841 SCLC patients were enrolled using SEER database. Difference in clinicopathological characteristics of SCLC and c-SCLC patients was analyzed using chi-square. Kaplan–Meier was applied to compare their survival before and after propensity score matching (PSM). Cox regression model was adopted to assess the impact of different clinical variables on survival. Logistic regression was applied to identify risk factors for c-SCLC and SCLC patients.

Results

Differences in race, sex, T stage, N stage, surgery, bone, brain and liver metastasis were detected between c-SCLC and SCLC patients. c-SCLC patients had better overall survival (OS) than SCLC patients before PSM. Age, race, sex, T stage, N stage, surgery, bone, brain, liver and lung metastasis were prognostic factors affecting OS for c-SCLC and SCLC (P < 0.05). However, a significant OS benefit was not observed in c-SCLC after adjusting for clinicopathological variables (HR, 0.950; 95% CI, 0.842–1.073; P=0.411). No significant OS difference was found between c-SCLC and SCLC patients after PSM (P = 0.789). c-SCLC patients had lower risk of lymph node (OR: 0.555; 95% CI: 0.439–0.703; P < 0.001) and liver metastasis (OR: 0.591; 95% CI: 0.448–0.779; P < 0.001), whereas had no significant differences in bone and brain metastasis risks (P > 0.05) compared with SCLC patients.

Conclusion

The prognosis of c-SCLC did not significantly differ from that of SCLC if clinicopathological characteristics are controlled. Better prognosis for c-SCLC patients over SCLC patients may be ascribed to fewer liver and lymph node metastases upon diagnosis.

Trends and variations in the treatment of stage I-III small cell lung cancer from 2008 to 2019: A nationwide population-based study from the Netherlands

OBJECTIVES

Recent treatment patterns for small cell lung cancer (SCLC) in the Netherlands were unknown. This nationwide population-based study describes trends and variations in the treatment of stage I-III SCLC in the Netherlands over the period 2008-2019.

MATERIALS AND METHODS

Patients were selected from the population-based Netherlands Cancer Registry. Treatments were studied stratified for clinical stage. In stage II-III, factors associated with the use of concurrent (cCRT) versus sequential chemoradiation (sCRT) and accelerated versus conventionally fractionated radiotherapy in the context of cCRT were identified.

RESULTS

In stage I (N = 535), 29% of the patients underwent surgery in 2008-2009 which increased to 44% in 2018-2019. Combined use of chemotherapy and radiotherapy decreased in stage I from 47% to 15%, remained constant (64%) in stage II (N = 472), and increased from 57% (2008) to 70% (2019) in stage III (N = 5,571). Use of cCRT versus sCRT in stage II-III increased over time (odds ratio (OR) _{2008-2011 vs 2016-2019}: 0.53 (95%-confidence interval (95%CI): 0.41-0.69)) and was strongly associated with lower age, WHO performance status 0, and diagnosis in a hospital with in-house radiotherapy. Forty-six percent of patients with stage III received cCRT in 2019. Until 2012, concurrent radiotherapy was mainly conventionally fractionated, thereafter a hyperfractionated accelerated scheme was administered more frequently (57%). Accelerated radiotherapy was strongly associated with geographic region (OR_{south vs north}: 4.13 (95%CI: 3.00-5.70)), WHO performance (OR_{1 vs 0}: 0.50 (95%CI: 0.35-0.71)), and radiotherapy facilities treating ≥ 16 vs < 16 SCLC patients annually (OR: 3.01 (95%CI: 2.38-3.79)).

CONCLUSIONS

The use of surgery increased in stage I. In stages II and III, the use of cCRT versus sCRT increased over time, and since 2012 most radiotherapy in cCRT was accelerated. Treatment regimens and radiotherapy fractionation schemes varied between patient groups, regions and hospitals. Possible unwarranted treatment variation should be countered.

Patterns of Recurrence and Survival Rate After Complete Resection of Pathological Stage N2 Small-Cell Lung Cancer

The benefits of surgical resection for patients with stage N2 limited-disease small-cell lung cancer (LD-SCLC) remain controversial. This retrospective study analyzed the survival and recurrence patterns of the patients diagnosed with pathological N2 (p-N2) LD-SCLC after radical resection. A total of 171 p-N2 LD-SCLC patients who underwent radical pulmonary resection and systematic lymphadenectomies at Shanghai Chest Hospital from July 2005 to June 2015 were enrolled. The influence of the mediastinal lymph node status (single or multiple nodes, single- or multiple-station) on the survival and recurrence patterns was retrospectively analyzed. The main recurrence sites were outside the chest cavity (54.8%) and hematogenous metastasis (67.4%). The bone and liver as initial recurrence sites had a poor prognosis, with a median overall survival (OS) of 13.100 months and 11.900 months, respectively. The median disease-free survival (DFS) of patients diagnosed with single and multiple p-N2 after surgery were 19.233 and 9.367 months (P = 0.001), and the median OS were 43.033 and 17.100 months (P < 0.001), respectively. In conclusion, recurrence occurred in the form of hematogenous metastasis mostly in the extra-thoracic part. Interestingly, patients diagnosed with single p-N2 benefited from radical resection. Surgery may be a treatment option regardless of the T stage if N2 SCLC with a single metastatic lymph node can be identified preoperatively.

[Surgery for small-cell lung cancer]

Small-cell lung cancer (SCLC) is a high-grade neuroendocrine carcinoma, metastatic at the time of initial diagnosis in 70% of cases. Within the 30% of localised tumours only 5% of patients are eligible for surgical treatment according to the recommendations of learned societies. These recommendations are mainly based on old phase II and III randomised prospective trials and more recent registry studies. Surgical care is only possible within a multimodal treatment and essentially concerns small-sized tumours without involvement of hilar or mediastinal lymph nodes. As with non-small cell lung cancer (NSCLC), lobectomy with radical lymph node removal is the recommended procedure to achieve complete tumour resection. Patient selection for surgery includes age, performance status and comorbidity factors. Adjuvant chemotherapy combining Platinum salts and Etoposide for resected stage I tumours is recommended by ASCO, ACCP and NCCN. The precise sequence of neo-adjuvant or adjuvant treatments remains controversial because of the large heterogeneity in clinical practice reported in the studies and the context at the time of SCLC discovery. The 5-year survival rate of patients with early stage disease (pT1-2N0M0) treated by lobectomy and adjuvant chemotherapy is between 30% and 58%, which validates the primary place that surgery must have in these early forms. There is certainly little or even no place for such a therapeutic sequence in locally advanced stages (T3-T4 or N2). However, the stage heterogeneity, as in NSCLC, makes final conclusions difficult. In fact, some registry studies with pairing scores reported a median survival of more than 20 months in N2 SCLC. So, all files of SCLC must be evaluated in a multidisciplinary meeting in order to find the optimal solution for patients with rare and heterogeneous tumours.

