Elsevier

Current Problems in Cancer

Volume 36, Issue 3, May–June 2012, Pages 117-130
Current Problems in Cancer

Role of Surgery for Small Cell Lung Cancer

https://doi.org/10.1016/j.currproblcancer.2012.03.003Get rights and content

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Solitary Pulmonary Nodule

An SPN technically fits into the limited-stage category of T1-2, N0, but warrants specific consideration. These nodules can pose a particular dilemma for the thoracic surgeon if a patient is undergoing a thoracoscopic or open wedge resection for diagnosis of a nodule not suspected to be SCLC and on frozen section the pathologist raises that concern. Presumably, the patient in this situation would not have suspicious mediastinal adenopathy, which would define this as very limited-stage SCLC. The

Limited-Stage SCLC

Limited-stage SCLC is broken up by the NCCN guidelines into limited-stage T1-2, N0 and limited stage in excess of T1-2, N0. The guidelines provide for surgery preferably lobectomy for clinical T1-2, N0 and treatment options if nodal disease is found after resection. However, the NCCN guidelines state that patients with disease in excess of T1-2, N0 do not benefit from surgery.1 In a recent article by Koletsis et al.6 in the Journal of Cardiothoracic Surgery, there have not been any data for

Results of Surgery Alone in SCLC

At present, treatment of very limited disease SCLC with surgery alone is highly controversial. During the past 30 years, chemoradiotherapy has remained the gold standard in the treatment of this disease. In retrospective reviews, the 5-year survival of patients who were treated with surgery alone was lower than in patients treated with multidisciplinary approach.5 After surgery alone, the 5-year survival rate was only about 10%. The pattern of failure in most cases was distant metastases.5, 12

Results of Surgery With Adjuvant Chemotherapy

The first observations that the administration of adjuvant chemotherapy after surgery could be of value came from the Veterans Administration Surgical Oncology Group.5, 18 Most patients had been operated on for an undiagnosed peripheral tumor, ultimately proven to be SCLC, and were subsequently given postoperative chemotherapy. Maassen and Greschuchna19 reported that 25% of SCLC patients who were treated with resection and adjuvant chemotherapy did not have a diagnosis of SCLC before the

Results of Neoadjuvant Chemotherapy With Surgery

Dusmet et al.3 reviewed many of the results dealing with neoadjuvant chemotherapy and surgery for SCLC. Williams et al.20 reported their experience with neoadjuvant therapy between 1981 and 1985. There were 189 patients with SCLC. After staging, 57 were considered to have limited disease. Nineteen were ineligible for surgery because of their poor condition. Thirty-eight eligible patients received 3 courses of induction chemotherapy. Five had a complete response (CR), 26 had a partial response

Mixed Histology Tumors

According to the World Health Organization classification of lung carcinoma (1999), the variants of SCLC admixed with various other histologic types are defined as combined small-cell carcinoma. Recent surgical series of neuroendocrine lung tumors revealed that 26.6% of resected SCLC fell into this category.10, 27 In studies of induction chemotherapy followed by adjuvant surgery for pathologically confirmed SCLC, an NSCLC component was found in the resected specimen in 11%-15%.10, 28, 29 The

Salvage Surgery

Few treatment options exist for patients who have SCLC, who do not respond to initial therapy, or who relapse after a primary response. Typically, only brief palliation is achieved with second-line chemotherapy or radiation. A few studies have attempted to evaluate whether surgery might be useful as salvage therapy for selected patients who have limited SCLC.31 Yamada et al.32 reported on 9 patients who underwent surgery: 2 of whom had failed to respond to chemotherapy, 6 who had achieved PR,

NCCN and Chest Guidelines

The Chest guidelines for the evaluation of patients with pulmonary nodules4 state that in surgical candidates with an SPN that has been diagnosed as SCLC, they recommend surgical resection with adjuvant chemotherapy, provided that noninvasive and invasive staging exclude the presence of regional or distant metastasis. In patients who have an SPN and in whom SCLC is diagnosed intraoperatively, they recommend anatomic resection (with systemic mediastinal lymph node sampling or dissection) under

Conclusions

In keeping with the above stated guidelines from Chest and the NCCN and reviewing the literature, there appears to be agreement regarding the utility of, including surgery in the management, an SPN found to be SCLC, and limited-stage (T1-2, N0) SCLC provided an extensive preoperative workup is completed to prove there is no occult nodal disease or distant metastases. Once the stage is proven to be beyond limited preoperatively, although evidence does exist to include surgery, this would need to

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