Journal of Thoracic Oncology:
Letters to the Editor
University Clinic of Respiratory and Allergic Diseases; Golnik, Slovenia; firstname.lastname@example.org
Disclosure: The author declares no conflict of interest.
To the Editor:
Unusual results of surgical treatment in small-cell lung cancer (SCLC) patients were published by Lim et al.1 in the article “The role of surgery in he treatment of limited disease small cell lung cancer. Time to reevaluate” in the October issue of the Journal of Thoracic Oncology. In the group of 59 completely resected SCLC no patient had any documentation of preoperative chemotherapy, 13 patients had received adjuvant chemotherapy, two patients adjuvant radiotherapy, and one adjuvant chemo-radiotherapy. Despite this, the 5-year survival rate was 52%! This calculated (not observed) percentage of survival is quite comprehensible considering the median time to follow-up was only 2.8 years. Less acceptable is the paradoxical statement of survival by Union Internationale Contre le Cancer (UICC) clinical stage and clinical nodal status: patients with a more progressed stage had better survival. The results were similar when the pathologic stage was used for analysis. So, the authors state that “UICC classification had a poor discriminatory value for prognosis,” “the influence of nodal involvement was unclear; the best prognostic subgroup was in patients with N2 disease.”
The prognostic value of UICC tumor node metastasis staging in SCLC has been established in many clinical studies. In the International Society of Chemotherapy-Lung Cancer Study Group, multinational, prospective, and randomized study of 183 SCLC patients treated surgically, which also included patients from Slovenia, the N0 patients had a significantly better survival rate than the N1 and N2 patients.2
Lim et al. did not explain their unusual observations. Searching for a reason for such results, there is (beside accidental findings due to the small number of individual groups of patients) a reasonable possibility that patients in a higher stage more frequently received adjuvant therapy that could have led to better survival. From this point of view, the published study actually evaluated the role of adjuvant therapy in resected SCLC.
A solitary limited pulmonary tumor without enlarged regional lymph nodes and without suspicion of distant metastases represents a challenge for the thoracic surgeon, even in the case of confirmed SCLC. In the literature, one finds data on successful surgical treatment of SCLC without chemotherapy, but the survival rate of such cases is low. This is substantiated by the survival rate in the period before routine use of chemotherapy. With the present knowledge of SCLC, the omission of adjuvant chemotherapy is too risky, whether the chemotherapy is adjuvant therapy to surgery or surgery adjuvant to chemotherapy.
Based on our own experience in Slovenia,3 as in many thoracic centers world wide, surgery and chemotherapy are routinely performed in the case of selected small, solitary, preferably peripheral SCLC after consistently being carried through complete staging. Still, the percentage of such cases is very low.
Lučka Debevec, MD, PhD
University Clinic of Respiratory and Allergic Diseases
1. Lim E, Belcher E, Yap YK, Nicholson AG, Goldstraw P. The role of surgery in the treatment of limited disease small cell lung cancer: time to reevaluate. J Thorac Oncol 2008;3:1267–1271.
2. Karrer K, Ulsperger E. Surgery for cure followed by chemotherapy in small cell carcinoma of the lung. For the ISC-Lung Cancer Study Group. Acta Oncol 1995;34:899–906.
3. Debevec M, Orel J. Treatment of small cell lung cancer by surgery, chemotherapy, and irradiation. Lung Cancer 1991;7:339–344.