Role of surgery in multimodality therapy for small cell lung cancer
- Eric Vallières, MD, FRCSC
Eric Vallières, MD, FRCSC
- Section Editor — Lung Cancer
- Surgical Director of the Lung Cancer Program
- Swedish Cancer Institute
- Section Editors
- Rogerio C Lilenbaum, MD, FACP
Rogerio C Lilenbaum, MD, FACP
- Section Editor — Lung Cancer
- Yale Cancer Center
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
Small cell lung cancer (SCLC) is distinct from non-small cell carcinoma (NSCLC) both biologically and clinically. SCLC comprises approximately 15 percent of all lung cancers. It occurs almost exclusively in cigarette smokers; in one series, only 2 percent of 500 patients with SCLC did not have a smoking history . SCLC is also the most common histologic subtype among uranium miners, probably due to exposure to radioactive radon, which is a byproduct of uranium decay . (See "Pathobiology and staging of small cell carcinoma of the lung".)
SCLC is distinguished from NSCLC by its rapid growth characteristics and the early development of widespread metastases. SCLC is highly responsive to chemotherapy, while there is a substantial historical experience documenting the futility of surgery and/or radiation therapy (RT) without systemic chemotherapy. Prior to the introduction of systemic chemotherapy, median survivals for patients with limited stage (LS) disease (limited to the ipsilateral hemithorax and regional lymph nodes) and extensive stage (ES) disease were approximately 12 weeks and 5 weeks, respectively . Many studies have demonstrated that chemotherapy significantly improves survival when compared with surgery or RT alone, and combination chemotherapy is the mainstay of therapy for both LS and ES SCLC. (See "Pathobiology and staging of small cell carcinoma of the lung", section on 'Staging'.)
Although the combination of chemotherapy plus radiation improves survival in patients with LS-SCLC, local recurrence rates in patients undergoing chemoradiotherapy are between 35 and 50 percent . This high local failure rate has led to reconsideration of the role of surgery as a way to improve rates of local control.
OVERVIEW OF TREATMENT OF LS-SCLC
Patients with SCLC are often staged as those with LS disease (limited to the ipsilateral hemithorax and regional lymph nodes) and those with more extensive stage (ES) disease. Most patients with LS-SCLC will have clinical or pathologic evidence of mediastinal lymph node disease. Careful staging, including invasive staging of the mediastinum and MRI of the brain, is indicated to identify the small fraction of patients with LC-SCLC who do not have mediastinal or metastatic disease. (See "Pathobiology and staging of small cell carcinoma of the lung", section on 'Staging'.)
●For patients with LS-SCLC who have clinical or pathologic evidence of mediastinal disease, chemoradiotherapy is indicated as the initial treatment. (See "Limited stage small cell lung cancer: Initial management", section on 'Benefit of treatment'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Ihde DC, Pass HI, Glatstein EJ. Small cell lung cancer. In: : Principles and Practice of Oncology, DeVita V, Hellman S, Rosenberg S (Eds), JB Lippincott, Philadelphia 1993. p.723.
- Archer VE, Saccomanno G, Jones JH. Frequency of different histologic types of bronchogenic carcinoma as related to radiation exposure. Cancer 1974; 34:2056.
- Zelen M. Keynote address on biostatistics and data retrieval. Cancer Chemother Rep 3 1973; 4:31.
- Pignon JP, Arriagada R, Ihde DC, et al. A meta-analysis of thoracic radiotherapy for small-cell lung cancer. N Engl J Med 1992; 327:1618.
- Comparative trial of surgery and radiotherapy for the primary treatment of small-celled or oat-celled carcinoma of the bronchus. First report to the Medical Research Council by the working-party on the evaluation of different methods of therapy in carcinoma of the bronchus. Lancet 1966; 2:979.
- 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.
- Martini N, Wittes RE, Hilaris BS, et al. Oat cell carcinoma of the lung. Clin Bull 1975; 5:144.
- Mountain CF, Carr DT, Anderson WA. A system for the clinical staging of lung cancer. Am J Roentgenol Radium Ther Nucl Med 1974; 120:130.
- Vallières E, Shepherd FA, Crowley J, et al. The IASLC Lung Cancer Staging Project: proposals regarding the relevance of TNM in the pathologic staging of small cell lung cancer in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol 2009; 4:1049.
- Yu JB, Decker RH, Detterbeck FC, Wilson LD. Surveillance epidemiology and end results evaluation of the role of surgery for stage I small cell lung cancer. J Thorac Oncol 2010; 5:215.
- Shepherd FA, Ginsberg RJ, Patterson GA, et al. A prospective study of adjuvant surgical resection after chemotherapy for limited small cell lung cancer. A University of Toronto Lung Oncology Group study. J Thorac Cardiovasc Surg 1989; 97:177.
- Kreisman H, Wolkove N, Quoix E. Small cell lung cancer presenting as a solitary pulmonary nodule. Chest 1992; 101:225.
- Quoix E, Fraser R, Wolkove N, et al. Small cell lung cancer presenting as a solitary pulmonary nodule. Cancer 1990; 66:577.
- Jett JR, Schild SE, Kesler KA, Kalemkerian GP. Treatment of small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e400S.
- NCCN guidelines http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on October 28, 2013).
- Yang CF, Chan DY, Speicher PJ, et al. Role of Adjuvant Therapy in a Population-Based Cohort of Patients With Early-Stage Small-Cell Lung Cancer. J Clin Oncol 2016; 34:1057.
- Shepherd FA, Ginsberg RJ, Feld R, et al. Surgical treatment for limited small-cell lung cancer. The University of Toronto Lung Oncology Group experience. J Thorac Cardiovasc Surg 1991; 101:385.
- Wong AT, Rineer J, Schwartz D, Schreiber D. Assessing the Impact of Postoperative Radiation Therapy for Completely Resected Limited-Stage Small Cell Lung Cancer Using the National Cancer Database. J Thorac Oncol 2016; 11:242.
- Lad T, Piantadosi S, Thomas P, et al. A prospective randomized trial to determine the benefit of surgical resection of residual disease following response of small cell lung cancer to combination chemotherapy. Chest 1994; 106:320S.
- Eberhardt W, Stamatis G, Stuschke M, et al. Prognostically orientated multimodality treatment including surgery for selected patients of small-cell lung cancer patients stages IB to IIIB: long-term results of a phase II trial. Br J Cancer 1999; 81:1206.
- Lewiński T, Zuławski M, Turski C, Pietraszek A. Small cell lung cancer I--III A: cytoreductive chemotherapy followed by resection with continuation of chemotherapy. Eur J Cardiothorac Surg 2001; 20:391.
- OVERVIEW OF TREATMENT OF LS-SCLC
- SURGERY ALONE FOR LS-SCLC
- SURGERY IN MULTIMODALITY TREATMENT FOR LS-SCLC
- Surgery as initial therapy
- - Postoperative chemotherapy
- - Postoperative radiation therapy
- - Prophylactic cranial irradiation
- Surgery after induction chemotherapy
- INFORMATION FOR PATIENTS