Small cell lung cancer

Diffusion-weighted imaging vs STIR turbo SE imaging: capability for quantitative differentiation of small-cell lung cancer from non-small-cell lung cancer

OBJECTIVE

To compare the capability of differentiation of small-cell lung cancer (SCLC) from non-SCLC (NSCLC) between diffusion-weighted imaging (DWI) and short tau inversion recovery (STIR) turbo spin-echo imaging.

METHODS

The institutional review board of Kobe University Hospital, Kobe, Japan, approved this study, and written informed consent was obtained from each patient. 49 patients with NSCLC (30 males and 19 females; mean age, 66.8 years) and 7 patients with SCLC (5 males and 2 females; mean age, 68.6 years) enrolled and underwent DWI and STIR. To quantitatively differentiate SCLC from NSCLC, apparent diffusion coefficient (ADC) values on DWI and contrast ratios (CRs) between cancer and muscle on STIR were evaluated. ADC values and CRs were then compared between the two cell types by Mann-Whitney's U-tests, and the diagnostic performances were compared by McNemar's test.

RESULTS

There were significant differences of mean ADC values (p < 0.001) and mean CRs (p = 0.003). With adopted threshold values, the specificity (85.7%) and accuracy (85.7%) of DWI were higher than those of STIR (specificity, 63.3%; p = 0.001 and accuracy, 66.1%; p = 0.001). In addition, the accuracy of combination of both indexes (94.6%; p = 0.04) could significantly improve as compared with DWI alone.

CONCLUSION

DWI is more useful for the differentiation of SCLC from NSCLC than STIR, and their combination can significantly improve the accuracy in this setting.

ADVANCES IN KNOWLEDGE

Pulmonary MRI, including DWI and STIR, had a potential of the suggestion of the possibility as SCLC.

Klotho predicts good clinical outcome in patients with limited-disease small cell lung cancer who received surgery

BACKGROUND

The important role of surgery in early-stage small cell lung cancer (SCLC) has been recognized, and curative surgical resection is recommended. However, the role of adjuvant chemotherapy for stage I SCLC has not yet been evaluated, and novel approaches focusing on the specific genomic characteristics of SCLC may be invaluable for customized therapy. In this study, we focused on the Klotho gene, which is an anti-aging gene known to be a potential tumor suppressor. We investigated whether the expression of Klotho, assessed by immunohistochemistry, can predict survival in patients with resected SCLC.

METHODS

The medical records of patients diagnosed as having limited-disease (LD) SCLC and treated by surgical resection (n=30) at Tokyo Medical University Hospital were retrospectively reviewed. The expression status of Klotho, and of the ATP-binding cassette (ABC) transporters MRP1, MDR and breast cancer resistant protein (BCRP), which can cause resistance to anticancer drugs, including irinotecan, was assessed by immunohistochemical analysis in resected surgical specimens of patients with early-stage SCLC.

RESULTS

Of the 30 patients, Klotho expression was seen in the specimens from 18 patients (60.0%), but not in those of the remaining 12 patients (40.0%). The immunostaining for Klotho was mostly localized in the cytoplasm. The expression of Klotho was significantly associated with the overall survival (OS) (ratio 0.088; 95% confidence interval 0.019-0.409; P=0.002). The administration of perioperative chemotherapy had no significant effect in improving the survival, as assessed by the Kaplan-Meier method. However, the patients showing Klotho expression in the resected specimens in p-stage I and II, may have benefited from perioperative chemotherapy. A multivariate analysis revealed no significant association between the expression status of MRP1, MDR or BCRP and the OS.

CONCLUSION

Expression of Klotho was predictive of a favorable outcome following resection in limited-disease SCLC patients, and the Klotho expression status may serve as a new biomarker for the need of additional therapies to be developed in the future.

Surveillance epidemiology and end results evaluation of the role of surgery for stage I small cell lung cancer

INTRODUCTION

This study was performed to evaluate the clinical outcomes of surgery for stage I small cell lung cancer (SCLC).

METHODS

The National Cancer Institute Surveillance Epidemiology and End Results (SEER) database was analyzed to evaluate outcomes for patients with SCLC treated from 1988 to 2004. Patients with stage I disease were selected. Kaplan-Meier survival curves were constructed for overall survival (OS) and cause-specific survival for patient strata based on type of surgery and radiation use or nonuse. Although SEER does not provide chemotherapy details, it is assumed that most, if not all, of these patients received systemic therapy.

