The role of thoracic radiotherapy in the management of limited-stage small cell lung cancer: past, present, and future

Advanced small cell carcinoma of the bladder: clinical characteristics, treatment patterns and outcomes in 960 patients and comparison with urothelial carcinoma

To describe the clinical characteristics, treatment patterns and outcomes in advanced small cell bladder cancer (aSCBC) patients and compare to those with urothelial carcinoma (UC). Individuals in the National Cancer Data Base with a diagnosis of either nodal (TxN+M0) or distant metastatic (TxNxM1) disease were identified from 1998 to 2010. We assessed the relationships between stage, treatment modalities and survival in the aSCBC cohort and compared these to UC patients. In the 960 patient aSCBC cohort (62% M1), 50% received palliative therapy alone, 68% in M1 versus 21% in M0 groups (P < 0.0001). Single modality local therapy (15%) and surgical (21%) or radiation-based (14%) multimodal therapy (MMT) were used in the other 50%. Cystectomy-based MMT was utilized in 45% of N+M0 versus 6.4% of NxM1 patients (P < 0.0001). Median overall survival (OS) for aSCBC patients was 8.6 months; 13.0 months in N+M0 versus 5.3 months in NxM1 patients (P < 0.0001). Survival was similar between TxN1M0 and TxN2-3M0 patients (14.8 months vs. 12.1 months, P = 0.15). Urothelial carcinoma patients (n = 27,796, 45% M1) lived longer compared to aSCBC patients in the N+M0 group (17.3 months vs. 13.0 months, P = 0.0007). There were not clinically significant differences in OS between UC and aSCBC patients in the M1 group. Advanced SCBC is a rare disease with a poor survival and palliative therapy is common, especially in M1 patients. In comparison to UC, the outcomes for aSCBC patients are worse in those with lymph node only involvement but similar in those with distant disease.

The start of chemotherapy until the end of radiotherapy in patients with limited-stage small cell lung cancer

BACKGROUND/AIMS

Chemotherapy combined with radiation therapy is the standard treatment for limited stage small cell lung cancer (LS-SCLC). Although numerous studies indicate that the overall duration of chemoradiotherapy is the most relevant predictor of outcome, the optimal chemotherapy and radiation schedule for LS-SCLC remains controversial. Therefore we analyzed the time from the start of any treatment until the end of radiotherapy (SER) in patients with LS-SCLC.

METHODS

We retrospectively analyzed 29 patients diagnosed histologically with LS-SCLC and divided them into two groups: a short SER group (< 60 days) and a long SER (> 60 days) group. Patients were treated with irinotecan-based chemotherapy and thoracic radiotherapy.

RESULTS

Sixteen patients were in the short SER group and 13 patients were in the long SER group. Short SER significantly prolonged survival rate (p = 0.03) compared with that of long SER. However, no significant differences in side effects were observed.

CONCLUSIONS

Short SER should be considered to improve the outcome of concurrent chemoradiotherapy for LS-SCLC.

Upfront gefitinib/erlotinib treatment followed by concomitant radiotherapy for advanced lung cancer: a mono-institutional experience

BACKGROUND

Upfront tyrosine kinase inhibitor (TKI) has proved effective for selective advanced lung cancer patients in Taiwan. We hypothesized that early integration of radiotherapy during TKI treatment would decrease the chance of drug resistance and prolong progression-free survival (PFS).

METHODS

This study included 25 patients with stage IIIb or IV non-squamous cell, non-small cell lung cancer (NSqCLC) who responded to upfront TKI treatment. Multi-target radiotherapy was administered during the TKI treatment course. Tomotherapy comprising a hypofractionated schedule with a dose of 40-50 Gy in 16-20 fractions was used for individual metastatic lesions.

RESULTS

The patients' median follow-up duration was 30 months (range, 9-62 months). Of the 23 patients who had stage IV disease, 9 had oligometastases (≤5 gross target volumes) and 14 were in the more advanced stages of the disease. Twelve patients received more than 1 cycle of radiotherapy (median, 3; range, 2-6) with TKI being the only systemic treatment before they were salvaged with chemotherapy. The overall response rate after radiotherapy was 84.0%, and the median PFS was 16 months. The 3-year overall survival rate was 62.5% (95% confidence interval [CI], 39.1-85.8%). Toxicities were generally tolerated but it is necessary to prevent radiation-induced pneumonitis.

CONCLUSION

We showed that combined first-line TKI therapy and early multi-target radiotherapy are very effective in selected patients that respond to TKI, when the status of mutations in the epidermal growth factor receptor (EGFR) are not known before the treatment. Our data may aid expansion of the effectiveness of TKI treatment through radiotherapy in Asian patients with stage IV NSqCLC.

