Bolstering the Case for Lobectomy in Stages I, II, and IIIA Small-Cell Lung Cancer Using the National Cancer Data Base

Improved survival of patients with stage III small-cell lung cancer with primary resection: A SEER-based analysis

INTRODUCTION

Small cell lung cancer (SCLC) is mostly diagnosed in stage III-IV patients and associated with poor prognosis. To date, surgery is no gold-standard treatment for any SCLC stage and evidence is lacking whether it is beneficial. Here we investigate the impact of surgery, with special attention to stage III SCLC patients, sub-stages and treatment combinations.

METHODS

The overall survival (OS) and cancer-specific survival (CSS) of 33,198 SCLC patients (SEER database) were analyzed retrospectively, using various statistical analyses, including propensity score matching (PSM), recursive partitioning, and sequential landmark analyses.

RESULTS

Independent of stage, the OS of patients with surgery-including treatments was almost always better than without surgery. This holds true for stage I-II patients, even after PMS analysis (p < 0.017). The same was found for stage IV patients that underwent surgery plus chemotherapy vs. chemotherapy alone (p = 0.013 after PSM). Stage III patients showed a robust improvement in OS and CSS after surgery (OS: 18 vs.13 months) or surgery plus chemotherapy (OS: 20 vs.15 months) as confirmed by well-balanced PSM and sequential landmark analyses of long-term survivors. More detailed analyses using two independent approaches showed prolonged OS in T3-4/N0-1 and T1-2/N2 stage III patients after surgery or surgery plus chemotherapy. Importantly, primary site surgery had a major survival advantage over surgery at regional sites (p < 0.003).

CONCLUSION

Our study demonstrates that selected patients of all stages, including stage III T3-4/N0-1 and T1-2/N2, can benefit greatly from surgery-including treatments. Thus, surgery should be included into hospital treatment recommendations for specifically selected SCLC patients. Condensed abstract Primary resection in patients with stage III SCLC needs re-evaluation. Selected patients with stage III SCLC benefit significantly from surgery. Patients with T3-4/N0-1 and T1-2/N2 stage III SCLC should be considered for surgery.

Role of Surgery in Potentially Resectable Small-Cell Lung Cancer Based on the Eighth Edition of the TNM Classification: A Population Study of the US SEER Database

BACKGROUND

This study aimed to identify a specific SCLC population that would benefit from surgery.

METHODS

This study utilized patient data retrieved from the Surveillance, Epidemiology, and End Results (SEER) database spanning 2010 to 2017. To mitigate clinical biases, the propensity score matching (PSM) technique was employed. Separate cohorts were aligned using PSM according to the AJCC 8th edition TNM classification. The Kaplan-Meier method and a competing risk model were applied to evaluate overall survival (OS) and lung cancer-specific survival (LCSS), respectively.

OUTCOMES

Among the 3394 patients with potentially resectable SCLC included in the study, 3062 underwent chemoradiotherapy and 332 underwent surgical treatment with adjuvant chemotherapy. Surgery was associated with better OS (median OS: 49 months; 95% CI: 35-63 months vs. 27 months; 95% CI: 21-33 months, p < 0.001) and LCSS (SHR, 0.578; 95% CI: 0.411-0.815, p < 0.001) in stage I patients after PSM. However, there was no significant difference in OS and LCSS between the surgery and nonsurgery groups in stage II and III patients after PSM. In the entire cohort, lobectomy was associated with improved OS (median OS: 48.6 vs. 28.7 months, p < 0.0001), but not LCSS (SHR, 0.696; 95% CI: 0.466-1.040, p = 0.078) compared with sublobar resection after PSM.

CONCLUSION

Surgery with adjuvant chemotherapy significantly improved the survival prognosis of patients with early-stage SCLC. However, surgical treatment should be carefully considered in patients with stage II/III disease. Lobectomy is oncologically equal to sublobar resection.

The effects of surgical resection in the treatment of limited-stage small cell lung cancer: a multicenter retrospective study

This study aimed to examine the effects of surgical resection on the treatment of limited-stage small cell lung cancer and identify patient characteristics that may indicate a benefit from surgical resection. We retrospectively reviewed medical data from patients diagnosed with small cell lung cancer between January 2013 and December 2020 at three hospitals. A total of 478 patients were included in the study, 153 patients received surgery treatment and 325 patients received non-surgery treatment. Survival differences between the surgical resection group and the nonsurgical resection group were analyzed using the Kaplan-Meier method and the log-rank test. The overall survival in the surgical resection group was significantly improved compared to that in the nonsurgical resection group (HR: 0.58, 95% CI: 0.370-0.876, p = 0.0126). Surgical resection significantly improved overall survival compared to nonsurgical resection in stage I disease (HR: 0.56, 95% CI: 0.34-0.94, p = 0.029) and stage IIA disease (HR: 0.60, 95% CI: 0.40-0.92, p = 0.019). However, no significant differences in overall survival were found between surgical resection and nonsurgical resection in stage IIB disease (HR: 0.86, 95% CI: 0.57-1.29, p = 0.46) and stage III disease (HR: 0.99, 95% CI: 0.71-1.39, p = 0.97). The overall survival of patients who underwent lobectomy was significantly better than that of patients who underwent sublobular resection (HR: 1.85, 95% CI: 1.15-4.16, p = 0.021) and who underwent pneumonectomy (HR: 2.04, 95% CI: 1.29-5.28, p = 0.009). Surgical resection should be recommended for patients diagnosed with stage I-IIA SCLC. When deciding on the surgical type, it is preferable to choose lobectomy over sublobar resection or pneumonectomy.

Conditional Survival of Patients with Limited-Stage Small Cell Lung Cancer After Surgery: A National Real-World Cohort Study

BACKGROUND

The prognosis of limited-stage small cell lung cancer (LS-SCLC) after surgery usually is estimated at diagnosis, but how the prognosis actually evolves over time for patients who survived for a predefined time is unknown.

METHODS

Data on patients with a diagnosis of LS-SCLC after surgery between 2004 and 2015 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The 5-year conditional cancer-specific survival (CCSS) and conditional overall survival (COS) were calculated.

RESULTS

This study analyzed 997 patients (555 women, 55.7%) with a median age, of 67 years (interquartile range [IQR], 60-73 years). The 5-year CCSS and COS increased from 44.7% and 38.3%, respectively, at diagnosis to 83.7% and 67.9% at 5 years after diagnosis. Although there were large differences with different stages (stages I, II, and III) at diagnosis (respectively 59.5%, 28.4%; 28.1% for CCSS and 50.6%, 24.8%, and 23.6% for COS), the gap decreased with time, and the rates were similar after 5 years (respectively 85.0%, 80.3%, and 79.4% for CCSS; 65.6%, 56.9%, and 61.3% for COS). The 5-year conditional survival for the patients who received lobectomy was better than for those who received sublobectomy or pneumonectomy. Multivariable analyses showed that only age and resection type were independent predictors for CCSS and COS, respectively, throughout the period.

CONCLUSION

Conditional survival estimates for LS-SCLC generally increased over time, with the most significant improvement in patients with advanced stage of disease. Resection type and old age represented extremely important determinants of prognosis after a lengthy event-free follow-up period.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and validation of prognostic models for small cell lung cancer patients with liver metastasis: a SEER population-based study

BACKGROUND

This study was to establish and validate prediction models to predict the cancer-specific survival (CSS) and overall survival (OS) of small-cell lung cancer (SCLC) patients with liver metastasis.

