Surgery as a Potential Treatment Option for Patients With Stage III Small-Cell Lung Cancer: A Propensity Score Matching Analysis

Improved survival of patients with stage III small-cell lung cancer with primary resection: A SEER-based analysis

INTRODUCTION

Small cell lung cancer (SCLC) is mostly diagnosed in stage III-IV patients and associated with poor prognosis. To date, surgery is no gold-standard treatment for any SCLC stage and evidence is lacking whether it is beneficial. Here we investigate the impact of surgery, with special attention to stage III SCLC patients, sub-stages and treatment combinations.

METHODS

The overall survival (OS) and cancer-specific survival (CSS) of 33,198 SCLC patients (SEER database) were analyzed retrospectively, using various statistical analyses, including propensity score matching (PSM), recursive partitioning, and sequential landmark analyses.

RESULTS

Independent of stage, the OS of patients with surgery-including treatments was almost always better than without surgery. This holds true for stage I-II patients, even after PMS analysis (p < 0.017). The same was found for stage IV patients that underwent surgery plus chemotherapy vs. chemotherapy alone (p = 0.013 after PSM). Stage III patients showed a robust improvement in OS and CSS after surgery (OS: 18 vs.13 months) or surgery plus chemotherapy (OS: 20 vs.15 months) as confirmed by well-balanced PSM and sequential landmark analyses of long-term survivors. More detailed analyses using two independent approaches showed prolonged OS in T3-4/N0-1 and T1-2/N2 stage III patients after surgery or surgery plus chemotherapy. Importantly, primary site surgery had a major survival advantage over surgery at regional sites (p < 0.003).

CONCLUSION

Our study demonstrates that selected patients of all stages, including stage III T3-4/N0-1 and T1-2/N2, can benefit greatly from surgery-including treatments. Thus, surgery should be included into hospital treatment recommendations for specifically selected SCLC patients. Condensed abstract Primary resection in patients with stage III SCLC needs re-evaluation. Selected patients with stage III SCLC benefit significantly from surgery. Patients with T3-4/N0-1 and T1-2/N2 stage III SCLC should be considered for surgery.

The effects of surgical resection in the treatment of limited-stage small cell lung cancer: a multicenter retrospective study

This study aimed to examine the effects of surgical resection on the treatment of limited-stage small cell lung cancer and identify patient characteristics that may indicate a benefit from surgical resection. We retrospectively reviewed medical data from patients diagnosed with small cell lung cancer between January 2013 and December 2020 at three hospitals. A total of 478 patients were included in the study, 153 patients received surgery treatment and 325 patients received non-surgery treatment. Survival differences between the surgical resection group and the nonsurgical resection group were analyzed using the Kaplan-Meier method and the log-rank test. The overall survival in the surgical resection group was significantly improved compared to that in the nonsurgical resection group (HR: 0.58, 95% CI: 0.370-0.876, p = 0.0126). Surgical resection significantly improved overall survival compared to nonsurgical resection in stage I disease (HR: 0.56, 95% CI: 0.34-0.94, p = 0.029) and stage IIA disease (HR: 0.60, 95% CI: 0.40-0.92, p = 0.019). However, no significant differences in overall survival were found between surgical resection and nonsurgical resection in stage IIB disease (HR: 0.86, 95% CI: 0.57-1.29, p = 0.46) and stage III disease (HR: 0.99, 95% CI: 0.71-1.39, p = 0.97). The overall survival of patients who underwent lobectomy was significantly better than that of patients who underwent sublobular resection (HR: 1.85, 95% CI: 1.15-4.16, p = 0.021) and who underwent pneumonectomy (HR: 2.04, 95% CI: 1.29-5.28, p = 0.009). Surgical resection should be recommended for patients diagnosed with stage I-IIA SCLC. When deciding on the surgical type, it is preferable to choose lobectomy over sublobar resection or pneumonectomy.

