Adjuvant surgery after carboplatin and VP16 in resectable small cell lung cancer

The real benefit of surgical treatment of small cell lung cancer (SCLC) has never been demonstrated, mainly because of the rarity of surgical cases and the difficulty in comparing surgical and medical series for the different classifications systems used by surgeons (tumor, node, metastasis) and medical oncologists and radiotherapists (Veterans Administrations Lung Cancer Study Group).

We prospectively assessed the utility of surgery after chemotherapy (carboplatin plus VP16 with or without ifosfamide) with or without radiotherapy in 23 patients with preoperative diagnosis of resectable stage I to IIIA SCLC. A median of three (range: three to six) courses of chemotherapy were administered. Five pneumonectomies, 12 lobectomies (seven sleeve resections), and two segmentectomies were performed, and all except one received radical lymph node dissection. Four (17%) patients received exploratory thoracotomy. Nine (39%) patients received postoperative thoracic radiotherapy.

Pathological stages were complete response in four patients, stage I in seven patients, stage II in seven patients, and stage III in five patients. Thirty-day morbidity and mortality were 9% and 0%, respectively. Surgery-related mortality at 90 days was 9%. Median follow-up was 19 months. Overall and local relapse rates were 52% and 17%, respectively. Median overall and disease-free survival were 24 and 12 months. Patients with complete response or pathological stage I had a significantly better Kaplan-Meier survival and lower incidence of relapse than those with more advanced pathological stage (p = 0.025 and 0.027, respectively, log rank).

Survival after chemotherapy and surgery in the series correlated with pathological but not pretreatment stage. Only patients with pathological stage 0 or I disease seem to benefit from surgical resection.