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MS11 - Addressing Challenges with Surgical Resection of Lung Cancer (ID 74)
- Event: WCLC 2019
- Type: Mini Symposium
- Track: Treatment in the Real World - Support, Survivorship, Systems Research
- Presentations: 1
- Now Available
MS11.04 - Surgical Resection of SCLC - Not so Obsolete Any Longer (Now Available) (ID 3503)
15:45 - 17:30 | Presenting Author(s): Gustavo Lyons
More than 2 million new lung cancer cases were detected worldwide in 2018, and small cell lung cancer (SCLC) represents about 13-15 % of all lung cancers.
Although surgery was initially regarded as the treatment of choice for all types of lung cancer, it was abandoned for SCLC almost 30 years ago after the results of the Medical Research Council (MRC) randomized trial conducted by Fox et al. in 1973, which showed poor mean survival for the surgical group when compared to the RT group (6.5 months vs. 10 months, P = 0.04). (1) These results led to the abandonment of surgery as a standard treatment in favor of chemotherapy. Two subsequent meta-analyses revealed that the addition of thoracic radiation to systemic chemotherapy improved survival, and that has become the standard of care. (2)
After the introduction of TNM classification, investigators proposed that surgery was postulated to be indicated in limited-SCLC, particularly stage T1, N0, with 5-year survival rates of as high as 52.6% for stage 1 disease. (3) Further, surgical resection after induction chemoradiotherapy demonstrated a control of local relapse in almost 100% of the patients and 5- and 10-year survival rates for patients with stage IIB to IIA were 39% and 35%, respectively, for all patients (resected or not) and 44% and 41% for patients treated with a trimodality approach including adjuvant surgery. (4) Another argument for surgical resection is that the final histology of SCLC might reveal a component of NSCLC in 11-25% cases. (5)
In a recent series of Wakeam et al. including 2,089 patients with SCLC undergoing surgery who were matched 1:1 to those undergoing NST, surgery was associated with longer survival for stage I (median overall survival [OS] 38.6 months vs. 22.9 months), for stage II (median OS 23.4 months vs. 20.7 months), and stage IIIA (median OS 21.7 vs. 16.0 months. In analyses by T and N stage, longer OS was observed in resected patients with stage T3/T4 N0 (median OS 33.0 vs. 16.8 months, p=0.008) and node positivity (N1+ 24.4 vs. 18.3 months p=0.03; N2+ 20.1 vs. 14.6 months p=0.007). (6)
A recent meta-analysis that included a total of 41,483 patients concluded that surgical resection was associated with superior OS in stage I (HR = 0.56, 95% CI: 0.49–0.64, p< 0.001), stage II (HR = 0.75, 95% CI: 0.57–0.99, P = 0.04), and stage III diseases (HR = 0.70, 95% CI: 0.56–0.88, P = 0.002). (11) Unlike stage I disease, there is no consensus for surgery in stage II and stage IIIA SCLC.
Surgical resection is concordant with NCCN and ASCO guidelines; however, evidence shows that in the vast majority of T1 and T2 N0M0 patients, surgery is not offered in the absence of any documented contraindication. Rostadt et al., in a series of 2,442 patients with SCLC, found out that 26% were stages IA and IB and thus candidates for surgical resection, while only 38 patients (1.5%) underwent surgical therapy. (8)
CT screening identifies SCLC at an earlier stage – with better survival – than usual care and offers the hope that more SCLC patients may become long-term survivors. Austin et al. carried out a multinational study of baseline and annual repeat CT screenings of 48,037 volunteers at risk for lung cancer. (9) They found 48 SCLC cases, 92% of which were asymptomatic at diagnosis. Clinical stage was IA in 16 patients (33%), II in 5 (11%), III in 20 (42%), and IV in 7 (15%). Estimated cure rates were 36% overall and 54% for the clinical stage I cases.
Surgical resection is indicated in SCLC in stages I and IIA after precise staging including mediastinoscopy. Patients should receive systemic therapy after resection and mediastinal radiation therapy in cases with nodal metastases. Surgical resection in stages I and IIA SCLC is concordant with NCCN and ASCO guidelines; however, surgery is offered only in one-third of the patients in the absence of any documented contraindication. CT screening identifies SCLC at an earlier stage and offers the hope that more SCLC patients may be candidates for surgical resection and become long-term survivors. Selected cases in stages IIB and IIIA may be candidates for surgery as part of the multidisciplinary treatment.
1) Fox W, Scadding JG. Medical Research Council comparative trial of surgery and radiotherapy for primary treatment of small-celled or oat-celled carcinoma of bronchus. Ten-year follow-up. Lancet. 1973; 2: 63–5.)
2) Pignon JP, Arriagada R, Ihde DC, et al. A meta-analysis of thoracic radiotherapy for small-cell lung cancer. N Engl J Med. 1999;341:476-484. Warde P, Payne D. Does thoracic irradiation improve survival and local control in limited-stage small-cell carcinoma of the lung? A meta-analysis. J Clin Oncol. 1992;10:890-895.)
3) Schreiber D, Rineer J, Weedon J, Vongtama D, Wortham A, Kim A, et al. Survival outcomes with theuse of surgery in limited-stage small cell lung cancer: should its role be re-evaluated? Cancer. 2010;116: 1350–57.
4) Eberhardt W, Korfee S. New approaches for small-cell lung cancer: Local treatments. Cancer Control 2003;10:289-96.
5) Asamura H, Kameya T, Matsuno Y, Noguchi M, Tada H, Ishikawa Y, et al. Neuroendocrine neoplasms of the lung: A prognostic spectrum. J Clin Oncol 2006;24:70-6.)
6) Wakeam E, Acuna SA, Leighl NB, Giuliani ME, Finlayson SRG, Varghese TK, et al. Surgery Versus Chemotherapy and Radiotherapy For Early and Locally Advanced Small Cell Lung Cancer: A Propensity-Matched Analysis of Survival. Lung Cancer. 2017; 109: 78–88.
7) Liu T, Chen Z, Dang J, Li G (2018) The role of surgery in stage I to III small cell lung cancer: A systematic review and meta-analysis. PLoS ONE 13(12): e0210001.
8) Hans Rostadt, Anne Naalsundb, Randi Jacobsena, Trond Eirik Stranda, Helge Scottc, Erik Heyerdahl Strømc, Jarle Norsteina. Should more patients have been offered surgical therapy? European Journal of Cardio-thoracic Surgery 26 (2004) 782–786)
9) Austin JH, Yip R, D'Souza BM, Yankelevitz DF, Henschke CI, International Early Lung Cancer Action Program Investigators. Small-cell carcinoma of the lung detected by CT screening: stage distribution and curability. Lung Cancer. 2012 76(3): 339-43.)
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