Analysis of long-term survivors with small-cell lung cancer

Real World Analysis of Small Cell Lung Cancer Patients: Prognostic Factors and Treatment Outcomes

In this observational study, we assessed treatment patterns and prognostic factors in patients with small cell lung cancer (SCLC) in a large state-mandated healthcare organization in Israel. Methods: All incident cases with histologically confirmed SCLC who initiated systemic anti-cancer treatment between 2011 and 2017 were identified. Treatment patterns and overall survival (OS) were evaluated for each line of therapy. Results: A total of 235 patients were identified (61% male, median age 64 years, 95% ever smokers, 64% had extensive stage). The first-line treatment was platinum-etoposide regimen for 98.7% of the cohort. The second and third-line regimen were given to 43% and 12% of patients, respectively. Mean OS for extensive and limited stage patients was 9.1 and 23.5 months respectively. In a multivariable model, increased risk for mortality was observed among patients with an ECOG performance status (PS) of 2 compared to a PS of 0-1 for the extensive stage patients (Hazard ratio (HR) = 1.63, 95% confidence ratios (CI): 1.00-2.65); and for males compared to females for the limited stage patients (HR = 2.17; 95% CI: 1.12-4.20). Regarding all 2nd line patients in a multivariable model incorporating relevant confounding factors, demonstrated a significantly better outcome with platinum-based regimens compared to topotecan. Median survival after initiation of 2nd line in platinum-sensitive patients was longer (p = 0.056) for those re-challenged with platinum-based regimen (n = 7): 6.8mo (6.1-not reported (NR)), compared with those switched to a different treatment (n = 27): 4.5 mo (2.6-6.6) for extensive stage patients, and a non-significant difference was also observed for limited stage patients. Conclusion: To our knowledge, this is one of the largest real-world studies of SCLC patients. OS for SCLC patients was similar to that reported in clinical trials. PS for extensive stage patients and sex for limited stage patients were significant correlates of prognosis. Re-challenge of the platinum-based doublet was associated with longer OS compared to switching treatment in extensive stage patients.

Treatment and survival of patients with small-cell lung cancer: small steps forward, but not for patients >80

BACKGROUND

Seventy-five percent of newly diagnosed patients with small-cell lung cancer (SCLC) are aged 60+ and quite a few are treated less aggressively because of fear of toxic effects. We described trends in treatment and survival of unselected SCLC patients.

PATIENTS AND METHODS

For the present study, all 13,007 SCLC patients aged 60+ diagnosed in The Netherlands from 1997 to 2007 were included.

RESULTS

Among patients with limited disease, the proportion receiving chemoradiation increased from 35% to almost 60% for those aged 60-69, from 28% to 48% in age group 70-74, from 17% to 33% in age group 75-79, but remained <10% for those aged 80+. Among patients with extensive disease, the proportion receiving chemotherapy (CT) decreased from 81% of patients aged 60-64 to 23% of those aged 85+, without substantial changes over time. Survival has only improved for patients <80 years.

CONCLUSIONS

CT (+radiotherapy) has improved survival for unselected SCLC patients <80. A better understanding of the impact of frailty on completion of treatment and toxic effects among patients aged 80+ would enable the treating physician to anticipate toxic effects better and to discuss risks and benefits of treatment with the patient.

Acute Renal Failure Secondary to Small Cell Lung Cancer with Tumor Infiltration of the Kidneys

Acute renal failure secondary to tumor infiltration of the kidneys is uncommon and largely described in patients with lymphoma or leukemia. We report a 64-year-old man previously diagnosed with limited stage small cell lung cancer who presented with acute renal failure (ARF). Renal imaging showed bilateral enlargement with features suggestive of an infiltrative process. A kidney biopsy established the diagnosis of metastatic small cell lung cancer with diffuse renal parenchymal infiltration. This case emphasizes the rare potential for cancers to metastasize to the kidneys, which can result in ARF. Early recognition of this cause of ARF is crucial, in particular, when the tumor is amenable to chemotherapy or irradiation.