Surgery in Small-Cell Lung Cancer

Simple Summary

Small-cell lung cancer (SCLC) accounts for approximately 15% of all lung cancers and is one of the most aggressive tumors, with poor prognosis and limited therapeutic options. This review summarizes the main results observed with surgery in SCLC, discussing the critical issues related to the use of this approach. Following two old randomized clinical trials showing no benefit with surgery, several prospective, retrospective, and population-based studies have demonstrated the feasibility of a multimodality approach including surgery in addition to chemotherapy and radiotherapy in patients with selected stage I SCLC. Currently, the International Guidelines recommend a surgical approach in selected stage I SCLC patients, after adequate staging within a multimodal approach and after a multidisciplinary evaluation.

Abstract

Small-cell lung cancer (SCLC) is one of the most aggressive tumors, with a rapid growth and early metastases. Approximately 5% of SCLC patients present with early-stage disease (T1,2 N0M0): these patients have a better prognosis, with a 5-year survival up to 50%. Two randomized phase III studies conducted in the 1960s and the 1980s reported negative results with surgery in SCLC patients with early-stage disease and, thereafter, surgery has been largely discouraged. Instead, several subsequent prospective studies have demonstrated the feasibility of a multimodality approach including surgery before or after chemotherapy and followed in most studies by thoracic radiotherapy, with a 5-year survival probability of 36–63% for patients with completely resected stage I SCLC. These results were substantially confirmed by retrospective studies and by large, population-based studies, conducted in the last 40 years, showing the benefit of surgery, particularly lobectomy, in selected patients with early-stage SCLC. On these bases, the International Guidelines recommend a surgical approach in selected stage I SCLC patients, after adequate staging: in these cases, lobectomy with mediastinal lymphadenectomy is considered the standard approach. In all cases, surgery can be offered only as part of a multimodal treatment, which includes chemotherapy with or without radiotherapy and after a proper multidisciplinary evaluation.

Predictors of survival following surgical resection of limited-stage small cell lung cancer

BACKGROUND

Adjuvant chemotherapy, postoperative radiation (PORT), and prophylactic cranial irradiation (PCI) have been individually examined in limited-stage small cell lung cancer (SCLC). There is a paucity of data on the effectiveness of each adjuvant treatment modality when used in combination after surgical resection of SCLC.

METHODS

Data were collected from 5 cancer centers on all patients with limited-stage SCLC who underwent surgical resection between 1986 and 2019. Univariate and multivariable models were conducted to identify predictors of long-term outcomes, focusing on freedom from recurrence and survival benefit of adjuvant chemotherapy, PORT, and PCI.

RESULTS

A total of 164 patients were analyzed. Multivariable Cox regression analysis did not identify any adjuvant therapies to significantly influence recurrence in this cohort. Specifically, PORT was not associated with a significant influence on locoregional recurrence and PCI was not significantly associated with intracranial outcomes. Adjuvant chemotherapy improved survival in all stage I through III disease (hazard ratio, 0.49; 95% confidence interval, 0.29-0.81; P = .005) and even in pathologically node negative patients (hazard ratio, 0.49; 95% confidence interval, 0.27-0.91; P = .024). Although PCI was found to improve survival in univariate analysis, it was not significant in a multivariable model. PORT was not found to affect survival on either univariate or multivariable analysis.

CONCLUSIONS

This is among the largest multi-institutional studies on surgically resected limited-stage SCLC. Our results highlight survival benefit of adjuvant chemotherapy, but did not identify a statistically significant influence from mediastinal PORT or PCI in our cohort. Larger prospective studies are needed to determine the benefit of PORT or PCI in a surgically resected limited-stage SCLC population.

Effective ferroptotic small-cell lung cancer cell death from SLC7A11 inhibition by sulforaphane

Small-cell lung cancer (SCLC) is a highly aggressive cancer with poor prognosis, due to a lack of therapeutic targets. Sulforaphane (SFN) is an isothiocyanate derived from cruciferous vegetables and has shown anticancer effects against numerous types of cancer. However, its anticancer effect against SCLC remains unclear. The present study aimed to demonstrate the anticancer effects of SFN in SCLC cells by investigating cell death (ferroptosis, necroptosis and caspase inhibition). The human SCLC cell lines NCI-H69, NCI-H69AR (H69AR) and NCI-H82 and the normal bronchial epithelial cell line, 16HBE14o- were used to determine cell growth and cytotoxicity, evaluate the levels of iron and glutathione, and quantify lipid peroxidation following treatment with SFN. mRNA expression levels of cystine/glutamate antiporter xCT (SLC7A11), a key component of the cysteine/glutamate antiporter, were measured using reverse transcription-quantitative PCR, while the levels of SLC7A11 protein were measured using western blot analysis. Following the addition of SFN to the cell culture, cell growth was significantly inhibited, and cell death was shown in SCLC and multidrug-resistant H69AR cells. The ferroptotic effects of SFN were confirmed following culture with the ferroptosis inhibitor, ferrostatin-1, and deferoxamine; iron levels were elevated, which resulted in the accumulation of lipid reactive oxygen species. The mRNA and protein expression levels of SLC7A11 were significantly lower in SFN-treated cells compared with that in the control cells (P<0.0001 and P=0.0006, respectively). These results indicated that the anticancer effects of SFN may be caused by ferroptosis in the SCLC cells, which was hypothesized to be triggered from the inhibition of mRNA and protein expression levels of SLC7A11. In conclusion, the present study demonstrated that SFN-induced cell death was mediated via ferroptosis and inhibition of the mRNA and protein expression levels of SLC7A11 in SCLC cells. The anticancer effects of SFN may provide novel options for SCLC treatment.

Comparative study of clinicopathological characteristics and prognosis between combined and pure small cell lung cancer (SCLC) after surgical resection

Background

Histologically, SCLC are classified as pure (P‐SCLC) and combined subtypes (C‐SCLC). Currently, few studies compare the clinicopathological characteristics and explore the treatment strategies applied to them.

Methods

Between July 2005 and April 2016, the clinical records of 297 postoperative patients with pathologically confirmed SCLC were retrospectively analyzed. Kaplan‐Meier method and Cox regression model were separately used for stratified univariate and multivariate survival analysis.

