Low diffusion capacity predicts poor prognosis in extensive stage small cell lung cancer: a single-center analysis of 10 years

BACKGROUND

Poor pulmonary function and chronic obstructive pulmonary disease (COPD) are associated with poorer overall survival (OS) in non-small-cell lung cancer (NSCLC) patients. Few studies have investigated the association between pulmonary function and OS in small-cell lung cancer (SCLC) patients. We compared the clinical characteristics of extensive disease SCLC (ED-SCLC) with or without moderately impaired diffusion capacity for carbon monoxide (DLco) and investigated the factors associated with survival in ED-SCLC patients.

METHODS

This retrospective single-center study was performed between January 2011 and December 2020. Of the 307 SCLC patients who received cancer therapy during the study, 142 with ED-SCLC were analyzed. The patients were divided into DLco < 60% group and DLco ≥ 60% groups. OS and predictors of poor OS were analyzed.

RESULTS

The median OS of the 142 ED-SCLC patients was 9.3 months and the median age was 68 years. In total, 129 (90.8%) patients had a history of smoking, and 60 (42.3%) had COPD. Thirty-five (24.6%) patients were assigned to the DLco < 60% group. Multivariate analysis revealed that DLco < 60% (odds ratio [OR], 1.609; 95% confidence interval [CI], 1.062-2.437; P = 0.025), number of metastases (OR, 1.488; 95% CI, 1.262-1.756; P < 0.001), and < 4 cycles of first-line chemotherapy (OR, 3.793; 95% CI, 2.530-5.686; P < 0.001) were associated with poor OS. Forty (28.2%) patients received < 4 cycles of first-line chemotherapy; the most common reason for this was death (n = 22, 55%) from grade 4 febrile neutropenia (n = 15), infection (n = 5), or massive hemoptysis (n = 2). The DLco < 60% group had a shorter median OS than the DLco ≥ 60% group (10.6 ± 0.8 vs. 4.9 ± 0.9 months, P = 0.003).

CONCLUSIONS

In this study, approximately one quarter of the ED-SCLC patients had DLco < 60%. Low DLco (but not forced expiratory volume in 1 s or forced vital capacity), a large number of metastases, and < 4 cycles of first-line chemotherapy were independent risk factors for poor survival outcomes in patients with ED-SCLC.

Five-Year Overall Survival and Prognostic Factors in Patients with Lung Cancer: Results from the Korean Association of Lung Cancer Registry (KALC-R) 2015

PURPOSE

This study aimed to provide the clinical characteristics, prognostic factors, and 5-year relative survival rates of lung cancer diagnosed in 2015.

MATERIALS AND METHODS

The demographic risk factors of lung cancer were calculated using the KALC-R (Korean Association of Lung Cancer Registry) cohort in 2015, with survival follow-up until December 31, 2020. The 5-year relative survival rates were estimated using Ederer II methods, and the general population data used the death rate adjusted for sex and age published by the Korea Statistical Information Service from 2015 to 2020.

RESULTS

We enrolled 2,657 patients with lung cancer who were diagnosed in South Korea in 2015. Of all patients, 2,098 (79.0%) were diagnosed with non-small cell lung cancer (NSCLC) and 345 (13.0%) were diagnosed with small cell lung cancer (SCLC), respectively. Old age, poor performance status, and advanced clinical stage were independent risk factors for both NSCLC and SCLC. In addition, the 5-year relative survival rate declined with advanced stage in both NSCLC (82%, 59%, 16%, 10% as the stage progressed) and SCLC (16%, 4% as the stage progressed). In patients with stage IV adenocarcinoma, the 5-year relative survival rate was higher in the presence of epidermal growth factor receptor (EGFR) mutation (19% vs. 11%) or anaplastic lymphoma kinase (ALK) translocation (38% vs. 11%).

CONCLUSION

In this Korean nationwide survey, the 5-year relative survival rates of NSCLC were 82% at stage I, 59% at stage II, 16% at stage III, and 10% at stage IV, and the 5-year relative survival rates of SCLC were 16% in cases with limited disease, and 4% in cases with extensive disease.

Small-Cell Lung Cancer Long-Term Survivor Patients: How to Find a Needle in a Haystack?