RESULTS

A total of 1560 patients were identified as having stage I SCLC. Median age was 70 years (range 27-94 years). Two hundred forty-seven patients underwent lobectomy, 121 had local tumor excision/ablation, 10 had a pneumonectomy, and surgery was unknown in 21. One thousand one hundred sixty-one did not have any cancer-directed surgery. Of those who had lobectomy, 205 (83%) did not receive radiation therapy (RT), 38 (15%) did receive RT, and use of RT was unknown in 4 (2%).For those who had lobectomy without RT (n = 205), 3- and 5-year OS was 58.1% (95% confidence interval [CI] 51.1-64.5%) and 50.3% (95% CI 43.1-57.1%), respectively. For those patients who had a lobectomy with RT (n = 38), 3- and 5-year OS was 64.9% (95% CI 45.5-78.9%) and 57.1% (95% CI 37.4-72.7%), respectively.

CONCLUSIONS

Surgery without RT seems to offer reasonable OS outcomes in a cohort of stage I patients who undergo lobectomy. These results should be considered with the understanding that systemic therapy information and margin status are not available from the SEER database.

CT findings of early-stage small cell lung cancer in a low-dose CT screening programme

The survival of patients with small cell lung cancer (SCLC) is related to T, N, M components, and early diagnosis and treatment of limited stage SCLC may improve survival. The objective of this study was to review the initial and annual repeat screening computed tomography (CT) images of all five patients with SCLC, encountered in our 1996-1998 population-based screening for lung cancer, to clarify any subtle, characteristic CT findings of early-stage small cell lung cancer. The medical records of the patients were reviewed to examine demographic and clinical features. We identified characteristic CT features of SCLC in the lung periphery, which were related to gross pathologic findings with longitudinal spread along the bronchial wall: a small spindle-shaped or pyramidal lesion was found as a subtle CT finding of SCLC, and irregularly shaped nodular lesions (vermiform, pine-cone-like or tandem-like nodular lesions) appeared at a more advanced stage. Tumour volume doubling time of the cases ranged from 38 days to 217 days. All five patients were male smokers: four patients underwent surgery and adjuvant chemotherapy; three of them remain alive, while the remaining patient, an interval case, died of lung cancer. One patient refused treatment and died of a cause other than lung cancer. Annual repeat CT screening was useful for detecting SCLC cases mostly at a curable stage, and information about CT features, presented here, should help physicians identify SCLC at an earlier-stage and lead to a more successful treatment of the disease.

Topotecan in the treatment of recurrent small cell lung cancer: an update

Small cell lung cancer (SCLC) is an aggressive malignancy with a high propensity for early regional and distant metastasis. Response rates to first-line chemotherapy are typically high, but short lived. The outlook for patients with recurrent SCLC is poor. A variety of single- and multi-agent chemotherapy regimens have met with limited success in patients with recurrent SCLC, and survival is generally measured in weeks. Until recently, further chemotherapy was not widely considered appropriate for patients with relapsed SCLC. The choice of chemotherapy at relapse is dependent on many factors, including type of and response to first-line therapy, the treatment-free interval, and the patient's performance status. Intravenous topotecan (Hycamtin; GlaxoSmithKline; Philadelphia, PA) has provided oncologists and patients in many countries with an effective and tolerable therapeutic option for recurrent SCLC. The clinical profile of topotecan was established in several phase II studies and confirmed in a randomized, phase III trial versus cyclophosphamide, doxorubicin (Adriamycin; Bedford Laboratories; Bedford, OH), and vincristine (Oncovin; Eli Lilly and Company; Indianapolis, IN)--CAV. In those studies, topotecan exhibited antitumor activity in both chemosensitive and refractory disease. Further, topotecan therapy is associated with significant symptom palliation in this patient population. Because the toxicity profile of topotecan is predictable, generally manageable, and noncumulative, the agent also has potential utility in patients with a poor prognosis and/or a poor performance status. Alternative dosing regimens (lower dose, weekly) and the introduction of an oral formulation may expand the use of topotecan as a single agent and in combination therapy in the second- and first-line treatment of this disease.

Allelotypes and Fluorescence In situ Hybridization Profiles of Poorly Differentiated Endocrine Carcinomas of Different Sites

PURPOSE

The aim of this work was to investigate the genotypic profiles of 36 poorly differentiated endocrine carcinoma (PDEC) of different sites to verify if their very similar phenotype may reflect similar pattern of genetic anomalies and if useful diagnostic or prognostic markers may be pointed out.

