Surgical results for small cell lung cancer based on the new TNM staging system. Thoracic Surgery Study Group of Osaka University, Osaka, Japan

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.

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.

Prognostic Value of Clinical Staging According to TNM in Patients With SCLC: A Real-World Surveillance Epidemiology and End-Results Database Analysis

Introduction

SCLC is one of the most lethal malignancies. Classically, staging has been performed using a dual classification distinguishing limited from the extensive stage. This study aimed to evaluate the prognostic value of TNM staging in a real-world population of patients with SCLC.

Methods

Patients were selected from the Surveillance Epidemiology and End Results database. Chi-square bivariate analysis was used for the association of binary qualitative variables. A multivariate Cox regression analysis was performed to determine the impact of these prognostic factors on median overall survival (mOS) and long-term survival.

Results

A total of 26,221 patients were included (50.7% men, 55.7% ≥65 y, 82% White). At diagnosis, 18,574 (70.83%) presented metastases, which were more frequent in the liver (n = 11,896, 64%). In the overall population, mOS was 8 (7.86–8.14) months, which decreased according to each increasing category of TNM staging (p < 0.0001). The worse mOS was found among patients with stage IV SCLC (6 mo, 95% confidence interval: 5.83–6.17). Long-term survival decreased according to TNM staging, with patients having stage IV SCLC exhibiting the lowest survival rates at all follow-up time points. Within stage IV, the lowest mOS values were found in patients greater than or equal to 65 years and in those with liver metastases. Among the TNM stages corresponding to the limited stage, stage IB revealed the lowest hazard ratios value for risk of death compared with stage IA (hazard ratio = 1.161, 95% confidence interval: 0.97–1.40, p = 0.114), which increased gradually within the limited-stage SCLC. In the multivariate analysis, TNM staging, male sex, and older age resulted in poor prognostic factors for survival.

Conclusions

TNM staging seems to define prognosis in patients with SCLC in the real-world setting, particularly for those patients with earlier disease.

Role of surgery in a case-control study of patients with clinical stage IIIA small cell lung cancer

Background

The role of surgery in the multidisciplinary treatment of clinical stage IIIA small cell lung cancer is yet to be verified. This study was performed to determine the benefit of surgery in patients with stage IIIA small cell lung cancer.

Methods

Patients diagnosed with stage IIIA small cell lung cancer at Shanghai Pulmonary Hospital from 2005 to 2015 were included and divided into two groups: the surgery with neoadjuvant and adjuvant chemotherapy group and the concurrent chemo-radiotherapy group. Overall survival was compared between the two groups. A multivariate Cox regression model was constructed to evaluate factors associated with overall survival.

Results

Of 69 patients with stage IIIA small cell lung cancer during the study period, 40 patients (58%) underwent surgery with neoadjuvant and adjuvant chemotherapy, and 29 patients (42%) underwent concurrent chemo-radiotherapy. Patients in the surgery with neoadjuvant and adjuvant chemotherapy group had a longer overall survival compared with patients in the concurrent chemo-radiotherapy group (median survival: 33.1 vs. 16.2 months, respectively; 2-year overall survival: 44.2% vs. 14.9%, respectively; log-rank: P=0.045). A multivariate analysis revealed that surgery with neoadjuvant and adjuvant chemotherapy (hazard ratio: 0.374; 95% confidence interval: 0.173–0.808, P=0.012) was independently associated with overall survival.

Conclusions

Patients with stage IIIA small cell lung cancer treated with surgical resection plus chemotherapy demonstrated longer overall survival compared with those who underwent concurrent chemo-radiotherapy. Surgery may be an option for clinical stage IIIA small cell lung cancer after induction chemotherapy in selected patients.

GOECP/SEOR radiotherapy guidelines for small-cell lung cancer

Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancers. The main treatment is chemotherapy (Ch). However, the addition of radiotherapy significantly improves overall survival (OS) in patients with non-metastatic SCLC and in those with metastatic SCLC who respond to Ch. Prophylactic cranial irradiation reduces the risk of brain metastases and improves OS in both metastatic and non-metastatic patients. The 5-year OS rate in patients with limited-stage disease (non-metastatic) is slightly higher than 30%, but less than 5% in patients with extensive-stage disease (metastatic). The present clinical guidelines were developed by Spanish radiation oncologists on behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Society of Radiation Oncology to provide a current review of the diagnosis, planning, and treatment of SCLC. These guidelines emphasise treatment fields, radiation techniques, fractionation, concomitant treatment, and the optimal timing of Ch and radiotherapy. Finally, we discuss the main indications for reirradiation in local recurrence.

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.

Propensity Score Matching Analysis for the Role of Surgery in Small Cell Lung Cancer

BACKGROUND

The role of surgery for small cell lung cancer (SCLC) is not clear. We aimed to evaluate this issue using a population-based database.

METHODS

Patients diagnosed between 2004 and 2014 with SCLC staged T1-4 N0-2 M0 disease were retrieved from the Surveillance, Epidemiology, and End Results database. Propensity score matching (PSM) was used to reduce bias between the surgical and nonsurgical patient groups. The Kaplan-Meier method and Cox regression analysis were used to compare overall survival (OS) for the matched patients.

RESULTS

A total of 8,811 patients were retrieved, including 863 patients who underwent surgical resection. After 1:1 PSM, a matched cohort with 1,562 patients was generated. In the matched cohort, surgery was associated with 5-year OS improvement (from 16.8 to 36.7%, p < 0.001) and lung cancer-specific survival improvement (from 21.6 to 43.2%, p < 0.001). Survival benefits of surgery were significant in all subgroups, including N1-2 disease, except for patients with a tumor size >5.0 cm or T3 disease.

CONCLUSIONS

Patients with SCLC of limited stage can benefit from surgery, including N1-2 disease. However, patients with a tumor size >5.0 cm or advanced T stage may be unable to benefit from surgery.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Effects of Surgery on Survival of Early-Stage Patients With SCLC: Propensity Score Analysis and Nomogram Construction in SEER Database

Purpose: We aimed to assess the survival benefit of surgery for patients with stage IA–IIB small cell lung cancer (SCLC) and construct a nomogram for predicting overall survival (OS).

Methods: Patients who had been diagnosed with stage IA–IIB SCLC between 2004 and 2014 and who had received active treatment were selected from the Surveillance, Epidemiology, and End Results database. The primary endpoint was OS. Cox proportional hazards models and propensity score (PS) analyses were used to compare the associations between surgery and OS. The probability of 1- and 3-year OS was predicted using a nomogram.

Results: We reviewed 2,246 patients. The median OS of the surgery and non-surgery groups was 35 months and 19 months, respectively. Multivariable Cox proportional hazards models showed a survival benefit in the surgery group (hazards ratio [HR], 0.642; 95% confidence interval [CI], 0.557–0.740; P < 0.001). To balance the between-group measurable confounders, the impact of surgery on OS was assessed using PS matching. After PS matching, OS analysis still favored surgical resection. The PS-stratification, PS-weighting, and PS-adjustment models showed similar results to demonstrate a statistically significant benefit for surgery. Further, the nomogram was well calibrated and had good discriminative ability (Harrell's C-index = 0.645).

