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Zhao J, Nguyen A, Ding L, David EA, Atay SM, Wightman SC, McFadden PM, Kim AW. Trends in pneumonectomy for treatment of small-cell lung cancer. Asian Cardiovasc Thorac Ann 2020; 28:583-591. [PMID: 32878450 DOI: 10.1177/0218492320955054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND According to practice guidelines, patients with clinical stage T1-2 node-negative small-cell lung cancer are candidates for surgical resection. However, the role of pneumonectomy in small-cell lung cancer patients is not well understood. The objective of this study was to assess the extent to which pneumonectomy is used and to evaluate the survival implications for small-cell lung cancer patients who underwent pneumonectomy. METHODS A total of 106 small-cell lung cancer patients who underwent pneumonectomy between 2006 and 2016 and met the study criteria were identified in the National Cancer Database. Demographics and treatment regimens are described, and overall survival was assessed using Kaplan-Meier and log-rank tests. RESULTS The most common treatment was surgery with adjuvant chemotherapy, followed by surgery only and surgery with neoadjuvant therapy. The 5-year overall survival for the entire cohort after pneumonectomy was 23%. In subgroup analysis, the 5-year overall survival was 30% for guideline-concordant clinical stage I patients and 28% for clinical stage II/III patients who underwent pneumonectomy. There was no statistical difference in survival according to pathologic N disease. Patients with a right-sided pneumonectomy had higher mortality than patients with a left-sided pneumonectomy. CONCLUSIONS This study suggests a role for pneumonectomy in clinical stage I and potentially some clinical stage II and III small-cell lung cancer patients. Right-sided pneumonectomy is associated with higher mortality and should be approached with caution. Despite declining trends over the past decades, pneumonectomy is still an effective treatment that is able to achieve acceptable survival outcomes.
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Affiliation(s)
- Jasmine Zhao
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alexandra Nguyen
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Li Ding
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Elizabeth A David
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Scott M Atay
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sean C Wightman
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - P Michael McFadden
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anthony W Kim
- Division of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Che K, Shen H, Qu X, Pang Z, Jiang Y, Liu S, Yang X, Du J. Survival Outcomes for Patients with Surgical and Non-Surgical Treatments in Stages I-III Small-Cell Lung Cancer. J Cancer 2018; 9:1421-1429. [PMID: 29721052 PMCID: PMC5929087 DOI: 10.7150/jca.23583] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/21/2018] [Indexed: 02/07/2023] Open
Abstract
Objectives: Chemotherapy and radiation therapy are the standard treatments for patients with small-cell lung cancer (SCLC). However, recent studies suggest that patients with limited stage (I-III) SCLC may benefit from surgical treatment. This study was performed to evaluate the survival outcomes of surgery for stage I-III SCLC. Methods: This analysis used data from the Surveillance, Epidemiology, and End Results (SEER) database. All stage I-III (excluding N3 and Nx) SCLC patients received a diagnosis between 2004 and 2014. Overall survival (OS) and lung cancer-specific survival (LCSS) were determined by Kaplan-Meier analysis and compared using the log-rank test. A Cox proportional hazard model identified relevant survival variables. Results: A total of 4,780 histologically confirmed patients were identified from the SEER database, comprising 1,018 patients (21.3%) with stage I disease; 295 (6.2%) with stage II; and 3,467 (72.5%) with stage III disease. Among all of the patients, 520 had been treated with surgery, the majority (n = 344; 66.2%) of whom had stage I disease. The hazard ratio (HR) for OS and LCSS, in patients who underwent surgery, according to stage were as follows: OS, 0.369 and LCSS, 0.335 in stage I; OS, 0.549 and LCSS, 0.506 in stage II; and OS, 0.477 and LCSS, 0.456 in stage III (all p < 0.001). Patients who underwent surgery had significantly better OS, and lobectomy was associated with the best outcome. Conclusions: Surgical resection was associated with significantly improved OS outcomes and should be considered in the management of stage I-III SCLC.
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Affiliation(s)
- Keying Che
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Hongchang Shen
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Xiao Qu
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Zhaofei Pang
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Yuanzhu Jiang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Shaorui Liu
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Xudong Yang
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
| | - Jiajun Du
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China.,Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jingwu Road, Jinan, 250021, P.R. China
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Yang Z, Zheng R, Gao Y, Zhang Q. Gene expression profiles on predicting protein interaction network and exploring of new treatments for lung cancer. Mol Biol Rep 2014; 41:8203-10. [PMID: 25205123 DOI: 10.1007/s11033-014-3722-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/28/2014] [Indexed: 01/09/2023]
Abstract
In the present study, we aimed to explore disease-associated genes and their functions in lung cancer. We downloaded the gene expression profile GSE4115 from Gene Expression Omnibus (GEO) database. Total 97 lung cancer and 90 adjacent non-tumor lung tissue (normal) samples were applied to identify the differentially expressed genes (DEGs) by paired t test and variance analysis in spectral angle mapper (SAM) package in R. Gene Ontology (GO) functional enrichment analysis of DEGs were performed with Database for Annotation Visualization and Integrated Discovery, followed by construction of protein-protein interaction (PPI) network from Human Protein Reference Database (HPRD). Finally, network modules were analyzed by the MCODE algorithm to detect protein complexes in the PPI network. Total 3,102 genes were identified as DEGs at FDR < 0.05, including 1,146 down-regulated and 1,956 up-regulated DEGs. GO functional enrichment analysis revealed that up-regulated DEGs mainly participated in cell cycle and intracellular related functions, and down-regulated DEGs might influence cell functions. There were 39,240 pairs of PPIs in human obtained from HPRD databases, 3,102 DEGs were mapped to this PPI network, in which 2,429 pairs of PPIs and 1,342 genes were identified. With MCODE algorithm, 48 modules were selected, including five corresponding modules and three modules with differences in gene expressing profiles. In addition, three DGEs, FXR2, ARFGAP1 and ELAVL1 were discovered as potential lung cancer related genes. The discovery of featured genes which were probably related to lung cancer, has a great significance on studying mechanism, distinguishing normal and cancer tissues, and exploring new treatments for lung cancer.