METHODS

In the retrospective cohort study, SCLC patients with liver metastasis between 2010 and 2015 were retrospectively retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly divided into the training group and testing group (3: 1 ratio). The Cox proportional hazards model was used to determine the predictive factors for CSS and OS in SCLC with liver metastasis. The prediction models were conducted based on the predictive factors. The performances of the prediction models were evaluated by concordance indexes (C-index), and calibration plots. The clinical value of the models was evaluated by decision curve analysis (DCA).

RESULTS

In total, 8,587 patients were included, with 154 patients experiencing CSS and 154 patients experiencing OS. The median follow-up was 3 months. Age, gender, marital status, N stage, lung metastases, multiple metastases surgery of metastatic site, chemotherapy, and radiotherapy were independent predictive factors for the CSS and OS of SCLC patients with liver metastasis. The prediction models presented good performances of CSS and OS among patients with liver metastasis, with the C-index for CSS being 0.724, whereas the C-index for OS was 0.732, in the training set. The calibration curve showed a high degree of consistency between the actual and predicted CSS and OS. DCA suggested that the prediction models provided greater net clinical benefit to these patients.

CONCLUSION

Our prediction models showed good predictive performance for the CSS and OS among SCLC patients with liver metastasis. Our developed nomograms may help clinicians predict CSS and OS in SCLC patients with liver metastasis.

Clinical insights into small cell lung cancer: Tumor heterogeneity, diagnosis, therapy, and future directions

Small cell lung cancer (SCLC) is characterized by rapid growth and high metastatic capacity. It has strong epidemiologic and biologic links to tobacco carcinogens. Although the majority of SCLCs exhibit neuroendocrine features, an important subset of tumors lacks these properties. Genomic profiling of SCLC reveals genetic instability, almost universal inactivation of the tumor suppressor genes TP53 and RB1, and a high mutation burden. Because of early metastasis, only a small fraction of patients are amenable to curative-intent lung resection, and these individuals require adjuvant platinum-etoposide chemotherapy. Therefore, the vast majority of patients are currently being treated with chemoradiation with or without immunotherapy. In patients with disease confined to the chest, standard therapy includes thoracic radiotherapy and concurrent platinum-etoposide chemotherapy. Patients with metastatic (extensive-stage) disease are treated with a combination of platinum-etoposide chemotherapy plus immunotherapy with an anti-programmed death-ligand 1 monoclonal antibody. Although SCLC is initially very responsive to platinum-based chemotherapy, these responses are transient because of the development of drug resistance. In recent years, the authors have witnessed an accelerating pace of biologic insights into the disease, leading to the redefinition of the SCLC classification scheme. This emerging knowledge of SCLC molecular subtypes has the potential to define unique therapeutic vulnerabilities. Synthesizing these new discoveries with the current knowledge of SCLC biology and clinical management may lead to unprecedented advances in SCLC patient care. Here, the authors present an overview of multimodal clinical approaches in SCLC, with a special focus on illuminating how recent advancements in SCLC research could accelerate clinical development.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

Overall Survival After Mohs Surgery for Early-Stage Merkel Cell Carcinoma

Importance

Merkel cell carcinoma (MCC) is a rare cutaneous malignant neoplasm with increasing incidence and high mortality. Although it is accepted that the optimal treatment for localized tumors is surgical, the data surrounding the optimal surgical approach are mixed, and current National Comprehensive Cancer Network guidelines state that Mohs micrographic surgery (MMS) and wide local excision (WLE) can both be used. The current National Comprehensive Cancer Network guidelines do not advocate a preference for MMS or WLE and suggest that they can be used interchangeably.

Objective

To evaluate the association of surgical approach with overall survival after excision of localized T1/T2 MCC.

Design, Setting, and Participants

This retrospective cohort study used the National Cancer Database to assess adults with T1/T2 MCC who were diagnosed between January 1, 2004, and December 31, 2018, with pathologically confirmed, negative regional lymph nodes and treated with surgery. The National Cancer Database includes all reportable cases from Commission on Cancer-accredited facilities. Data analysis was performed from October 2022 to May 2023.

Exposure

Surgical approach.

Main Outcomes and Measures

Overall survival.

Results

A total of 2313 patients (mean [SD] age, 71 [10.6] years; 1340 [57.9%] male) were included in the study. Excision with MMS had the best unadjusted survival, with mean (SE) survival rates of 87.4% (3.4%) at 3 years, 84.5% (3.9%) at 5 years, and 81.8% (4.6%) at 10 years vs 86.1% (0.9%) at 3 years, 76.9% (1.2%) at 5 years, and 60.9% (2.0%) at 10 years for patients treated with WLE. Patients treated with narrow-margin excision had similar survival as those treated with WLE, with mean (SE) survival rates of 84.8% (1.4%) at 3 years, 78.3% (1.7%) at 5 years, and 60.8% (3.6%) at 10 years. On multivariable survival analysis, excision with MMS was associated with significantly improved survival compared with WLE (hazard ratio, 0.59; 95% CI, 0.36-0.97; P = .04). High-volume MCC centers were significantly more likely to use MMS over WLE compared with other centers (odds ratio, 1.99; 95% CI, 1.63-2.44; P < .001).

Conclusions and Relevance

In this cohort study, the use of MMS (compared with WLE) was associated with significantly improved survival for patients with localized MCC with pathologically confirmed negative lymph nodes treated with surgery. These data suggest that Mohs surgery may provide a more effective treatment for MCC primary tumors than conventional WLE, although the lack of randomization and potential for selection bias in this study highlight the need for future prospective work evaluating this issue.

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

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

Reconsidering N component of cancer staging for T1-2N0-2M0 small-cell lung cancer: a retrospective study based on multicenter cohort

BACKGROUND

The current nodal (pN) classification still has limitations in stratifying the prognosis of small cell lung cancer (SCLC) patients with pathological classifications T1-2N0-2M0. Thus. This study aimed to develop and validate a modified nodal classification based on a multicenter cohort.

MATERIALS AND METHODS

We collected 1156 SCLC patients with pathological classifications T1-2N0-2M0 from the Surveillance, Epidemiology, and End Results database and a multicenter database in China. The X-tile software was conducted to determine the optimal cutoff points of the number of examined lymph nodes (ELNs) and lymph node ratio (LNR). The Kaplan-Meier method, the Log-rank test, and the Cox regression method were used in this study. We classified patients into three pathological N modification categories, new pN#1 (pN0-#ELNs > 3), new pN#2 (pN0-#ELNs ≤ 3 or pN1-2-#LNR ≤ 0.14), and new pN#3 (N1-2-#LNR > 0.14). The Akaike information criterion (AIC), Bayesian Information Criterion, and Concordance index (C-index) were used to compare the prognostic, predictive ability between the current pN classification and the new pN component.

RESULTS

The new pN classification had a satisfactory effect on survival curves (Log-rank P < 0.001). After adjusting for other confounders, the new pN classification could be an independent prognostic indicator. Besides, the new pN component had a much more accurate predictive ability in the prognostic assessment for SCLC patients of pathological classifications T1-2N0-2M0 compared with the current pN classification in the SEER database (AIC: 4705.544 vs. 4731.775; C-index: 0.654 vs. 0.617, P < 0.001). Those results were validated in the MCDB from China.

CONCLUSIONS

The multicenter cohort developed and validated a modified nodal classification for SCLC patients with pathological category T1-2N0-2M0 after surgery. Besides, we propose that an adequate lymph node dissection is essential; surgeons should perform and consider the situation of ELNs and LNR when they evaluate postoperative prognoses of SCLC patients.