Conclusion: Our analysis suggests that surgery is a viable option for patients with early-stage SCLC. Our nomogram is a viable tool for quantifying treatment trade-off assumptions and may assist clinicians in decision-making. Future work is needed to validate our results and improve our tools.

The impact of quantitative CT-based tumor volumetric features on the outcomes of patients with limited stage small cell lung cancer

INTRODUCTION

Limited stage small cell lung cancer (LS-SCLC) has a poor prognosis. Additional prognostic markers are needed for risk-stratification and treatment intensification. This study compares quantitative CT-based volumetric tumor measurements versus International Association for the Study of Lung Cancer (IASLC) TNM staging to predict outcomes.

MATERIALS & METHODS

A cohort of 105 patients diagnosed with LS-SCLC and treated with chemoradiation (CRT) from 2000 to 2013 were analyzed retrospectively. Patients were staged by the Union for International Cancer Control (UICC) TNM Classification, 8th edition. Tumor volumes and diameters were extracted from radiation planning CT imaging. Univariable and multivariable models were used to analyze relationships between CT features and overall survival (OS), locoregional recurrence (LRR), in-field LRR, any progression, and distant metastasis (DM).

RESULTS

Median follow-up was 21.3 months. Two-year outcomes were as follows: 38% LRR, 31% in-field LRR, 52% DM, 62% any progression, and 47% OS (median survival 16.5 months). On univariable analysis, UICC T-stage and N-stage were not associated with any clinical outcome. UICC overall stage was only statistically associated with in-field LRR. One imaging feature (3D maximum tumor diameter) was found to be significantly associated with LRR (HR 1.10, p = 0.003), in-field LRR (HR 1.10, p = 0.007), DM (HR 1.10, p = 0.02), any progression (HR 1.10, p = 0.008), and OS (HR 1.10, p = 0.03). On multivariable analysis, this feature remained significantly associated with all outcomes.

CONCLUSION

For LS-SCLC, quantitative CT-based volumetric tumor measurements were significantly associated with outcomes after CRT and may be better predictors of outcome than TNM stage.

Comparison Of Long Term Results Between Matched Chemoradiotherapy And Surgery For Limited Stage Small Cell Lung Cancer

Purpose

To compare the efficacy of chemoradiotherapy or surgery for limited-stage small cell lung cancer (SCLC).

Patients and methods

A retrospective analysis was performed on 138 patients with limited-stage SCLC who received surgery (69 patients) or chemoradiotherapy (69 patients) between January 2000 and September 2016 in Zhejiang Cancer Hospital. Patients of the chemoradiotherapy group were selected by using “pair-matched case-control” methodology from a cohort of 503 patients who received chemoradiotherapy.

Results

The major prognostic factors, including T, N stage, treatment duration, age, gender, and whether or not they received prophylactic cranial irradiation were well balanced between two groups. The median overall survival (OS) time and 5-year OS rate were 37.1 months and 45.0% in the surgical group vs 45.0 months and 45.0% in the chemoradiotherapy group (P=0.846). The median progression-free survival (PFS) time and 5-year PFS rate were 27.1 months and 37.8% vs 36.2 months and 40.0%, respectively, in the two groups (P=0.610). The 5-year OS rate (62.3% vs 40.1%, P=0.038) and 5-year PFS rate (80.1% vs 40.1%, P=0.048) in the surgical group were significantly higher than those of the chemoradiotherapy group in patients with stage I disease. The 5-year OS rate (41.2% vs 50.6%, P=0.946) and 5-year PFS rate (64.7% vs 42.1%, P=0.280) of surgery for stage II SCLC were comparable to chemoradiotherapy. As for stage III SCLC, compared with the surgical group, the chemoradiotherapy group had a better 5-year OS trend (25.1% vs 47.6%, P=0.220), but the difference did not reach statistical significance.

Conclusion

Surgery could confer survival benefits in patients with p-stage I disease, but not in patients with p-stage II and III disease.

Final report of a prospective randomized study on thoracic radiotherapy target volume for limited-stage small cell lung cancer with radiation dosimetric analyses

BACKGROUND

The thoracic radiotherapy (TRT) target volume for limited-stage small-cell lung cancer (SCLC) has been controversial for decades. In this report, the final results of a prospective randomized trial on the TRT target volume before and after induction chemotherapy are presented.

METHODS

After 2 cycles of etoposide and cisplatin, patients arm were randomized to receive TRT to the postchemotherapy or prechemotherapy tumor volume in a study arm and a control arm. Involved-field radiotherapy was received in both arms. TRT consisted of 1.5 grays (Gy) twice daily in 30 fractions to up to a total dose of 45 Gy. Lymph node regions were contoured, and intentional and incidental radiation doses were recorded.

RESULTS

The study was halted early because of slow accrual. Between 2002 and 2017, 159 and 150 patients were randomized to the study arm or the control arm, respectively; and 21.4% and 19.1% of patients, respectively, were staged using positron emission tomography/computed tomography (P = .31). With a median follow-up of 54.1 months (range, 19.9-165.0 months) in survivors, the 3-year local/regional progression-free probability was 58.2% and 65.5% in the study and control arms, respectively (P = .44), and the absolute difference was -7.3% (95% CI, -18.2%, 3.7%). In the study and control arms, the median overall survival was 21.9 months and 26.6 months, respectively, and the 5-year overall survival rate was 22.8% and 28.1%, respectively (P = .26). Grade 3 esophagitis was observed in 5.9% of patients in the study arm versus 15.5% of those in the control arm (P = .01). The isolated out-of-field failure rate was 2.6% in the study arm versus 4.1% in the control arm (P = .46), and all such failures were located in the supraclavicular fossa or contralateral hilum. The regions 7, 3P, 4L, 6, 4R, 5, and 2L received incidental radiation doses >30 Gy.

CONCLUSIONS

TRT could be limited to the postchemotherapy tumor volume, and involved-field radiotherapy could be routinely applied for limited-stage SCLC.

Long-term Survival After Surgery Compared With Concurrent Chemoradiation for Node-negative Small Cell Lung Cancer

OBJECTIVE

To determine whether surgery with adjuvant chemotherapy offers a survival advantage over concurrent chemoradiation for patients with cT1-2N0M0 small cell lung cancer (SCLC).

BACKGROUND

Although surgery with adjuvant chemotherapy is the recommended treatment for patients with cT1-2N0M0 SCLC per international guidelines, there have been no prospective or retrospective studies evaluating the impact of surgery versus optimal medical management for cT1-2N0M0 SCLC.

METHODS

Outcomes of patients with cT1-2N0M0 SCLC who underwent surgery with adjuvant chemotherapy or concurrent chemoradiation in the National Cancer Data Base (2003-2011) were evaluated using Cox proportional hazards analyses and propensity-score-matched analyses.