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Affiliation(s)
- Zehui Yang
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, No.36 Sanhao Street, Heping District, Shenyang, 110004, China
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4
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Kenmotsu H, Niho S, Ito T, Ishikawa Y, Noguchi M, Tada H, Sekine I, Watanabe SI, Yoshimura M, Yamamoto N, Oshita F, Kubota K, Nagai K. A pilot study of adjuvant chemotherapy with irinotecan and cisplatin for completely resected high-grade pulmonary neuroendocrine carcinoma (large cell neuroendocrine carcinoma and small cell lung cancer). Lung Cancer 2014; 84:254-8. [DOI: 10.1016/j.lungcan.2014.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/18/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
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Kenmotsu H. Efficacy of chemotherapy in limited-disease small-cell lung cancer. Lung Cancer Manag 2013. [DOI: 10.2217/lmt.13.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Small-cell lung cancer (SCLC) accounts for approximately 13% of all lung cancers, and limited-disease SCLC is defined as a disease that can be encompassed within a tolerable radiation field. Concurrent chemoradiotherapy is considered to be the standard treatment for limited-disease SCLC. In both concurrent and consolidation chemoradiotherapies, the combination of etoposide and cisplatin is considered to be a standard chemotherapy regimen. To develop novel treatment for SCLC, several clinical trials of molecular-targeted therapy or immunotherapy have been reported. However, no molecular-targeted drug has shown clinical activity in limited-disease SCLC. In future studies, understanding the molecular profile of SCLC will be necessary for the development of molecular-targeted therapies for SCLC. This review provides an overview of chemotherapy regimens for limited-disease SCLC.
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Affiliation(s)
- Hirotsugu Kenmotsu
- Division of Thoracic Oncology, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka 411-8777, Japan
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Bakalos G, Miligkos M, Doxani C, Mpoulimari I, Rodopoulou P, Zintzaras E. Assessing the relative effectiveness and tolerability of treatments in small cell lung cancer: A network meta-analysis. Cancer Epidemiol 2013; 37:675-82. [DOI: 10.1016/j.canep.2013.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 02/01/2023]
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7
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Role of pulmonary resection in the diagnosis and treatment of limited-stage small cell lung cancer: revision of clinical diagnosis based on findings of resected specimen and its influence on survival. Gen Thorac Cardiovasc Surg 2012; 60:43-52. [DOI: 10.1007/s11748-011-0847-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 06/13/2011] [Indexed: 12/12/2022]
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8
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Pirker R, Berzinec P, Brincat S, Kasan P, Ostoros G, Pesek M, Plāte S, Purkalne G, Rooneem R, Skricková J, Stanculeanu D, Timcheva C, Tzekova V, Zakotnik B, Zielinski CC, Zwitter M. Therapy of small cell lung cancer with emphasis on oral topotecan. Lung Cancer 2010; 70:7-13. [PMID: 20576312 DOI: 10.1016/j.lungcan.2010.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/18/2010] [Accepted: 05/23/2010] [Indexed: 01/22/2023]
Abstract
Systemic chemotherapy plays the major role in the management of patients with small cell lung cancer. Cisplatin plus etoposide is the most widely used regimen and is considered as standard in patients with limited disease. Cisplatin plus irinotecan improved survival compared to cisplatin plus etoposide in a Japanese trial but failed to do so in two trials in Caucasians. Cisplatin plus topotecan had similar efficacy compared to cisplatin plus etoposide in patients with extensive disease. In the second-line setting, topotecan showed similar efficacy but better tolerability compared to cyclophosphamide, doxorubin plus vincristine. Oral topotecan was as efficacious as its intravenous formulation and was shown to improve survival compared to best supportive care alone in patients previously treated with chemotherapy. Thus topotecan is considered as the standard second-line chemotherapy in patients with small cell lung cancer.