Results

A total of 46 cases (15.5%) of C‐SCLCs and 251 cases (85.5%) of pure SCLCs (P‐SCLCs) were included in this study. The average age of C‐SCLCs was a little higher than that of P‐SCLCs (59.65 ± 8.72 vs. 56.56 ± 10.12; P = 0.053). More patients had a history of smoking in C‐SCLC (78.3% vs. 63.3%; P = 0.074). The five‐year overall survival (OS) rate for P‐SCLCs and C‐SCLCs was 65.1% and 56.7%, respectively (P = 0.683). For P‐SCLC, stage and an intervention of prophylactic cranial irradiation (PCI) were independent factors that affected OS. In C‐SCLCs cases, performing sublobectomy was an independent risk factor for poor prognosis.

Conclusions

We identified no significant difference in clinical characteristics and outcome between C‐SCLCs and P‐SCLCs. However, the factors affecting the prognosis of the two subtypes were slightly inconsistent. For C‐SCLCs, the extent of resection had a greater impact on survival, and lobectomy combined with systemic lymph node dissection should therefore be performed as extensively as possible. In addition, PCI was beneficial in improving the SCLC OS rate.

Key points

This study demonstrated the prognosis of C‐SCLCs did not significantly differ from that of P‐SCLCs, but was more susceptible to the extent of resection. Patients with C‐SCLC who underwent limited resection had a significantly increased risk of shorter OS.

This study highlighted the importance of performing lobectomy for resectable C‐SCLC patients. This study also proved the benefit of PCI in improving the OS rate for both P‐SCLC and C‐SCLC patients.

The effect of extent of resection on outcomes in patients with limited stage small cell lung cancer

BACKGROUND

There is poor understanding of the comparative effectiveness of lobar and sublobar resections for limited-stage small cell lung cancer (SCLC). We analyzed the National Cancer Database to examine the outcomes of patients undergoing wedge resection (WR), segmentectomy (SR), and lobectomy (LB) for limited-stage SCLC.

METHODS

Patients with cT1-2N0M0 SCLC (2004-2015) who underwent definitive surgery were identified and stratified by extent of resection: WR, SR, or LB. The primary outcome was overall survival (OS) and secondary outcomes were margin-positive resection (>R0) and pathologic nodal upstaging.

RESULTS

A total 1948 patients met study criteria: 619 (32%) underwent WR, 96 (5%) SR, and 1233 (63%) LB. Patients receiving LB were more likely to be younger, have fewer comorbidities, and be privately insured. The unadjusted 5-year OS of WR, SR, and LB patients was 31% (95% confidence interval [CI], 27-35), 35% (95% CI, 25-49), and 45% (95% CI, 42-49), respectively. In a multivariable Cox model, WR was associated with worse OS (hazard ratio, 1.53; 95% CI, 1.31-1.79) and SR similar OS (hazard ratio, 1.20; 95% CI, 0.87-1.67) compared with LB. SR was associated with similar survival compared with LB in a propensity score-matched multivariable analysis as well. WR was also associated with greater odds of >R0 resection compared with LB.

CONCLUSIONS

In this study, patients with limited-stage SCLC undergoing WR experienced worse survival compared with those undergoing LB; survival was similar between segmentectomy and LB.

Surgery as a Potential Treatment Option for Patients With Stage III Small-Cell Lung Cancer: A Propensity Score Matching Analysis

Surgery is commonly recommended for patients with stage I small-cell lung cancer (SCLC), whereas chemotherapy and radiotherapy are considered the standard treatment for patients with stage III SCLC. However, recent studies have suggested that a small proportion of patients with SCLC at an advanced stage may benefit from surgical resection. Therefore, in this study, we investigated the effectiveness of surgery in patients with stage III SCLC. Patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2013. Propensity score matching (PSM) was used to eliminate any clinical bias. The overall survival (OS) was determined using the Kaplan–Meier method and compared using the log-rank test. The Cox proportional-hazards model was used to identify the effect of surgery on the OS. Of 9606 patients with stage III SCLC, 234 underwent surgery. Compared with the non-surgical group, a higher proportion of patients undergoing surgery had T1 and N0-N1 disease (risen by 10.7% for T1; 12.6% for N0-N1) and a lower proportion had T4 and N3 disease (decreased by 14.3% for T4; 12.5% for N3). The Kaplan-Meier analysis showed that patients who underwent surgery had a better OS before and after PSM. The multivariate analysis showed that surgery was beneficial for patients with stage III SCLC (HR: 0.651, 95% CI 0.524–0.808, P < 0.001). In conclusion, surgical resection might be associated with improved OS for patients with stage III SCLC and may be considered for the treatment of these patients. Further prospective studies are required to confirm these findings.

Surgery in patients with small cell lung cancer: A period propensity score matching analysis of the Seer database, 2010-2015

Surgery as a therapeutic modality for non-small cell lung cancer is widely accepted in clinical practice. However, the role of surgery for small cell lung cancer (SCLC) remains controversial. Therefore, in the present study a period propensity score matching analysis using the Surveillance, Epidemiology and End Results (SEER) Registry database was performed to investigate the role of surgery on survival in patients with SCLC. Patients with SCLC between January 2010 and December 2015 were identified from the SEER database, and individual data for each case regarding general clinical characteristics, surgery of primary site (SPS), cause-specific death classification and survival time were retrieved. Differences of cause-specific survival (CSS) between subgroups were estimated by the log-rank test. Cox regression analysis was used to evaluate the effects of multiple variables on CSS, and differences between the incidences of cause-specific death were examined using a χ² test. A total of 1,707 records met the inclusion criteria and were retrieved for analysis. There were significant differences of CSS in the clinicopathological features of N (P=0.01), Stage (P<0.01) and Surgery (P<0.01) when comparing non-surgery with surgery, and in N (P<0.001), Stage (P=0.006) and Surgery (P=0.049) when comparing sublobectomy with lobectomy or bilobectomy (lobe/s). Patients who did not receive surgery (P<0.001) or who received sublobectomy (P=0.03) had an increased risk of mortality when compared with patients who received surgery and lobe/s. The findings of the present study indicate that surgery should be taken into consideration when an initial treatment strategy is made in patients for patients with SCLC at clinical stage I–IIA (T1-2,N0,M0), regardless of whether they are >50 years of age, their sex, histology and grade. The results suggest that certain patients with SCLC with stage IIB (N1) can also benefit from lobe/s, although further investigation is required. In addition, lobe/s is preferable to sublobectomy when surgery is performed. However, the present study was unable to comprehensively analyze the efficacy of pneumonectomy for SCLC.