RESULTS

During the study period, 681 (30%) patients underwent surgery with adjuvant chemotherapy and 1620 (70%) underwent concurrent chemoradiation. After propensity-score matching, all 14 covariates were well balanced between the surgery (n = 501) and concurrent chemoradiation (n = 501) groups. Surgery was associated with a higher overall survival (OS) than concurrent chemoradiation (5-year OS 47.6% vs 29.8%, P < 0.01). To minimize selection bias due to comorbidities, we limited the propensity-matched analysis to 492 patients with no comorbidities; surgery remained associated with a higher OS than concurrent chemoradiation (5-year OS 49.2% vs 32.5%, P < 0.01).

CONCLUSIONS

In a national analysis, surgery with adjuvant chemotherapy was used in the minority of patients for early stage SCLC. Surgery with adjuvant chemotherapy for node-negative SCLC was associated with improved long-term survival when compared to concurrent chemoradiation. These results suggest a significant underuse of surgery among patients with early stage SCLC and support an increased role of surgery in multimodality therapy for cT1-2N0M0 SCLC.

Role of surgery in patients with early stage small-cell lung cancer

Purpose

Currently, systemic chemotherapy combined with thoracic radiation is the standard treatment for patients with small-cell lung cancer (SCLC). However, the treatment of early stage SCLC remains controversial. This study evaluated the survival outcomes of surgical treatments and the effect of adjuvant chemotherapy and radiotherapy on lung cancer-specific survival (LCSS) in patients with early stage SCLC.

Methods

Using the Surveillance, Epidemiology, and End Results registry, we identified 2,453 patients with early stage SCLC (1,295 women and 1,158 men) who had complete clinical information between 2004 and 2015. The Kaplan-Meier analysis was used to determine the propensity score based on the characteristics of patients with early stage SCLC. LCSS was compared between patients treated with surgery and non-surgery after adjusting, stratifying, or matching patients with early stage SCLC. In addition, we compared the effects of chemotherapy and radiotherapy on LCSS in patients with early stage SCLC.

Results

Overall, 687 (28.0%) and 1,766 (72.0%) patients with early stage SCLC did and did not undergo surgery, respectively. Kaplan-Meier analysis demonstrated a statistically significant difference in survival curves between the surgery and non-surgery groups (log-rank p<0.001). Compared with the non-surgery group, the LCSS of the surgery group was better (hazard ratio [HR]:0.494, 95% confidence interval [CI]:0.415-0.587, p<0.001) in patients with early stage SCLC when using a Cox model for multivariate analysis. There was no statistically significant difference (p=0.847) in LCSS between patients with early stage SCLC with and without chemotherapy in the multivariate analysis. Radiotherapy had favorable effects on LCSS (HR: 0.579, 95% CI: 0.500-0.671, p<0.001) in patients with early stage SCLC using multivariate analysis.

Conclusions

Our study results suggest that LCSS conferred by surgery was higher than that conferred by non-surgery and that radiotherapy is associated with better survival in patients with early stage SCLC. This study findings should be confirmed in prospective studies.

Stereotactic ablative radiation therapy versus conventionally fractionated radiation therapy for stage I small cell lung cancer

BACKGROUND

The National Comprehensive Cancer Network (NCCN) recently revised recommendations for inoperable stage I small cell lung cancer (SCLC), having added stereotactic ablative radiotherapy (SABR)/chemotherapy to the historical paradigm of concurrent conventionally-fractionated radiation therapy (CFRT)/chemotherapy. Despite the conformality, convenience, and cost-effectiveness of SABR, the NCCN continues to recommend both CFRT/chemotherapy and SABR/chemotherapy primarily because these approaches have not been comparatively analyzed to date.

METHODS

The National Cancer Database was queried for histologically-confirmed T1-2N0M0 SCLC; all patients received chemotherapy. Multivariable logistic regression ascertained factors associated with SABR/chemotherapy. Kaplan-Meier analysis assessed overall survival (OS); multivariable Cox proportional hazards modeling examined factors associated with OS. Survival was also calculated following propensity matching.

RESULTS

Of 2,107 patients, 7.1% underwent SABR/chemotherapy, and 92.9% received CFRT/chemotherapy. The median (interquartile range) dose of SABR was 50 (48-54) Gy in 4 (3-5) fractions, and 55.8 (45-60) Gy in 30 (30-33) fractions for CFRT. Patients receiving SABR/chemotherapy were more often older, had T1 disease, treated at academic/integrated network facilities, and managed in more recent years (p < 0.05 for all). Respective median survival figures were 29.2 versus 31.2 months (p = 0.77), which persisted following propensity matching (25.4 versus 34.3 months, p = 0.85). On multivariable analysis, radiotherapeutic technique was not associated with OS (p = 0.95).

CONCLUSIONS

For stage I SCLC, SABR/chemotherapy affords statistically equivalent outcomes to CFRT/chemotherapy. Because randomized studies addressing this uncommon scenario would almost certainly suffer from inadequate accrual, these retrospective data should be strongly considered in efforts to institute SABR/chemotherapy as the preferred option for this population.

Clinical Outcomes of Stereotactic Body Radiotherapy for Patients With Stage I Small-Cell Lung Cancer: Analysis of a Subset of the Japanese Radiological Society Multi-Institutional SBRT Study Group Database

Stereotactic body radiotherapy (SBRT) is widely used as a curative treatment option for stage I non-small-cell lung cancer, but for patients with stage I small-cell lung cancer, the role of stereotactic body radiotherapy is unclear. In this study, we retrospectively analyzed the outcomes of a subset of patients with stage I small-cell lung cancer treated with stereotactic body radiotherapy in the database of the Japanese Radiological Society-Multi-Institutional stereotactic body radiotherapy Study Group. The 43 patients treated with stereotactic body radiotherapy for stage I small-cell lung cancer between 2004 and 2012 at 11 Japanese institutions were studied: median age = 77 years; 32 (74%) males and 11 females; and 80% were medically inoperable. The clinical stage was IA in 31 and IB in 12. In all patients, the lung tumors were pathologically proven as small-cell lung cancer. A total dose of 48 to 60 Gy was administered in 4 to 8 fractions. The median biologically effective dose (α/β = 10 Gy) was 105.6 Gy. Chemotherapy and prophylactic cranial irradiation were administered in only 8 patients, respectively. The median follow-up time was 23.2 months. The 2-year overall survival, progression-free survival, and distant metastasis-free survival rates were 72.3%, 44.6%, and 47.2%, respectively. The 2-year local control was 80.2%. Regarding the patterns of failure, distant metastasis, lymph node metastasis, and local recurrence were observed in 47%, 28%, and 16% of patients, respectively. No ≥grade 3 stereotactic body radiotherapy-related toxicities were observed. Although stereotactic body radiotherapy was thus revealed to be effective for the local control of stage I small-cell lung cancer, the incidence of distant metastases was high. Further investigations of larger cohorts are needed, including analyses of the effects of combined chemotherapy.