Differentially expressed nucleolar TGF-beta1 target (DENTT) shows tissue-specific nuclear and cytoplasmic localization and increases TGF-beta1-responsive transcription in primates

Differentially Expressed Nucleolar TGF-beta1 Target (DENTT) is a new member of the TSPY/TSPY-like/SET/NAP-1 (TTSN) superfamily whose mRNA is induced by TGF-beta1 in TGF-beta1-responsive human lung cancer cells. Monkey DENTT mRNA contains a 2085-bp open reading frame that encodes a predicted polypeptide of 695 amino acids with five nuclear localization signals, two coiled-coil regions, and a domain that shows significant identity to a region that defines the TTSN superfamily. RT-PCR amplification and Western blot analyses showed DENTT mRNA and protein in adult monkey tissues, including the adrenal gland, cerebral cortex, and ovary. Immunohistochemical staining showed that numerous neurons were intensely immunoreactive for DENTT, as were anterior pituitary secretory cells, thyroid follicular cells, and smooth muscle cells of arteries and lung bronchial walls. DENTT expression was also prominent in monkey bronchiolar-alveolar adenomas and cell lines. While the addition of TGF-beta1 or retinoic acid to monkey normal lung bronchial 12MBr6 cells and human lung cancer NCI-H727 cells increased DENTT protein production, TGF-beta1 together with retinoic acid resulted in a more sustained increase in DENTT production than with TGF-beta1 or retinoic acid alone. Transient transfection studies showed that ectopic DENTT expression significantly increased TGF-beta1-responsive 3TP-Lux and CAGA12-Lux reporter transcription in 12MBr6 and NCI-H727 cells with TGF-beta1 addition, while ectopic DENTT expression had no significant effect on the transcription of a retinoic acid-responsive element reporter in the presence of retinoic acid or TGF-beta1. These findings suggest new possibilities for DENTT as a TGF-beta1-regulated, but not a retinoic acid-regulated member of the TTSN superfamily in primate physiology.

Recurrent small cell lung cancer presenting as bilateral adnexal masses

BACKGROUND

Small cell lung cancer (SCLC) carries a very poor prognosis, although recent advances in chemotherapy have produced some long-term survivors. Despite this, recurrences are common, and these patients require a high level of surveillance. Given that the female gender is a favorable prognostic factor in patients with SCLC and that more women are becoming lung cancer survivors, it is important to consider sites of metastasis that are restricted to women.

CASE

This is a presentation of a 42-year old previously diagnosed with SCLC who presented with an isolated recurrence of SCLC in the ovaries. This is a case report of an isolated recurrence of SCLC in the ovaries with a review of the literature.

CONCLUSION

Although systemic relapses and recurrences often occur in these patients, isolated metastasis such as this can occur and should be considered in female patients with a history of small cell lung cancer.

Germ line polymorphisms of the tumor suppressor gene p53 and lung cancer

Two p53 variable sites (BstUI and MspI SNPs in exon 4 and intron 6, respectively) and their haplotype combinations were studied in 109 patients (84 males and 25 females) with lung cancer and 113 healthy controls from the region of Eastern Slovakia. There were no differences found between lung cancer patients and controls carrying the distribution of p53 BstUI and MspI alleles. However, the genotype distribution showed a significantly higher proportion of MspI heterozygotes in lung cancer patients (P=0.048, OR 1.83, 95% CI 1.00-3.34) than in controls. The analysis based on haplotype frequencies showed the presence of BstUI-MspI 2-1 haplotype in cancer patients (5.4%) in contrast to the absence of this haplotype in healthy controls. The results of this study suggest that the p53 MspI polymorphism may modify the susceptibility to lung cancer as a single factor rather than in combination with BstUI polymorphism.

Trends in incidence and prognosis of the histological subtypes of lung cancer in North America, Australia, New Zealand and Europe

BACKGROUND

Since the incidence of the histological subtypes of lung cancer in industrialised countries has changed dramatically over the last two decades, we reviewed trends in the incidence and prognosis in North America, Australia, New Zealand and Europe, according to period of diagnosis and birth cohort and summarized explanations for changes in mortality.