Temporal trends, ethnic determinants, and short-term and long-term risk of cardiac death in cancer patients: a cohort study

BACKGROUND

We evaluated the risk of cardiac death in patients with prior cancer diagnoses and compared risk by cancer type and ethnicity in a large US population.

METHOD

Utilizing the Surveillance, Epidemiology, and End Results database, data on patients with a cancer diagnosis between 2000 and 2014 were obtained. We calculated the standardized mortality ratio (SMR) of cardiac death after a cancer diagnosis and the excess risk per 10,000 person-years. We stratified the analysis according to the time interval between cancer and cardiac events, cancer site, cancer stage, and race.

RESULTS

A total of 4,671,989 patients with a cancer diagnosis were included, of which 163,255 died due to cardiac causes within 10 years of diagnosis. We found a significantly higher rate of cardiac death for cancer patients [SMR=1.16, 95% confidence interval (CI) 1.15-1.16] compared to the general population. When observed for each cancer site, the highest SMR was after a diagnosis of hepatocellular carcinoma (SMR=2.58, 95% CI 2.45-2.72), pancreatic cancer (SMR=2.36, 95% CI 2.25-2.47), and lung cancer (SMR=2.30, 95% CI 2.27-2.34). Patients with metastatic disease had a higher rate of cardiac death (SMR=2.16, 95% CI 2.13-2.19). When stratified by ethnicity, SMR for cardiac death was 1.76, 2.28, 3.68, 2.65, and 1.84 for whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics, respectively.

CONCLUSIONS

Cancer patients are more vulnerable to cardiac death than the general population, especially those with nonwhite ethnicity; liver, lung, and pancreatic cancers; and history of metastasis. Healthcare providers should be aware of this risk and pay particular attention to the highest-risk groups.

Current Diagnosis and Management of Small-Cell Lung Cancer

Small-cell lung cancer (SCLC) is an aggressive disease with distinct pathological, clinical, and molecular characteristics from non-small-cell lung cancer. SCLC has high metastatic potential, resulting in a clinically poor prognosis. Early concurrent chemo-radiation is the standard of care for limited-stage SCLC (LS-SCLC). Prophylactic cranial irradiation (PCI) is recommended for patients with LS-SCLC without progression of disease after initial therapy. A combination of etoposide and cisplatin or carboplatin remains the mainstay of first-line treatment for ES-SCLC, with the addition of atezolizumab, now becoming standard. Most SCLCs initially respond to therapy but almost invariably recur. Topotecan and amrubicin (in Japan) remain the primary chemotherapy options for relapsed SCLC. Immunotherapy, including nivolumab with or without ipilimumab, is now available for refractory disease. In general, the poor prognosis of SCLC has not improved significantly for more than 3 decades. Recently, next-generation molecular profiling studies have identified new therapeutic targets for SCLC. A variety of proapoptotic agents, compounds capitalizing on DNA-repair defects, immunotherapy agents, and antibody-drug conjugates are being evaluated in SCLC, with a number of them showing early promise.

Effect of histological subtype and treatment modalities on T1-2 N0-1 small cell lung cancer: A population-based study

Background

Combined small cell lung cancer (C‐SCLC) is rare and its clinical features, appropriate treatment, and prognosis are poorly understood. Reports conflict over the prognosis of C‐SCLCs compared to pure small cell lung cancer.

Methods

The records of patients diagnosed with primary SCLC from 1988 to 2014 were extracted from the Surveillance, Epidemiology, and End Results database. The general features of C‐SCLCs were compared to those of SCLCs. T1–2 N0–1 data was extracted and the effects of the histological subtype, treatment modality, and other prognostic factors on lung cancer‐specific survival (CSS) was analyzed in a 3:1 matched dataset. Analysis was performed using the 8th edition tumor node metastasis staging system and previous staging systems adjunctively.

Results

C‐SCLCs comprised 1.5% of all SCLCs (1486/98 667); 184 cases of C‐SCLCs and 2681 cases of non‐combined SCLCs (NC‐SCLCs) were included in this study. C‐SCLCs were more likely to be of a higher grade and to occur in the upper lobe than NC‐SCLCs. Before matching, C‐SCLCs showed better CSS (hazard ratio 0.69; P < 0.001). However, stratified Cox proportional hazards analysis in the matched dataset revealed that only treatment modality and age at diagnosis were associated with CSS; the histological subtype had no effect on survival. Of all treatment modalities, surgery with chemoradiation showed the best CSS in T1–2 N0–1 SCLC.

Conclusion

In early SCLC, surgery with chemoradiation shows the best CSS. C‐SCLC patients might benefit more from multimodal treatments, including surgery, than SCLC patients.

Association of Chemoradiotherapy With Outcomes Among Patients With Stage I to II vs Stage III Small Cell Lung Cancer: Secondary Analysis of a Randomized Clinical Trial

Importance

There is limited evidence to guide stage I to II small cell lung cancer (SCLC) treatment.

Objective

To examine the characteristics and outcomes among patients with stage I to II SCLC treated with modern chemoradiotherapy.

Design, Setting, and Participants

In this post hoc secondary analysis of the Concurrent Once-Daily vs Twice-Daily Radiotherapy Trial (CONVERT), a multicenter phase 3 trial conducted in patients with limited-stage SCLC from April 7, 2008, to November 29, 2013, patients with TNM stage I to II SCLC were compared with those with stage III disease. Data analysis was performed from November 1, 2017, to February 28, 2018.

Interventions

In CONVERT, patients were randomized to receive twice-daily (45 Gy in 30 fractions) or once-daily (66 Gy in 33 fractions) chemoradiotherapy. Prophylactic cranial irradiation (PCI) was offered, if indicated.

Main Outcomes and Measures

The primary trial end point was overall survival (OS). TNM staging information was collected prospectively; this was an unplanned analysis because stratification was not performed according to TNM stage.

Results

A total of 509 (277 [54.4%] men; mean [SD] age, 61.5 [8.3] years) of 543 patients (93.7%) with TNM staging information were eligible for this subgroup analysis, and 86 of the 509 (16.9%) had TNM stage I to II disease. The median gross tumor volume was smaller in patients with stage I to II disease (38.4 cm3; range, 2.2-593.0 cm3) compared with patients with stage III disease (93 cm3; range, 0.5-513.4 cm3) (P < .001). No other significant differences were found in baseline and treatment characteristics and chemoradiotherapy adherence between the 2 groups or the number of patients with stage I to II disease (78 [90.7%]) and stage III disease (346 [81.8%]) who received PCI (P = .10). Patients with stage I to II disease achieved longer OS (median, 50 months [95% CI, 38 to not reached months] vs 25 months [95% CI, 21-29 months]; hazard ratio, 0.60 [95% CI, 0.44-0.83]; P = .001) compared with patients with stage III disease. In patients with stage I to II disease, no significant survival difference was found between the trial arms (median, 39 months in the once-daily arm vs 72 months in the twice-daily arm; P = .38). Apart from lower incidence of acute esophagitis in patients with stage I to II disease compared with patients with stage III disease (grade ≥3, 9 [11.3%] vs 82 [21.1%]; P < .001), the incidences of acute and late toxic effects were not significantly different.