Survival Outcomes for Patients with Surgical and Non-Surgical Treatments in Stages I-III Small-Cell Lung Cancer

Objectives: Chemotherapy and radiation therapy are the standard treatments for patients with small-cell lung cancer (SCLC). However, recent studies suggest that patients with limited stage (I-III) SCLC may benefit from surgical treatment. This study was performed to evaluate the survival outcomes of surgery for stage I-III SCLC.

Methods: This analysis used data from the Surveillance, Epidemiology, and End Results (SEER) database. All stage I-III (excluding N3 and Nx) SCLC patients received a diagnosis between 2004 and 2014. Overall survival (OS) and lung cancer-specific survival (LCSS) were determined by Kaplan-Meier analysis and compared using the log-rank test. A Cox proportional hazard model identified relevant survival variables.

Results: A total of 4,780 histologically confirmed patients were identified from the SEER database, comprising 1,018 patients (21.3%) with stage I disease; 295 (6.2%) with stage II; and 3,467 (72.5%) with stage III disease. Among all of the patients, 520 had been treated with surgery, the majority (n = 344; 66.2%) of whom had stage I disease. The hazard ratio (HR) for OS and LCSS, in patients who underwent surgery, according to stage were as follows: OS, 0.369 and LCSS, 0.335 in stage I; OS, 0.549 and LCSS, 0.506 in stage II; and OS, 0.477 and LCSS, 0.456 in stage III (all p < 0.001). Patients who underwent surgery had significantly better OS, and lobectomy was associated with the best outcome.

Conclusions: Surgical resection was associated with significantly improved OS outcomes and should be considered in the management of stage I-III SCLC.

Proton therapy for small cell lung cancer

The prognosis of limited-stage small cell lung cancer (LS-SCLC) continues to improve and is now roughly comparable to that of locally advanced non-small cell lung cancer (NSCLC). This shift, taken together with the decreased toxicities of modern radiotherapy (RT) for LS-SCLC compared with those reported in historical trials, necessitates further evaluation of whether proton beam therapy (PBT) could further reduce both acute and late toxicities for patients receiving concurrent chemoradiotherapy for LS-SCLC. These notions are discussed theoretically, with an emphasis on cardiac events. This is followed by a review of the published evidence to date demonstrating improved dosimetry with PBT over intensity-modulated RT and encouraging safety and efficacy profiles seen in early clinical reports. In addition to covering technical aspects of PBT for LS-SCLC such as intensity-modulated PBT, image-guidance for PBT, and adaptive planning, this review also discusses the need for increased data on intensity-modulated PBT for LS-SCLC, economic and quality of life analyses for future PBT SCLC studies, careful categorization of cardiac events in these patients, and the role for immunotherapy combined with photon- or proton-based RT for LS-SCLC.

Validation of the 8th TNM classification for small-cell lung cancer in a retrospective material from Sweden

BACKGROUND

The purpose of this study was to evaluate on a Swedish cohort of small cell lung cancer (SCLC) patients whether the 8th TNM staging system can provide additional prognostic information in comparison with the previous 6th and 7th TNM versions and the older 2-stage LD vs ED system.

METHODS

We reviewed the medical records of patients (pts) with SCLC diagnosed between January 2008 and February 2016 in the Stockholm and Gotland region. Each patient file was revised and reclassified from the VASGL system to the 6^th, 7^th and 8^th TNM system respectively. We assessed overall survival (OS) according to the T, N, M-descriptor and compared LD/ED with the 6^th, -7^th, -8^th editions of TNM. Four separate multivariate models adjusted for basic patient characteristics were performed.

RESULTS

In total, 706 pts were eligible for the study. Median OS was 7.7 months. Differences in survival between less advanced stages (IA-IIB) were difficult to assess since there were few patients (n = 32). The majority of patients (78%) migrated to new stage categories in the 8th TNM edition; IIIC, IVA and IVB. In the 8th TNM edition subjects with M1a disease had a similar prognosis to patients with multiple metastatic diseases, M1c. Conversely, subjects with a single metastasis had a similar prognosis to M0-disease. On multivariate analysis, stage was an independent prognostic factor independently of the classification system used.

CONCLUSION

In this cohort, the 8th TNM classification system seems to provide more accurate prognostic information in patients with SCLC when compared to the previous TNM versions. There were few cases with Stages I and II and therefore no robust conclusions can be drawn in this category. The reason single metastatic lesions (M1b) had a better prognosis when compared to M1c could be due to a more aggressive treatment approach in these patients.

The optimal treatment approaches for stage I small cell lung cancer

Although small cell lung cancer (SCLC) represents less than one-sixth of all lung cancer cases, it is an aggressive disease with a high metastatic potential to various sites including the brain. Most landmark trials assessing individual therapy benefits for SCLC dichotomized patients as having either limited or extensive disease. Over the last decade, however, there has been a clear shift towards categorizing and analyzing survival patterns using a more thorough staging system that accounts for tumor size and the degree of nodal or metastatic disease burden. For the 5% of patients who present with clinical stage I (cT1-2aN0M0) SCLC, extrapolating treatment recommendations from a rather heterogeneous population that constitutes limited disease SCLC remains controversial and has led to numerous investigations of alternative therapies such as stereotactic body radiation therapy (SBRT) for the management of this highly select group of patients. Given the changing landscape of multimodal therapy, this review will summarize relevant data pertaining to and outline optimal treatment algorithms for stage I SCLC, with a particular focus on SBRT as a primary mode of local therapy.

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.

Optimal Radiation Therapy for Small Cell Lung Cancer

OPINION STATEMENT

Radiation therapy plays an important role in the management of both limited stage and extensive stage small cell lung cancer. For limited stage disease, there has been a trend toward reduced size of thoracic radiation fields, which has the potential to reduce toxicity. FDG-PET staging helps make this possible by more accurately identifying areas of nodal and metastatic involvement. Trials have demonstrated similar outcomes using a range of radiation fractionation schedules, allowing flexibility in individualizing treatment. Using advanced radiation therapy techniques such as intensity-modulated radiation therapy, it may be possible to deliver fewer, higher dose fractions and achieve similar results to the hyperfractionated regimen. For extensive stage disease, consolidative thoracic radiation therapy after chemotherapy was recently shown to improve overall survival in certain patient subsets. Prophylactic cranial irradiation continues to play an important role in management of all stages of small cell lung cancer. Debate continues about the neurocognitive effects of this treatment, and whether MRI surveillance is an acceptable alternative. Strategies such as hippocampal avoidance may reduce the cognitive effects of prophylactic cranial irradiation in the future. Finally, in the last few years stereotactic ablative radiation therapy followed by chemotherapy has emerged as a promising treatment for stage I small cell lung cancer. This radiation treatment is usually given over 1-5 fractions and appears to provide a good rate of local control with a low rate of serious toxicity.

FDG PET/CT Overcomes Discordance Between Clinical and Pathologic TNM Classification of Small-size Primary Lung Cancer: Influence on Postoperative Prognosis

INTRODUCTION

We aimed to determine the concordance between the clinical stage (c-stage) and pathologic stage (p-stage) for patients with small-size lung cancer. Additionally we searched for prognostic factors other than the TNM stage.

