Small cell lung cancer presenting as a solitary pulmonary nodule

Utilization of Surgery and Its Impact on Survival in Patients With Early Stage Small-cell Lung Cancer in the United States

INTRODUCTION

For patients with T1 or T2 N0 M0 small-cell lung cancer (SCLC), lobectomy followed by chemotherapy is the standard of care. However, because of its tendency for early dissemination, patients are often treated with concurrent chemo-radiation without surgery. This study was conducted to evaluate the utilization of surgery and its impact on survival in patients with early stage SCLC.

MATERIALS AND METHODS

The National Cancer Database was queried to identify patients with T1 or T2 N0 M0 SCLC diagnosed from 2004 to 2013. Multivariate logistic regression modeling was utilized to identify factors associated with receipt of surgery. Patients were stratified into 3 groups: chemo-radiation, surgery followed by chemotherapy, and surgery followed by chemotherapy and prophylactic cranial irradiation (PCI). Kaplan-Meier estimators and Cox proportional-hazards regression were used to compare overall survival. Patients were matched on the propensity score.

RESULTS

A total of 3879 SCLC cases were identified. Of those cases, 80.7% received chemo-radiation. Surgery followed by chemotherapy with or without PCI was associated with better median overall survival (93.0 months [lower 95% confidence interval (CI), 72.5] and 61.7 months [95% CI, 51.8-76.5], respectively) compared with chemo-radiation (31.2 months [95% CI, 26.3-37.0]). PCI offered survival benefit in addition to surgery and chemotherapy (hazard ratio, 0.75).

CONCLUSIONS

Our study showed a significant survival benefit with surgery (lobectomy or more), adjuvant chemotherapy, and PCI in patients with T1-T2 N0 M0 SCLC.

Current Diagnosis and Management of Small-Cell Lung Cancer

Small-cell lung cancer (SCLC) is an aggressive disease with distinct pathological, clinical, and molecular characteristics from non-small-cell lung cancer. SCLC has high metastatic potential, resulting in a clinically poor prognosis. Early concurrent chemo-radiation is the standard of care for limited-stage SCLC (LS-SCLC). Prophylactic cranial irradiation (PCI) is recommended for patients with LS-SCLC without progression of disease after initial therapy. A combination of etoposide and cisplatin or carboplatin remains the mainstay of first-line treatment for ES-SCLC, with the addition of atezolizumab, now becoming standard. Most SCLCs initially respond to therapy but almost invariably recur. Topotecan and amrubicin (in Japan) remain the primary chemotherapy options for relapsed SCLC. Immunotherapy, including nivolumab with or without ipilimumab, is now available for refractory disease. In general, the poor prognosis of SCLC has not improved significantly for more than 3 decades. Recently, next-generation molecular profiling studies have identified new therapeutic targets for SCLC. A variety of proapoptotic agents, compounds capitalizing on DNA-repair defects, immunotherapy agents, and antibody-drug conjugates are being evaluated in SCLC, with a number of them showing early promise.

Diagnostic accuracy of computed tomography imaging for the detection of differences between peripheral small cell lung cancer and peripheral non-small cell lung cancer

Background

To evaluate the computed tomography features of peripheral small cell lung cancer and non-small cell lung cancer and to establish a predictive model to conveniently distinguish between them.

Materials and methods

We retrospectively reviewed the computed tomography features of 51 patients with peripheral small cell lung cancer and 207 patients with peripheral non-small cell lung cancer after pathological diagnosis. Thirteen computed tomography morphologic findings were included and analyzed statistically. Meaningful features were analyzed by logistic regression for multivariate analysis. We then used β-coefficients as the basis to establish an image scoring prediction model.

Result

The meaningful morphologic features for distinguishing between peripheral small cell lung cancer and other tumor types are multinodular shape and lymphadenectasis, with scores of 12 and 11, respectively. The scores ranged from −51 to 23, and the most reasonable cut-off was −24. The available area under the curve was 0.834 (95% confidence interval [CI] 0.783–0.877). Sensitivity and specificity were 86.3% (95% CI 0.737–0.943) and 69.6% (95% CI 0.628–0.758), respectively.

Conclusion

The image scoring predictive model that we constructed provides a simple and economical noninvasive method for distinguishing between peripheral small cell lung cancer and peripheral non-small cell lung cancer.

Disparities in the Management of Patients With Stage I Small Cell Lung Carcinoma (SCLC): A Surveillance, Epidemiology and End Results (SEER) Analysis

INTRODUCTION

Patients with stage I small cell lung carcinoma (SCLC) are candidates for surgery; however, not much is known regarding the utilization of surgical resection in the management of stage I SCLC and the factors that determine the patient's ability to receive surgery.