EXPERIMENTAL DESIGN

All tumors were microallelotyped at 57 microsatellite on 11 autosomes and the allelotypes of a selected panel of tumors were validated by interphasic fluorescence in situ hybridization with centromeric probes for chromosomes 1, 3, 6, 11, 17, and 18 and a probe specific for p53.

RESULTS

Regardless of the primary sites, PDECs exhibit very complex allelotypes (86%) and TP53 allelic imbalance (89%). Among these cases, fluorescence in situ hybridization analysis confirmed the presence of multiple aneusomies and a chromosome instability phenotype. Very low percentage of allelic imbalance (AI) and few aneuploidies were detected in only five PDECs for which an overall longer survival was observed. We found recurrent AI on 3p, 5, and 11q13 in lung PDECs, on 5q21, 8p, and 18q21 in colorectal PDECs and on 7 and 11q22 in gastric PDECs. Significantly better outcome was observed in patients with PDEC exhibiting 8q AIs and absence of AI at chromosome regions 6q25 and 6p.

CONCLUSIONS

The concurrence of p53 inactivation and aneuploidies or chromosome instability are the main features of PDECs. However, the specific allelotypes observed in relation to primary site support the hypothesis that PDECs and exocrine carcinomas of all sites may share early pathogenetic mechanisms. Molecular markers of potential diagnostic and prognostic values for PDECs of different sites have been identified.

Rescue of death receptor and mitochondrial apoptosis signaling in resistant human NSCLC in vivo

Non small cell lung carcinoma (NSCLC) is a highly lethal malignancy that often becomes resistant to chemotherapy. To determine whether alterations in apoptotic signaling might contribute to such resistance, we established in vitro and in vivo models for sensitive and resistant human NSCLC. We found that resistance is due to multiple defects found in expression of CD95-L, CD95 and members of the Bcl-2 and IAP family, as well as caspase-8, -9 and -3 as examined by immunohistochemistry, Western blot analysis, gene array analysis and functional assays. Failure to activate death receptor, as well as mitochondrial apoptosis signaling, points to a central role of caspases. To restore apoptosis signaling we transfected NSCLC xenografts on nude mice with caspase-8 and -9. This treatment strongly induced apoptosis per se and sensitized the tumors to cisplatin-induced cell death. Thus, these findings indicate that re-expression of caspases might be an effective strategy to restore sensitivity for chemotherapy in NSCLC in vivo.

Docetaxel-based combined-modality chemoradiotherapy for locally advanced non-small cell lung cancer

The cytotoxic agent docetaxel not only has proven activity in non-small cell lung cancer-when used alone or in combination-but is also a potent radiosensitizer, and improved treatments are needed in all stages of this disease. In patients with locoregionally advanced (stage III) disease, docetaxel has shown efficacy with manageable toxicities when used alone or in combination with a platinum compound in a sequential manner before localized radical radiotherapy/surgery. Presently, therapeutic gains appear to be maximized by the use of concurrent chemotherapy and irradiation. This review focuses on research with combinations of docetaxel with either cisplatin or carboplatin and radiotherapy. Overall response and survival rates to date provide data worth pursuing. From phase I data, weekly docetaxel at 20 mg/m(2) plus cisplatin at 25 mg/m(2) or carboplatin to an area under the concentration time curve of 2 mg/ml*min with concurrent radiotherapy to 60 Gy over 6 weeks appear to be suitable for phase II trials. Predominant toxicities are esophagitis and neutropenia, but a low frequency of pulmonary toxicity is reported. Induction, concurrent, and consolidation docetaxel-based chemoradiotherapy in potentially resectable disease are all being investigated. Future research could include the investigation of computed tomography/ positron emission tomography-derived target volume radiotherapy, dose-escalated therapy, and alternative fractionation schedules in combination with docetaxel-based cytotoxic chemotherapy.

New approaches for small-cell lung cancer: local treatments

BACKGROUND

Limited-disease small-cell lung cancer (LD-SCLC) can be cured with combinations of systemic chemotherapy and local treatments, predominantly radiation therapy. While systemic control inside the brain has been further improved with the inclusion of prophylactic cranial irradiation, long-term local control remains suboptimal, even with newer chemoradiation protocols.

METHODS

The authors review the current management of LD-SCLC and discuss strategies to improve local control. They present their own experience with the inclusion of surgery in an aggressive combined-modality protocol for patients with LD-SCLC.