PATIENTS AND METHODS

We retrospectively reviewed the preoperative multidetector computed tomography (CT) and positron emission tomography/CT reports, surgical records, and pathologic reports of patients with primary lung cancer ≤ 3 cm. The Union for International Cancer Control TNM seventh edition classification of c-stage and p-stage were compared. The tumors were classified into multiple subgroups by concordance or discordance between the c-stage and p-stage. Disease-free survival (DFS) was assessed using survival analysis to assess the tumor characteristics that were predictive of prognosis.

RESULTS

A total of 289 surgically resected primary lung cancers were evaluated. The concordance between c-stage and p-stage was 65.4%, with moderate reproducibility (kappa coefficient, 0.467). The upstaging rate from c-stage I to p-stage II-IV was 9.4%, and these patients had significantly worse DFS than those with a concordant stage I classification (P < .001). The main reason for upstaging was an underestimation of metastases to the hilar lymph nodes (n = 7) or mediastinal lymph nodes (n = 11). A multivariate Cox proportional hazards model showed that the significant predictive factors for DFS were p-stage (hazard ratio, 1.342; P = .003) and maximum standardized uptake value on positron emission tomography/CT (hazard ratio, 12.162; P = .001).

CONCLUSION

The concordance rate between c-stage and p-stage for small primary lung cancers had moderate reproducibility. Discordance between c-stage I and p-stage II-IV significantly affected DFS. The maximum standardized uptake value of the primary lesion was an independent prognostic factor, and combining it with c-stage might improve the prediction of therapeutic outcomes.

Peripheral-type small cell lung cancer is associated with better survival and higher frequency of interstitial lung disease

OBJECTIVES

Small cell lung cancer (SCLC) can be subgrouped into central and peripheral types according to the location of the primary lesion. However, the clinical differences between these two types remain unclear. This study compared their clinical features.

MATERIALS AND METHODS

Data on 231 patients with pathologically diagnosed SCLC were retrospectively subgrouped into central or peripheral types. Progression-free survival (PFS), overall survival (OS), treatments, responses to first-line therapy, and frequency of interstitial lung disease (ILD) were compared between the two groups.

RESULTS

Of the 231 patients, 101 (44%) had central-type and 130 (56%) had peripheral-type SCLC. Peripheral-type SCLC was associated with a better performance status, higher frequency of ILD, and higher rate of limited disease stage. Patients with peripheral-type SCLC had a significantly longer OS than did those with central-type SCLC (median, 502 vs 370days, respectively; p=0.0186). Tumor location was not associated with PFS. PFS was poorer in patients with than without ILD (median, 143 vs 213days, respectively; p=0.0038), as was OS (median, 245 vs 545days, respectively; p=0.0014). Among patients without ILD, OS was longer in those with peripheral- than central-type tumors (median, 662 vs 421days, respectively; p=0.0074). Surgical resection was more often chosen for peripheral-type tumors, and this was one reason for the prolonged survival. There was no difference in the response to chemotherapy and/or radiotherapy between central- and peripheral-type SCLC. Multivariate analysis by a Cox proportional hazards model showed that male sex, a poor performance status, extensive disease, the presence of ILD, an elevated serum neuron-specific enolase concentration, and central-type SCLC were poor prognostic factors for OS.

CONCLUSION

Peripheral-type SCLC is associated with better OS and a higher frequency of ILD than is central-type SCLC. The presence of ILD is a poor prognostic factor for both PFS and OS.

Multi-Institutional Experience of Stereotactic Ablative Radiation Therapy for Stage I Small Cell Lung Cancer

PURPOSE

For inoperable stage I (T1-T2N0) small cell lung cancer (SCLC), national guidelines recommend chemotherapy with or without conventionally fractionated radiation therapy. The present multi-institutional cohort study investigated the role of stereotactic ablative radiation therapy (SABR) for this population.

METHODS AND MATERIALS

The clinical and treatment characteristics, toxicities, outcomes, and patterns of failure were assessed in patients with histologically confirmed stage T1-T2N0M0 SCLC. Kaplan-Meier analysis was used to evaluate the survival outcomes. Univariate and multivariate analyses identified predictors of outcomes.

RESULTS

From 24 institutions, 76 lesions were treated in 74 patients (median follow-up 18 months). The median age and tumor size was 72 years and 2.5 cm, respectively. Chemotherapy and prophylactic cranial irradiation were delivered in 56% and 23% of cases, respectively. The median SABR dose and fractionation was 50 Gy and 5 fractions. The 1- and 3-year local control rate was 97.4% and 96.1%, respectively. The median disease-free survival (DFS) duration was 49.7 months. The DFS rate was 58.3% and 53.2% at 1 and 3 years, respectively. The median, 1-year, and 3-year disease-specific survival was 52.3 months, 84.5%, and 64.4%, respectively. The median, 1-year, and 3-year overall survival (OS) was 17.8 months, 69.9%, and 34.0% respectively. Patients receiving chemotherapy experienced an increased median DFS (61.3 vs 9.0 months; P=.02) and OS (31.4 vs 14.3 months; P=.02). The receipt of chemotherapy independently predicted better outcomes for DFS/OS on multivariate analysis (P=.01). Toxicities were uncommon; 5.2% experienced grade ≥2 pneumonitis. Post-treatment failure was most commonly distant (45.8% of recurrence), followed by nodal (25.0%) and "elsewhere lung" (20.8%). The median time to each was 5 to 7 months.

CONCLUSIONS

From the findings of the largest report of SABR for stage T1-T2N0 SCLC to date, SABR (≥50 Gy) with chemotherapy should be considered a standard option.

Research progress in the treatment of small cell lung cancer

Small cell lung cancer (SCLC) accounts for approximately 10-15% of all lung cancers. No significant improvement has been made for patients with SCLC in the past several decades. The main progresses were the thoracic radiation and prophylactic cranial irradiation (PCI) that improved the patient survival rate. For patients with limited disease and good performance status (PS), concurrent chemoradiotherapy (CCRT) followed by PCI should be considered. For extensive disease, the combination of etoposide and platinum-based chemotherapy remains the standard treatment and consolidative thoracic radiotherapy is beneficial for patients who have a significant respond to initial chemotherapy. However, the prognosis still remains poor. Recently, efforts have been focused on molecular targets and immunotherapy. But numerous molecular targets methods have failed to show a significant clinical benefit in patients with SCLC. It is anticipated that further development of research will depend on the on-going trials for molecular targeted therapy and immunotherapy which are promising and may improve the outcomes for SCLC in the next decade.

Trends in stereotactic body radiation therapy for stage I small cell lung cancer

OBJECTIVES

We aimed to report trends in stereotactic body radiation therapy (SBRT) utilization, dose prescriptions, and chemotherapy administration for stage I small cell lung cancer (SCLC) in the United States.

MATERIALS AND METHODS

The National Cancer Data Base (NCDB) was used to identify patients with cT1-2 N0 SCLC treated with SBRT between 2004 and 2013. Trends in SBRT use and dose prescription were analyzed over time. Multivariable logistic regression was used to determine factors associated with the administration of chemotherapy with SBRT. The Kaplan-Meier method was used to estimate overall survival.