METHODS

The Surveillance, Epidemiology and End Results database was used to identify patients with stage I SCLC from 2007 to 2013. Continuous variables were compared with 1-way analysis of variance, and categorical variables were compared with χ² testing. Multivariable logistic regression analyses were used to obtain odds ratios.

RESULTS

Of the 1902 patients with stage I SCLC, 427 (22.4%) underwent resection, 116 (6.1%) resection and radiation, 815 (42.8%) received radiation alone, and 544 (28.6%) did not undergo surgery or radiation. Median overall survival for patients with surgery plus radiation was 60+ months, followed by surgery alone at 50 months, radiation at 27 months, and no resection/radiation 16 months. Patients with ≥ 4 lymph nodes removed during surgery had better overall survival of 60+ months compared with patients with < 4 lymph nodes removed (25 months); P < .001. Multivariate analysis demonstrated that elderly patients, men, African American individuals, Medicaid recipients, and patients with left-sided tumors were less likely to undergo resection. However, county-level socioeconomic factors, such as level of poverty, education, unemployment, and median income did not affect the likelihood of undergoing resection.

CONCLUSIONS

Fewer than one-third of all patients with stage I SCLC undergo resection despite better outcomes with resection. Elderly African American men with Medicaid insurance were less likely to receive resection.

Resected small cell lung cancer-time for more?

Small cell lung cancer (SCLC) often presents with either regional or systemic metastases, but approximately 4% of patients present with a solitary pulmonary nodule. Surgical resection can be an option for these patients and is endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. There are no prospective randomized clinical trials evaluating the role of adjuvant systemic therapy in these resected SCLC patients. A recent National Cancer Database analysis found that the receipt of adjuvant chemotherapy alone [hazard ratio (HR), 0.78; 95% CI, 0.63-0.95] or with brain radiation (HR, 0.52; 95% CI, 0.36-0.75) was associated with significantly improved survival as compared to surgery alone. As it is unlikely that a randomized prospective clinical trial addressing this question will be completed, these data should assist with decision making in these patients.

Multimodality Therapy for Limited-Stage Small-Cell Lung Cancer

Limited-stage small-cell lung cancer (SCLC) occurs in only one third of patients with SCLC, but it is potentially curable. Combined-modality therapy (chemotherapy and radiotherapy) has long been the mainstay of therapy for this condition, but more recent data suggest a role for surgery in early-stage disease. Prophylactic cranial irradiation seems to improve outcomes in patients who have responded to initial therapy. This review addresses the practical aspects of staging and treatment of patients with limited-stage SCLC.

Therapeutic procedure in small cell lung cancer

Small cell lung cancer (SCLC) represents 12.95% of all lung cancer diagnoses and continues to be a major clinical problem, with an aggressive clinical course and short disease-free duration after 1st line therapy. Treatment of SCLC remains challenging because of its rapid growth and development of drug resistance during the course of the disease. Chemotherapy remains the current optimal treatment and radical thoracic radiotherapy representing the best treatment option for fit patients with LD. Platinum-based chemotherapy is the treatment of choice in patients with good performance status, and the effect of cisplatin is important for concurrent chemoradiotherapy in LD cause of his radiosensitivity. Patients with progress disease after first-line chemotherapy have poor prognosis. Second-line therapy may produce a modest clinical benefit. A number of targeted agents have been investigated in LD and ED, mostly in unselected populations, with disappointing results. Prophylactic cranial irradiation (PCI) is recommended only for patients who had full response to first line chemotherapy, as target of improving overall survival and decreasing possibilities of brain metastases. New factors for target therapy are the hope for the management of this systematic disease. If we identify these targets for treatment of SCLC and overcome drug-resistance mechanisms, we will create new chemo-radiotherapy schedules for future.

Clinical applicability of staging small cell lung cancer according to the seventh edition of the TNM staging system

The two-stage system of limited and extensive disease has been widely employed for small cell lung cancer (SCLC). However, the International Association for the Study of Lung Cancer has proposed that the TNM classification should be incorporated into clinical practice. The purpose of this study was to evaluate the applicability of the Union for International Cancer Control (UICC) 7th TNM staging system to SCLC. We retrospectively reviewed the medical records of consecutive patients with newly diagnosed histologically proven SCLC between March 2005 and January 2010. Patients who had other concurrent malignancies or had combined-type SCLC were excluded. We assessed overall survival (OS) according to the T descriptor, N descriptor, M descriptor, and TNM stage grouping. In total, 320 SCLC patients were included. Median age was 65 years and 286 patients (89.4%) were male. Median OS was 12.7 months. There were no significant differences in OS according to the T descriptor (P = 0.880). However, there were significant differences in OS according to the N (P < 0.001) and M (P < 0.001) descriptors and TNM stage grouping (P < 0.001). Hazard ratios for OS, adjusted for known prognostic factors, differed significantly according to the N and M descriptor, and TNM stage grouping, but not according to the T descriptors. The UICC 7th TNM staging system may contribute to a more precise prognosis in SCLC patients. Further studies are required to evaluate the applicability of the TNM staging system to SCLC.