Heterogeneous distribution pattern of CD3+ tumor-infiltrated lymphocytes (TILs) and high combined positive score (CPS) favored the prognosis of resected early stage small-cell lung cancer

PURPOSE

This study aimed to illustrate the heterogeneity of immune features in small cell lung cancer (SCLC).

METHODS

Immunohistochemistry (IHC) staining of CD3, CD4, CD8 and PD-L1 were performed with 55 SCLC FFPE samples from radical resections. Quantitative assessment of CD3+ tumor-infiltrated lymphocytes (TILs) to present the heterogeneity in the tumor and the stroma areas. Hotspots of TILs were evaluated to illustrate the potential relationship between TIL-density and its immune competence. Programmed death ligand-1 (PD-L1) expressed on both tumor TILs (t-TILs) and stroma TILs (s-TILs) was evaluated and quantitatively described as values of tumor positive score (TPS) and combined positive score (CPS). The clinical value of TPS and CPS were further identified according to their relationship with disease-free survival (DFS).

RESULTS

More abundant CD3+ TILs were observed in the tumor stroma than that within the parenchyma (15.02±2.25% vs. 1.58±0.35%) . The amount of CD3+ s-TILs were positively correlated with DFS. The CD3+/CD4+ subset of the TILs was found more favorable to DFS compared to the CD3+/CD8+ subset. Hotspots of CD3+ TILs were observed in tumor regions and patients with more Hotspots of CD3+ TILs have better outcomes. CPS were more reliable than TPS to describe PD-L1 expression in SCLC and it was found positively correlated with tumor size and DFS.

CONCLUSIONS

The immune microenvironment of SCLC was heterogeneous. Hotspots, the amount of CD3/CD4+ TILs and the CPS value were found valuable in determine the anti-tumor immunity and predicting the clinical outcome of SCLC patients.

The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis

BACKGROUND

Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, data regarding the role of surgery in very limited SCLC is lacking.

METHODS

Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs. lower lobe as delineated by ICD-10 codes C34.1 and C34.3.

RESULTS

Four-hundred and forty-six patients received concurrent CRT; while 223 underwent treatment that contained surgery (93 surgery only, 87 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.21-4.48) while median OS for the CRT cohort was 2.45 years (95% CI 2.17-2.74). HR of death for surgery-inclusive treatment when compared to CRT is 0.67 (95% CI 0.55-0.81; P < .001). Subset analysis based on the location of the tumor in both the upper or lower lobes showed improved survival with surgery as compared to CRT regardless of the location. HR for the upper lobe was 0.63 (95% CI 0.50-0.80; P < .001) and lower lobe 0.61 (95% CI 0.42-0.87; P = .006). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.43-0.83; P = .002) favoring surgery.

CONCLUSIONS

Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study suggests a more expansive role for surgery in stage I SCLC.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Adjuvant Therapy Following Surgical Resection of Small Cell Lung Cancer: A Multi-Center Study

PURPOSE

This multi-center, retrospective study was conducted to evaluate the long-term survival in patients who underwent surgical resection for small cell lung cancer (SCLC) and to identify the benefit of adjuvant therapy following surgery.

MATERIALS AND METHODS

The data of 213 patients who underwent surgical resection for SCLC at four institutions were retrospectively reviewed. Patients who received neoadjuvant therapy or an incomplete resection were excluded.

RESULTS

The mean patient age was 65.29±8.93 years, and 184 patients (86.4%) were male. Lobectomies and pneumonectomies were performed in 173 patients (81.2%), and 198 (93%) underwent systematic mediastinal lymph node dissections. Overall, 170 patients (79.8%) underwent adjuvant chemotherapy, 42 (19.7%) underwent radiotherapy to the mediastinum, and 23 (10.8%) underwent prophylactic cranial irradiation. The median follow-up period was 31.08 months (interquartile range, 13.79 to 64.52 months). The 5-year overall survival (OS) and disease-free survival were 53.4% and 46.9%, respectively. The 5-year OS significantly improved after adjuvant chemotherapy in all patients (57.4% vs. 40.3%, p=0.007), and the survival benefit of adjuvant chemotherapy was significant in patients with negative node pathology (70.8% vs. 39.7%, p=0.004). Adjuvant radiotherapy did not affect the 5-year OS (54.6% vs. 48.5%, p=0.458). Age (hazard ratio [HR], 1.032; p=0.017), node metastasis (HR, 2.190; p < 0.001), and adjuvant chemotherapy (HR, 0.558; p=0.019) were associated with OS.

CONCLUSION

Adjuvant chemotherapy after surgical resection in patients with SCLC improved the OS, though adjuvant radiotherapy to the mediastinum did not improve the survival or decrease the locoregional recurrence rate.

Pathological Stage N1 Limited-Stage Small-Cell Lung Cancer Patients Can Benefit From Surgical Resection

PURPOSE

Surgery is controversial in limited-stage small-cell lung cancer (LS-SCLC) (except for T1-2, N0M0). This study aimed to analyze the survival of LS-SCLC patients with proximal lobe (N1) lymph node metastases after surgery and appropriate postoperative adjuvant treatment.

PATIENTS AND METHODS

We reviewed and followed up medical history and survival data of LS-SCLC patients from June 2007 to June 2016, and a total of 68 pathological stage N1 (p-N1) patients who underwent surgical resection and 71 clinical-stage N1 (c-N1) patients who received chemoradiotherapy were included in the final analysis.

RESULTS

The median follow-up of all the patients was 99.30 months. The median disease-free survival (DFS) of the surgery group was 13.567 months, and the median overall survival (OS) of the surgery and chemoradiotherapy groups were 29.600 months and 21.133 months (P-value < .001), respectively. The 2- and 5-year survival rates of the surgery group were 55.9% and 33.7%, and the 2- and 5-year survival rates of the chemoradiotherapy group were 39.8% and 9.4%, respectively. Meanwhile, postoperative thoracic radiotherapy appeared to be associated with a good prognosis (median OS 36.400 vs. 21.333 months, P-value .048), as did prophylactic cranial irradiation (median OS 50.867 vs. 22.600 months, P-value .007) in the surgery group.

CONCLUSIONS

Surgery may benefit patients with p-N1 SCLC, and in combination with appropriate postoperative adjuvant treatment, surgery may be a new therapeutic modality for SCLC.

Lobectomy versus sublobar resection for stage I (T1-T2aN0M0) small cell lung cancer: A SEER population-based propensity score matching analysis

OBJECTIVE

This study evaluated whether sublobar resection (sub-L) is non-inferior to lobectomy (L) for stage I (T1-T2aN0M0) small cell lung cancer (SCLC) regarding long-term overall survival (OS).

METHODS

Clinicopathological and prognostic data of patients with stage I (pT1-T2aN0M0) SCLC were retrieved. Kaplan-Meier curves and Breslow tests were performed for the assessment of OS. Propensity score matching (PSM) analysis was used to mediate the inherent bias of retrospective researches.

RESULTS

A total of 188 patients with stage I SCLC were included in this study after PSM. For resected stage I SCLC, surgery plus adjuvant therapy was related to a better OS compared with surgery only (p = 0.016). For resected stage I SCLC, no matter adjuvant therapy was performed or not, no significant difference was observed in long-term OS between the L and sub-L groups (p = 0.181). Further subgroup analysis demonstrated that the OS disadvantage of sub-L over L was not statistically significant for stage I SCLC patients underwent surgery only (p = 0.653), but also for the patients underwent surgery plus adjuvant therapy (p = 0.069). Moreover, in the subgroup analyses according to TNM stage (IA and IB), sex (male and female), and age (≥70 and <70 years), OS did not differ between the L and sub-L groups except in female patients (p = 0.008). Multivariate Cox regression analysis indicated that adjuvant therapy was positively associated with OS.

