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Surgical resection effective in stage I limited-disease small cell lung cancer
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Patients with stage I limited-disease small cell lung cancer who underwent surgical resection demonstrated a significant survival advantage compared with those who received nonsurgical treatment, according to results of a retrospective study.
Surgical resection also appeared effective in some patients with stage II or stage II limited-disease small cell lung cancer (LD-SCLC), results showed.
“Although chemotherapy and radiotherapy are recommended for patients with LD-SCLC, several series have reported favorable survival outcomes even in patients with stage II and stage III disease who underwent surgical resection,” Tomoyoshi Takenaka, MD, of the department of thoracic oncology at National Kyushu Cancer Center in Fukuoka, Japan, and colleagues wrote.
In the current study, Takenaka and colleagues analyzed the outcomes of 277 patients aged 38 to 89 years (median, 66 years; 81% men) treated for LD-SCLC from 1974 to 2011 at National Kyushu Cancer Center.
Researchers obtained demographic, clinical and treatment data for all patients from an institutional database.
LD-SCLC diagnosis in this study was based on the International Association for the Study of Lung Cancer (IASLC). Patients with malignant pleural effusion or pleuritic carcinomatosa were excluded.
Of the cohort, 50 patients (18%) were diagnosed with clinical stage I LD-SCLC, 53 (19%) were diagnosed with stage II LD-SCLC and 174 (63%) were diagnosed with stage III LD-SCLC.
Forty-four (88%) of patients with stage I disease underwent surgery, compared with 27 patients (52%) with stage II disease and 17 patients (10%) with stage III disease.
Of the 88 patients who underwent surgical resection, 10 received pneumonectomy, 74 received lobectomy and four received limited resection, including wedge resection or segmentectomy.
Nonsurgical treatment, including chemotherapy and chemoradiotherapy, was administered to 189 patients.
In the surgical resection group, 27 patients received induction chemotherapy and two patients received induction chemoradiotherapy. In the nonsurgical treatment group, radiotherapy was administered to four patients (8%) with stage I disease, 17 patients (32%) with stage II disease and 125 patients (72%) with stage III disease.
Median follow-up was 16 months.
In the entire cohort, median survival was 18 months.
Researchers used the Kaplan-Meier method to estimate survival and used the log-rank test to evaluate differences in survival. An exploratory survival analysis was added to balance the background of the patients.
Median survival was 75 months for patients with stage I disease, 18 months for those with stage II disease and 15 months for those with stage III disease. Five-year OS rates were 58% for patients with stage I disease, 29% for those with stage II disease and 18% for those with stage III disease.
Results showed surgical resection was associated with a significantly higher rate of 5-year survival among patients with stage I disease (62% vs. 25%; P<.01), but not among those with stage II disease (33% vs. 24%; P=.95) or stage III disease (18% vs. 18%; P=.35).
Propensity matching analysis compared the long-term survival between the resection and nonsurgical treatment groups among patients with stage II and stage III disease. Researchers matched 44 pairs of patients in each group.
Results showed 5-year survival rates were 28% in the surgical resection group vs. 11% in the nonsurgical treatment group (P=.04).
Five-year survival rates according to period of treatment were 20% in the 1970s/1980s, 21% in the 1990s and 40% in the 2000s (P=.01).
“Surgical resection provided a survival benefit for the patients with clinical stage I SCLC and some cases of stage II or stage III disease in this study,” Takenaka and colleagues wrote. “The outcomes of treatment for SCLC have been improved beginning in the 2000s. A further prospective study is warranted to clarity the possibility of extending the indications for surgical resection to curatively treat LD-SCLC in the present situation.”
Disclosure: See the full study for a list of the researchers’ relevant financial disclosures.
Perspective
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Kathryn F. Mileham, MD
Surgery including lobectomy with mediastinal nodal evaluation is preferred for the 2% to 5% of patients with surgically resectable stage I small cell lung cancer (SCLC). Those with pathologic N0 findings should receive adjuvant chemotherapy, and those with pathologic N+ disease should receive chemotherapy concurrent with mediastinal radiation. This standard of care has been re-evaluated in a broader sense in the retrospective review by Takenaka and colleagues. The detailed examination of 277 patients from 1974 to 2011 with limited-stage SCLC confirmed a significant improvement in 5-year survival in patients with clinical stage I disease who underwent surgical resection. This is certainly consistent with standard of care practice for these rare patients.The management of stages II and III SCLC is a bit more challenging and intriguing. Currently, treatment guidelines advocate patients with limited-stage SCLC beyond T1-2, N0 findings be treated with concurrent chemoradiation. This retrospective report suggests that there may be a benefit to surgery in select cases of stages II/III SCLC. With stagnate treatment paradigms and poor 5-year OS rates, now may be a prudent opportunity to re-evaluate the multidisciplinary treatment of patients with stages II/III SCLC.
In parallel, the approach to patients with extensive-stage (stage IV) SCLC has become increasingly multidisciplinary. Prophylactic cranial irradiation and thoracic radiation have shown to be beneficial in patients whose disease is responsive to chemotherapy. Although currently not standard of care, future studies analyzing patients with stage II/III SCLC for potential benefits of expanding multidisciplinary care — including medical oncology and radiation oncology, as well as surgical oncology — should be considered.
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