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Affiliation(s)
- Robert Pirker
- Department of Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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Schreiber D, Rineer J, Weedon J, Vongtama D, Wortham A, Kim A, Han P, Choi K, Rotman M. Survival outcomes with the use of surgery in limited-stage small cell lung cancer: should its role be re-evaluated? Cancer 2010; 116:1350-7. [PMID: 20082453 DOI: 10.1002/cncr.24853] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although chemotherapy and radiation therapy currently are recommended in limited-stage small cell lung cancer (L-SCLC), several small series have reported favorable survival outcomes in patients who underwent surgical resection. The authors of this report used a US population-based database to determine survival outcomes of patients who underwent surgery. METHODS The Surveillance, Epidemiology, and End Results (SEER) registry was used to identify patients who were diagnosed with L-SCLC between 1988 and 2002 coded by SEER as localized disease (T1-T2Nx-N0) or regional disease (T3-T4Nx-N0). Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) for all patients. RESULTS In total, 14,179 patients were identified, including 863 patients who underwent surgical resection. Surgery was associated more commonly with T1/T2 disease (P < .001). Surgery was associated with improved survival for both localized disease and regional disease with improvements in median survival from 15 months to 42 months (P < .001) and from 12 months to 22 months (P < .001), respectively. Lobectomy was associated with the best outcome (P < .001). Patients with localized disease who underwent lobectomy with had a median survival of 65 months and a 5-year OS rate of 52.6%; whereas patients who had regional disease had a median survival of 25 months and a 5-year OS rate of 31.8%. On multivariate analysis, the benefit of surgery varied in a time-dependant fashion. However, the benefit of lobectomy remained across all time intervals (P = .002). CONCLUSIONS The use of surgery, and particularly lobectomy, in selected patients with L-SCLC was associated with improved survival outcomes. Future prospective studies should consider the role of surgery as part of the multimodality management of this disease.
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Affiliation(s)
- David Schreiber
- Department of Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, NY, USA.
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Riquet M, Le Pimpec Barthes F, Scotté F, Fabre E, Cazes A, Foucault C, Danel C. [Relevance of surgery in small cell lung cancer]. REVUE DE PNEUMOLOGIE CLINIQUE 2009; 65:129-135. [PMID: 19524800 DOI: 10.1016/j.pneumo.2009.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 02/13/2009] [Indexed: 05/27/2023]
Abstract
Surgery is the most effective treatment of lung cancer provided that there is complete resection. Even though the results in the early stages of small cell lung cancers (SCLC) are encouraging, many oncologists still consider SCLC a contra-indication. The authors report their experience. They retrospectively reviewed the clinical and pathological characteristics and long-term results of 104 patients (mean age: 58.6, male: N=82 and female: N=22) who underwent lung resection with mediastinal lymphadenectomy (lobectomy: N=51 and pneumonectomy: N=53) for small cell lung cancer between 1984 and 2006. The diagnosis was established before the operation in 49 patients (47.1%) of whom 61.2% (N=30) received neoadjuvant therapy. The survival (5-year survival rate 21.7%, median=18 months), postoperative mortality (deaths: N=6) included, depended on the stage: stage I: N=39, 5-year, 34.3%, median=29; stage II: N=23, 5-year, 26.1%, median=12; stage III: N=37, 5-year, 2.7%, median=12 (p=0.000067). There were no 5-year survivors among the N2 patients. The survival did not depend on the diagnostic aspect of the resection, the non-small cell lung cancer histological patterns or perioperative neoadjuvant and adjuvant therapy. The pneumonectomies were more frequent in case of neoadjuvant treatment (23/30 versus 30/47, p=0.00084). The results and the review of the literature indicate that surgery for small cell lung cancer may provide a cure in stages I and II and should not to be ruled out. The only contra-indication is proven pN2. A multicentre, randomised study on surgery versus medical treatment in the early stages should confirm this conclusion.
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Affiliation(s)
- M Riquet
- Université Paris-Descartes, France.
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11
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Jiang L, Yang KH, Mi DH, Liu YL, Tian JH, Ma B, Tan JY, Bai ZG. Safety of Irinotecan/Cisplatin Versus Etoposide/Cisplatin for Patients with Extensive-Stage Small-Cell Lung Cancer: A Metaanalysis. Clin Lung Cancer 2007; 8:497-501. [DOI: 10.3816/clc.2007.n.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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de Antonio DG, Alfageme F, Gámez P, Córdoba M, Varela A. Results of surgery in small cell carcinoma of the lung. Lung Cancer 2006; 52:299-304. [PMID: 16567022 DOI: 10.1016/j.lungcan.2006.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Revised: 01/18/2006] [Accepted: 01/23/2006] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The experiences published by various groups have re-opened the debate on the role of surgery in the management of patients with small cell lung cancer, especially in those with early stage disease (T1-T2 N0). Our study reports the survival rate of 47 patients with small cell lung cancer treated surgically. PATIENTS AND METHODS Ours is a prospective study that selected patients with lung cancer recommended for surgery (n=2994) between 1993 and 1997 based on operability criteria accepted by the Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery. We report the clinical as well as pathological stages of the patients with small cell lung cancer (n=47), later analysing the 5-year survival rate after surgery using the Kaplan-Meier method. RESULTS In 31 patients (66%), resection was complete; 3 patients (6%) received induction treatment and 30 (64%) adjuvant treatment. Five years later, 26% (95% CI 12-40%) of the patients that received surgical treatment were still alive. When we analysed the patients that underwent complete resection, 31% (95% CI 13-49%) survived 5 years or more. In patients at stage Ip (n=15), 36% (95% CI 11-61%) were still living after 5 years. CONCLUSION Until future studies compare surgery plus chemotherapy versus chemotherapy and radiotherapy, it seems reasonable to offer surgical treatment to those patients with early stage small cell lung cancer (T1-T2-N0).
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Affiliation(s)
- David Gómez de Antonio
- Hospital Universitario Puerta de Hierro, c/San Martin de Porres, 4 28035, Madrid, Spain.