METHODS

Review of the literature based on a computerised search (Medline database 1966-2000).

RESULTS

Although the incidence of lung cancer has been decreasing since the 1970s/1980s among men in North America, Australia, New Zealand and north-western Europe, the age-adjusted rate continues to increase among women in these countries, and among both men and women in southern and eastern Europe. These trends followed changes in smoking behaviour. The proportion of adenocarcinoma has been increasing over time; the most likely explanation is the shift to low-tar filter cigarettes during the 1960s and 1970s. Despite improvement in both the diagnosis and treatment, the overall prognosis for patients with non-small-cell lung cancer hardly improved over time. In contrast, the introduction and improvement of chemotherapy since the 1970s gave rise to an improvement in - only short-term (<2 years) - survival for patients with small-cell lung cancer.

CONCLUSIONS

The epidemic of lung cancer is not over yet, especially in southern and eastern Europe. Except for short-term survival of small cell tumours, the prognosis for patients with lung cancer has not improved significantly.

Late recurrence of small-cell lung cancer: a case report

A 67-year-old man was admitted with small-cell lung cancer (SCLC). The patient was given four courses of platinum-containing chemotherapy followed by chest irradiation, and good partial response (PR) was obtained. The patient did well for 4 years, until he sought treatment for a painful subcutaneous tumor. Chest computed tomography scan revealed the mass extending from the tumor in lung parenchyma with osteolytic lesion of the third rib bone. Pathologic examination of the subcutaneous lesion revealed SCLC. The patient was given two courses of the same combination chemotherapy administered as initial therapy. Regression of the mass was observed, and the response was evaluated as a good PR. How to approach late recurrence of SCLC is discussed.

Enhanced tumorigenesis and reduced transforming growth factor-beta type II receptor in lung tumors from mice with reduced gene dosage of transforming growth factor-beta1

To elucidate the role of transforming growth factor-beta1 (TGF-beta1) and the TGF-beta type II receptor (TGF-beta RII) as tumor-suppressor genes in lung carcinogenesis, we mated C57BL/6 mice heterozygous (HT) for deletion of the TGF-beta1 gene with A/J mice to produce AJBL6 TGF-beta1 HT progeny and their wild-type (WT) littermates. Immunohistochemical staining, in situ hybridization, and northern blot analyses showed lower staining and hybridization for TGF-beta1 protein and mRNA, respectively, in the lungs of normal HT mice versus WT mice. Competitive reverse transcription-polymerase chain reaction (CRT-PCR) amplification showed the level of TGF-beta1 mRNA in the lungs of HT mice to be fourfold lower than the level in WT lung. When challenged with ethyl carbamate, lung adenomas were detected in 55% of HT mice by 4 mo but only in 25% of WT littermates at this time. Whereas all HT mice had adenomas by 6 mo, it was not until 10 mo before all WT mice had adenomas. After 12 mo, the average number of adenomas was fivefold higher in HT lungs than in WT lungs. Most dramatic was the appearance of lung carcinomas in HT mice 8 mo before they were visible in WT mice. Thus, the AJBL6 TGF-beta1 HT mouse provides an excellent model system to examine carcinogen-induced lung tumorigenesis by increasing progressive lesion incidence and multiplicity relative to their WT littermates. Immunohistochemical staining showed expression of the TGF-beta type I receptor (TGF-beta RI) at moderate to strong levels in lung adenomas and carcinomas in HT and WT mice. In contrast, whereas weak immunostaining for TGF-beta RII was detected in 67% of HT carcinomas at 12 mo, only 22% of WT carcinomas showed weak staining for this protein. Individual lung carcinomas showing reduced TGF-beta RII expression and adjacent normal bronchioles were excised from HT lungs using laser capture microdissection, and CRT-PCR amplification of the extracted RNA showed 12-fold less TGF-beta RII mRNA in these carcinomas compared with bronchioles. Decreasing TGF-beta RII mRNA levels occurred with increasing tumorigenesis in lung hyperplasias, adenomas, and carcinomas, with carcinomas having fourfold and sevenfold lower levels of TGF-beta RII mRNA than adenomas and hyperplasias, respectively. These data show enhanced ethyl carbamate-induced lung tumorigenesis in AJBL6 HT mice compared with WT mice, suggesting that both TGF-beta1 alleles are necessary for tumor-suppressor activity. Reduction of TGF-beta RII mRNA expression in progressive stages of lung tumorigenesis in HT mice suggests that loss of TGF-beta RII may play an important role in the promotion of lung carcinogenesis in mice with reduced TGF-beta1 gene dosage when challenged with carcinogen.