Stereotactic body radiotherapy (SBRT) for solitary pulmonary nodules clinically diagnosed as lung cancer with no pathological confirmation: comparison with non-small-cell lung cancer

INTRODUCTION

In non-surgical candidates with solitary pulmonary nodules (SPNs) and no histological confirmation, optimal management remains uncertain.

METHODS

Between February 2005 and February 2011 we treated 298 lung cancers with stereotactic body radiotherapy (SBRT), including SPNs clinically diagnosed as lung cancer (CDLC). Among them, we extracted patients treated with a total dose of 40-50 Gy per 5 fractions and followed up more than 6 months. Patients who had a history of previously treated lung cancer, or were diagnosed pathologically, or suspected as having small-cell lung cancer or large cell neuroendcrine cancer were excluded from this study. The remaining patients were divided into two groups; CDLC and non-small-cell lung cancer (NSCLC) patients and their outcomes were assessed and compared.

RESULTS

Fifty-eight CDLC and 115 NSCLC patients were included in this study. The proportions of female and inoperable cases were significantly higher in the CDLC group. Other characteristics, including T stage and standard uptake value, were well balanced. Median follow-up durations were 20.2 (range, 6.0-58.8) and 21.2 (range, 6-63.7) months, respectively. The 3-year local control, regional-free, metastasis-free, progression-free, cause-specific survival, and overall survival rates were 80% and 87% (p = 0.73), 88% and 91% (p = 0.72), 70% and 74% (p = 0.57), 64% and 67% (p = 0.45), 74% and 71% (p = 0.17), 54% and 57% (p = 0.48), respectively.

CONCLUSION

These results indicate that the treatment outcome of CDLC group was almost identical to that of NSCLC and that few benign lesions seemed to be included. We advocate that SBRT can be legitimately applied to CDLC, provided that they are carefully diagnosed by integrating various clinical findings.

Update on small cell carcinoma and its differentiation from squamous cell carcinoma and other non-small cell carcinomas

Small cell lung cancer (SCLC) comprises 14% of all lung cancers, and >30,000 new cases are diagnosed per year in the United States. SCLC is one of the most distinctive malignancies in the entire field of oncology with characteristic clinical properties, responsiveness to specific chemotherapy, genetic features and a highly reliable pathological diagnosis. SCLC is defined by light microscopy, and the most important stain is a good-quality hematoxylin and eosin (H&E)-stained section. The vast majority of cases can be diagnosed on H&E alone; however, in problem cases, immunohistochemistry can be very helpful in making the distinction from other tumors. Cytology is also a powerful tool, often being more definitive than small biopsies with scant tumor cells, crush artifact and/or necrosis. As virtually all SCLCs present in advanced stages, most patients are diagnosed based on small biopsy and cytology specimens. Historically, there has been significant evolution in the histological subclassification of SCLC dating from 1962 when Kreyberg proposed the oat cell and polygonal cell types. The current subclassification recognizes only two subtypes: pure SCLC and combined SCLC. Pathologists need to do their best to make a diagnosis of SCLC or other histological types of lung cancer and this can be achieved in most cases. This review will address some of the diagnostic problems that occur in the minority of cases and outline practical ways to address them. Brief reference will be made to other neuroendocrine lung tumors with an overview of the molecular pathogenesis of this spectrum of tumors.

[Imaging and PET/CT of lung cancer]

Lung cancer is one of the most frequently occurring cancer in the world. Imaging plays a critical role for screening, diagnosing, staging, and following patients. Although morphologic imaging such as chest X-ray and CT are still useful for these purpose, major limitations occur in the proper evaluation of diagnosing and staging. Metabolic imaging using PET significantly increases the accuracy of staging. This paper will review the role of imaging in patients suspected or diagnosed with lung cancer.

Pathology of lung cancer

This article reviews current concepts in pathologic classification of lung cancer based on 1999 World Health Organization (WHO)/International Association for the Study of Lung Cancer (IASLC) classification. Preinvasive lesions including squamous dysplasia/carcinoma in situ, atypical adenomatous hyperplasia and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia are discussed in addition to current concepts of bronchioloalveolar carcinoma and neuroendocrine tumors.