RESULTS

Of 9265 patients with clinical stage I SCLC who were examined for initial treatment allocation, 285 were treated with SBRT and represented the subject of the primary analysis. SBRT utilization increased from 2004 (0.4% of all stage I patients diagnosed that year) to 2013 (6.4%). During this same time period, definitive surgical management also increased from 14.9% of all patients in 2004 to 28.5% in 2013. The median SBRT biologically effective dose (BED₁₀) was 112.5Gy (range, 72-290) and only 33 out of 285 (11.6%) received a BED₁₀<100Gy. Nearly half of all patients (130/285, 45.6%) received chemotherapy, with 42.7% of those patients receiving their chemotherapy prior to SBRT. On multivariable logistic regression, only age<75 (the median) vs. ≥75years (OR 4.97, 95% CI 2.96-8.35, p<0.001) and year of diagnosis 2004-2008 vs. 2009-2013 (OR 2.58, 95% CI 1.27-5.26, p=0.009) were predictive of chemotherapy use with SBRT. After median follow up of 45 months, the median survival was 23.5 months.

CONCLUSIONS

Our findings suggest that SBRT utilization for stage I SCLC has increased between 2004 and 2013, highlighting the need for additional research to validate the feasibility of this management approach for inoperable patients.

Prognostic Impact of Node-Spreading Pattern in Surgically Treated Small-Cell Lung Cancer: A Multicentric Analysis

OBJECTIVE

Although surgery in selected small-cell lung cancer (SCLC) patients has been proposed as a part of multimodality therapy, so far, the prognostic impact of node-spreading pattern has not been fully elucidated. To investigate this issue, a retrospective analysis was performed.

METHODS

From 01/1996 to 12/2012, clinico-pathological, surgical, and oncological features were retrospectively reviewed in a multicentric cohort of 154 surgically treated SCLC patients. A multivariate Cox proportional hazard model was developed using stepwise regression, in order to identify independent outcome predictors. Overall (OS), cancer-specific (CSS), and Relapse-free survival (RFS) were calculated by Kaplan-Meier method.

RESULTS

Overall, median OS, CSS, and RFS were 29 (95 % CI 18-39), 48 (95 % CI 19-78), and 22 (95 % CI 17-27) months, respectively. Lymphadenectomy was performed in 140 (90.9 %) patients (median number of harvested nodes: 11.5). Sixty-seven (47.9 %) pN0-cases experienced the best long-term survival (CSS: 71, RFS: 62 months; p < 0.0001). Among node-positive patients, no prognostic differences were found between pN1 and pN2 involvement (CSS: 22 vs. 15, and RFS: 14 vs. 10 months, respectively; p = 0.99). By splitting node-positive SCLC according to concurrent N1-invasion, N0N2-patients showed a worse CSS compared to those cases with combined N1N2-involvement (N0N2: 8 months vs. N1N2: 22 months; p = 0.04). On the other hand, the number of metastatic stations (p = 0.80) and the specific node-level (p = 0.85) did not affect CSS. At multivariate analysis, pN+ (HR: 3.05, 95 % CI 1.21-7.67, p = 0.02) and ratio between metastatic and resected lymph-nodes (RL, HR: 1.02, 95 % CI 1.00-1.04, p = 0.03) were independent predictors of CSS. Moreover, node-positive patients (HR: 3.60, 95 % CI 1.95-6.63, p < 0.0001) with tumor size ≥5 cm (HR: 1.85, 95 % CI 0.88-3.88, p = 0.10) experienced a worse RFS.

CONCLUSIONS

In selected surgically treated SCLC, the long-term survival may be stratified according to the node-spreading pattern.

Role of Adjuvant Therapy in a Population-Based Cohort of Patients With Early-Stage Small-Cell Lung Cancer

PURPOSE

Data on optimal adjuvant therapy after complete resection of small-cell lung cancer (SCLC) are limited, and in particular, there have been no studies evaluating the role of adjuvant chemotherapy, with or without prophylactic cranial irradiation, relative to no adjuvant therapy for stage T1-2N0M0 SCLC. This National Cancer Data Base analysis was performed to determine the potential benefits of adjuvant chemotherapy with and without prophylactic cranial irradiation in patients who undergo complete resection for early-stage small-cell lung cancer.

PATIENTS AND METHODS

Overall survival of patients with pathologic T1-2N0M0 SCLC who underwent complete resection in the National Cancer Data Base from 2003 to 2011, stratified by adjuvant therapy regimen, was evaluated using Kaplan-Meier and Cox proportional hazards analysis. Patients treated with induction therapy and those who died within 30 days of surgery were excluded from analysis.

RESULTS

Of 1,574 patients who had pT1-2N0M0 SCLC during the study period, 954 patients (61%) underwent complete R0 resection with a 5-year survival of 47%. Adjuvant therapy was administered to 59% of patients (n = 566), including chemotherapy alone (n = 354), chemoradiation (n = 190, including 99 patients who underwent cranial irradiation), and radiation alone (n = 22). Compared with surgery alone, adjuvant chemotherapy with or without radiation was associated with significantly improved survival. In addition, multivariable Cox modeling demonstrated that treatment with adjuvant chemotherapy (hazard ratio [HR], 0.78; 95% CI, 0.63 to 0.95) or chemotherapy with radiation directed at the brain (HR, 0.52; 95% CI, 0.36 to 0.75) was associated with improved survival when compared with no adjuvant therapy.

CONCLUSION

Patients with pT1-2N0M0 SCLC treated with surgical resection alone have worse outcomes than those who undergo resection with adjuvant chemotherapy alone or chemotherapy with cranial irradiation.

Stereotactic Radiotherapy for Stage I Small Cell Lung Cancer

Although the use of stereotactic ablative radiotherapy (SABR) for stage I small cell lung cancer is in its infancy, there are many reasons to believe that with more time and experience, it could emerge as the standard of care in inoperable patients, and perhaps even have equipoise with surgery for operable patients. Reporting of modeling studies and as much clinical data as possible are very much needed.

Surgical results of resectable small cell lung cancer

Background

The standard of care for patients with small cell lung cancer (SCLC) is chemotherapy and radiotherapy, even for patients with limited disease. To define the role of surgical resection in patients with limited SCLC, we investigated the outcomes of patients diagnosed with limited-stage disease (LD) SCLC.

Methods

The records of 57 LD SCLC patients who underwent surgical resection from April 1974 to March 2012 were retrospectively analyzed.

Results

There were six women and 51 men, with a median age of 63.5 years. The overall five-year survival rate was 28.6% (median, 18.2 months). The p-stage II and III patients had a significantly worse survival than the p-stage I patients (13.4% vs. 43.4%, P = 0.0036). However, the c-stage was not found to correlate with survival. Patients who underwent pneumonectomy had a significantly worse outcome than those who underwent other surgical procedures (0.0% vs. 32.0%, P = 0.0002). In a multivariate Cox proportional hazards analysis, p-stage II or III (hazard ratio [HR] 3.040 P = 0.0017) and pneumonectomy (HR 6.177, P = 0.00159) were significant independent predictors of an adverse survival outcome.