CONCLUSIONS

Surgery plus adjuvant therapy confers a better survival benefit than surgery only for stage I SCLC patients. However, as far as the range of surgical resection is concerned, sublobar resection may be non-inferior to lobectomy regarding OS. Our study could conduce to the development of optimal therapeutic strategies for stage I SCLC patients. Further validation is warranted in larger retrospective and prospective cohort studies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical and prognostic implications of CD47 and PD-L1 expression in surgically resected small-cell lung cancer

BACKGROUND

Pharmacological inhibition of the immune-checkpoint molecule CD47 has shown promising results in preclinical small-cell lung cancer (SCLC) models, whereas anti-programmed death-ligand 1 (PD-L1) inhibitors have been recently implemented in the standard of care of advanced-stage SCLC patients. Nevertheless, the expression pattern, clinical relevance and prognostic implication of both CD47 and PD-L1 are rather controversial in surgically treated SCLC patients.

MATERIALS AND METHODS

In total, 104 Caucasian SCLC patients from two Central European thoracic centers were included in this study. CD47 and PD-L1 expression as well as the expression of the four major SCLC molecular subtype markers (ASCL1, NEUROD1, YAP1 and POU2F3) were measured by immunohistochemistry. Expression levels were independently evaluated and statistically correlated with clinicopathological data and survival.

RESULTS

Positive CD47 and PD-L1 expressions were seen in 84.6% and 9.6% of the samples, respectively. Meanwhile, the tumor-associated stroma was positive for PD-L1 in 59.6% of the cases. Stromal PD-L1 expression correlated with longer overall survival (OS) (versus PD-L1-negative stroma; median OS was 42 versus 14 months, respectively, P = 0.003) and was confirmed as an independent predictor of favorable outcome upon multivariate analysis (hazard ratio 0.530, 95% confidence interval 0.298-0.943, P = 0.031). Notably, neither CD47 nor PD-L1 presence was related to a distinct molecular SCLC subtype.

CONCLUSION

CD47 shows a remarkably high expression while tumoral PD-L1 expression is generally low in surgically treated SCLC. Importantly, stromal PD-L1 expression may indicate a favorable clinical outcome and serve as a novel prognostic factor in these patients. Additional studies are warranted to further investigate the clinical impact of CD47 and PD-L1 expression in SCLC.

Pathologic responses to neoadjuvant chemoimmunotherapy in primary limited-stage small-cell lung cancer

BACKGROUND

Immunotherapy has been proved to have a large effect on extensive-stage small cell lung cancer, but the role of immunotherapy in limited-stage small-cell lung cancer (LS-SCLC) is still unknown.

METHODS

A retrospective study of six patients with LS-SCLC who were treated with neoadjuvant chemoimmunotherapy (durvalumab plus etoposide combined with cisplatin) was performed. Patients were evaluated by the safety, feasibility and pathologic responses of neoadjuvant chemoimmunotherapy.

RESULTS

Neoadjuvant durvalumab combined chemotherapy was associated with few immediate adverse events and did not delay planned surgery. All patients achieved partial pathologic response (pPR) instead of major pathologic response, or pathologic complete response. No association was observed between programmed death-ligand 1 expression in tumor specimens and the pathologic response. However, tumors with high expression of immune cells such as CD4+ T cells, CD8+ T cells and FoxP3+ Tregs tended to have better pathologic responses than tumors with low expression of immune cells.

CONCLUSIONS

Neoadjuvant durvalumab combined chemotherapy could induce pPR with few side effects in resectable LS-SCLC. The immune cells in the tumor microenvironment might play an important role in neoadjuvant chemoimmunotherapy in resectable LS-SCLC.

The role of surgery in older patients with T1-2N0M0 small cell lung cancer: A propensity score matching analysis

Background

Surgical resection could improve the survival of patients with early-stage small cell lung cancer (SCLC). However, there is a lack of dedicated studies concentrating on surgical treatment in older patients with T1-2N0M0 SCLC. Thus, we performed this population-based study to investigate whether older patients with T1-2N0M0 SCLC could benefit from surgery.

Methods

We collected the data of patients with SCLC between 2000 and 2015 from the Surveillance, Epidemiology, and End Results Program database. Older patients (≥ 65 years) with T1-2N0M0 SCLC were included, and we converted the staging information into those of the eighth edition. The propensity score matching (PSM) was used to balance the distribution of clinical characteristics between surgery and no-surgery groups.

Results

Before PSM, the distribution proportions of clinical characteristics in 1,229 patients were unbalanced. The Kaplan–Meier curves of overall survival (OS) and cancer-specific survival (CSS) showed that the patients in the surgery group were better than those in the non-surgery group (all P &lt; 0.001). After 1:2 PSM, the distribution proportions of clinical characteristics in 683 patients were balanced (all P &gt; 0.05). The OS and CSS of patients in the surgery group were still better than that of patients in the no-surgery group (all P &lt; 0.001), and subgroup analysis showed that the surgery was a protective factor for OS and CSS in all clinical characteristics subgroups (almost P &lt; 0.001). The multivariate Cox analysis further confirmed this result (OS: HR, 0.33; 95% CI, 0.27–0.39; P &lt; 0.001; CSS: HR, 0.29; 95% CI, 0.23–0.36; P &lt; 0.001). The result of subgroup analysis based on age, T stage, and adjuvant therapy showed that surgery was related to better OS and CSS compared with non-surgery group (almost P &lt; 0.001) and that lobectomy exhibited the longer survival than sublobectomy. Age, sex, and race were the independent prognostic factors for OS in patients undergoing surgery, whereas only the factor of age affects the CSS in patients with surgery.

Conclusions

Older patients with T1-2N0M0 SCLC can benefit significantly from surgical treatment, and lobectomy provides better prognosis than sublobectomy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Lymph Node Dissection on Survival and Tumor Recurrence for Patients with Resected cT1-2N0 Small Cell Lung Cancer

BACKGROUND

The role of lymph node (LN) dissection for early-stage small cell lung cancer (SCLC) remains unclear. Therefore, this study aimed to investigate the impact of LN dissection on patient survival and tumor recurrence for patients with cT1-2N0M0 SCLC.

METHODS

Patients with cT1-2N0M0 SCLC who underwent intent-to-cure surgery at our institution between 2011 and 2019 were retrospectively reviewed. The survival outcomes of patients with systematic LN dissection (n = 112) and LN sampling (n = 35) were compared before and after propensity score-matching (PSM), as were the outcomes for patients with (pN+) and without (pN0) pathologic nodal metastasis. The prognostic impact of LN dissection was evaluated through multivariable analysis.

RESULTS

The dissection group displayed significantly better overall survival (66.4% vs. 48.4%; P = 0.009) and recurrence-free survival (RFS) (63.5% vs. 37.6%;, P = 0.003) than the sampling group at 5 years. The rate of local recurrence was significantly lower in the dissection group than in the sampling group (11.6% vs. 42.9%; P < 0.001). After adjustment by multivariable analysis and PSM, LN dissection retained its independent favorable effects. The overall nodal upstaging rate was 37.6%, and the dissection group had a tendency of better RFS in both the pN0 (P = 0.05) and pN+ (P = 0.036) patients.

CONCLUSION

Systematic LN dissection is associated with improved survival of patients who undergo surgery for cT1-2N0 SCLC. Further studies are warranted to verify the necessity of LN dissection in the surgery for SCLC.