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Affiliation(s)
- Michael Dusmet
- The Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
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Fennell DA. Bcl-2 as a target for overcoming chemoresistance in small-cell lung cancer. Clin Lung Cancer 2003; 4:307-13. [PMID: 14609451 DOI: 10.3816/clc.2003.n.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Small-cell lung cancer (SCLC) is an aggressive malignancy that is frequently metastatic at presentation and has a poor prognosis. Although initially sensitive to primary therapy, acquisition of apoptosis resistance is typical, resulting in failure of secondary chemotherapy following relapse. Expression of the antiapoptosis protein Bcl-2 is prevalent in SCLC. The understanding of this oncoprotein's function has increased dramatically over the past decade. In vitro and in vivo evidence supports a role for overexpression of Bcl-2 in SCLC and supports the notion that it is a major factor contributing to apoptosis resistance. Targeting Bcl-2 may provide a novel therapeutic approach to overcoming chemoresistance in SCLC. This article discusses the relevance of Bcl-2 to apoptosis susceptibility in SCLC and its exploitation using gene silencing to improve the clinical outcome in this disease.
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Affiliation(s)
- Dean A Fennell
- Lung Cancer Section, Department of Medical Oncology, St Bartholomew's Hospital, London, United Kingdom.
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Fujita K, Nishimura K, Nonomura N, Hirota S, Okuyama A. Early stage small cell carcinoma of the urinary bladder. Int J Urol 2001; 8:643-4. [PMID: 11903694 DOI: 10.1046/j.1442-2042.2001.00388.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 73-year-old man with primary small cell carcinoma of the bladder underwent radical cystectomy. The pathological findings revealed the tumor confined to the submucosal layer (pT1) without metastasis. No adjuvant chemotherapy was carried out. He is alive with no evidence of the disease 24 months after the operation.
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Affiliation(s)
- K Fujita
- Department of Urology, Osaka University Medical School, Osaka, Japan
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Cooper WA, Thourani VH, Gal AA, Lee RB, Mansour KA, Miller JI. The surgical spectrum of pulmonary neuroendocrine neoplasms. Chest 2001; 119:14-8. [PMID: 11157578 DOI: 10.1378/chest.119.1.14] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES The purpose of this study is to review our experience with the spectrum of neuroendocrine neoplasms of the lung with emphasis on the histopathologic classification and surgical therapy of each class of neoplasm. DESIGN This retrospective review covers the entire spectrum of neuroendocrine neoplasms of the lung over an 11-year period (January 1985 to December 1995) in a university hospital setting. Only patients who underwent surgical resection were included in this review. PATIENTS During this period, a total of 77 patients underwent lung resection for the following neuroendocrine neoplasms: typical carcinoid (TC), 50 patients; atypical carcinoid (AC), 5 patients; large cell neuroendocrine carcinoma (LCNEC), 9 patients; mixed large-small cell neuroendocrine carcinoma (LSNEC), 4 patients; or small cell neuroendocrine carcinoma (SCC), 9 patients. There were 37 men (48.1%) and 40 women (51.9%) among the patients, with a mean age of 57.9 years (range, 14 to 87 years). INTERVENTIONS Primary surgical resection consisted of the following procedures: 52 lobectomies (67.5%); 10 pneumonectomies (13%); 13 limited resections (16.9%); 1 left main bronchus sleeve resection; and 1 carinal resection. Six patients had the following concomitant procedures: pericardiectomy, 2 patients; mediastinoscopy, 1 patient; chest wall resection, 1 patient; stapling blebs, 1 patient; and transdiaphragmatic liver biopsy, 1 patient. Four patients underwent bilobectomies, and two patients underwent multiple wedge resections. RESULTS The hospital mortality rate was 2.6% (2 of 77 patients), and both patients died of pulmonary failure. Follow-up was obtained in 62 of 77 patients (80.9%) for an average of 38.1 months (range, 2 to 132 months). There were a total of 13 deaths, and 8 were disease-related (LCNEC, 4 deaths; SCC, 2 deaths; LSNEC, 1 death; and AC tumor, 1 death. The mean disease-free intervals for patients with these neoplasms were the following: TC tumor, 41.3 months; AC tumor, 20 months; LCNEC, 20.4 months; LSNEC, 25 months; and SCC, 48 months. The overall 3-year survival rate was 45.2% (28 of 62 patients). CONCLUSION This report will emphasize the classification, surgical management, and treatment considerations of pulmonary neuroendocrine neoplasms. Despite the poor overall prognosis in high-grade neuroendocrine tumors of the lung, surgery remains a viable adjunct in the early stages of this disease.
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Affiliation(s)
- W A Cooper
- General Thoracic Surgery Service, Section of Cardiothoracic Surgery, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
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Abstract
The role of surgery in small cell lung cancer (SCLC) is controversial. Surgery has several potential advantages because it may reduce the frequency of local relapses, it does not impede the intensity of chemotherapy, it does not affect the bone marrow, and surgical staging may be of prognostic significance. Several smaller retrospective studies which focus on surgery alone, surgery with adjuvant chemotherapy or radiotherapy, or chemotherapy followed by adjuvant surgery have been reported. Five-year survival data have ranged from 10-50% according to stage, both T-status and nodal status appearing to be significant prognostic factors. Only one prospective randomized trial has been reported concerning the addition of surgery to chemotherapy alone. This trial does not favour surgery. The reason for this could be a selection bias in the smaller non-randomized studies or a result of stage migration. Nevertheless, surgery may yet play an important role in SCLC, especially in diagnosis and staging, and with new improved non-invasive staging procedures, such as positron emission tomography, resection may lead to cure in selected patients. Prospective randomized studies are needed to settle this issue.