Survival of small-cell lung cancer patients after surgery: A single-center retrospective cohort study

This study summarized and analyzed the clinical characteristics and prognosis of small-cell lung cancer (SCLC) patients after surgical treatment. The clinical data of 130 patients (99 males and 31 females) with SCLC treated by surgery and confirmed by postoperative pathological examination at Peking Union Medical College Hospital from April 2004 to April 2019 were retrospectively analyzed. Clinical characteristics, surgery, pathological stage, and perioperative treatment were summarized. Kaplan-Meier survival curve and Cox regression analysis were performed. Pathological examination revealed that 36 (27.69%) patients had stage I SCLC, 22 (16.92%) patients had stage II SCLC, 65 (50.00%) patients had stage III SCLC, and 7 (5.39%) patients had stage IV SCLC. The overall median survival time was 50 months (95% confidence interval, 10.8-89.2 months). The median survival time of stage I, II, III and IV SCLC patients was 148, 42, 32, and 10 months, respectively. In patients who underwent surgical treatment, postoperative adjuvant therapy and tumor stage were independent prognostic factors for survival (p < 0.05).Lobectomy and lymph nodes resection combined with adjuvant therapy were cautiously recommended for stage I-IIIa SCLC patients.

Clinical insights into small cell lung cancer: Tumor heterogeneity, diagnosis, therapy, and future directions

Small cell lung cancer (SCLC) is characterized by rapid growth and high metastatic capacity. It has strong epidemiologic and biologic links to tobacco carcinogens. Although the majority of SCLCs exhibit neuroendocrine features, an important subset of tumors lacks these properties. Genomic profiling of SCLC reveals genetic instability, almost universal inactivation of the tumor suppressor genes TP53 and RB1, and a high mutation burden. Because of early metastasis, only a small fraction of patients are amenable to curative-intent lung resection, and these individuals require adjuvant platinum-etoposide chemotherapy. Therefore, the vast majority of patients are currently being treated with chemoradiation with or without immunotherapy. In patients with disease confined to the chest, standard therapy includes thoracic radiotherapy and concurrent platinum-etoposide chemotherapy. Patients with metastatic (extensive-stage) disease are treated with a combination of platinum-etoposide chemotherapy plus immunotherapy with an anti-programmed death-ligand 1 monoclonal antibody. Although SCLC is initially very responsive to platinum-based chemotherapy, these responses are transient because of the development of drug resistance. In recent years, the authors have witnessed an accelerating pace of biologic insights into the disease, leading to the redefinition of the SCLC classification scheme. This emerging knowledge of SCLC molecular subtypes has the potential to define unique therapeutic vulnerabilities. Synthesizing these new discoveries with the current knowledge of SCLC biology and clinical management may lead to unprecedented advances in SCLC patient care. Here, the authors present an overview of multimodal clinical approaches in SCLC, with a special focus on illuminating how recent advancements in SCLC research could accelerate clinical development.

An extensive surgical resection in stage T4 small cell lung cancer with cardiac invasion: A case report and literature review

Introduction and importance

We report a rare case of a patient with a mass involving both the hilum and the heart, but its specific nature could not be determined. SCLC was confirmed by postoperative pathology. It revealed that radical surgical resection for T4 SCLC should be considered an important part of multimodality treatment.

Case presentation

A 49-year-old gentleman complained of mild chest tightness for a week. Two large mass lesions were detected on CECT in the left atrium and left hilum. After an MDT discussion, an extended resection was recommended. Postoperative pathology denoted a complete excision with no residuals and negative lymph nodes.

Clinical discussion

Due to the rarity of lung metastases to the heart, it is vital to determine the homology between the hilar mass and the cardiac mass. Based on this, simultaneous surgical treatment is done and it is very beneficial for patients by eliminating those hazards, such as acute mechanical cardiac obstruction, and cardiac embolism. Our literature review demonstrates that the SCLC tumour progresses rapidly after cardiac metastasis, limiting the chance of a complete resection. Furthermore, complete resection of T4 tumours in NSCLC has been attempted many times, so it should also be tried on SCLC.