Conclusions and Relevance

Patients with stage I to II SCLC in CONVERT achieved long-term survival with acceptable toxic effects after chemoradiotherapy and PCI. This study suggests that patients with stage I to II small cell lung cancer treated with modern chemoradiotherapy have better outcomes compared with patients with stage III disease, providing information that practitioners can potentially give their patients to aid clinical decisions.

Trial Registration

ClinicalTrials.gov identifier: NCT00433563.

The role of surgery in stage I to III small cell lung cancer: A systematic review and meta-analysis

Background

The role of surgery in treating small cell lung cancer (SCLC) remains controversial. This meta-analysis aims to determine whether surgical-based treatment improves survival in comparison to radiotherapy, chemotherapy, and chemoradiotherapy for stage I to III SCLC.

Methods

PubMed, PubMed Central, EMBASE, Web of Science, and Cochrane Library were searched for relevant articles. The main outcome were overall survival (OS), reported as hazard ratios (HRs), and 95% confidence intervals (CIs).

Results

Two randomized control trials (RCTs) and 13 retrospective studies that included a total of 41,483 patients were eligible. Surgical resection significantly improved OS when compared to non-surgical treatment in retrospective studies (HR = 0.56, 95% CI: 0.49–0.64, P < 0.001), but not in the 2 “older” RCTs (HR = 0.77, 95% CI: 0.32–1.84, P = 0.55). In the subgroup analysis for retrospective studies, surgical resection was associated with superior OS in stage I (HR = 0.56, 95% CI: 0.49–0.64, P < 0.001), stage II (HR = 0.75, 95% CI: 0.57–0.99, P = 0.04), and stage III diseases (HR = 0.70, 95% CI: 0.56–0.88, P = 0.002). Sublobar resection resulted in worse OS than a lobectomy (HR = 0.64, 95% CI: 0.56–0.74, P < 0.001) for patients undergoing surgical resection.

Conclusions

Surgery-based multi-modality treatment appears to be associated with a favorable survival advantage in stage I and selected stage II to III SCLC. Lobectomy is likely to provide superior OS when compared to sublobar resection. Further prospective RCTs are needed to confirm these findings.

Analysis of unexpected small cell lung cancer following surgery as the primary treatment

PURPOSE

Small cell lung cancer (SCLC) is considered a systemic disease and surgery is generally not recommended to treat it. High heterogeneity within the tumor and preoperative diagnostic capabilities can sometimes fail to identify SCLC correctly, leading to a subset of unexpected SCLC patients that are diagnosed only after pulmonary resections.

METHODS

We retrospectively reviewed the clinical records of patients who were diagnosed as having SCLC only after surgery between 2008 and 2015 at a single institution.

RESULTS

A total of 125 unexpected SCLC patients were identified, including those with pure (p-SCLC; n = 76, 60.8%) and combined (c-SCLC; n = 49, 39.2%) SCLC. Highly differential diagnoses were observed between pre- and postoperative tissue examinations. Sixty-nine (55.2%) patients with postoperatively pathological-proven SCLC, including 31 with p-SCLC and 38 with c-SCLC, were diagnosed preoperatively with poorly differentiated carcinoma (n = 23), squamous carcinoma (n = 14), adenocarcinoma (n = 10), malignant cells with necrosis (n = 10), large cell carcinoma (n = 8), or carcinoid (n = 4). Also, inconsistencies between the clinical (c-) and pathological (p-) stages were found in this cohort, which were less common in patients with preoperative PET examination than those without (24.4% vs. 43.8%; p = 0.032). Multivariable analyses showed that higher p-stage (hazards ratio (HR) = 1.7349, p = 0.0025), sub-lobar resection (HR = 1.9078, p = 0.0395), and a lack of prophylactic cranial irradiation treatment (PCI, HR = 0.3873, p = 0.0057) were unfavorable prognostic factors for overall survival.

CONCLUSION

Non-resection approaches reveal an inadequate diagnosis of SCLC. PET examination facilitates the evaluation of the clinical staging of SCLC. For unexpected SCLC undergoing resection, favorable outcomes can be achieved if radical resection and postoperative PCI are performed.

Efficacy of surgery and prophylactic cranial irradiation in stage II and III small cell lung cancer

Background: The role of surgery for stage II and III small cell lung cancer (SCLC) remains controversial. The use of prophylactic cranial irradiation (PCI) for resected SCLC was limited. This study aimed to assess the efficacy of surgery in patients with stage II and III SCLC, and evaluate the value of PCI on resected disease. Methods: A total of 269 consecutive patients with stage II-IIIA SCLC were retrospectively reviewed from January 2010 to December 2015. Of these, 116 patients received surgical resection, and 153 underwent non-surgical treatment. Resected patients were matched 1:1 with non-surgical patients (n=70 in each group). Results: The median follow-up was 30 months. The 1-, 3- and 5-year overall survival (OS) for matched patients were 80.0%, 44.3% and 31.7% in surgical group, and 80.0%, 24.3% and 20.0% in non-surgical group (P=0.009), respectively. Multivariate analysis in matched patients showed that surgery (HR=0.603, 95%CI: 0.404-0.900) and PCI (HR=0.637, 95%CI: 0.427-0.950) were independent prognostic factors for OS. In subgroup analysis, OS benefit related to surgery was marginal for stage II (P=0.09) and IIIA patients (P=0.061), but was significant for selected stage IIIA patients who received adjuvant chemo-radiation and PCI (P=0.01). PCI was associated with improved OS for non-surgical patients (P=0.036), and stage IIIA of surgical patients (P=0.047). Conclusions: These findings suggest a potential OS benefit of surgery in stages II and IIIA patients, particularly in selected stage IIIA patients who received adjuvant chemo-radiation and PCI. The use of PCI for surgical patients with stage IIIA was associated with improved OS.

