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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Is Surgery Ever an Option for Small Cell Lung Cancer? - by Dr. Laskin
Sat, 01/19/2008 - 06:28
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

Dr. Laskin has appreciated the warm welcome. Not only have you not scared her off, she's written her first post for us.

By the way, it's misleading to have my name and picture and "about the author" next to these posts by our new faculty -- the software upgrade will fix this. Here's her picture, so you can associate a name with a face (I had threatened to use a Wonder Woman picture if she didn't supply one).

Laskin photo Dr. Laskin And without further adieu, her post:

Small cell lung cancer (SCLC) is a distinct sub-set of lung cancers representing about 15% of the entire group. We tend to think of it as a completely different cancer, and so we call all of the other lung cancers collectively “non-small cell lung cancer” (NSCLC); terms you are all familiar with from this website. Dr. West has previously posted an introduction to SCLC (post here) as well as the standard approach to both limited (post here) and extensive stage disease (post here) so I will try not to repeat too many of these points. Recently a question came up about the utility of surgery in the treatment of SCLC, and this is what this posting will address. When and how is surgery a part of the care for people with SCLC?

Since SCLC is generally considered a more systemic (whole body) disease with a high rate of chemo and radiation response, surgery is not usually the first treatment approach when the diagnosis is already known. So, the bottom line is that there is little or no consensus on the role of surgery for SCLC either as a first-line treatment or after chemo and/or radiation. But let’s explore some of the data.

The most common surgical intervention is when surgery is the first-line of treatment of a lung nodule when the diagnosis (pathology) is not known pre-operatively or when a small biopsy looks like NSCLC but at surgery is found to be SCLC. Post-operative (adjuvant) chemo and often local radiation therapy is important to consider to minimize the risk of recurrence; the majority of oncologists would consider at least adjuvant chemo if not chemo-radiation to be the standard of care.

A randomized trial in the 1960’s compared immediate surgery with radiation for potentially resectable SCLCs and found clear advantages to radiation in both the rate or complications and overall survival. Since then there have been some retrospective studies looking at the experience of primary surgical resection if a SCLC is small and potentially surgically resectable. The pooled data (which is “old”, from the 1970-80’s) suggests that patients might do reasonably well with this approach, with 5-year survival rates of up to 50%; however these are old studies and are not properly conducted prospective (planned, treating patients all the same way) clinical trials, so they must be taken with a grain of salt.

For patients with early stage SCLC, there have been a few prospective studies looking at the possible role for surgery after initial chemo and/or radiation therapy, but again these studies tended to use outdated chemotherapy, or the radiation and chemo were not given concurrently -- both of which may well impact on the results. In addition, the results of this strategy for patients with more advanced disease (stage III) were very poor, and it is not recommended for this patient group. More recently a research team in Germany has been using surgery after chemo-radiation with some success, particularly with increased rates of local control; however this is one team’s experience and has not been tested in a randomized study.

Investigators in Japan are also looking at this question apparently in a randomized study, but no results have been published or presented to my knowledge. Last week the results of a Japanese retrospective review of a large combined surgical database of over 13,000 lung cancers were published (abstract here). Of these, 390 SCLC (3%) were included, which leads one to believe that although some SCLC surgery is done, it is not a common practice. Again this is retrospective, but the 5 year survival rates for patients with minimal disease were pretty good: for example, stage I at 60% and stage IIA at 40%, but no information was given regarding their pre- or post-operative chemo or radiation therapy.

In summary, I think of SCLC as a systemic disease that is sensitive to chemo and radiation therapy, and so these should represent the core of treatment. However, although controversies exist, I think first-line surgical therapy in rare cases, very small tumours without any sign of lymph node involvement, followed by adjuvant therapy is an acceptable route. I think surgery after initial chemo-radiation cannot be recommended at the present time, though it should perhaps be studied in the context of a clinical trial.

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