Stage I and II Small-Cell Lung Cancer-New Challenge for Surgery

Purpose

The recommended treatment for small-cell lung cancer (SCLC) currently is surgery in stage I disease. We wondered about stage II SCLC and present a meta-analysis on mean-survival of patients that underwent surgery for stage I and II compared to controls.

Methods

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

Results

Out of 6826 records, seven studies with a total of 11,241 patients (‘surgery group’: 3911 patients; ‘non-surgery group’: 7330; treatment period: 1984–2015) were included. Heterogeneity between the studies was revealed in absence of any publication bias. Patient characteristics did not differ between the groups (p-value > 0.05). The mean-survival in an analysis of patients in stage I was 36.7 ± 10.8 months for the ‘surgery group’ and 20.3 ± 5.7 months for the ‘non-surgery group’ (p-value = 0.0084). A combined analysis of patients in stage I and II revealed a mean-survival of 32.0 ± 16.7 months for the ‘surgery group’ and 19.1 ± 6.1 months for the ‘non-surgery group’ (p-value = 0.0391). In a separate analysis of stage II, we were able to demonstrate a significant survival benefit after surgery (21.4 ± 3.6 versus 16.2 ± 3.9 months; p-value = 0.0493).

Conclusion

Our meta-analysis shows a significant survival benefit after surgery not only in the recommended stage I but also in stage II SCLC. Our data suggests that both stages should be considered for surgery of early SCLC.

New perspectives in the management of small cell lung cancer

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

Lung Cancer Computational Biology and Resources

Comprehensive clinical, pathological, and molecular data, when appropriately integrated with advanced computational approaches, are transforming the way we characterize and study lung cancer. Clinically, cancer registry and publicly available historical clinical trial data enable retrospective analyses to examine how socioeconomic factors, patient demographics, and cancer characteristics affect treatment and outcome. Pathologically, digital pathology and artificial intelligence are revolutionizing histopathological image analyses, not only with improved efficiency and accuracy, but also by extracting additional information for prognostication and tumor microenvironment characterization. Genetically and molecularly, individual patient tumors and preclinical models of lung cancer are profiled by various high-throughput platforms to characterize the molecular properties and functional liabilities. The resulting multi-omics data sets and their interrogation facilitate both basic research mechanistic studies and translation of the findings into the clinic. In this review, we provide a list of resources and tools potentially valuable for lung cancer basic and translational research. Importantly, we point out pitfalls and caveats when performing computational analyses of these data sets and provide a vision of future computational biology developments that will aid lung cancer translational research.

Propensity score matched analysis for the role of surgery in stage Ⅲ small cell lung cancer based on the eighth edition of the TNM classification: a population study of the US SEER database and a Chinese hospital

OBJECTIVE

Patients with very early stage small cell lung cancer (SCLC) can benefit from surgery. However, the role of surgery in local advanced SCLC patients remains controversial. We designed this study to investigate the role of surgery on survival of this subset population.

METHODS

The included patients were identified from the Surveillance, Epidemiology, and End Results SEER database from 1998 to 2016 and Shanghai Chest Hospital of China from 2009 to 2016. Propensity score matching(PSM) was used to balance clinical bias. The overall survival (OS) and lung cancer-specific survival (LCSS) were compared by the Kaplan-Meier analysis. Cox proportional hazards regression was used to identify factors associated with survival.

RESULTS

Among the 3005 stage Ⅲ patients, 570 (18.97%) patients underwent surgery. Compared with non-surgical group, patients undergoing surgery were more likely to be male, had smaller tumor size, mediastinal lymph node involvement and lower pathologic stage. The Kaplan-Meier analysis showed that surgical patients had a better OS and LCSS before and after PSM. 418 surgical patients were well matched with non-surgical patients. In matched surgical group, there were 224 (53.59%) patients who underwent lobectomy (LB), 147 (35.17%) patients who received sublobectomy (SLB), 31 (7.41%) patients who underwent pneumonectomy and 16 (3.83%) patients with unknown surgery type. The 5-year OS of the 4 subgroups were 28.80%, 12.50%, 8.70% and 13.50%, respectively (P = 0.002). In a multivariable Cox model, SLB (hazard ratio, 1.53; 95%CI, 1.20-1.96; P = 0.001) and pneumonectomy (hazard ratio, 1.72; 95%CI, 1.12-2.65; P = 0.013) were associated with worse OS compared with LB.

CONCLUSION

Surgical resection significantly improved OS and LCSS of stage Ⅲ SCLC patients in our study. Furthermore, LB had advantage over other surgery type but further exploration in larger prospective clinical trials is needed.

Comparative Study of Pulmonary Combined Large-Cell Neuroendocrine Carcinoma and Combined Small-Cell Carcinoma in Surgically Resected High-Grade Neuroendocrine Tumors of the Lung

Objectives

Pulmonary large-cell neuroendocrine carcinoma (LCNEC) and small-cell lung cancer (SCLC) are both classified as pure and combined subtypes. Due to the low incidence and difficult diagnosis of combined LCNEC (C-LCNEC) and combined SCLC (C-SCLC), few studies have compared their clinical features and prognosis.

Materials and Methods

We compared the clinical features, mutation status of driver genes (EGFR, ALK, ROS1, KRAS, and BRAF), and prognosis between C-LCNEC and C-SCLC. Univariate and multivariate Cox regression analyses were applied for survival analysis.

Results

We included a total of 116 patients with C-LCNEC and 76 patients with C-SCLC in the present study. There were significant differences in distribution of smoking history, tumor location, pT stage, pN stage, pTNM stage, visceral pleural invasion (VPI), and combined components between C-LCNEC and C-SCLC (P<0.05 for all). C-SCLC was more advanced at diagnosis as compared to C-LCNEC. The incidence of EGFR mutations in C-LCNEC patients was higher than C-SCLC patients (25.7 vs. 5%, P=0.004). We found that tumor size, pN stage, peripheral CEA level, and adjuvant chemotherapy were independently prognostic factors for DFS and OS in C-LCNEC patients, while peripheral NSE level, pT stage, pN stage, VPI and adjuvant chemotherapy were independently associated with DFS and OS for C-SCLC patients (P<0.05 for all). Propensity score matching with adjustment for the confounders confirmed a more favorable DFS (P=0.032) and OS (P=0.019) in patients with C-LCNEC in comparison with C-SCLC patients upon survival analysis.

Conclusions

The mutation landscape of driver genes seemed to act in different way between C-SCLC and C-LCNEC, likely by which result in clinical phenotype difference as well as better outcome in C-LCNEC.

Impact of Adjuvant Therapy on Survival in Surgically Resected Limited-Stage Small Cell Lung Cancer

Background

Data on efficacy of adjuvant therapy for surgically resected small cell lung cancer are scant. This study was determined to reveal the survival benefits of different adjuvant treatment modalities for limited-stage small cell lung cancer patients following surgical resection.

Methods

Data of patients with histologically confirmed small cell lung cancer after surgical resection were collected from November 2006 to June 2019. Survival analyses were calculated by Kaplan–Meier method, with log-rank test to evaluate statistical significance. Prognostic factors were identified by multivariate analysis using cox proportional hazards model. Further survival analysis and cox regression analysis stratified by clinicopathologic features were conducted to evaluate the survival benefits of different adjuvant treatment modalities.