Better cancer specific survival in young small cell lung cancer patients especially with AJCC stage III

It has been reported that younger patients with non-small cell lung cancer (NSCLC) tend to have a better prognosis. Yet, few studies have focused on the clinicopathological characteristics and prognosis of young small cell lung cancer (SCLC), especially for patients with age < 50. In our study, we used Surveillance, Epidemiology, and End Results (SEER) population-based data and identified 16503 patients with SCLC including 711 patients aged < 50, 3338 patients aged 50-59, 5937 patients aged 60-69, 4649 patients aged 70-79 and 1868 patients aged ≥ 80 between 2010 and 2013. The Kaplan-Meier methods was used to develop the survival curve, and the results showed that the SCLC patients with aged < 50 tended to a better over survival (OS) and cancer specific survival (CSS) (all, P < 0.001). In addition, Cox regression model was used to analyze survival prognosis factors and perform subgroup analysis. The results showed that age was an independent prognostic factor for CSS (P < 0.001). Importantly, we found that for the patients with AJCC stage III subgroup, the age < 50 had apparent CSS benefit compared with any other age group (all, P < 0.01). Interestingly, for the patients with no surgery, radiation and no radiation subgroup, the age < 50 had no apparent CSS benefit only compared with age 50-59 (all, P > 0.05). In conclusion, our study demonstrated that the SCLC patients with aged < 50 tended had a better survival benefit, especially for patients with AJCC stage III.

Prognostic significance of 18F-fluorodeoxyglucose uptake of bone marrow measured on positron emission tomography in patients with small cell lung cancer

OBJECTIVES

We investigated whether ¹⁸F-fluorodeoxyglucse (FDG) uptake of bone marrow (BM) on positron emission tomography/computed tomography (PET/CT) has implications for predicting clinical outcomes in patients with small cell lung cancer (SCLC).

METHODS

We retrospectively enrolled 70 SCLC patients who underwent FDG PET/CT prior to treatment. On PET/CT, maximum FDG uptake of all tumor lesions (Tmax), coefficient of variation (COV) of FDG uptake of primary tumor, and mean FDG uptake of BM (BM SUV) were measured. The relationships of BM SUV with PET/CT parameters of SCLC and serum markers were evaluated. Univariate and multivariate analyses were performed to assess the significance of BM SUV for predicting progression-free survival (PFS) and overall survival (OS).

RESULTS

BM SUV had significant positive correlations with Tmax, COV of primary tumor, white blood cell count, and serum C-reactive protein level (p < .05). On univariate analysis, BM SUV showed significant association with only PFS (p = .006). On multivariate analysis, Veterans Administration Lung Cancer Study Group (VALSG) stage, N stage, M stage, Tmax, and BM SUV were independent prognostic factors for PFS (p < .05) and, for OS, VALSG stage and M stage were independent prognostic factors (p < .05). Among patients with limited disease, patients with high FDG uptake of BM had significantly worse PFS than did those with low FDG uptake of BM (p < .05), but, there was no significant difference in PFS between patients with extensive disease and patients with limited disease and high FDG uptake of BM (p > .05).

CONCLUSION

FDG uptake of BM was an independent predictor of disease progression in SCLC patients. Patients with limited disease and high FDG uptake of BM had similar PFS to those with extensive disease.

Prophylactic cranial irradiation in resected small cell lung cancer: A systematic review with meta-analysis

Background: The use of PCI in early operable patients with small cell lung cancer (SCLC) is still controversial. Therefore, we conducted a systematic review with meta-analysis to investigate the effects of PCI in resected SCLC patients.

Methods: Relevant studies were identified from PubMed and EMBASE databases, the pooled hazard risks were obtained by the random-effects model. We also analyzed the brain metastasis (BM) risk in p-stage I patients without PCI.

Results: Five retrospective studies were identified and a total of 1691 patients were included in our analysis, 315 of them received PCI. For all the resected patients, PCI was associated with improved overall survival (HR: 0.52, 95% CI: 0.33-0.82), and reduced brain metastasis risk (RR: 0.50, 95%CI: 0.32-0.78). However, with regard to p-stage I patients, no survival benefit was brought by PCI (HR: 0.87, 95% CI: 0.34-2.24). Moreover, the pooled analysis of 7 studies found that the 5-year brain metastasis risk was relatively low (12%, 95% CI: 8%-17%) for p-stage I patients without PCI.

Conclusions: PCI might be associated with a favorable survival advantage and reduced BM risk in complete resected SCLC patients, except for p-stage I patients.

The revision of 8th edition TNM stage criteria is more accurate in prediction postoperative survival for SCLC patients

OBJECTIVES

The 8th edition TNM lung cancer classification was enacted in January 2017. An important change is the old T2a was revised to new T2a and T2b. Whether a postoperative survival difference exists between the two stages is still undefined. The purpose of this study is to investigate the postoperative outcomes of small cell lung cancer (SCLC) patients and compare the survival difference between the two stages.

METHODS

Data of patients with SCLC who underwent surgery between October 2005 and August 2013 at our institute were reviewed. A total number of 194 patients were enrolled and were reclassified according to the 8th edition TNM stage. Survival was determined by Kaplan-Meier analysis, the log-rank test was used to compare survival differences.

RESULTS

Surgical resection included 165 lobectomy or bilobectomy, 19 sublobectomy and 10 pneumonectomy. There were 159 patients received chemotherapy, 35 underwent surgery alone. The 5-year survival rate and median survival time (MST) of whole group was 34.5% and 45 months. For patients who received similar therapy (surgery plus chemotherapy) in N0 stage, the MST of T2a stage was 83 months, significantly longer than 62 months in T2b stage (P = 0.017).

CONCLUSIONS

In the 8th edition TNM lung cancer stage criteria, the postoperative survival of T2a is superior to T2b for non-metastatic SCLC at N0 stage.

Transfection with Livin and Survivin shRNA inhibits the growth and proliferation of non‑small cell lung cancer cells

Lung cancer is reported to be a major public health issue worldwide and the overall prognosis of patients remains poor. The expression levels of Livin and Survivin, of the inhibitors of apoptosis (IAP) family, are associated with prognostic significance in the majority of solid tumors. Therefore, in the presents study, short hairpin (sh)RNA expression vectors inhibiting the Livin and Survivin genes were constructed to examine the effects of the transfection of Livin shRNA and/or Survivin shRNA on the biological functions of tumor cells. The transfection efficiency was measured using fluorescence reverse transcription‑quantitative polymerase chain reaction and western blot analyses. The cell growth inhibition ratio was measured using a CCK assay. Cell apoptosis following transfection and in tumor tissues were measured using a TUNEL assay, and a cancer xenograft model was used to investigate the effect of Livin shRNA and/or Survivin shRNA on tumor growth. The results indicated that the mRNA and protein expression levels were suppressed following the transfection of Livin and Survivin shRNA into tumor cells (P<0.05, compared with control group). The growth of tumor cells in vivo and in vitro was significantly inhibited following transfection with Livin and Survivin shRNA, compared with that in the other groups (P<0.05). Taken together, the transfection of cells with Livin and Survivin inhibited tumor growth in vivo and in vitro, with the co‑transfection of Livin and Survivin shRNA showing increased efficiency, compared with transfection of either the Livin vector or Survivin vector alone. The combined inhibition of Livin and Survivin may be a promising multitargeted gene therapeutic strategy in cancer treatment.