Small-cell lung cancer (SCLC) is an aggressive malignancy characterized by a rapid progression and a high resistance to treatments. Unlike other solid tumors, there has been a scarce improvement in emerging treatments and survival during the last years. A better understanding of SCLC biology has allowed for the establishment of a molecular classification based on four transcription factors, and certain therapeutic vulnerabilities have been proposed. The universal inactivation of TP53 and RB1, along with the absence of mutations in known targetable oncogenes, has hampered the development of targeted therapies. On the other hand, the immunosuppressive microenvironment makes the success of immune checkpoint inhibitors (ICIs), which have achieved a modest improvement in overall survival in patients with extensive disease, difficult. Currently, atezolizumab or durvalumab, in combination with platinum–etoposide chemotherapy, is the standard of care in first-line setting. However, the magnitude of the benefit is scarce and no predictive biomarkers of response have yet been established. In this review, we describe SCLC biology and molecular classification, examine the SCLC tumor microenvironment and the challenges of predictive biomarkers of response to new treatments, and, finally, assess clinical and molecular characteristics of long-term survivor patients in order to identify possible prognostic factors and treatment vulnerabilities.

Clinical outcomes of extensive-stage small cell lung cancer patients treated with thoracic radiotherapy at different times and fractionations

Objective

The purpose of this study was to assess whether thoracic radiotherapy (TRT) combined with chemotherapy (CHT) showed promising anti-tumour activity in extensive-stage small cell lung cancer (ES-SCLC), to explore practice patterns for the radiation time and dose/fractionation and to identify prognostic factors for patients who would benefit from CHT/TRT.

Methods

A total of 492 ES-SCLC patients were included from January 2010 to March 2019, 244 of whom received CHT/TRT. Propensity score matching was performed to minimize bias between the CHT/TRT and CHT-alone groups. Patients in the CHT/TRT group were categorized into four subgroups based on the number of induction CHT cycles. For effective dose fractionation calculations, we introduced the time-adjusted biological effective dose (tBED). Categorical variables were analysed with chi-square tests and Fisher’s exact tests. Kaplan–Meier curves were generated to estimate survival rates using the R-project. Multivariate prognostic analysis was performed with Cox proportional hazards models.

Results

Patients who received CHT/TRT experienced improved overall survival (OS) (18.1 vs 10.8 months), progression-free survival (PFS) (9.3 vs 6.0 months) and local recurrence-free survival (LRFS) (12.0 vs 6.6 months) before matching, with similar results after matching. In the CHT/TRT group, the median LRFS times for the groups based on the radiation time were 12.7, 12.0, 12.0, and 9.0 months, respectively. Early TRT had a tendency to prolong PFS (median 10.6 vs 9.8 vs 9.0 vs 7.7 months, respectively, p = 0.091) but not OS (median 17.6 vs 19.5 vs 17.2 vs 19.0 months, respectively, p = 0.622). Notably, patients who received TRT within 6 cycles of CHT experienced prolonged LRFS (p = 0.001). Regarding the radiation dose, patients in the high-dose group (tBED > 50 Gy) who achieved complete response and partial response (CR and PR) to systemic therapy had relatively short OS (median 27.1 vs 22.7, p = 0.026) and PFS (median 11.4 vs 11.2, p = 0.032), but the abovementioned results were not obtained after the exclusion of patients who received hyperfractionated radiotherapy (all p > 0.05).

Conclusion

CHT/TRT could improve survival for ES-SCLC patients. TRT performed within 6 cycles of CHT and hyperfractionated radiotherapy (45 Gy in 30 fractions) may be a feasible treatment scheme for ES-SCLC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01773-x.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Refining Prognosis in Lung Cancer: A Report on the Quality and Relevance of Clinical Prognostic Tools

INTRODUCTION

Accurate, individualized prognostication for lung cancer patients requires the integration of standard patient and pathologic factors, biological, genetic, and other molecular characteristics of the tumor. Clinical prognostic tools aim to aggregate information on an individual patient to predict disease outcomes such as overall survival, but little is known about their clinical utility and accuracy in lung cancer.

METHODS

A systematic search of the scientific literature for clinical prognostic tools in lung cancer published from January 1, 1996 to January 27, 2015 was performed. In addition, web-based resources were searched. A priori criteria determined by the Molecular Modellers Working Group of the American Joint Committee on Cancer were used to investigate the quality and usefulness of tools. Criteria included clinical presentation, model development approaches, validation strategies, and performance metrics.