Results

In total, 153 out of 157 patients were analyzed. Multivariate analysis showed male sex, lymph node metastasis, residual tumor, VPI and non-adjuvant therapy were independently associated with poor prognosis. Subgroup analyses revealed both adjuvant chemotherapy and adjuvant chemoradiotherapy were significantly associated with superior survival for stage pT2-4 (HR=0.176, 95%CI:0.053-0.578, p=0.004; and HR=0.115, 95%CI:0.033-0.405, p=0.001) and pure SCLC patients (HR=0.182, 95%CI:0.067-0.494, p=0.001; and HR=0.181, 95%CI:0.071-0.465, p<0.001). For pN0 patients, adjuvant chemotherapy was associated with better survival (HR=0.219, 95%CI:0.054-0.891, p=0.034), while adjuvant chemoradiotherapy was associated with improved survival for pN+ patients (HR=0.324, 95%CI:0.138-0.760, p=0.010).

Conclusions

For patients without pathologic lymph node metastasis, there is a survival benefit with adjuvant chemotherapy. However, for patients with pathologic lymph node metastasis, adjuvant chemoradiotherapy might achieve a significant survival benefit. Further prospective studies are needed to validate the results.

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

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

Effect of surgery on survival in patients with stage III N2 small cell lung cancer: propensity score matching analysis and nomogram development and validation

Background

The standard treatment of stage III N2 small cell lung cancer (SCLC) is concurrent chemoradiation, and surgery is not recommended. This study was aimed to evaluate whether surgery has survival benefits in patients with stage III N2 SCLC and investigate the factors influencing survival of surgery.

Methods

Patients diagnosed with stage T1-4N2M0 SCLC from 2004 to 2015 were selected from the Surveillance Epidemiology End Results database. Propensity score matching (PSM) was used to balance confounders between patients who underwent surgery and those treated with radiation and/or chemotherapy. We compared overall survival (OS) of the two groups using Kaplan-Meier curves and a Cox proportional hazard model. We also identified prognostic factors in patients with surgical resection, and a nomogram was developed and validated for predicting postoperative OS.

Results

−A total of 5576 patients were included in the analysis; of these, 211 patients underwent surgery. PSM balanced the differences between the two groups. The median OS was longer in the surgery group than in the non-surgery group (20 vs. 15 months; p = 0.0024). Surgery was an independent prognostic factor for longer OS in the multivariate Cox regression analysis, and subgroup analysis revealed a higher survival rate in T1 stage patients treated with surgery (hazard ratio = 0.565, 95% confidence interval: 0.401–0.798; p = 0.001). In patients who underwent surgery, four prognostic factors, including age, T stage, number of positive lymph nodes, and radiation, were selected into nomogram development for predicting postoperative OS. C-index, decision curve analyses, integrated discrimination improvement, and time-dependent receiver operating characteristics showed better performance in nomogram than in the tumor-node-metastasis staging system. Calibration plots demonstrated good consistency between nomogram predicted survival and actual observed survival. The patients were stratified into three different risk groups by prognostic scores and Kaplan-Meier curves showed significant difference between these groups.

Conclusions

These results indicate that surgery can prolong survival in patients with operable stage III N2 SCLC, particularly those with T1 disease. A nomogram that includes age, T stage, number of positive lymph nodes, and radiation can be used to predict their long-term postoperative survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02364-6.

Comprehensive analysis of prognostic predictors for patients with limited-stage small-cell lung cancer who underwent resection followed by adjuvant chemotherapy

Background

The prognosis of patients with limited-stage small-cell lung cancer (LS-SCLC) who undergo resection followed by adjuvant chemotherapy (ACT) is uncertain. Thus, we combined clinicopathological characteristics and next-generation sequencing (NGS) to answer this question.

Methods

In total, the data of 51 LS-SCLC patients who had undergone complete surgical resection and postoperative ACT were retrospectively collected. NGS examinations with a 68-gene panel were performed for each specimen. Patients' genetic status and potentially clinical correlations were statistically evaluated. Progression-free survival (PFS) and overall survival (OS) were plotted using Kaplan-Meier curves. The independent prognostic factors for the primary cohort were investigated using univariable and multivariable cox proportional hazard regression analyses. Subgroup analyses were also conducted based on retinoblastoma protein 1 (RB1) status.

Results

Combined SCLC (c-SCLC) had similar clinical and pathological characteristics to that of pure SCLC (p-SCLC). TP53 and RB1 were 2 major genetic mutations present in both p-SCLC and c-SCLC. c-SCLC had a unique genetic profile that was related to the PI3K/AKT/mTOR and WNT/β-catenin signaling pathways. There was no prognostic difference between c-SCLC and p-SCLC. However, the pathological node (N) stage of lymphovascular invasion (LVI), which was related to PFS and age, corelated with OS. Neither pathological subtypes nor genetic mutations affected the survival outcomes. Notably, RB1 mutated c-SCLC resulted in poorer DFS compared to that of p-SCLC among LS-SCLC patients who underwent resection followed by ACT.

Conclusions

Our examination of LS-SCLC patients who underwent resection followed by ACT showed that c-SCLC and p-SCLC had a clinical and prognostic similarity and a genetic peculiarity. Thus, it is essential that a new classification system be proposed for SCLC. Such a system is especially needed for LS-SCLC.

Stereotactic ablative radiotherapy in T1-2N0M0 small cell lung cancer: A systematic review and meta-analysis

OBJECTIVES

Stereotactic ablative radiotherapy (SABR) is used to treat inoperable early-stage, node-negative small cell lung cancer (SCLC). We performed a systematic review and meta-analysis of the literature on SABR for T1-2N0M0 SCLC to summarize outcomes including local control (LC), overall survival (OS), recurrence rates, and toxicity.

MATERIALS AND METHODS

This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. A systematic review of PubMed and EMBASE (inception to April 2021) was conducted. Two authors independently reviewed articles for inclusion and extracted study-level data. Random-effects meta-analysis was conducted using R (version 3.6.2) at a significance threshold of 0.05.

RESULTS

Eleven studies were identified in the systematic review and seven (399 patients) were selected for meta-analysis. Inoperability was noted as the indication for SABR in 94% (75-100%) of patients. Median follow-up and tumor size were 19.5 months (11.9-32) and 24 mm (19-29), respectively. Chemotherapy and PCI use rates were 44.1% (95% confidence interval [CI], 27.0-61.9%) and 13.8% (95% CI, 0.4-41.2%), respectively. Local control was 97.3% (95% CI, 92.3-99.8%) at 1 year and 95.7% (95% CI, 74.2-100.0%) at 2 years. Overall survival was 86.3% (95% CI, 74.4-94.9%) at 1 year and 63.7% (95% CI, 45.7-79.9%) at 2 years. Nodal and distant recurrence rates were 17.8% (95% CI, 7.5-31.2%) and 26.9% (95% CI, 7.4-53.0%), respectively. The rates of grade 1, grade 2, and grade 3 toxicity (CTCAE) were 12.6% (95% CI, 6.7-19.9%), 6.7% (95% CI, 3.3-11.2%), and 1.4% (95% CI, 0.0-5.3%), respectively. No grade 4 or 5 events were observed across the studies.

CONCLUSION

SABR for inoperable early-stage, node-negative SCLC is locally effective with limited toxicity. Prospective studies are required to further evaluate the role of SABR for patients at higher risk of toxicity with surgery or combined chemoradiation.

[Surgery for small-cell lung cancer]

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

A new nomogram and risk classification system for predicting survival in small cell lung cancer patients diagnosed with brain metastasis: a large population-based study

BACKGROUND

The prognosis of patients with small cell lung cancer (SCLC) is poor, most of them are in the extensive stage at the time of diagnosis, and are prone to brain metastasis. In this study, we established a nomogram combined with some clinical parameters to predict the survival of SCLC patients with brain metastasis.