[A meta-analysis of the timing of chest radiotherapy in patients with limited-stage small cell lung cancer]

背景与目的

研究结果显示序贯化放疗是小细胞肺癌主要的治疗手段，它可以提高患者的生存率，但是何时开始实施放疗仍然存在争议。本研究旨在探讨放疗实施时间对局限期小细胞肺癌预后的影响。

方法

通过计算机检索Medline、CENTRAL(the Cochrane central register of controlled trials)、中国生物医学文献数据库系统(CBM)、中国期刊全文数据库(CNKI)等收集国内外公开发表的关于早期放疗(化疗开始后30天内开始放疗)对比后期放疗(化疗开始30天以后开始放疗)治疗局限期小细胞肺癌的随机对照研究。应用统计软件Stata 11.0进行数据分析。研究人群为局限期小细胞肺癌；干预措施为胸部放疗+化疗；结局指标为2/3年死亡率和放疗相关副反应。以优势比(odds ratio, OR)及相应的95%置信区间(confidence interval, CI)作为效应指标对结局进行比较。Q统计量的I²检验来检测各研究间的统计学异质性。双侧P＜0.05认为各研究间存在明显的异质性。采用Begg法对发表偏倚进行量化检测。

结果

最终纳入分析的文章6篇，共1 189例患者，其中早期放疗组587例，后期放疗组602例。接受早期放疗与接受后期放疗相比，两者2/3年生存优势差别无统计学意义(OR=0.78, 95%CI: 0.55-1.05, P=0.093)；单独分析放疗性肺炎(OR=1.93, 95%CI: 0.97-3.86, P=0.797)疗性食管炎(OR=1.43, 95%CI: 0.95-2.13, P=0.572)相关血小板减少(OR=1.23, 95%CI: 0.88-1.77, P=0.746)差别均无统计学意义。

结论

接受早期放疗与接受后期放疗相比，2/3年生存优势、放疗相关副反应无明显区别。

Hepatocyte growth factor in lung repair and pulmonary fibrosis

Pulmonary remodeling is characterized by the permanent and progressive loss of the normal alveolar architecture, especially the loss of alveolar epithelial and endothelial cells, persistent proliferation of activated fibroblasts, or myofibroblasts, and alteration of extracellular matrix. Hepatocyte growth factor (HGF) is a pleiotropic factor, which induces cellular motility, survival, proliferation, and morphogenesis, depending upon the cell type. In the adult, HGF has been demonstrated to play a critical role in tissue repair, including in the lung. Administration of HGF protein or ectopic expression of HGF has been demonstrated in animal models of pulmonary fibrosis to induce normal tissue repair and to prevent fibrotic remodeling. HGF-induced inhibition of fibrotic remodeling may occur via multiple direct and indirect mechanisms including the induction of cell survival and proliferation of pulmonary epithelial and endothelial cells, and the reduction of myofibroblast accumulation.

Timing of chest radiotherapy in patients with limited stage small cell lung cancer: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

We undertook a systematic review and literature-based meta-analysis to determine whether the timing of chest radiotherapy may influence the survival of patients with limited stage small cell lung cancer (LS-SCLC).

OBJECTIVES

To establish the most effective way of combining chest radiotherapy with chemotherapy for patients with limited-stage small cell lung cancer in order to improve long-term survival.

MATERIALS

Eligible studies were identified according to the Cochrane Collaboration Guidelines and were randomised controlled clinical trials comparing different timing of chest radiotherapy in patients with LS-SCLC. Early chest irradiation was defined as beginning within 30 days after the start of chemotherapy.

RESULTS

Seven randomised trials were eligible. The overall survival at 2 years or at 5 years was not significantly different between early or late chest radiotherapy. When only trials were considered that used platinum chemotherapy concurrent with chest radiotherapy, significantly higher 2 and 5-year survival rates were observed when chest radiotherapy (RT) was started within 30 days after the start of chemotherapy (2-year survival: HR: 0.73, 95% CI 0.57-0.94, p=0.01; 5-year survival: HR: 0.65, 95% CI 0.45-0.93, p=0.02). This was even more pronounced when the overall treatment time of chest radiotherapy was less than 30 days. In studies that did not show a survival advantage by early chest radiation, a lower dose-intensity of chemotherapy in the early vs. late arm was observed.

CONCLUSIONS

When platinum-based chemotherapy concurrently with chest RT is used, the 2- and 5-year survival rates of patients with LS-SCLC may be in favour of early chest radiotherapy, with a significant difference if the overall treatment time of chest radiation is less than 30 days.

Subcarinal node is the significant node that affects survival in resected small cell lung cancer

PURPOSE

Our aim was to clarify the significance of surgery and the prognostic factors in patients with small cell lung cancer (SCLC).

