Benefits of surgery in the multimodality treatment of stage IIB-IIIC small cell lung cancer

Different treatment modalities on the prognosis of patients with stage I-IIIa small cell lung cancer: a population based study

Background

Several studies have shown that surgery may improve prognosis in patients with limited-stage small cell lung cancer (LS-SCLC). This study aimed to compare the effects of different treatment modalities on lung cancer specific survival (LCSS) and overall survival (OS) in LS-SCLC patients.

Methods

The Surveillance, Epidemiology and End Results (SEER) database was used to identify patients diagnosed with LS-SCLC. Kaplan-Meier analysis was used to determine the effect of each factor on LCSS and OS. Multivariate analysis was used to analyze the relationship between patient characteristics and survival of different treatment modalities.

Results

After a series of screening steps, this study ultimately analyzed the prognosis of patients with stage I-IIIa SCLC under different treatment modalities. The results showed that lobectomy plus postoperative chemoradiotherapy was significantly better than chemoradiotherapy or lobectomy in treatment (all P<0.05). For stage II and IIIA patients, lobectomy plus postoperative chemotherapy ± radiotherapy had similar efficacy to chemoradiotherapy in improving patients' LCSS and OS (all P>0.05), and lobectomy plus postoperative chemotherapy ± radiotherapy did not significantly improve LCSS or OS compared with lobectomy (all P>0.05).

Conclusions

For stage II-IIIa SCLC patients, lobectomy might have similar efficacy to chemoradiotherapy in improving LCSS and OS, and there is no need for adjuvant chemotherapy ± radiotherapy after surgery. For stage I SCLC patients, lobectomy plus postoperative chemoradiotherapy might be superior to chemoradiotherapy or lobectomy in improving LCSS and OS; however, the conclusion might be biased. These results suggest that the effect of surgery on SCLC patients may be worthy of further study.

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.

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.

A systematic literature review of real-world treatment outcomes of small cell lung cancer

BACKGROUND

Robust evidence from real-world studies is needed to aid decision-makers and other stakeholders in choosing the best treatment options for patients. The objective of this work was to assess real-world outcomes of treatment strategies for limited- and extensive-stage small cell lung cancer (SCLC) prior to the global introduction of immunotherapies for this disease.

METHODS

Searches were conducted in MEDLINE and Embase to identify articles published in English from October 1, 2015, through May 20, 2020. Searches were designed using a combination of Medical Subject Heading (Medline), Emtree (Embase subject headings), and free-text terms such as SCLC. Observational studies reporting data on outcomes of initial treatment strategies in patients with limited- and extensive-stage SCLC were included. Studies with limited sample sizes (<100 patients), enrolled all patients prior to 2010, or did not report outcomes for limited- and extensive-stage SCLC separately were excluded. Data were extracted into a predesigned template by a single researcher. All extractions were validated by a second researcher, with disagreements resolved via consensus.

RESULTS

Forty articles were included in this review. Most enrolled patients from the United States (n = 18 articles) or China (n = 12 articles). Most examined limited-stage (n = 27 articles) SCLC. All studies examined overall survival as the primary outcome. Articles investigating limited-stage SCLC reported outcomes for surgery, chemotherapy and/or radiotherapy, and adjuvant prophylactic cranial irradiation. In studies examining multiple treatment strategies, chemoradiotherapy was the most commonly utilized therapy (56%-82%), with chemotherapy used in 18% to 44% of patients. Across studies, median overall survival was generally higher for chemoradiotherapy (15-45 months) compared with chemotherapy alone (6.0-15.6 months). Studies of extensive-stage SCLC primarily reported on chemotherapy alone, consolidative thoracic radiotherapy, and radiotherapy for patients presenting with brain metastases. Overall survival was generally lower for patients receiving chemotherapy alone (median: 6.4-16.5 months; 3 years, 5%-14.9%) compared with chemotherapy in combination with consolidative thoracic radiotherapy (median: 12.1-18.0 months; 3 years, 15.0%-18.1%). Studies examining whole-brain radiotherapy for brain metastases reported lower median overall survival (5.6-8.7 months) compared with stereotactic radiosurgery (10.0-14.5 months).

CONCLUSIONS

Under current standard of care, which has remained relatively unchanged over the past few decades, prognosis remains poor for patients with SCLC.

Precision Interventional Brachytherapy: A Promising Strategy Toward Treatment of Malignant Tumors

Precision interventional brachytherapy is a radiotherapy technique that combines radiation therapy medicine with computer network technology, physics, etc. It can solve the limitations of conventional brachytherapy. Radioactive drugs and their carriers change with each passing day, and major research institutions and enterprises worldwide have conducted extensive research on them. In addition, the capabilities of interventional robotic systems are also rapidly developing to meet clinical needs for the precise delivery of radiopharmaceuticals in interventional radiotherapy. This study reviews the main radiopharmaceuticals, drug carriers, dispensing and fixation technologies, and interventional robotic precision delivery systems used in precision brachytherapy of malignant tumors. We then discuss the current needs in the field and future development prospects in high-precision interventional brachytherapy.

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.

MRPL42 is activated by YY1 to promote lung adenocarcinoma progression

Mammalian mitochondrial ribosomal proteins are a group of protein factors encoded by nuclear genes, responsible for the synthesis of proteins in mitochondria. As a member of mitochondrial ribosomal proteins, MRPL42 (mitochondrial ribosomal protein L42) belongs to 28S and 39S subunits. The current literature showed that its role in lung adenocarcinoma (LUAD) was not clear. We found that MRPL42 was highly expressed in early-stage LUAD tissues and cell lines, and remarkably related to the prognosis of patients. Knockdown of MRPL42 could reduce the proliferation and colonization, promote cell cycle arrest in G1/S phase, and weaken the migration and invasion ability of LUAD cells in vitro. Moreover, depletion of MRPL42 also inhibited tumor growth in vivo. Bioinformatics analysis found that YY1 may bind to the promoter region upstream of the MRPL42 gene to promote the transcription of MRPL42, which was verified by the ChIP and Dual luciferase reporter assay. QRT-PCR confirmed that knocking down YY1 could attenuate the expression of MRPL42. In summary, MRPL42 acts as an oncogene in LUAD, and its expression level is regulated by YY1.

Neutrophil-to-lymphocyte ratio can predict outcome in extensive-stage small cell lung cancer

Background

The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) were analyzed in various carcinomas and their potential prognostic significance was determined. The objective of present study was to determine the correlation between these parameters and the survival of patients with small cell lung cancer (SCLC), since very few studies have been published on this type of carcinoma.

Patients and methods

One hundred and forty patients diagnosed with SCLC at University Hospital Center Zagreb, between 2012 and 2016 were retrospectively analyzed. Extensive-stage disease (ED) was verified in 80 patients and limited-stage disease (LD) in 60 patients. We analyzed the potential prognostic significance of various laboratory parameters, including NLR, PLR, and LMR, measured before the start of treatment.

Results

Disease extension, response to therapy, chest irradiation and prophylactic cranial irradiation (PCI), as well as hemoglobin, monocyte count, C-reactive protein (CRP), and lactate dehydrogenase (LDH) showed a prognostic significance in all patients. When we analyzed the patients separately, depending on the disease extension, we found that only skin metastases as well as LDH and NLR values, regardless of the cut-off value, had a prognostic significance in ED. Meanwhile, the ECOG performance status, chest irradiation, PCI, and hemoglobin and creatinine values had a prognostic significance in LD.

Conclusions

NLR calculated before the start of the treatment had a prognostic significance for ED, while PLR and LMR had no prognostic significance in any of the analyzed groups of patients.