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Affiliation(s)
- U Lassen
- Finsen Center, Department of Oncology, National University Hospital, 9 Blegdamsvej, Copenhagen, DK-2100, Denmark
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18
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Hage R, Elbers JR, Brutel de la Rivière A, van den Bosch JM. Surgery for combined type small cell lung carcinoma. Thorax 1998; 53:450-3. [PMID: 9713442 PMCID: PMC1745233 DOI: 10.1136/thx.53.6.450] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Combined type small cell lung cancer (SCLC) has been reported to occur in, at most, 1% of all cases of SCLC. These tumours consist of SCLC with a component of squamous cell carcinoma and/or adenocarcinoma. The survival of patients with combined and pure SCLC after surgical resection was assessed. METHODS From 1977 to 1994 2115 patients with bronchogenic carcinoma underwent pulmonary resection. From this group 26 patients (1.2%) were diagnosed as having combined SCLC and 74 patients (3.5%) as having pure SCLC. RESULTS From the 26 patients with combined SCLC (mean age 66.4 years) three were classified as pT1N0M0, eight as pT2N0M0, four as postoperative stage II, and 11 as postoperative stage III. Histological examination showed a component of squamous cell carcinoma in 21 patients. There were 18 (69%) lobectomies, seven (27%) pneumonectomies, and one (4%) segmentectomy. In all patients surgery was thought to be curative. Overall hospital mortality was 4% (n = 1). Cumulative five year survival was 31% for all hospital survivors with combined SCLC postoperative stage I, 50% for those with pT1N0M0, and 25% for those with pT2N0M0 disease. No patients with postoperative stage II and III disease survived for five years. In the 74 patients with pure SCLC hospital mortality was 3% (n = 2); cumulative five year survival was 39% in patients with postoperative stage I disease, 46% for those with pT1N0M0 and 35% for those with pT2N0M0. When compared with pure SCLC, no significant differences in five year survival were evident in patients with postoperative stage I disease. CONCLUSIONS Surgical resection in patients with combined SCLC postoperative stage I yields a cumulative five year survival of 31% while for those with stage II and III disease there were no survivors at five years. In patients with stage I combined or pure SCLC surgery can offer a long term disease free interval or may even be curative.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/surgery
- Aged
- Aged, 80 and over
- Carcinoma, Small Cell/mortality
- Carcinoma, Small Cell/pathology
- Carcinoma, Small Cell/surgery
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/surgery
- Female
- Humans
- Lung Neoplasms/mortality
- Lung Neoplasms/pathology
- Lung Neoplasms/surgery
- Male
- Middle Aged
- Neoplasm Staging
- Neoplasms, Multiple Primary/mortality
- Neoplasms, Multiple Primary/pathology
- Neoplasms, Multiple Primary/surgery
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- R Hage
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
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19
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20
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Maestu I, Pastor M, Gómez-Codina J, Aparicio J, Oltra A, Herranz C, Montalar J, Munárriz B, Reynés G. Pretreatment prognostic factors for survival in small-cell lung cancer: a new prognostic index and validation of three known prognostic indices on 341 patients. Ann Oncol 1997; 8:547-53. [PMID: 9261523 DOI: 10.1023/a:1008212826956] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIMS a) To identify which pretreatment clinical or blood parameters were predictive of patients survival in small-cell lung cancer (SCLC) in a retrospective analysis. b) To validate three known prognostic indices: Royal Marsden Model (index 1), London Group (index 2) and Manchester Score (index 3). PATIENTS AND METHODS From 1981 to 1993, 341 SCLC patients were treated with chemotherapy with or without surgery or radiotherapy. Univariate and multiple regression analyses of survival were performed and the feasibility of these models was explored, index 1: Karnofsky index, albumin, sodium and alkaline phosphatase; index 2: ECOG performance status (PS), albumin and alanine transaminase; and index 3; lactate dehydrogenase (LDH), disease extent, sodium, Karnofsky index, alkaline phosphatase and bicarbonate. RESULTS Significant prognostic factors for survival after univariate and multiple regression analysis were: disease extent, PS, creatine kinase, neutrophilia, LDH, hypoalbuminemia, hyperglycemia and bicarbonate. A new prognostic index was performed that included LDH, hypoalbuminemia, neutrophilia, disease extent and PS. It defined three prognostic groups (PG). Median survival and two-year survival for these PG were 12.3, 8 and 3.4 months and 16.5%, 2.3% and 0%, respectively. The following PG were identified after application of the three models proposed: Index 1 identified two PG with 0% and 16.6% two-year survival (P < 0.001); index 2 detected three PG with 0%, 5% and 15.7% two-year survival (P < 0.001) and index 3 detected three PG with 0%, 2.5% and 16.2% two-year survivals, respectively (P < 0.001). CONCLUSION A new prognostic index is proposed allowing identification of three different PG. The feasibility of three known prognostic models was validated and demonstrated. Variables other than disease extent or PS (albumin or LDH) should be taken into account in designing future clinical trials.