METHOD

A retrospective review of 50 patients with limited SCLC who underwent a pulmonary resection and mediastinal nodal dissection during the 10-year period from 1988 to 1997 was undertaken. The TNM classification was applied to all cases of SCLC.

RESULTS

A Cox regression multivariate analysis indicated lymph node metastasis (P = 0.0117) and adjuvant therapy (P = 0.0429) to be independent prognostic factors in SCLC patients. Concerning the patients with lymph node metastasis, the prognosis was related only to the involvement of the subcarinal node (station 7). Although no patient with lymph node involvement in station 7 could be a 2-year survivor, in the case of patients with lymph node involvement except in station 7, 47.1% of them were 2-year survivors and 25.1% were 4-year survivors. Among the patients with lymph node metastasis, a univariate analysis indicated the prognosis to be significantly poorer in patients with station 7 involvement than in those without station 7 involvement (P = 0.0224).

CONCLUSION

Involvement in the subcarinal node might be a prognostic factor for SCLC.

Systematic review and meta-analysis of randomised, controlled trials of the timing of chest radiotherapy in patients with limited-stage, small-cell lung cancer

BACKGROUND

We undertook a systematic review and literature-based meta-analysis to determine whether the timing of chest radiotherapy may influence the survival of patients with limited-stage small-cell lung cancer (LS-SCLC).

MATERIALS

Eligible randomised controlled clinical trials were identified according to the Cochrane Collaboration Guidelines, comparing different timing of chest radiotherapy in patients with LS-SCLC. Early chest irradiation was defined as beginning within 30 days after the start of chemotherapy.

RESULTS

Considering all seven eligible trials, the overall survival at 2 or 5 years was not significantly different between early or late chest radiotherapy. When only trials were considered that used platinum chemotherapy concurrent with chest radiotherapy, a significantly higher 5-year survival was observed when chest radiotherapy was started within 30 days after the start of chemotherapy (2-year survival: OR: 0.73, 95% CI 0.51-1.03, P = 0.07; 5-year survival: OR: 0.64, 95% CI 0.44-0.92, P = 0.02). This was even more pronounced when the overall treatment time of chest radiotherapy was less than 30 days.

CONCLUSIONS

There are indications that the 5-year survival rates of patients with LS-SCLC are in favour of early chest radiotherapy, with a significant difference if the overall treatment time of chest radiation is less than 30 days.

Time between the first day of chemotherapy and the last day of chest radiation is the most important predictor of survival in limited-disease small-cell lung cancer

PURPOSE

To identify time factors for combined chemotherapy and radiotherapy predictive for long-term survival of patients with limited-disease small-cell lung cancer (LD-SCLC).

METHODS

A systematic overview identified suitable phase III trials. Using meta-analysis methodology to compare results within trials, the influence of the timing of chest radiation and the start of any treatment until the end of radiotherapy (SER) on local tumor control, survival, and esophagitis was analyzed. For comparison between studies, the equivalent radiation dose in 2-Gy fractions, corrected for the overall treatment time of chest radiotherapy, was analyzed.

RESULTS

The SER was the most important predictor of outcome. There was a significantly higher 5-year survival rate in the shorter SER arms (relative risk [RR] = 0.62; 95% CI, 0.49 to 0.80; P = .0003), which was more than 20% when the SER was less than 30 days (upper bound of 95% CI, 90 days). A low SER was associated with a higher incidence of severe esophagitis (RR = 0.55; 95% CI, 0.42 to 073; P < .0001). Each week of extension of the SER beyond that of the study arm with the shortest SER resulted in an overall absolute decrease in the 5-year survival rate of 1.83% +/- 0.18% (95% CI).

CONCLUSION

A low time between the first day of chemotherapy and the last day of chest radiotherapy is associated with improved survival in LD-SCLC patients. The novel parameter SER, which takes into account accelerated proliferation of tumor clonogens during both radiotherapy and chemotherapy, may facilitate a more rational design of combined-modality treatment in rapidly proliferating tumors.

Early versus late chest radiotherapy for limited stage small cell lung cancer

BACKGROUND

It is standard clinical practice to combine chemotherapy and chest radiotherapy in treating patients with limited-stage small cell lung cancer. However, the best way to integrate both modalities is unclear.

OBJECTIVES

To establish the most effective way of combining chest radiotherapy with chemotherapy for patients with limited-stage small cell lung cancer in order to improve long-term survival.

SEARCH STRATEGY

The electronic databases MEDLINE, EMBASE, Cancerlit and the Cochrane Central Register of Controlled Trials (CENTRAL), reference lists, handsearching of journals and conference proceedings, and discussion with experts were used to identify potentially eligible trials, published and unpublished.