Conclusions

Surgical treatment can be considered in SCLC patients with pathologically proven N0 status, although pneumonectomy should be avoided.

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

OBJECTIVES

Although chemotherapy and radiotherapy are recommended for patients with limited disease small cell lung cancer (LD-SCLC), several series have reported favorable survival outcomes even in patients with stages II and III disease who underwent surgical resection. The purpose of this study is to compare the outcomes of the use of surgical resection to the other conventional non-surgical treatments in patients with LD-SCLC with respect to each clinical stage.

MATERIALS AND METHODS

We retrospectively reviewed 277 patients who received treatment for LD-SCLC and compared the outcomes of the use of surgical resection to the other conventional non-surgical treatments.

RESULTS

The clinical stage was stage I in 50 cases (18%), stage II in 53 cases (19%) and stage III in 174 cases (63%). Eighty-eight patients received surgical resection and 189 patients were treated with non-surgical treatment. Surgery was performed in 44 patients (88%) with stage I, 27 patients (52%) with stage II and 17 patients (10%) with stage III disease. The five-year survival rates of the patients according to clinical stage were 58% in stage I, 29% in stage II and 18% in stage III. The five-year survival rates of the patients with and without surgical resection according to clinical stage were as follows: 62% and 25% in stage I (p<0.01), 33% and 24% in stage II (p=0.95), 18% and 18% in stage III (p=0.35), respectively. In 44 propensity score-matched pairs with stages II and III disease, including matching for variables such as age, gender and the PS, the five-year survival rates was better in patients with surgical resection than in those without surgery (p=0.04).

CONCLUSION

Surgical resection is effective for the patients with stage I LD-SCLC and some cases of stage II or III disease.

Gene expression profiles on predicting protein interaction network and exploring of new treatments for lung cancer

In the present study, we aimed to explore disease-associated genes and their functions in lung cancer. We downloaded the gene expression profile GSE4115 from Gene Expression Omnibus (GEO) database. Total 97 lung cancer and 90 adjacent non-tumor lung tissue (normal) samples were applied to identify the differentially expressed genes (DEGs) by paired t test and variance analysis in spectral angle mapper (SAM) package in R. Gene Ontology (GO) functional enrichment analysis of DEGs were performed with Database for Annotation Visualization and Integrated Discovery, followed by construction of protein-protein interaction (PPI) network from Human Protein Reference Database (HPRD). Finally, network modules were analyzed by the MCODE algorithm to detect protein complexes in the PPI network. Total 3,102 genes were identified as DEGs at FDR < 0.05, including 1,146 down-regulated and 1,956 up-regulated DEGs. GO functional enrichment analysis revealed that up-regulated DEGs mainly participated in cell cycle and intracellular related functions, and down-regulated DEGs might influence cell functions. There were 39,240 pairs of PPIs in human obtained from HPRD databases, 3,102 DEGs were mapped to this PPI network, in which 2,429 pairs of PPIs and 1,342 genes were identified. With MCODE algorithm, 48 modules were selected, including five corresponding modules and three modules with differences in gene expressing profiles. In addition, three DGEs, FXR2, ARFGAP1 and ELAVL1 were discovered as potential lung cancer related genes. The discovery of featured genes which were probably related to lung cancer, has a great significance on studying mechanism, distinguishing normal and cancer tissues, and exploring new treatments for lung cancer.

Surgery for small cell lung cancer

Small-cell lung cancer (SCLC) comprises approximately 14% of all lung cancer cases. Most patients present with locally advanced or metastatic disease and are therefore treated nonoperatively with chemotherapy, radiotherapy, or both. A small subset of patients with SCLC present with early-stage disease and will benefit from surgical resection plus chemotherapy. The rationale for radiotherapy in these patients remains controversial.

Retrospective study of surgical resection in the treatment of limited stage small cell lung cancer

BACKGROUND

Patients with small cell lung cancer (SCLC) are mainly treated by chemotherapy/radiotherapy, either alone or combined. Surgical resection is an optional treatment for few SCLC patients. The efficacy of surgical intervention for SCLC remains controversial. This study evaluates the validity of surgery for patients with limited stage SCLC.

METHODS

We conducted a retrospective review of 59 patients with limited stage SCLC who received trimodal therapy from 2004 to 2011. Progression-free survival (PFS) and overall survival (OS) were calculated using the statistic methods of Kaplan-Meier and the log-rank test.

RESULTS

Among the 59 limited stage SCLC patients, 54 patients with stage I-III SCLC received surgical treatment with curative intent, and 42.6% (23/54) patients received preoperative chemotherapy. The radical resection rate of the group of preoperative chemotherapy and the group of initial surgical resection were 82.6% (19/23) and 54.8% (17/31), respectively. The corresponding five-year survival rates were 59% and 22% with significant differences (P = 0.032 and 0.041, respectively). In total, 36 (66.7%) patients underwent radical surgery with resection of the primary mass and mediastinal lymph nodes. In the radical surgery series, five-year survival, according to stage I-III categories, were 59%, 53%, and 26%, respectively. For the 30 stage III patients, the five-year survival of the radical group of 26% was lower than the non-radical group of 67%, and PFS analysis showed similar tendencies.

CONCLUSION

Preoperative chemotherapy is the most favorable initial treatment for patients with limited disease SCLC. Complete surgical resection is considered for patients with stage I and II. Surgical resection remains of no benefit for stage III SCLC patients with persistent N2/N3 after chemotherapy.

Multidisciplinary modalities achieve encouraging long-term survival in resectable limited-disease esophageal small cell carcinoma

Background

The management of limited-disease esophageal small cell carcinoma is not well defined, and the role of surgery is still controversial. We aim to determine the optimal treatment strategy in limited-disease of esophageal small cell carcinoma.

Methods and Findings

We conducted a retrospective review of 141 patients with limited-disease esophageal small cell carcinoma from 3 institutions in China who underwent treatment between July 1994 and September 2008, July 1994 and July 2011, and June 2004 and December 2010, respectively. The survival rate was calculated by the Kaplan-Meier method, and the log-rank test was used to assess the survival differences between the groups. Cox proportional hazards model were used to further determine the independent factors impacting overall survival. The median survival time was 16.1 months for the entire cohort of patients, with a 5-year survival rate of 6.7%. The median survival times for surgery alone, surgery combined with chemotherapy, surgery combined with radiotherapy, surgery combined with chemotherapy and radiotherapy, chemotherapy plus radiotherapy, and chemotherapy alone were 18.0 months, 15.0 months, 23.0 months, 25.0 months, 17.1 months, and 6.1 months, respectively; the corresponding 5-year survival rates were 0%, 15.4%, 0%, 38.9%, 0%, and 0%, respectively. For the 105 patients who underwent R0 resection, the median disease-free survival time was 12.0 months, with a 95% confidence interval of 9.5 months to 14.5 months. The multivariate Cox regression analysis demonstrated that advanced pathological staging (p = 0.003), and pure esophageal small cell carcinoma (p = 0.035) were independent factors decreasing overall survival.