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Affiliation(s)
- I Maestu
- Medical Oncology Department, University Hospital La Fe, Valencia, Spain
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21
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Colder CD, Postmus PE. The role of surgery in small-cell lung cancer: a case history. Ann Oncol 1996; 7:303-9. [PMID: 8740796 DOI: 10.1093/oxfordjournals.annonc.a010576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- C D Colder
- Department of Pulmonology, Free University Hospital, Amsterdam, The Netherlands
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Valli M, Fabris GA, Dewar A, Hornall D, Sheppard MN. Atypical carcinoid tumour of the lung: a study of 33 cases with prognostic features. Histopathology 1994; 24:363-9. [PMID: 8045525 DOI: 10.1111/j.1365-2559.1994.tb00538.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Atypical carcinoids of the lung (well-differentiated neuroendocrine carcinomas) are rare tumours of uncertain prognosis. We have studied 33 cases--male to female ratio 2:1, age range 22-75 years, mean 55 years, 80% smokers, 15 peripheral and 18 central, tumour size 1.2-9.5 cm. Microscopically they had a nesting/insular, trabecular or lobular pattern. Nuclear morphology was variable, round cells, large cells and spindle cells being identified with small cell areas in five tumours. Mitotic activity varied from 4 to 80 per 1.52 mm2. Areas of necrosis were seen in all tumours. All 33 tumours were cytokeratin positive (AE1/AE3 and CAM5.2), 32 were positive for neuron-specific enolase, synaptophysin and chromogranin A. Electronmicroscopy showed dense core granules in 29 available cases. Nineteen cases were stage I, nine stage II, four stage III and one stage IV. Follow-up information was available for 22 cases. Size, location, stage and large cell/small cell morphology were important prognostic indicators. Large tumour size, large cell or mixed large cell/small cell morphology, peripheral localization and advanced stage were adverse prognostic indicators. Mitotic activity and the presence of necrosis did not appear to influence stage or behaviour.
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Affiliation(s)
- M Valli
- Department of Histopathology, University of Ancona, Italy
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23
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Smit EF, Groen HJ, Timens W, de Boer WJ, Postmus PE. Surgical resection for small cell carcinoma of the lung: a retrospective study. Thorax 1994; 49:20-2. [PMID: 8153935 PMCID: PMC474078 DOI: 10.1136/thx.49.1.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND A retrospective review was undertaken of the survival of 21 patients with histologically proven small cell carcinoma of the lung resected between 1977 and 1991. METHODS Twenty one patients (20 men) of median age 60 (range 44-73) years underwent surgical resection. Patients were subjected to standard clinical staging procedures. Preoperative diagnosis was small cell carcinoma of the lung in 13, non-small cell lung cancer in one, and uncertain in seven patients. Clinical staging was stage I disease in 11 and stage II in 10 patients. RESULTS Resection included pneumonectomy in 12 cases, lobectomy in eight, and one wedge resection. Resection was complete in 16 patients. Postoperative histopathological examination confirmed small cell carcinoma of the lung in 19 specimens and mixed small cell and non-small cell carcinoma of the lung in two. Pathological staging was stage I in 11, stage II in three, and stage III in seven patients. The final pathological diagnosis of the resected specimens (n = 18) was atypical carcinoid in one, pure small cell carcinoma of the lung in 15, and mixed small cell and non-small cell carcinoma of the lung in two patients. Fourteen patients also received chemotherapy and 10 received prophylactic cranial irradiation postoperatively. Excluding the patient with a final diagnosis of atypical carcinoid, the median survival (n = 20) was 29 months (range two to 133+). Median survival for patients with pathological stage I and II disease (n = 13) was 40 months (range nine to 133+) and for patients with pathological stage III disease (n = 7) 20 months (range two to 116+). The median disease free survival was 23 months. Eleven patients relapsed between two and 101 months. There was no advantage for those patients who received postoperative chemotherapy. CONCLUSION Curative resection offers the best chance for long term survival in patients with small cell carcinoma of the lung with very limited stage disease.
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Affiliation(s)
- E F Smit
- Department of Pulmonary Diseases, University Hospital, Groningen, The Netherlands
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24
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Abstract
The treatment of choice for most cases of non-small-cell lung cancer is surgical resection; however, which patients with stage IIIA disease are surgical candidates is debatable. For many patients with stage IIIA or IIIB disease, the preferred modality is thoracic radiotherapy. In several randomized prospective trials, the addition of chemotherapy to thoracic radiotherapy produced a significant but clinically small survival advantage over radiotherapy alone. For patients with stage IV lung cancer, no curative treatment or "standard therapy" is available. Accordingly, many patients are offered investigational agents in phase I or II clinical trials. Small-cell lung cancer has a 60 to 90% rate of initial response to available chemotherapeutic agents. Patients with limited disease are generally given combination chemotherapy and thoracic radiotherapy, approximately 50% of whom have a complete clinical remission. Patients with extensive disease (spread beyond one radiation port) also have a high rate of initial response to chemotherapy, but only 20 to 40% have a complete remission and few survive for 5 years. New agents are being tested in previously untreated patients with extensive small-cell lung cancer. Promising new chemotherapeutic agents for lung cancer are being studied in clinical trials. Currently, only 1% of patients with lung cancer in the United States are enrolled in prospective clinical trials. Primary-care physicians are urged to encourage their patients to consider participation in approved prospective clinical trials at reputable medical centers, in an effort to discover new, effective agents with novel mechanisms of action. Information about such studies is available through Physician Desk Query (PDQ) or the cancer hotline (1-800-4-CANCER).