Survival in small cell lung carcinoma is independent of Bcl-2 expression

Bcl-2 overexpression is a common event in small cell carcinomas (SCLC). The bcl-2 oncoprotein has a unique oncogenic role by inhibiting programmed cell death (apoptosis), resulting in tumorigenesis and chemoresistance. Forty-two cases of SCLC were stained immunohistochemically with bcl-2 monoclonal antibody (Biogenex, San Ramon, CA) after using an antigen retrieval step with citrate buffer. bcl-2 positivity was determined as detection of the oncoprotein in greater than 10% of noncrushed neoplastic cells. Twenty-five of 42 (60%) patients had extensive disease at presentation, 10 of 42 (24%) had limited disease, and 7 of 42 (16%) had disease localized to the lung. Twenty-four of 42 (57%) tumors were bcl-2 positive, and 18 of 42 (43%) tumors were bcl-2 negative. Follow-up in patients ranged from 7 days to 96 months (mean follow-up, 20 months). The median survival of patients with bcl-2-positive tumors was 11 months, as opposed to 13 months for bcl-2-negative tumors. There was no significant difference in median survival between bcl-2-positive and bcl-2-negative SCLC (log rank test, P = .2256). Using Cox's proportional hazards model, median survival in SCLC was determined to be independent of age at diagnosis, stage at presentation, therapeutic modality, and bcl-2 expression. bcl-2 expression does not significantly influence survival in SCLC.

Small cell lung carcinoma causing epidural hematoma: case report

BACKGROUND

Epidural hematoma usually stems from trauma, yet it may occur from other etiologies, including neoplasms. We present a case of small cell lung carcinoma with focal hemorrhagic central nervous system metastasis producing an epidural hematoma, and review the associated literature.

CLINICAL PRESENTATION

A 67-year-old man was undergoing chemotherapy for small cell carcinoma of the lung. Acute neurologic deterioration resulted from a large parietal epidural hematoma of non-traumatic origin.

INTERVENTION

The clot was evacuated via craniotomy with marked improvement in his clinical state. Metastatic tumor was present in the scalp, muscle, bone, and dura. No gross brain invasion was apparent.

CONCLUSIONS

This case illustrates the wisdom of including metastatic disease in the differential diagnosis of intracranial hemorrhage. Even epidural hematoma may result from metastatic cancer. The prevalence of lung carcinoma and the aging of the population may produce an increased appearance of this phenomenon. Appropriate evaluation and rapid intervention will aid the patient in both the acute and long-term phases, and should improve the quality of survival.

Variation in survival of patients with lung cancer in Europe, 1985-1989. EUROCARE Working Group

In this study, we report on the variation in the prognosis for adult patients with lung cancer within Europe, by age, histology and country from 1985-1989. We considered trends in survival since 1978 for most countries. Survival analysis was carried out on 173,448 lung cancer cases diagnosed between 1985 and 1989 in 44 population-based cancer registries, participating in the EUROCARE study. Relative 1-year survival rates for patients with lung cancer varied from 24 to 40%, being highest in Finland, France, The Netherlands and Switzerland and lowest in Denmark, England, Poland and Scotland. Half of all patients under the age of 45 years died within 1 year of diagnosis, increasing to almost 80% for those aged 75 years or older. Whilst the prognosis for patients with non-small cell carcinoma remained more or less constant between 1978 and 1989 (25% in Denmark and 44% in Finland), that for patients with small cell carcinoma improved slightly, especially in The Netherlands (Eindhoven from 17 to 24%) and Switzerland (Geneva from 24 to 32%). In conclusion, a fairly large variation in lung cancer relative survival rates existed between European countries. The most likely explanation for the differences is the variation in access to specialised care. Except for a slight improvement in short-term survival for patients with small cell lung cancer, survival has remained poor since 1978.