Conclusions

Our data suggested that multidisciplinary modalities achieved encouraging long-term survival in patients with resectable limited-disease of esophageal small cell carcinoma.

Surgical treatment of early stage small cell lung cancer

BACKGROUND

Chemotherapy with radiation has to be considered the standard therapy for limited-stage small cell lung cancer but surgical resection is possible in a small subgroup in which it may improve survival. Surgery is not recommended as the standard treatment, but a few small studies have demonstrated a benefit of surgery in highly selected cases of limited-stage small cell lung cancer.

METHODS

We conducted a retrospective study of 29 patients with limited-stage small cell lung cancer undergoing surgical resection in our department. There were 7 (24%) women and 22 (76%) men with a median age of 62 years (range, 46-82 years). Medical history, histology and survival status were extracted from the medical database of the University Medical Center Freiburg.

RESULTS

The median overall survival was 20.7 months. In 15 patients who received neoadjuvant treatment, the median survival was 89.4 months. Karnofsky performance status and neoadjuvant chemotherapy had a significant influence on median survival (p <0.0004).

CONCLUSIONS

We concluded that surgical resection can be beneficial in a highly selected group of patients as a part of a multidisciplinary approach. In addition, surgical resection is safe with acceptable mortality and morbidity.

Clinical characteristics and outcomes of patients with small cell lung cancer detected by CT screening

The present study was performed to evaluate the clinical characteristics and survival outcomes in patients with small cell lung cancer (SCLC) detected by low-dose computed tomography (CT). We retrospectively reviewed clinical records of patients with SCLC treated at our hospital between 1997 and 2011 and selected patients with SCLC detected by CT screening. We identified 12 patients (male/female 11/1; mean age 67.8 years old. Nine patients had limited disease (LD), and 3 had extensive disease (ED). Five LD patients underwent thoracic surgery, and the pathological staging information included stage IA (n = 1), IB (n = 1), IIA (n = 1), and IIIB (n = 2). Although 2 patients with pathological stages IA and IB had >10-year survival, the median survival times (MST) in LD and ED were 25 months (95 % CI 17.0-32.9) and 16 months (95 % CI; not evaluated), respectively. In addition, MST in 12 patients was not significantly different from that in SCLC patients in general care in our hospital. This analysis suggested that CT screening contributes to the detection of early-stage SCLC in patients that are potentially suitable for surgery, but it remains unclear how to improve clinical outcome in patients with SCLC.

Surgical outcomes in patients with small cell lung cancer: comparative analysis of computed tomograpy-detected patients with others

Background

It is shown that low-dose computed tomography (CT) screening is useful for a reduction in lung-cancer-specific mortality in heavy smokers. However, the information about effectiveness according to the histological types of lung cancer has not been adequately investigated especially small cell lung cancer (SCLC). The present study was performed to see the clinical benefit of CT screening in patients with SCLC following thoracotomy.

Methods

We retrospectively reviewed the outcome in patients with early stage SCLC who initially underwent thoracotomy. The clinical stages and actuarial survival were estimated according to the three means of detection of SCLC: chest CT, radiographic screen, and symptomatically prompted cases.

Results

Sixty-nine patients (men/women, 63/6; mean age, 70 years) with SCLC underwent thoracotomy between 1991 and 2010 including chest CT (n = 13), radiographic screening (n = 39), and symptomatically prompted cases (n = 17). Pathological staging information included stage IA (n = 25), IB (n = 8), IIA (n = 13), IIB (n = 5), IIIA (n = 11), and IIIB (n = 7). Median survival time was 30.0 (95% confidence interval (CI): 22.0 to 57.0) months, with overall survival at 5 years of 34.3% (95% CI, 23.47 to 47.3). Nine patients (69%) with stage I were detected by CT which was significantly higher than those in other detection arms. However, there were no significant differences in the survival between CT and other detection arms.

Conclusions

CT examination may be useful for detection in early stage SCLC potentially suitable for surgery, but the contribution to better clinical outcome in patients with SCLC remains unclear.

Factors affecting the risk of brain metastasis in small cell lung cancer with surgery: is prophylactic cranial irradiation necessary for stage I-III disease?

PURPOSE

The use of prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC) with surgical resection has not been fully identified. This study undertook to assess the factors affecting the risk of brain metastases in patients with stage I-III SCLC after surgical resection. The implications of PCI treatment for these patients are discussed.

METHODS AND MATERIALS

One hundred twenty-six patients treated with surgical resection for stage I-III SCLC from January 1998-December 2009 were retrospectively analyzed to elucidate the risk factors of brain metastases. Log-rank test and Cox regression model were used to determine the risk factors of brain metastases.

RESULTS

The median survival time for this patient population was 34 months, and the 5-year overall survival rate was 34.9%. For the whole group, 23.0% (29/126) of the patients had evidence of metastases to brain. Pathologic stage not only correlated with overall survival but also significantly affected the risk of brain metastases. The 5-year survival rates for patients with pathologic stages I, II, and III were 54.8%, 35.6%, and 14.1%, respectively (P=.001). The frequency of brain metastases in patients with pathologic stages I, II, and III were 6.25% (2/32), 28.2% (11/39), and 29.1% (16/55) (P=.026), respectively. A significant difference in brain metastases between patients with complete resection and incomplete resection was also observed (20.5% vs 42.9%, P=.028). The frequency of brain metastases was not found to be correlated with age, sex, pathologic type, induction chemotherapy, adjuvant chemotherapy, or adjuvant radiation therapy.

CONCLUSIONS

Stage I SCLC patients with complete resection had a low incidence of brain metastases and a favorable survival rate. Stage II-III disease had a higher incidence of brain metastases. Thus, PCI might have a role for stage II-III disease but not for stage I disease.

Surgical Resection for Small Cell Lung Cancer: Pneumonectomy versus Lobectomy

Background. There are some patients with SCLC that are diagnosed in the operating room by cryosection and surgeons had to perform surgical resection for these patients. The aim of this study is to compare the effective of pneumonectomy with lobectomy for SCLC. Methods. A retrospective study was undertaken in 75 patients with SCLC that were diagnosed by cryosection during surgery. 31 of them underwent pneumonectomy, 44 underwent lobectomy. Local recurrence rate and survival rate according to surgical procedures and cancer stages were analyzed. Results. There was significant difference in the overall survival rate between lobectomy and pneumonectomy groups (P = 0.044). For patients with stage II SCLC, the overall survival rate after pneumonectomy was significantly better than after lobectomy (P = 0.028). No significant difference in overall survival rate was found between the two surgical groups in patients with stage III SCLC (P = 0.933). The local recurrence rate in lobectomy group was significant higher that in pneumonectomy group (P = 0.0017). Conclusions. SCLC was responsive to surgical therapy. When surgeons have to select an appropriate method of operation for patients with SCLC during surgery, pneumonectomy may be the right choice for these patients. Pneumonectomy can result in significantly better local control and higher survival rate compare with lobectomy.