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Affiliation(s)
- J R Jett
- Division of Thoracic Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
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27
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Abstract
A total of 351 previously untreated patients presented to this department with limited small cell bronchogenic carcinoma between 1974 and 1985. They were treated with either radical or palliative radiotherapy (152), chemotherapy alone (63), or combined chemoradiotherapy (136). Their 5-year survival rates were 2.6%, 0%, and 5.1% with median survival being 25.7, 29.0 and 47.4 weeks, respectively. Forty-seven patients were given radical radiotherapy, 30 of these received chemotherapy as initial treatment (20), as adjuvant (3) or at relapse (7). Their 5-year survival rate was 12.8%, with a median of 58 weeks, compared with 2.1% and 31.5 weeks for 241 patients who had palliative radiotherapy (P < 0.001). Seventeen of the 47 patients (36%) and 135 of the 241 patients (56%) were given radiotherapy alone. Univariate analysis showed that gender and age had no significant influence on survival but lymph node status did. The median survival for patients who had no lymph node metastases was 37 weeks compared with 24.5 for those who had (P < 0.01). The median and long-term survival rates for patients in this report contradict previous reports that radiotherapy has no influence on survival. Only patients who received radiotherapy, either alone, or with chemotherapy, have survived 5 years.
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Affiliation(s)
- G A Newaishy
- Department of Clinical Oncology, Western General Hospital, Edinburgh, UK
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Müller LC, Salzer GM, Huber H, Prior C, Ebner I, Frommhold H, Präuer HW. Multimodal therapy of small cell lung cancer in TNM stages I through IIIa. Ann Thorac Surg 1992; 54:493-7. [PMID: 1324655 DOI: 10.1016/0003-4975(92)90441-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Since 1977, Innsbruck University Hospital has been employing a multimodal therapy concept for small cell bronchial carcinomas in stages I to IIIa. This concept includes all three treatment forms effective in this tumor, namely, chemotherapy, surgery, and radiotherapy. The therapy scheme is stage-dependent and begins in stages T1-3 N0-1 with lung resection and in stage N2 with chemotherapy. To date, 45 patients have been included in a prospective, nonrandomized (phase II) trial: 7 in TNM stage I, 11 in stage II, and 27 in stage IIIa (6 T3 and 21 N2). The actuarial 5-year survival rate of the entire group (including therapy-related lethality, early recurrences, and protocol violations) is 36%; it is 57% for those in stage I, 28% for those in stage II, and 34% for those in stage IIIa. Median survival time is 18 months. Patients with completed multimodal treatment have a 5-year survival rate of 56% regardless of disease stage. Three patients died of tumor-unrelated causes after 47, 52, and 54 months.
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Affiliation(s)
- L C Müller
- Department of Surgery II, University of Innsbruck, Austria
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Shah SS, Thompson J, Goldstraw P. Results of operation without adjuvant therapy in the treatment of small cell lung cancer. Ann Thorac Surg 1992; 54:498-501. [PMID: 1324656 DOI: 10.1016/0003-4975(92)90442-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The role of surgery in the treatment of small cell lung cancer remains a subject of debate. We carried out a retrospective review of 87 patients with small cell lung cancer referred to one surgeon for staging and treatment. Thirty patients (34.5%) were deemed suitable for thoracotomy. Fourteen patients had stage I disease, 5 patients had stage II disease, and 11 patients had stage III disease. Twenty-eight of the 30 patients (93.3%) went on to have surgical resection. The actual overall 5-year survival in all patients who underwent thoracotomy was 43.3%. The actual 5-year survival for patients in stages I and III was 57.1% and 55.5%, respectively. No patients with stage II disease survived 5 years. We conclude that there is a small group of patients with small cell lung cancer in whom, with careful preoperative staging, the prospects of cure by operation are similar to those with non-small lung cancer.
