Download Small cell lung cancer and surgery

Small cell lung cancer and surgery
Dr. Jens Soerensen
Dept Oncology
Finsen Centre/National University Hospital
Blegdamsvej 9
2100 Copenhagen
DENMARK
[email protected]
AIMS

To provide on update on current knowledge on the role of surgery in small cell lung cancer
(SCLC)
SUMMARY
Introduction
Small cell lung cancer (SCLC) accounts for 13-15% of all lung cancers. Most patients (80%) have
metastatic disease at time of diagnosis (Extensive Disease, M1, stage 4) while 15% have disease
confined to the lung and regional lymph nodes (Localized Disease, T1-3N0-3M0, Stages I-III). The
tumors are polyclonal and metastasise early in the course of the disease. Even though they generally
respond well to chemotherapy resistant clones may relatively shortly result in disease progression
following initial response to treatment. Prognosis is grim even in case of localized disease with 5-year
survival rates of around 12-25% even with use of the conventional treatment using concomitant
chemo-radiotherapy. Surgery has been little explored in this setting but may benefit a subpopulation
of patients (1). The latter will be highlighted below.
Surgical results in SCLC
Surgery has traditionally not been considering an option in SCLC because of its high propensity for
development of widespread micrometastases. However, the newer staging system and methods have
improved the ability for more accurate staging and selection of operable cases. Somewhat
encouraging results have been obtained with surgery in very limited disease (VLD, T1-2N0-1M0),
though randomized studies between surgery and modern chemo-radiotherapy treatment strategy have
not been conducted. Retrospective studies of surgery with adjuvant chemotherapy have revealed 5year survivals of 26-76% in stage I, 14-50% in stage II, and 0-40% in stage III (2).
A recent retrospective analysis based on 465 resected SCLC patients from the English National
Cancer Data Repository revealed a 31% 5-year survival rate across stages (3). Another study using
data from the American SEER database reported a 40% 5-year survival rate, being better than for nonsurgical comparative patients. The survival was better with surgery in stage I (median 36 vs. 18
months) and stage II (median 25 vs. 14 months), both being statistically significant.(4). With respect
to the type of surgery, another study showed better outcome with lobectomy than either
pneumonectomy or sublobar resection (5). The same study showed better outcome with surgery plus
non-surgical treatment than for neither treatment alone in stage I. The patients having best prognosis
in the surgical retrospective studies have been the VLD patients having T1-2N0-1M0 (6) who in
several studies have 5-year survivals of 40-50%.
A consensus meeting by European Society for Medical Oncology (ESMO) on SCLC concluded in
2010 that surgery may be indicated in selected VLD patient provided that mediastinal node
exploration was carried out and was negative (7). Surgery should be followed by chemotherapy.
Postoperative radiotherapy should be considered in pathological N1 and in cases revealing unforeseen
N2 disease at surgery. These conclusions are part of the current ESMO guidelines on treatment of
SCLC (8).
Conclusions
There are no randomized data comparing modern chemo-radiotherapy against surgery with adjuvant
chemotherapy. However, there is a body of retrospective analyses suggesting that some selected
patients in VLD SCLC having T1-2N0-1M0 disease may benefit from and could at least may be
considered for surgery followed by chemotherapy. Randomized trials are encouraged to further
illuminate this field.
REFERENCES
1. Goldstein SD1, Yang SC. Role of surgery in small cell lung cancer.Surg Oncol Clin N Am. 2011
Oct;20(4):769-77
2. Veronesi G, Bottoni E, Finocchiaro G, Alloisio M. When is surgery indicated for small-cell lung
cancer? Lung Cancer. 2015 Dec;90(3):582-9.
3. Lüchtenborg M, Riaz SP, Lim E, Page R, Baldwin DR, Jakobsen E, Vedsted P, Lind M, Peake
MD, Mellemgaard A, Spicer J, Lang-Lazdunski L, Møller H. Survival of patients with small cell
lung cancer undergoing lung resection in England, 1998-2009. Thorax. 2014 Mar;69(3):269-73.
4. Weksler B, Nason KS, Shende M, Landreneau RJ, Pennathur A. Surgical resection should be
considered for stage I and II small cell carcinoma of the lung. Ann Thorac Surg. 2012
Sep;94(3):889-93.
5. Combs SE, Hancock JG, Boffa DJ, Decker RH, Detterbeck FC, Kim AW. Bolstering the case for
lobectomy in stages I, II, and IIIA small-cell lung cancer using the National Cancer Data Base. J
Thorac Oncol. 2015 Feb;10(2):316-23.
6. Schreiber D, Rineer J, Weedon J, Vongtama D, Wortham A, Kim A, Han P, Choi K, Rotman M.
Survival outcomes with the use of surgery in limited-stage small cell lung cancer: should its role
be re-evaluated? Cancer. 2010 Mar 1;116(5):1350-7.
7. Stahel R, Thatcher N, Früh M, Le Péchoux C, Postmus PE, Sorensen JB, Felip E; Panel members.
1st ESMO Consensus Conference in lung cancer; Lugano 2010: small-cell lung cancer. Ann
Oncol. 2011 Sep;22(9):1973-80.
8. Früh M, De Ruysscher D, Popat S, Crinò L, Peters S, Felip E; ESMO Guidelines Working Group.
Small-cell lung cancer (SCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and
follow-up. Ann Oncol. 2013 Oct;24 Suppl 6:vi99-105.
EVALUATION
1. Which TNM group is very limited Stage SCLC?
a. T1-3N0-3M0
b. T1-3N0-2M0
c. T1-2N0-1M0
d. T1N0M0
2. Which is preferable local treatment?
•
•
•
•
•
•
Male, 72 years, PS1, 37pck yrs
FEV1 1.6 l/s, 67%
DLCO 59%
No major comorbidities
EBUS neg. N2 nodes
PET-CT scan: T1bN0M0
CT-guided biopsy: SCLC
a.
b.
c.
d.
e.
Sequential chemo-radiotherapy
Early concomitant accelerated chemo-radiotherapy
Stereotactic radiotherapy
Surgery
No local treatment
3. Which is preferable local treatment?
•
•
•
•
•
•
a.
b.
c.
d.
e.
f.
g.
Female, 65 years, PS1, 28pck yrs
FEV1 1.8 l/s, 72%
DLCO 61%
No major comorbidities
EBUS pos. N2 nodes
PET-CT scan: T1bN2M0
CT-guided biopsy: SCLC
Sequential chemo-radiotherapy
Early concomitant accelerated chemo-radiotherapy
Stereotactic radiotherapy
Stereotactic radiotherapy and adj. chemo
Surgery alone
Surgery and adj. Chemo
Only chemotherapy
4. Preferable treatment?
•
•
•
•
•
•
•
a.
b.
c.
d.
e.
Male, 68 years, PS1, 24 pck yrs
FEV1 1.8 l/s, 72%
DLCO 61%
No major comorbidities
PET-CT-scan T1aN0M0
EBUS neg. N2 nodes
CT-guided biopsy: Inconclusive, obs malignancy
VATS wedge resection: SCLC T1aN0M0, histologically complete resection
Sequential chemo-radiotherapy
Concomitant chemo-radiotherapy
Completion lobectomy alone
Completion lobectomy followed by adj.chemotherapy
Adjuvant chemotherapy alone