Can surgery improve local control in small cell lung cancer?

Current therapy for small cell lung cancer (SCLC) consists of chemotherapy with or without radiotherapy. Radiotherapy is generally accepted as an essential treatment component of limited stage disease. However, the local failure rate after chemo- and radiotherapy is still high and ranges from 30 to 70%. Furthermore, despite having obtained a complete radiographic response, up to 75% of these patients will have residual disease in the tumor specimen, if resection is performed. Therefore, more effective means are needed to eradicate the primary tumor and to obtain an improved local disease control. Recent phase two trials of multimodal regimens for stage I-IIIA SCLC demonstrate that in selected patients with early stage SCLC the combination of surgery and chemotherapy with or without radiotherapy is feasible with low morbidity and mortality rates. The combination therapy results in satisfying long term outcome depending on the pathological tumor stage and a local disease control is achieved in almost all patients. It is remarkable that the pneumonectomy rate has decreased over the past decades from almost 100 to 27-39%. In order to confirm these promising results, a German multicenter prospective randomized phase III trial has been designed for patients with stage I-IIIA SCLC consisting of induction chemotherapy, followed by surgery, adjuvant thoracic radiotherapy and prophylactic cranial radiation compared to thoracic radiotherapy and prophylactic cranial radiation.

Pathological-radiological correlations: pathological and radiological correlation of endobronchial neoplasms: part II, malignant tumors

The majority of lung neoplasms are malignant. Many of these are central and have an associated endobronchial component. Most such neoplasms are of surface epithelial origin; however, neoplasms of submucosal gland, mesenchymal, and lymphoreticular origin may also demonstrate an endobronchial component. Because of their endobronchial location and associated symptoms, these patients often present at an earlier stage than purely parenchymal lung malignancies. The radiographic features in such cases may be similar to those associated with benign endobronchial tumors; however, there are certain radiological signs that are more suggestive of a malignant process. Despite these circumstances, conservative management such as endoscopic excision are inappropriate in most instances. The clinicopathologic and radiological features of these lesions are detailed.

Peripheral lung carcinomas associated with central fibrosis and mixed small cell and other histologic components

Three cases of peripheral small cell lung carcinoma (SCLC) with central fibrosis are presented. Central fibrosis is usually present in adenocarcinomas. Cases 1 and 2 are combined SCLCs with components of papillary adenocarcinoma, and case 3 is a mixed SCLC with a large cell component. Small cell components showed intermediate cell type in all cases. In cases 1 and 2, there was a gradual transition between small cell carcinoma and papillary adenocarcinoma. Small cell components showed Grimelius argyrophilia, but other neuroendocrine markers such as neuron specific enolase, chromogranin A, Leu-7 and synaptophysin were negative. The chest X-ray examination of case 1 demonstrated rapid enlargement of a tumor shadow, which was present two years before, for a recent year. Central fibrosis, coexistence of small cell carcinoma and papillary adenocarcinoma, and a change of growth rate in the chest X-ray may suggest that some SCLC derive from papillary adenocarcinomas.

Surgery for cure followed by chemotherapy in small cell carcinoma of the lung. For the ISC-Lung Cancer Study Group

The Lung Cancer Study Group of the International Society of Chemotherapy (ISC-LCSG) organized multinational, cooperative, prospective and randomized trials for the cure of patients with small cell lung cancer at early stages (T1,2N0M0). Surgery for cure was used first, followed by postoperative chemotherapy, and thereafter by prophylactic cranial irradiation. Eight cycles of standard chemotherapy (CAV-cyclophosphamide-doxorubicin-vincristine) or 6 intermittent cycles of alternating chemotherapy, using 3 different drug combinations, were administered 1-2 weeks postoperatively for 6 months after randomization. A total of 183 evaluable patients received surgery for cure at 23 cooperating hospitals. The preliminary evaluation of ISC-studies I and II per May 1993 resulted in the 30-month total survival of 63% from 68 patients after complete resection at TN0M0R0-stages and 37% from 27 patients after such resections at TN2M0R0-stages. Their incidence of local recurrence as first relapse was quite similar (11/47:8/39). The related 4-year recurrence-free survival (57%, 37%), indicating a plateau-like curve of long-term survivors. These promising results have to be confirmed by larger studies. We conclude that the indication for surgery as the first treatment step for SCLC should be the same as for the other non-small subtypes of lung cancers.

Surgical resection for small cell carcinoma of the lung: a retrospective study

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.