Conclusion

It is common for SCLC tumours to progress rapidly once they havemetastasized to the heart. An aggressive operation such as radical resection can reduce tumor burdens, minimize the risk of sudden acute death and improve patient follow-up treatment, all of which may prolong the survival of patients.

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In most cases, cardiac metastasis occurs in small-cell lung cancer with distant metastasis elsewhere. There are few cases in which there is no distant metastasis except lung and heart just like our case.

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Cases of extended resection of T4 stage NSCLC have been reported, but cases of extended resection of T4 stage SCLC are rare.

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We believe that the occurrence of cardiac metastasis in SCLC may indicate that the tumour enters the stage of accelerated growth. An extensive resection reduces the risks of embolism and cardiac pumping disorders brought by cardiac tumours to patients and is conducive to better acceptance of radiotherapy and chemotherapy in later stages.

Prognostic nomogram and novel risk-scoring system for small cell lung cancer with different patterns of metastases

OBJECTIVE

This research is aimed to develop the prognostic nomogram and novel risk-scoring system for small cell lung cancer (SCLC) with different patterns of metastases.

METHODS

Data on SCLC patients were extracted from the 2010-2015 Surveillance, Epidemiology, and End Results (SEER) database. This nomogram prognostic model was confirmed in the validation cohort. C-index and calibration curve were used to evaluate the accuracy of nomogram model. The predictive capability and net benefit of nomogram was estimated by decision curve analysis (DCA). The cut-off point of the risk stratification system based on nomogram was assessed by X-tile analysis.

RESULTS

Our Cox model indicated that age, gender, American Joint Committee on Cancer (AJCC) stage, metastases, chemotherapy, radiation and surgery were independent predictors for OS in SCLC patients. The C-index value of nomogram integrating significant variables for predicting OS in SCLC patients was 0.752 in SEER training set and 0.748 in SEER validation set, respectively. However, the TNM stage only had C-indexes of 0.464 and 0.472 for predicting OS, respectively. The nomogram prognostic model in this study showed higher C-indexes than those in the TNM stage. The C-index value and high quality of calibration plots indicate that the predictive ability of our nomogram model was of great superiority. DCA showed the nomogram had good clinical value. SCLC patients were further divided into low-risk and high-risk group according to nomogram predicted scores.

CONCLUSION

Our nomogram model that integrated significant factors can aid as an individualized clinical predictive tool in SCLC patients.

Propensity score matched analysis for the role of surgery in stage Ⅲ small cell lung cancer based on the eighth edition of the TNM classification: a population study of the US SEER database and a Chinese hospital

OBJECTIVE

Patients with very early stage small cell lung cancer (SCLC) can benefit from surgery. However, the role of surgery in local advanced SCLC patients remains controversial. We designed this study to investigate the role of surgery on survival of this subset population.

METHODS

The included patients were identified from the Surveillance, Epidemiology, and End Results SEER database from 1998 to 2016 and Shanghai Chest Hospital of China from 2009 to 2016. Propensity score matching(PSM) was used to balance clinical bias. The overall survival (OS) and lung cancer-specific survival (LCSS) were compared by the Kaplan-Meier analysis. Cox proportional hazards regression was used to identify factors associated with survival.

RESULTS

Among the 3005 stage Ⅲ patients, 570 (18.97%) patients underwent surgery. Compared with non-surgical group, patients undergoing surgery were more likely to be male, had smaller tumor size, mediastinal lymph node involvement and lower pathologic stage. The Kaplan-Meier analysis showed that surgical patients had a better OS and LCSS before and after PSM. 418 surgical patients were well matched with non-surgical patients. In matched surgical group, there were 224 (53.59%) patients who underwent lobectomy (LB), 147 (35.17%) patients who received sublobectomy (SLB), 31 (7.41%) patients who underwent pneumonectomy and 16 (3.83%) patients with unknown surgery type. The 5-year OS of the 4 subgroups were 28.80%, 12.50%, 8.70% and 13.50%, respectively (P = 0.002). In a multivariable Cox model, SLB (hazard ratio, 1.53; 95%CI, 1.20-1.96; P = 0.001) and pneumonectomy (hazard ratio, 1.72; 95%CI, 1.12-2.65; P = 0.013) were associated with worse OS compared with LB.