RESULTS

Thirty-two prognostic tools were identified. Patients with metastases were the most frequently considered population in non-small-cell lung cancer. All tools for small-cell lung cancer covered that entire patient population. Included prognostic factors varied considerably across tools. Internal validity was not formally evaluated for most tools and only 11 were evaluated for external validity. Two key considerations were highlighted for tool development: identification of an explicit purpose related to a relevant clinical population and clear decision points and prioritized inclusion of established prognostic factors over emerging factors.

CONCLUSIONS

Prognostic tools will contribute more meaningfully to the practice of personalized medicine if better study design and analysis approaches are used in their development and validation.

Retrospective analysis of outcomes and prognostic factors of chemotherapy for small-cell lung cancer

BACKGROUND

Small-cell lung cancer (SCLC) is responsive to initial chemotherapy but becomes resistant to cytotoxic drugs. The aim of this study was to evaluate what proportion of patients with SCLC had received the first- and further-line chemotherapy and which patients had benefited from chemotherapy.

METHODS

We retrospectively reviewed medical records of patients with SCLC who had been treated with the best supportive care alone and the first-, second-, or third-line chemotherapy at the Osaka Police Hospital from June 2007 until March 2015.

RESULTS

Among 145 patients diagnosed with SCLC and eligible for analysis, 118 patients received chemotherapy. We added five patients who initiated the second-line chemotherapy during the study period at our institution. Sixty-five and 31 patients received the second- and third-line chemotherapies, respectively. Multivariate logistic regression analysis detected age ≥75 years (odds ratio, 2.80; 95% confidence interval, 1.01-7.75; P=0.047) and European Clinical Oncology Group Performance Status (ECOG PS) 3-4 (14.3; 4.86-41.9; P<0.01) as factors disturbing the introduction of chemotherapy. Multivariate Cox hazard analyses also detected ECOG PS 2-4 (3.34; 2.00-5.58; P<0.01) as a factor decreasing overall survival after the first-line chemotherapy, and C-reactive protein level ≥1.0 mg/dL (2.67; 1.30-5.47; P<0.01) and progression-free survival after the first-line chemotherapy ≥6 months (2.85; 1.50-5.43; P<0.01) as factors influencing overall survival after the second-line chemotherapy.

CONCLUSION

Approximately two-thirds and one-third of the patients who receive chemotherapy proceed to the second- and third-line chemotherapies, respectively. Several factors, such as age, ECOG PS, C-reactive protein level, and progression-free survival after previous treatment may be useful when considering the introduction of further-line chemotherapy.

Prognostic significance of standardised uptake value (SUVmax ) measured on 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with small cell lung cancer

Certain prognostic factors for small cell lung cancer (SCLC) have been validated, but the prognostic role of 18F-FDG PET/CT still remains unclear. The aim of this study was to evaluate the prognostic significance of 18F-FDG PET/CT in patients with SCLC. We reviewed 142 patients with pathologically proven SCLC who underwent pre-treatment 18F-FDG PET/CT. Standardised uptake value (SUV_max ) and other potential prognostic variables were chosen for analysis. The mean age of the study population was 58.2 ± 10.1 years (range, 25-84), and 124 (87.3%) patients were men. The median SUV_max value was 11.6 (4.0-29.3). Among the variables included in the univariate analysis, performance status (P = 0.001), disease stage (P < 0.001), administration of thoracic radiotherapy (TRT; P < 0.001), albumin level (P = 0.030) and LDH level (P < 0.001) showed prognostic significance. Further, multivariate analysis showed that performance status (P = 0.007), albumin level (P = 0.002), LDH level (P < 0.001) and administration of TRT (P = 0.001) were independent prognostic factors for survival. In conclusion, performance status, TRT, LDH level and albumin level were identified as important prognostic factors, while 18F-FDG PET/CT uptake of the primary lesions did not have any prognostic significance for survival in patients with SCLC.

Syndrome of Inappropriate Antidiuretic Hormone Secretion: A Poor Prognosis in Small-cell Lung Cancer

BACKGROUND AND AIMS

Small cell lung cancer (SCLC) is frequently associated with syndrome of inappropriate antidiuretic hormone (SIADH) secretion. In this study we investigated the prognostic value of SIADH in Chinese patients with SCLC.