SELECTION CRITERIA

Randomised controlled clinical trials comparing different timing of chest radiotherapy in patients with limited-stage small cell lung cancer.

DATA COLLECTION AND ANALYSIS

Seven randomised trials were reviewed. There were differences in the timing and the overall treatment time of chest radiotherapy, the overall treatment time of , and the type of chemotherapy used.

MAIN RESULTS

No significant differences in the 2-year and the 5-year survival were found, whether chest radiotherapy was delivered within 30 days after the start of chemotherapy or later. When the only study that delivered chest radiotherapy during cycles of non-platinum chemotherapy was excluded, a trend for the 5-year survival was observed (RR:0.93, p=0.07) in favour of early radiation, but not for the 2-year survival. Survival at 5 years, but not at 2 years, was significantly better for those having early chest radiotherapy delivered in an overall treatment time of less than 30 days compared with a longer treatment time (RR: 0.90, p=0.006). These results, however, should be interpreted with caution because the largest trial has follow-up data at three years, but not later. It remains to be seen what the effect of longer follow up will be for 5-year survival rates. Local tumour control was not significantly different between early and late chest radiotherapy. The incidence of severe pneumonitis or severe oesophagitis was not significantly different for early versus late thoracic radiotherapy. However, a trend for a higher chance to develop pneumonitis when early chest radiotherapy was delivered during non-platinum based chemotherapy was observed.

AUTHORS' CONCLUSIONS

At present, it is uncertain whether the timing of chest radiotherapy as such is important for survival. The optimal integration of chemotherapy and chest radiotherapy in patients with limited-stage small cell lung cancer is unknown. Therefore, further research is needed to establish the most effective combination of radiotherapy and chemotherapy in this disease.

Standard- and high-dose etoposide, ifosfamide, carboplatin, and epirubicin in 100 patients with small-cell lung cancer: a mature follow-up report

BACKGROUND

We conducted a phase I-II trial to assess the feasibility and activity of a combination chemotherapy regimen with etoposide, ifosfamide, cisplatin or carboplatin, and epirubicin in limited-disease (LD, stages I-IIIB) and extensive-stage (ED, stage IV) small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Standard-dose chemotherapy (SDC) consisting of etoposide (500 mg/m2), ifosfamide (4000 mg/m2), cisplatin (50 mg/m2) and epirubicin (50 mg/m2) (VIP-E), followed by granulocyte colony-stimulating factor (G-CSF), was given to 100 patients with SCLC. Thirty patients with qualifying responses to VIP-E proceeded to high-dose chemotherapy (HDC) with autologous peripheral blood stem-cell transplantation (PBSCT) after etoposide (1,500 mg/m2), ifosfamide (12,000 mg/m2), carboplatin (750 mg/m2) and epirubicin (150 mg/m2) (VIC-E) conditioning. RESULTS OF STANDARD-DOSE VIP-E: Ninety-seven patients were evaluable for response. The objective response rate was 81% in LD SCLC (33% CR, 48% PR; excluding patients in surgical CR) and 77% in ED SCLC (18% CR, 58% PR). The treatment-related mortality (TRM) of SDC was 2%. Two additional patients in CR from their SCLC developed secondary non-small-cell lung cancers (NSCLC), and both were cured by surgery. The median survival was 19 months in LD SCLC and 6 months in ED SCLC. The five-year survivals were 36% in LD and 0% in ED SCLC. RESULTS OF HIGH-DOSE VIC-E: HDC was feasible in 16% of ED-, and 58% of LD-patients. All HDC patients (n = 30) improved or maintained prior responses. Four patients died of early treatment-related complications (TRM 13%). Two additional patients in CR from their SCLC developed secondary malignancies (esophageal cancer, secondary chronic myelogenous leukemia). The median survivals were 26 months in LD SCLC, and 8 months in ED SCLC. The five-year survival was 50% in LD and 0% in ED SCLC.

CONCLUSIONS

Despite high response rates, survival after VIP-E SDC and VIC-E HDC in patients with ED SCLC is not superior to that achieved with less toxic traditional regimens. The high five-year survival rates achieved with these protocols in LD SCLC probably reflect both patient selection (high proportion of patients with prior surgical resection) and the high activity of our chemotherapy regimen in combination with radiotherapy. A study comparing protocols using simultaneous radiation therapy and chemotherapy, and other dose-escalated forms of SDC with HDC is needed to further define the role of this treatment modality in SCLC. Given the high rate of secondary malignancies observed in patients in CR > 2 years in our study, close follow-up and early treatment of these neoplasms may contribute to maintaining overall survival in patients with SCLC.