METHODS

The 3522 eligible patients selected from the SEER database between 2010 and 2015 were randomly divided into training cohort and validation cohort. Univariate and multivariate Cox regression analysis were used to evaluate the ability of each parameter to predict OS. The regression coefficients obtained in multivariate analysis were visualized in the form of nomogram, thus a new nomogram and risk classification system were established. The calibration curves were used to verify the model. And ROC curves were used to evaluate the discrimination ability of the newly constructed nomogram. Survival curves were made by Kaplan-Meier method and compared by Log rank test.

RESULTS

Univariate and multivariate analysis showed that age, race, sex, T stage, N stage and marital status were independent prognostic factors and were included in the predictive model. The calibration curves showed that the predicted value of the 1- and 3-year survival rate by the nomogram was in good agreement with the actual observed value of the 1- and 3-year survival rate. And, the ROC curves implied the good discrimination ability of the predictive model. In addition, the results showed that in the total cohort, training cohort, and validation cohort, the prognosis of the low-risk group was better than that of the high-risk group.

CONCLUSIONS

We established a nomogram and a corresponding risk classification system to predict OS in SCLC patients with brain metastasis. This model could help clinicians make clinical decisions and stratify treatment for patients.

Fragmentation of Small-Cell Lung Cancer Regulatory States in Heterotypic Microenvironments

Small-cell lung cancers derive from pulmonary neuroendocrine cells, which have stem-like properties to reprogram into other cell types upon lung injury. It is difficult to uncouple transcriptional plasticity of these transformed cells from genetic changes that evolve in primary tumors or secondary metastases. Profiling of single cells is also problematic if the required sample dissociation activates injury-like signaling and reprogramming. Here we defined cell-state heterogeneities in situ through laser capture microdissection-based 10-cell transcriptomics coupled with stochastic-profiling fluctuation analysis. In labeled cells from a small-cell lung cancer mouse model initiated by neuroendocrine deletion of Rb1-Trp53, variations in transcript abundance revealed cell-to-cell differences in regulatory state in vitro and in vivo. Fluctuating transcripts in spheroid culture were partly shared among Rb1-Trp53-null models, and heterogeneities increased considerably when cells were delivered intravenously to colonize the liver. Colonization of immunocompromised animals drove a fractional appearance of alveolar type II-like markers and poised cells for paracrine stimulation from immune cells and hepatocytes. Immunocompetency further exaggerated the fragmentation of tumor states in the liver, yielding mixed stromal signatures evident in bulk sequencing from autochthonous tumors and metastases. Dozens of transcript heterogeneities recurred irrespective of biological context; their mapped orthologs brought together observations of murine and human small-cell lung cancer. Candidate heterogeneities recurrent in the liver also stratified primary human tumors into discrete groups not readily explained by molecular subtype but with prognostic relevance. These data suggest that heterotypic interactions in the liver and lung are an accelerant for intratumor heterogeneity in small-cell lung cancer. SIGNIFICANCE: These findings demonstrate that the single-cell regulatory heterogeneity of small-cell lung cancer becomes increasingly elaborate in the liver, a common metastatic site for the disease.See related articles by Singh and colleagues, p. 1840 and Sutcliffe and colleagues, p. 1868.

pN1 but not pN0/N2 predicts survival benefits of prophylactic cranial irradiation in small-cell lung cancer patients after surgery

Background

Prophylactic cranial irradiation has been shown to reduce brain metastases and provide survival benefits in small-cell lung cancer (SCLC). However, its role in limited-stage SCLC patients after surgery remains unclear. Further, it is unknown whether the effect of prophylactic cranial irradiation is generalizable in these patients with different pathological nodal (N0-N2) stages, a state indicating the presence of tumor metastases.

Methods

We combined data from a single medical center and Surveillance, Epidemiology, and End Results database. Propensity score matching analyses were performed (1:2) to evaluate the role of prophylactic cranial irradiation in SCLC patients after surgery. Cox proportional hazards regression model was used to identify predictors of survival.

Results

124 (18.7%) out of 664 surgically-treated SCLC patients received prophylactic cranial irradiation treatment. Within the entire cohort, multivariate Cox regression analysis identified dataset source, age, pathological T and N stages, adjuvant chemotherapy, resection type, and histology as independent prognostic factors for overall survival. Prophylactic cranial irradiation appeared to be associated with a better overall survival, but the difference is marginally significant (P=0.063). Further, we stratified patients based on the pathological N0-N2 stages using propensity score matching analyses, which showed that prophylactic cranial irradiation treatment was superior to non-prophylactic cranial irradiation treatment for surgically-treated SCLC patients with N1 stage only (univariate analysis: P=0.026; multivariate Cox: P=0.004), but not N0/N2 stage (univariate analysis: P=0.65 and P=0.28, respectively; multivariate Cox: P=0.99 and P=0.35, respectively).

Conclusions

Prophylactic cranial irradiation provides survival benefits for SCLC patients with pN1 after surgery but not with pathological N0/N2 stage. Our findings may provide helpful stratifications for clinical decision-making of prophylactic cranial irradiation intervention in SCLC patients.

Molecular profiles of small cell lung cancer subtypes: therapeutic implications

Small cell lung cancer (SCLC; accounting for approximately 13%-15% of all lung cancers) is an exceptionally lethal malignancy characterized by rapid doubling time and high propensity to metastasize. In contrast to the increasingly personalized therapies in other types of lung cancer, SCLC is still regarded as a homogeneous disease and the prognosis of SCLC patients remains poor. Recently, however, substantial progress has been made in our understanding of SCLC biology. Advances in genomics and development of new preclinical models have facilitated insights into the intratumoral heterogeneity and specific genetic alterations of this disease. This worldwide resurgence of studies on SCLC has ultimately led to the development of novel subtype-specific classifications primarily based on the neuroendocrine features and distinct molecular profiles of SCLC. Importantly, these biologically distinct subtypes might define unique therapeutic vulnerabilities. Herein, we summarize the current knowledge on the molecular profiles of SCLC subtypes with a focus on their potential clinical implications.

Advanced Lung Cancer Inflammation Index is a Prognostic Factor of Patients with Small-Cell Lung Cancer Following Surgical Resection

Purpose

Advanced lung cancer inflammation index (ALI) has been shown to predict overall survival (OS) in advanced non small-cell lung cancer (NSCLC), small-cell lung cancer (SCLC) and operable NSCLC. However, there were no studies of the correlation between ALI and operable SCLC. Therefore, this study is aimed to explore the relationship between ALI and the prognosis of operable SCLC.

Patients and Methods

A total of 48 patients with SCLC who underwent surgery at Hebei General Hospital and Zigong First People's Hospital were screened between 2016 and 2020. ALI was calculated as follows: body mass index (BMI, kg/m²)×serum albumin (ALB, g/dL)/neutrophil to lymphocyte ratio (NLR). Receiver operating characteristic (ROC) curve was used to determine the optimal cutoff value of ALI. Patients were divided into two groups according to the cutoff point of ALI: low ALI group with ALI<48.2 and high ALI group with ALI≥48.2. Kaplan-Meier and Cox regression analysis were performed to assess the potential prognostic factors associated with OS.

Results

The optimal cutoff value of ALI was determined as 48.2. The low ALI group displayed more adverse clinical characteristics and poorer survival rates. Multivariate analysis revealed that ALI and Charlson comorbidity index (CCI) were significantly correlated with OS.