RESULTS

Different approaches to improve local efficacy of treatment have been explored, including concurrent chemoradiation, administration of radiation as early as possible, newer fractionation schemas, and escalation of overall radiation doses. However, even following the currently most active chemoradiation protocols, local and locoregional relapse of LD-SCLC remains a problem. Surgery is feasible within this clinical setting and may add to long-term local control and possible cures.

CONCLUSIONS

Further investigation into the inclusion of surgery in LD-SCLC within carefully designed prospective clinical trials seems justified, although final evaluation would necessarily include prospective, randomized testing within a more "modernized" study design compared to the "old" and "historical" randomized Lung Cancer Study Group trial.

Small cell lung cancer: current therapy and promising new regimens

In this review, we cover current therapy and promising new regimens and highlight areas where improvement is needed in the management of small cell lung cancer.

Occult Small Cell Lung Cancer Associated with Paraneoplastic Neurologic Syndrome: Case Report

Cancer is often associated with paraneoplastic syndromes, which may be misinterpreted. We report a case of a patient with occult small cell lung cancer that was initially compounded by clinical features of a paraneoplastic neurologic syndrome. The presence of antineuronal antibodies and positron emission tomography scan guided the search for the underlying tumor.

Following chemo-radiotherapy the patient showed no evidence of disease for the next 18 months, whereas only a slight improvement in the neurologic disorders was observed. The course of the small cell lung cancer was very indolent and the paraneoplastic neurologic syndrome did not worsen with the use of cisplatin.

The silent epidemic: tobacco and the evolution of lung cancer and its treatment

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.

Long-term survival of a poor-risk octogenarian following wedge resection under VATS for small-cell lung cancer: report of a case

We describe herein the case of an 81-year-old man who has remained disease-free for more than 3 years after undergoing a wedge resection of cStage I small-cell lung cancer (SCLC) under video-assisted thoracoscopic surgery (VATS), with no adjunct chemotherapy or radiotherapy. The patient had compromised pulmonary function and was a poor surgical risk. As he could not have endured a conventional lobectomy or intensive chemotherapy, a nonanatomical wedge resection of the area of lung involved by the primary tumor was carried out under VATS. Cancer cells from the resected tumor were cultured and the growth characteristics and sensitivity to 12 anticancer drugs were examined. The majority of primary cultured cells proliferated in a monolayer, like paving stones, resembling the growth pattern of non-small-cell carcinoma cells in vitro. The subcultured cells were resistant to most of the drugs, but showed weak sensitivity to cisplatin (CDDP), adriamycin (ADR), and vincristine (VCR). Therefore, the patient was discharged with no adjunct postoperative therapy and was followed up at an outpatient clinic. He has remained alive and disease-free for more than 3 years. Thus, we considered that performing wedge resection under VATS for a primary tumor could be appropriate treatment for selected patients with cStage I SCLC in a peripheral region, especially if they are elderly and a poor surgical risk.

Topotecan: a new topoisomerase I inhibiting antineoplastic agent

OBJECTIVE

To review the pharmacologic, pharmacokinetic, therapeutic, and safety aspects of topotecan, a new antineoplastic agent, and to assess its role in the treatment of cancer.

DATA SOURCES

MEDLINE database English language only, January 1990-March 1998; SmithKline Beecham Pharmaceuticals; published articles, books, and abstracts.

STUDY SELECTION

Studies in humans with cancer, clinical case reports, open clinical trials, and controlled clinical studies. Efficacy studies were limited primarily to trials with at least 20 evaluable patients:

DATA EXTRACTION

Relevant data were extracted only from published reports. Data were obtained from studies in both articles and abstracts. Only articles written in English were reviewed.

DATA SYNTHESIS

Topotecan is an effective second- or third-line therapy for patients with advanced ovarian cancer and is comparable to ifosfamide, liposomal doxorubicin, and paclitaxel. Activity in combination with other agents and as a first-line agent is yet to be determined. Limited data indicate activity in small-cell lung cancer, cancers of the breast and uterus, and in nonlymphocytic leukemia. The dose-limiting toxicity is myelosuppression.

CONCLUSIONS

Topotecan is an effective second-line agent for patients with unresponsive or relapsed cancer of the ovary. It appears to be similar to other active agents in patients with this disease status. Its ultimate role in ovarian cancer and other neoplasms awaits additional evaluation in combination with other agents and as first-line therapy.