Benefits of postoperative thoracic radiotherapy for small cell lung cancer subdivided by lymph node stage: a systematic review and meta-analysis

BACKGROUND

Whether postoperative thoracic radiotherapy (PORT) is beneficial for small cell lung cancer (SCLC) of different lymph node stages remains uncertain; therefore, the purpose of this meta-analysis was to explore the clinical significance of PORT for SCLC patients subdivided by lymph node status.

METHODS

The PubMed, OVID, Web of SCI, EMBASE, Google Scholar, Cochrane Library, Chinese National Knowledge Infrastructure and Wanfang databases were systematically searched to identify eligible studies where SCLC patients received PORT based on lymph node stage. The main outcome measures were 1-, 3- and 5-year overall survival (OS) rates, as well as 1-, 2- and 3-year local regional recurrence (LRR) rates. All data were analyzed using STATA 12.0 and expressed as risk ratios (RR) with their corresponding 95% confidence intervals (95% CI).

RESULTS

Five cohort studies, including 3,497 SCLC patients (578 receiving PORT and 2,919 not) were included in this study. PORT significantly decreased the 1-, 2- and 3-year LRR rates (RR =0.14, 0.28 and 0.27, respectively; P_all<0.05), but did not improve the 1-, 3- or 5-year OS rates when all patients were analyzed together. However, subgroup analysis showed that in the pN0 group PORT did not improve the 1-, 3- or 5-year OS rates or decrease the 1-, 2- or 3-year LRR rates; in the pN1 group PORT reduced the 1-, 2- and 3-year LRR rates (RR =0.11, 0.16 and 0.17, respectively; P_all<0.05) and improved the 1-year OS rate (RR =0.40; P<0.001), but not the 3- or 5-year OS rates; in the pN2 group PORT significantly reduced the 1-, 2- and 3-year LRR rates (RR =0.14, 0.15 and 0.15 respectively; P_all<0.05) and improved the 1-, 3- and 5-year OS rates (RR =0.46, 0.72 and 0.85, respectively; P_all<0.05).

CONCLUSIONS

This is the first meta-analysis of the benefits of PORT for SCLC patients. Although derived from retrospective cohort studies, the data showed that PORT significantly reduced the risk of recurrence and improved survival for patients with pN2-SCLC; however, patients with pN0-SCLC did not benefit from PORT, whereas for patients with pN1-SCLC, PORT reduced the LRR rates and improved the 1-year survival rate. The long-term survival benefits of PORT remain unclear and will require further prospective studies.

Disparities in the Management of Patients With Stage I Small Cell Lung Carcinoma (SCLC): A Surveillance, Epidemiology and End Results (SEER) Analysis

INTRODUCTION

Patients with stage I small cell lung carcinoma (SCLC) are candidates for surgery; however, not much is known regarding the utilization of surgical resection in the management of stage I SCLC and the factors that determine the patient's ability to receive surgery.

METHODS

The Surveillance, Epidemiology and End Results database was used to identify patients with stage I SCLC from 2007 to 2013. Continuous variables were compared with 1-way analysis of variance, and categorical variables were compared with χ² testing. Multivariable logistic regression analyses were used to obtain odds ratios.

RESULTS

Of the 1902 patients with stage I SCLC, 427 (22.4%) underwent resection, 116 (6.1%) resection and radiation, 815 (42.8%) received radiation alone, and 544 (28.6%) did not undergo surgery or radiation. Median overall survival for patients with surgery plus radiation was 60+ months, followed by surgery alone at 50 months, radiation at 27 months, and no resection/radiation 16 months. Patients with ≥ 4 lymph nodes removed during surgery had better overall survival of 60+ months compared with patients with < 4 lymph nodes removed (25 months); P < .001. Multivariate analysis demonstrated that elderly patients, men, African American individuals, Medicaid recipients, and patients with left-sided tumors were less likely to undergo resection. However, county-level socioeconomic factors, such as level of poverty, education, unemployment, and median income did not affect the likelihood of undergoing resection.

CONCLUSIONS

Fewer than one-third of all patients with stage I SCLC undergo resection despite better outcomes with resection. Elderly African American men with Medicaid insurance were less likely to receive resection.

Clinical outcomes of surgically resected combined small cell lung cancer: a two-institutional experience

BACKGROUND

The combined small cell lung cancer (c-SCLC) was rare and its clinicopathological characteristics had not been thoroughly described. The aim of this study was to determine prognostic factors and survival in c-SCLC patients.

METHODS

Clinical records of patients with c-SCLC who underwent surgery between January 2009 and December 2013 in two institutions were retrospectively reviewed.

RESULTS

Ninety-seven patients were identified. The most common pathology was combined SCLC and large cell neuroendocrine carcinoma (LCNEC, N=46), followed by combined SCLC and squamous cell carcinoma (SCC) (N=32), combined SCLC and adenocarcinoma (AC) (N=12), and combined SCLC and adenosquamous carcinoma (ASC) (N=7). The overall survival (OS) rates of the entire cohort were 42.4% and 35.2% at 3 and 5 years, respectively. Multivariate analysis identified sex [female vs. male, hazards ratio (HR) =0.38; 95% confidence interval (CI): 0.19-0.79; P=0.010], age (<53 vs. >53 years, HR =0.28; 95% CI: 0.09-0.81; P=0.019), performance status (<2 vs. >2, HR =0.08; 95% CI: 0.02-0.32; P<0.001), combined non-small cell lung cancer (NSCLC) components (LCNEC vs. non-LCNEC, HR =3.00; 95% CI: 1.03-8.76; P=0.045), adjuvant therapy (yes vs. no, HR =0.33; 95% CI: 0.17-0.67; P=0.002) as significantly prognostic factors of OS in patients with complete resection and lymphadenectomy.

CONCLUSIONS

The mixed NSCLC components within c-SCLCs had a significant influence on the survival. Compared with surgery alone, adjuvant therapy was associated with significantly improved survival in patients with complete resection and lymphadenectomy.