Conclusion

Low ALI was correlated with poor prognosis in patients with SCLC who underwent surgery. Preoperative ALI might serve as a potential prognostic marker for patients with operable SCLC.

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.

Association of Race, Socioeconomic Factors, and Treatment Characteristics With Overall Survival in Patients With Limited-Stage Small Cell Lung Cancer

IMPORTANCE

It has been established that disparities in race and socioeconomic status are associated with outcomes of non-small cell lung cancer. However, it remains unknown whether this extends to stage I, II, or III small cell lung cancer (SCLC), or limited-stage SCLC (L-SCLC).

OBJECTIVE

To investigate the associations of race, socioeconomic factors, and treatment characteristics with survival among patients with L-SCLC.

DESIGN, SETTING, AND PARTICIPANTS

Demographic information for patients with L-SCLC diagnosed between 2004 and 2014 was obtained from the National Cancer Database. The follow-up end point is death or last follow-up (date of last contact). Patients were divided into 5 mutually exclusive cohorts by race. Data analysis was performed in October 2019.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards models were used to calculate univariable and multivariable models. Multivariable analyses were conducted to assess the associations of race and socioeconomic factors with risk-adjusted outcomes. Overall survival between groups was depicted by Kaplan-Meier curves.

RESULTS

Of 72 409 patients analyzed (median [range] age, 67.0 [23.0-90.0] years), 40 289 (55.6%) were women. The distribution of disease stage was 10 619 patients (14.7%) with stage I disease, 7689 patients (10.6%) with stage II disease, and 54 101 patients (74.7%) with stage III disease. The median (range) duration of follow-up was 8.2 (2.4-15.8) months. Compared with White patients, the hazard of death decreased to 0.92 (95% CI, 0.89-0.95; P < .001) for African American patients and 0.83 (95% CI, 0.77-0.91; P < .001) for Asian patients. The difference in median survival among different racial groups was significant only among those with stage III SCLC. Other factors associated with better survival were female sex, high income, high education, private insurance, diagnostic confirmation by positive cytological analysis, increase in number of sampled regional lymph nodes, and earlier stage at diagnosis.

CONCLUSIONS AND RELEVANCE

This analysis highlights disparities in race and socioeconomic factors associated with outcomes of L-SCLC. Racial minorities, including African American and Asian patients, have better survival than White patients for L-SCLC after adjustment for sociodemographic factors.

The number of lymph nodes examined is associated with survival outcomes and nodal upstaging in patients with stage I small cell lung cancer

OBJECTIVE(S)

Lymph node status is vital for patients with small cell lung cancer (SCLC). We sought to evaluate the association between the number of lymph nodes examined (NLNE) and prognosis and nodal upstaging in stage I SCLC patients.

METHODS

We queried the Surveillance, Epidemiology and End Results (SEER) database and our department for surgically treated patients with pathologic stage I SCLC to evaluate the correlation between NLNE and overall survival (OS). We further investigated the association between the NLNE and nodal upstaging in clinical stage I SCLC.

RESULTS

A total of 878 patients with pathologic stage I SCLC were enrolled from the SEER database. Univariate and multivariate Cox regression analysis revealed that removing more than 6 lymph nodes was associated with significantly improved OS. We validated the prognostic impact from examining more than 6 nodes in pathologic stage I SCLC patients from our department. Logistic regression analysis found that removing more than 6 nodes increased the odds of nodal upstaging for clinical stage I SCLC.

CONCLUSIONS

Adequate nodal examination leads to survival benefits and accurate nodal staging. Our analysis indicated that examining more than 6 lymph nodes could confer better OS and predict nodal upstaging for stage I SCLC patients.

Surgery for small cell lung cancer: When and how

OBJECTIVE

Since data from large retrospective observational studies and cancer registries became available, suggesting a benefit for patients undergoing surgery, the role of surgery in the treatment of small cell lung cancer (SCLC) needs to be reconsidered. The aim of this study was to evaluate outcomes and results of patients with SCLC undergoing intent-to-treat surgery.

MATERIAL AND METHODS

We retrospectively analyzed 324 patients (1998-2018) with a diagnosis of SCLC referred to our Institution. 65 patients underwent surgical resection with curative intent. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) for all patients.

RESULTS

Among the patients, 39 (60.0 %) patients had surgery upfront, whereas 24 (36.9 %) had surgery after chemotherapy (CT) alone, and 2 (3.1 %) after CT plus radiotherapy (RT). Twenty-nine (44.6 %) patients were stage I or had a complete response to induction treatment, 21 (32.3 %) had stage II, and 15 (23.1 %) stage III. Forty-four (67.7 %) patients underwent adjuvant treatment: 21 (32.3 %) had CT, 31 (47.7 %) RT, and 7 (10.8 %) both. Prophylactic cranial irradiation was administered in 15 patients (23.1 %). The median OS after initial diagnosis at 1, 5, 10 years was 1, 5, 10 years was 81.4 %, 41.4 % and 25.4 % respectively. Among patients who underwent surgical resection with curative intent, those with clinical stage I had a longer survival (5-year OS 62.9 %) p < 0.0001.

CONCLUSION

patients with stage I SCLC could be considered the best candidates for surgery, in a multidisciplinary setting. Instead, considering their worse survival, those with stage II and III should be carefully selected for the surgical approach, and alternative therapy should be considered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgery for limited stage small cell lung cancer

Small cell lung cancer (SCLC) is an aggressive tumor type characterized by rapid growth and overall poor prognosis. For the past several decades, chemotherapy and radiotherapy have served as the cornerstone of treatment. Recently, however, the role of surgery for early stage disease has gained considerable interest. Multiple retrospective and observational studies have shown excellent survival for early stage SCLC treated with surgical resection. We herein review the past and present evidence regarding surgical options for limited stage SCLC.

Treatments for combined small cell lung cancer patients

Background

Combined small cell lung cancer (CSCLC) is a subtype of small cell lung cancer (SCLC) which contains both components of SCLC and non-small cell lung cancer (NSCLC). The prognostic outcomes and treatment strategy of it are still unclear. A large-scale retrospective study was performed to investigate proper treatments for CSCLC.

Methods

All cases of CSCLC were identified from the SEER database during the period of 2004–2016. Clinical characteristics, first-line treatments, surgical procedures and survival data including overall survival (OS) and cancer-specific survival (CSS) were analyzed.

Results

A total of 37,639 SCLC patients were identified. CSCLC accounted for 2.1% (784/37,639). The mean age of CSCLC cohort is 67.3±9.9 years old. Male and white ethnicity patients were accounted for larger proportions (55.7% and 80.4%). The oncological characteristics of CSCLC were consistent with SCLC that most of patients were diagnosed as higher grade and advanced stages. The prognosis of CSCLC was better than SCLC but worse than NSCLC in IA-IIIA stages. No difference was observed in IIIB-IV. Surgery was beneficial in IA-IB stage CSCLC. Adjuvant chemotherapy seemed to have few effects on early stage patients. Trimodality treatment could significantly improve OS in IIA-IIIA CSCLC patients. Chemotherapy-based treatment is predominant choice in advanced stage patients.

Conclusions

CSCLC is a rare and special subtype of SCLC. It has better survival outcome than non-CSCLC in early stage. Surgical treatment is crucial in early stage of CSCLC. Prognostic improvement might be achieved from trimodality treatment in stage IIA-IIIA. Chemotherapy-based treatments should be considered in advanced stage. The effect of surgical treatments in advanced stage patients should be further investigated.