Improvement and plateau in survival of small-cell lung cancer since 1975: a population-based study

BACKGROUND

Cytotoxic therapy appears to have improved short-term survival for patients with small-cell lung cancer, but little is known about the results for unselected patients and trends in long-term survival.

PATIENTS AND METHODS

One thousand seven hundred ninety-six patients with small-cell lung cancer diagnosed between 1975 and 1994 in southeastern Netherlands. We studied treatment policy for and survival of unselected patients since 1975, when cytotoxic therapy emerged.

RESULTS

The proportion patients receiving chemotherapy, with or without irradiation, almost tripled from 30% to 82% for patients younger than 70 years of age and from 15% to 56% for those over 70, whereas the proportion receiving only radiotherapy decreased from 36% to 5% in both age groups. The short-term (< 2 year) survival rate improved markedly between 1975 and 1989, especially for patients younger than 70 (median survival increased from five to 10 months). Two-year survival remained poor (8%). Two percent of all patients younger than 70 years at diagnosis survived for at least eight years, but these patients still represent an excess five-year mortality of 39%.

CONCLUSIONS

In southeastern Netherlands short-term survival of patients with small-cell lung cancer improved markedly up to the end of the 1980s, but a major impact on cure rates has not been achieved.

Women and lung cancer: waiting to exhale

Lung cancer is now the leading cause of cancer deaths among women. In the United States, 64,300 women are expected to die of lung cancer in 1996. Smoking is responsible for about 80% of lung cancer cases. Unfortunately, the prevalence of smoking among women remains unacceptably high at about 22% and is expected to surpass the rate in men by the year 2000. Smoking rates are highest among young girls and the less educated. Whether lung cancer represents a different disease in women than in men is unclear. Data are conflicting regarding the magnitude of the relative risk of developing lung cancer due to smoking between the genders. There appears to be a difference in the relative distribution of lung cancer histologic features between men and women that is not explained entirely by differences in smoking patterns. Women who smoke appear to be at higher risk of developing small cell lung cancer than squamous cell lung cancer, whereas men who smoke have a similar risk for the two histologic conditions. Furthermore, women smokers are more likely to develop adenocarcinoma of the lung, and estrogens may play a causative role in this phenomenon. Data are unclear regarding whether the outcome of lung cancer treatment differs between genders. Solutions to the lung cancer epidemic among US women include (1) prevention of the disease by reducing smoking rates, (2) improving early detection methods, and (3) exploring new therapeutic strategies.

Survival of patients with limited small cell lung cancer in whom complete remission was obtained (a non-randomised retrospective study of 124 consecutive patients

The aim of this study was to assess whether thoracic radiotherapy (TRT) is necessary for those patients (pts) with limited small cell lung cancer (SCLC) who obtained CR after induction chemotherapy (ChT). The analysis include retrospective material of 124 consecutive pts with limited SCLC. All pts had induction ChT (3-5 courses): 78 with CAVE (cyclophosphamide, doxorubicine, etoposide) and 46--with other regimens without etoposide. After induction ChT 55 pts were irradiated on tumor and mediastinum and in 69 the same ChT was continued for 6-8 courses or till progression. After induction ChT CR was obtained in 31 pts, PR in 67 and NR in 26. TRT significantly increased the number of CR among those pts who did not achieve satisfactory tumor response after induction ChT. The median survival was 24 months for those patients who obtained CR, 12 months for those who obtained PR and 9 months for those who did not respond. In the group of patients who obtain CR, survival was the same for those treated with ChT alone and for those treated with ChT and TRT. We conclude that in the treatment of individual patient with limited SCLC TRT is indicated for those who did not obtain CR after ChT. Whether patients in whom CR after chemotherapy was obtained can further gain by application of TRT is worth further randomised studies.