CONCLUSION

Surgical resection significantly improved OS and LCSS of stage Ⅲ SCLC patients in our study. Furthermore, LB had advantage over other surgery type but further exploration in larger prospective clinical trials is needed.

Effect of surgery on survival in patients with stage III N2 small cell lung cancer: propensity score matching analysis and nomogram development and validation

Background

The standard treatment of stage III N2 small cell lung cancer (SCLC) is concurrent chemoradiation, and surgery is not recommended. This study was aimed to evaluate whether surgery has survival benefits in patients with stage III N2 SCLC and investigate the factors influencing survival of surgery.

Methods

Patients diagnosed with stage T1-4N2M0 SCLC from 2004 to 2015 were selected from the Surveillance Epidemiology End Results database. Propensity score matching (PSM) was used to balance confounders between patients who underwent surgery and those treated with radiation and/or chemotherapy. We compared overall survival (OS) of the two groups using Kaplan-Meier curves and a Cox proportional hazard model. We also identified prognostic factors in patients with surgical resection, and a nomogram was developed and validated for predicting postoperative OS.

Results

−A total of 5576 patients were included in the analysis; of these, 211 patients underwent surgery. PSM balanced the differences between the two groups. The median OS was longer in the surgery group than in the non-surgery group (20 vs. 15 months; p = 0.0024). Surgery was an independent prognostic factor for longer OS in the multivariate Cox regression analysis, and subgroup analysis revealed a higher survival rate in T1 stage patients treated with surgery (hazard ratio = 0.565, 95% confidence interval: 0.401–0.798; p = 0.001). In patients who underwent surgery, four prognostic factors, including age, T stage, number of positive lymph nodes, and radiation, were selected into nomogram development for predicting postoperative OS. C-index, decision curve analyses, integrated discrimination improvement, and time-dependent receiver operating characteristics showed better performance in nomogram than in the tumor-node-metastasis staging system. Calibration plots demonstrated good consistency between nomogram predicted survival and actual observed survival. The patients were stratified into three different risk groups by prognostic scores and Kaplan-Meier curves showed significant difference between these groups.

Conclusions

These results indicate that surgery can prolong survival in patients with operable stage III N2 SCLC, particularly those with T1 disease. A nomogram that includes age, T stage, number of positive lymph nodes, and radiation can be used to predict their long-term postoperative survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02364-6.

Prognostic factors of patients with small cell lung cancer after surgical treatment

Background

The current National Comprehensive Cancer Network guidelines recommend surgical treatment for patients with stages I–IIA small cell lung cancer (SCLC), but it still cannot deny the effect of surgical treatment on other limited-stage SCLC. Although more advanced diagnostic methods are now used for the diagnosis and classification of SCLC, the selection of surgical candidates is still arbitrary.

Methods

Data were collected from patients with SCLC who underwent surgery at the First Affiliated Hospital of Zhengzhou University from January 2011 to January 2021. Kaplan-Meier method was used to calculate cumulative survival curves, and log-rank test was used to evaluate differences among different subgroups. The Cox proportional hazard regression model was used to assess the predictive power of the variables for prognosis and survival.