METHODS

We prospectively studied a total of 385 patients with SCLC diagnosed in our institution. The relationship between the SIADH and treatment outcomes including progression-free survival (PFS) and overall survival (OS) were analyzed. Univariate analysis and Cox multivariate analyses were used for statistical analyses. PFS and OS curves were drawn using Kaplan-Meier method.

RESULTS

The median PFS and OS in patients with SIADH was 6.7 months (95% confidence interval [CI]: 4.3-9.1) and 11.6 months (95% CI: 7.4-15.7), respectively. The corresponding PFS and OS in SCLC without SIADH was 9.2 months (95% CI: 8.6-9.8) and 19.2 months (95% CI: 16.5-21.9), respectively; the difference between groups was statistically significant (p = 0.007 and p = 0.000, respectively). The association of SIADH with poor PFS (p = 0.000) and OS (p = 0.002) retained its statistical significance after adjusting for potential confounding variables. In addition, PFS (p = 0.000) and OS (p = 0.000) of SIAHD patients with plasma sodium <125 mmol/L or without plasma sodium recovery to normal level are both shorter than in patients without SIADH. OS in SIAHD patients with plasma sodium recovery time to normal level is also shorter than patients without SIADH (p = 0.03).

CONCLUSIONS

SIADH is a common occurrence in patients with SCLC and is associated with poor prognosis for SCLC in Chinese patients.

Myc protein expression correlates with MYC amplification in small-cell lung carcinoma

AIMS

Myc family members are important contributors to oncogenesis in a variety of tumours. Identification of therapeutic targets is needed in small-cell lung carcinoma (SCLC), an aggressive disease with limited treatment options. Sequencing studies have identified MYC amplification in 2-7% of SCLCs. This study aims to determine the rate of MYC gene amplification and its correlation with Myc protein overexpression in SCLC.

METHODS AND RESULTS

One hundred and three cases of formalin-fixed, paraffin-embedded SCLC were examined. Myc protein expression was scored according to the extent of immunohistochemical staining. MYC copy number (CN) was evaluated with dual-colour chromogenic in-situ hybridization (CISH) for the MYC locus and a chromosome 8 (Chr8) centromeric control. Amplification was defined as a MYC/Chr8 ratio of ≥2. Thirty-eight per cent of SCLCs had some degree of Myc protein expression, and 9% of cases were MYC-amplified. MYC CN was significantly correlated with the extent of Myc protein expression (Spearman's ρ = 0.57, P < 0.01). There was no significant association between Myc expression or CN and clinicopathological features.

CONCLUSIONS

MYC amplification by CISH was identified in 9% of SCLCs, and correlated with protein expression. As novel Myc-targeted therapies are developed, CISH and IHC should be considered as biomarkers of Myc pathway dysregulation in SCLC.

The clinical impact of the sum of the maximum standardized uptake value on the pretreatment with F-FDG-PET/CT in small-cell lung cancer

OBJECTIVES

The aim of this study was to investigate the clinical significance of the sum of the maximum standardized uptake value (sumSUVmax) on pretreatment positron emission tomography/computed tomography ((18)F-FDG-PET/CT) in newly diagnosed small-cell lung cancer (SCLC).

METHODS

We retrospectively analyzed 145 SCLC patients from March 2005 to June 2013 who underwent pretreatment (18)F-FDG-PET/CT. The sumSUVmax was assessed in all malignant lesions up to a maximum of 5 lesions and a maximum of 2 lesions per organ according to RECIST 1.1.

RESULTS

A significant difference was found between the low and high sumSUVmax groups (low vs. high sumSUVmax, 91.5 vs. 77.3%; p = 0.018) in the response rate (RR) following frontline platinum-based chemotherapy. The group with low sumSUVmax showed significantly better overall survival (OS; p < 0.001) as well as better progression-free survival (PFS; p < 0.001) compared with the group with high sumSUVmax. Moreover, multivariate analysis revealed that a high sumSUVmax alone was an independent poor prognostic factor for OS (hazard ratio 2.676; 95% confidence interval, 1.674-4.277; p < 0.001).

CONCLUSIONS

This study showed that the sumSUVmax adopted from RECIST 1.1 on pretreatment (18)F-FDG PET/CT was significantly correlated with response to treatment, OS, and PFS in patients with SCLC.