Percutaneous Thermal Ablation for Small-Cell Lung Cancer: Initial Experience with Ten Tumors in Nine Patients

PURPOSE

To evaluate outcomes in a small cohort of patients with local or disseminated small-cell lung cancer (SCLC) who received percutaneous thermal ablation therapy.

MATERIALS AND METHODS

Ten biopsy-proven SCLC tumors in 9 consecutive patients (5 men, 4 women; average age, 73.8 y ± 12.4) were retrospectively evaluated. Average tumor sizes were 1.8 cm ± 0.5 and 2.6 cm ± 1.2 among patients with local and disseminated disease, respectively. Microwave and radiofrequency ablation were each used for 5 tumors. None of the patients with local SCLC received adjuvant therapy following thermal ablation. Median follow-up duration was 16 months (range, 2-48 mo). Median and 1-year overall survival (OS) were compared for patients in the local and disseminated disease groups.

RESULTS

Median and 1-year OS were better among patients treated for local SCLC compared with disseminated disease (47.0 vs 5.5 mo and 3 [100%] vs 2 [40%], respectively). Pneumothorax occurred in 5 patients (55.6%), and 3 patients received successful outpatient thoracostomy tube placement. No patients were hospitalized, and there were no major complications.

CONCLUSIONS

This preliminary analysis suggests favorable outcomes in selected patients with local SCLC who undergo percutaneous thermal ablation without adjuvant therapy.

A review of the role of surgery for small cell lung cancer and the potential prognostic value of enumeration of circulating tumor cells

Small cell lung cancer (SCLC) is disseminated in the majority of patients at first presentation and, thus, treated with chemoradiotherapy. Despite initial high response rates, chemoresistance appears rapidly and results in a dismal prognosis. However, patients with limited cancer may exhibit better disease control upon surgical treatment. Correct staging is highly critical in the selection of those patients which are likely to benefit from surgery. Studies of the inclusion of surgery in the multimodal treatment of SCLC vary widely in number of patients, selection, treatment and follow-up. Nevertheless surgical therapy for confined SCLCs achieves favorable long-term survival compared to chemoradiotherapy, depending on a precise assessment of the degree of tumor dissemination. Recently, extremely high counts of circulating tumor cells (CTCs) were reported in patients with SCLC compared to other malignancies. In several studies the number of CTCs was found to constitute a prognostic parameter and a marker of response to therapy. Therefore, the assessment of CTCs as so-called "Liquid Biopsy" seems to constitute a more precise method to detect tumor dissemination earlier when compared to clinical staging. In conclusion, in the era of precision oncology enumeration and identification of CTCs of SCLC patients have the potential to help in the selection of patients most suitable for tumor surgery.

Management of small-cell lung cancer with radiotherapy-a pan-Canadian survey of radiation oncologists

BACKGROUND

The management of small-cell lung cancer (sclc) with radiotherapy (rt) varies, with many treatment regimens having been described in the literature. We created a survey to assess patterns of practice and clinical decision-making in the management of sclc by Canadian radiation oncologists (ros).

METHODS

A 35-item survey was sent by e-mail to Canadian ros. The questions investigated the role of rt, the dose and timing of rt, target delineation, and use of prophylactic cranial irradiation (pci) in limited-stage (ls) and extensive-stage (es) sclc.

RESULTS

Responses were received from 52 eligible ros. For ls-sclc, staging (98%) and simulation or dosimetric (96%) computed tomography imaging were key determinants of rt suitability. The most common dose and fractionation schedule was 40-45 Gy in 15 once-daily fractions (40%), with elective nodal irradiation performed by 31% of ros. Preferred management of clinical T1/2aN0 sclc favoured primary chemoradiotherapy (64%). For es-sclc, consolidative thoracic rt was frequently offered (88%), with a preferred dose and fractionation schedule of 30 Gy in 10 once-daily fractions (70%). Extrathoracic consolidative rt would not be offered by 23 ros (44%). Prophylactic cranial irradiation was generally offered in ls-sclc (100%) and es-sclc (98%) after response to initial treatment. Performance status, baseline cognition, and pre-pci brain imaging were important patient factors assessed before an offer of pci.

CONCLUSIONS

Canadian ros show practice variation in sclc management. Future clinical trials and national treatment guidelines might reduce variability in the treatment of early-stage disease, optimization of dose and targeting in ls-sclc, and definition of suitability for pci or consolidative rt.

Multimodality Therapy for Limited-Stage Small-Cell Lung Cancer

Limited-stage small-cell lung cancer (SCLC) occurs in only one third of patients with SCLC, but it is potentially curable. Combined-modality therapy (chemotherapy and radiotherapy) has long been the mainstay of therapy for this condition, but more recent data suggest a role for surgery in early-stage disease. Prophylactic cranial irradiation seems to improve outcomes in patients who have responded to initial therapy. This review addresses the practical aspects of staging and treatment of patients with limited-stage SCLC.

Prognostic impact of clinical variables on surgically resected small-cell lung cancer: Results of a retrospective multicenter analysis (FIGHT002A and HOT1301A)

OBJECTIVES

Several American and Japanese guidelines recommend surgery for patients with c-stage I small-cell lung cancer (SCLC), whereas the European Society of Medical Oncology (ESMO) guidelines recommend surgery for patients with not only c-stage I but also c-stage II (T2N1) SCLC. In addition, previous studies identified various factors other than clinical stage that are related to survival in these patients. Thus, further validation and examination of the association of clinical stage and other clinical variables with survival are required for establishing practical management of early-stage SCLC.

PATIENTS AND METHODS

We reviewed the clinical courses of 156 SCLC patients who had undergone surgery at 17 institutions between January 2003 and January 2013.

RESULTS

Clinical stages (tumor-node-metastasis [TNM] version 7) of the 156 patients were 98 cases in IA, 14 in IB, 16 in IIA, 7 in IIB, 18 in IIIA, and 3 in IIIB. Median overall survival (OS) was 33.3 months (95% confidence interval: 20.9-45.8). Multivariate analysis revealed that OS was longer in patients either at c-stage II and under, with a maximum tumor diameter of <20mm, with preoperative diagnosis, without a history or presence of other types of cancer, or who underwent prophylactic cranial irradiation (PCI).

CONCLUSION

These results indicate that a history or presence of other types of cancer might be a major decisive factor for surgery. Patients with c-stages I and II (c-T2N1) can be considered for surgery, and PCI may be useful in patients undergoing surgery in a practical setting, partly supporting the ESMO guidelines.(1).