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Affiliation(s)
- S S Shah
- Department of Thoracic Surgery, Royal Brompton National Heart & Lung Hospitals, London, England
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Carey FA, Prasad US, Walker WS, Cameron EW, Lamb D, Bird CC. Prognostic significance of tumor deoxyribonucleic acid content in surgically resected small-cell carcinoma of lung. J Thorac Cardiovasc Surg 1992. [DOI: 10.1016/s0022-5223(19)34890-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- M N Sheppard
- Department of Lung Pathology, National Heart and Lung Institute, Royal Brompton National Heart and Lung Hospital, London
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Affiliation(s)
- C F Moutain
- Department of Thoracic Surgery, University of Texas M.D. Anderson Cancer Center, Houston 77030
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Abstract
The solitary pulmonary nodule (SPN), a single intrapulmonary spherical lesion that is fairly well circumscribed, is a common clinical problem. About half of SPNs seen in clinical practice are malignant, usually bronchogenic carcinomas. Some nodules are primary tumors of other kinds or metastatic. Virtually all benign SPNs are tuberculous or fungal granulomas. The standard management of the SPN of unknown cause is prompt surgical removal unless benignity is established by prior chest roentgenograms showing that the nodule has been stable (i.e., showing no growth) for 2 years or by the presence of a "benign" pattern of calcification. Less universally accepted criteria for benignity include (1) transthoracic needle aspiration biopsy (TNAB) showing a specific benign process, and (2) patient's age under 30 to 35 years. Bronchoscopy has a low diagnostic yield, particularly for benign nodules. SPNs usually grow at constant rates, expressed as the "doubling time" (DT). A nodule with a DT between 20 and 400 days is usually malignant. Benign nodules usually have a DT greater than 400 days. The prospective determination of DT by serial chest roentgenograms (the "wait and watch" strategy) is widely criticized but has clinical utility in special circumstances, particularly if the likelihood of malignancy is low and/or the anticipated surgical mortality is high. The presence and pattern of calcification are best shown by high-resolution thin-section computed tomography (CT). Diffuse, laminated, central or "popcorn" patterns of calcification indicate benignity. An eccentric calcium deposit or a stippled pattern does not rule out malignancy. CT densitometry will often show "occult" calcification in nodules that show no direct visual evidence of calcium deposition. The characteristics of the edge of the nodule correlate with the likelihood of malignancy. Nodules with irregular or spiculated margins are almost always malignant. The probability that the nodule is malignant (pCA) is related to the age of the patient, the diameter of the nodule, the amount of tobacco smoke inhalation, the overall prevalence of malignancy in SPNs, the nature of the edge of the lesion, and the presence or absence of occult calcification. It is possible by Bayesian techniques to combine these factors to calculate a more precise and comprehensive prediction of pCA in any given nodule. The 5-year survival after nodule resection depends on the size of the nodule at the time of surgery; it may be as high as 80% with nodules that are 1 cm in diameter. Lymph node involvement is uncommon with small tumors, and many authorities question the need for CT staging in such cases.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- G A Lillington
- Department of Internal Medicine, University of California, Davis, Medical Center, Sacramento
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Morris JF, Krishnamurthy S, Antonovic R, Duncan C, Turner FE, Krishnamurthy GT. Technetium-99m monoclonal antibody fragment (Fab) scintigraphy in the evaluation of small cell lung cancer: a preliminary report. INTERNATIONAL JOURNAL OF RADIATION APPLICATIONS AND INSTRUMENTATION. PART B, NUCLEAR MEDICINE AND BIOLOGY 1991; 18:613-20. [PMID: 1660451 DOI: 10.1016/0883-2897(91)90031-f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Small cell lung cancer (SCC) has the most rapid growth rate of the four cell types and metastasizes early. Present imaging modalities for staging include chest x-ray, CT, MRI and bone scans. In this preliminary study, we assessed the clinical role of 99mTc-monoclonal antibody (MOAB) scintigraphy in five patients with histologically proven SCC. Each patient was infused with 20-30 mCi of 99mTc labeled Fab fragment of MOAB (NR-LU-10, NeoRx, Seattle, Wash.). Total body simultaneous anterior and posterior images were obtained 14-16 h post injection. SPECT images of the chest were obtained through a 360 degrees rotation of the gamma camera and recorded on a 62 x 64 x 16 matrix. Images (1.2 cm thick) were generated in transaxial, sagittal and coronal views. Fourteen of fifteen chest lesions detected by CT were confirmed by 99mTc MOAB scintigraphy. Scintigraphy detected one additional chest lesion not seen by CT. Scintigraphy failed to detect a brain lesion (2 cm), a chest lesion, and two adrenal lesions, all of which were seen by CT. In one patient with multiple (more than 10) lesions in the liver, both scintigraphy and CT detected all lesions. Three spine lesions seen on 99mTc MDP scan and positive for metastasis on MRI concentrated 99mTc MOAB, but two rib lesions seen on 99mTc MDP bone scan did not concentrate 99mTc MOAB. It is concluded from these preliminary results that the potential usefulness of 99mTc MOAB scintigraphy as a complementary imaging modality in the staging of small cell lung cancer should be investigated further.
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Affiliation(s)
- J F Morris
- Pulmonary Disease Section, Veterans Administration Medical Center, Portland, OR 97207
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Sánchez de Cos Escuín J, Masa Jiménez F, de la Cruz Ríos J, Martínez Verdasco A. Poliquimioterapia secuencial (carboplatino/vp-16) versus alternante (carboplatino/vp-16 y ciclofosfamida/vincristina/adriamicina) en el carcinoma microcítico de pulmón. Arch Bronconeumol 1990. [DOI: 10.1016/s0300-2896(15)31572-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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36
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Sharples PM. Death of children with head injury: Author's reply. West J Med 1990. [DOI: 10.1136/bmj.300.6723.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Pigott TJD, Lowe JS. Death of children with head injury. West J Med 1990. [DOI: 10.1136/bmj.300.6723.534-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sheppard MN. Small cell lung cancer. West J Med 1990. [DOI: 10.1136/bmj.300.6723.535-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Small cell lung cancer. BMJ (CLINICAL RESEARCH ED.) 1990; 300:535. [PMID: 2156589 PMCID: PMC1662297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Small cell lung cancer. West J Med 1990. [DOI: 10.1136/bmj.300.6723.535-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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