Results

Smoking index, surgical resection method, TNM stage of postoperative pathology, and postoperative chemotherapy were significantly correlated with postoperative survival (P<0.05), which were independent predictors for postoperative survival. Patients with a smoking index >800 had a higher risk of death after surgery [hazard ratio (HR): 7.050, 95% confidence interval (CI): 3.079–16.143, P<0.001]. Compared with patients who underwent pulmonary lobectomy, those who underwent other pneumoresections (e.g., wedge resection, segmental resection, sleeve resection) had an increased risk of death (HR: 2.822, 95% CI: 1.030–7.734, P=0.044). Compared with stage I patients, stage II and stage III patients had an increased risk of death, with HRs of 6.039 and 3.145, respectively. Compared with those who received ≤4 courses of postoperative chemotherapy, those who received >4 courses of postoperative chemotherapy had reduced postoperative mortality risk (HR: 0.211, 95% CI: 0.097–0.459, P<0.001).

Conclusions

A high smoking index suggests worse prognosis; therefore, patients who smoke should be advised to quit smoking. Compared with stage II and stage III patients, surgical treatment is recommended for stage I SCLC patients. TNM staging, especially N staging, should be evaluated prior to surgery. Pulmonary lobectomy with mediastinal lymph node dissection should be the preferred surgical treatment for patients with SCLC. Patients should receive at least 5 courses of adjuvant chemotherapy after surgery.

[Surgery for small-cell lung cancer]

Small-cell lung cancer (SCLC) is a high-grade neuroendocrine carcinoma, metastatic at the time of initial diagnosis in 70% of cases. Within the 30% of localised tumours only 5% of patients are eligible for surgical treatment according to the recommendations of learned societies. These recommendations are mainly based on old phase II and III randomised prospective trials and more recent registry studies. Surgical care is only possible within a multimodal treatment and essentially concerns small-sized tumours without involvement of hilar or mediastinal lymph nodes. As with non-small cell lung cancer (NSCLC), lobectomy with radical lymph node removal is the recommended procedure to achieve complete tumour resection. Patient selection for surgery includes age, performance status and comorbidity factors. Adjuvant chemotherapy combining Platinum salts and Etoposide for resected stage I tumours is recommended by ASCO, ACCP and NCCN. The precise sequence of neo-adjuvant or adjuvant treatments remains controversial because of the large heterogeneity in clinical practice reported in the studies and the context at the time of SCLC discovery. The 5-year survival rate of patients with early stage disease (pT1-2N0M0) treated by lobectomy and adjuvant chemotherapy is between 30% and 58%, which validates the primary place that surgery must have in these early forms. There is certainly little or even no place for such a therapeutic sequence in locally advanced stages (T3-T4 or N2). However, the stage heterogeneity, as in NSCLC, makes final conclusions difficult. In fact, some registry studies with pairing scores reported a median survival of more than 20 months in N2 SCLC. So, all files of SCLC must be evaluated in a multidisciplinary meeting in order to find the optimal solution for patients with rare and heterogeneous tumours.

The current role of surgery and SBRT in early stage of small cell lung cancer

BACKGROUND

Early stage small cell lung cancer (T1-2N0M0SCLC) represents 7% of all SCLC. The standard treatment in patients with intrathoracic SCLC disease is the use of concurrent chemoradiotherapy (CRT). Nowadays, the recommended management of this highly selected group is surgical resection due to favorable survival outcomes. For medically inoperable patients or those who refuse surgery, there is an increasing interest in evaluating the role of Stereotactic Body Radiotherapy (SBRT) for T1-2N0SCLC, transferring the favorable experience obtained on inoperable NSCLC (Non-Small-cell Lung Cancer). In the era of multimodality treatment, adjuvant systemic therapy plays an important role even in the management of early SCLC, increasing the disease-free survival (DFS) and Overall Survival (OS). The benefit of Prophylactic Cranial Irradiation (PCI), that currently has a Category I recommendation for localized stage SLCL, remains controversial in this selected subgroup of patients due to the lower risk of brain metastasis.

AIM

This review summarizes the most relevant data on the local management of T1-2N0M0SCLC (surgery and radiotherapy), and evaluates the relevance of adjuvant treatment.

RELEVANCE FOR PATIENTS

Provides a critical evaluation of best current clinical management options for T1-2N0M0 SCLC.