The importance of surgical and multimodality treatment for small cell bronchial carcinoma

In a cooperative international lung cancer multimodality treatment trial, 112 patients with small cell lung cancer underwent initial surgical resection and were then randomized to receive one of two intensive postoperative chemotherapeutic regimens, followed by prophylactic cranial irradiation in the disease-free patients. Regimen A consisted of eight courses of cyclophosphamide, doxorubicin, and vincristine and regimen B of two courses of three sequential drug combinations: (1) cyclophosphamide, lomustine, and methotrexate; (2) cyclophosphamide, doxorubicin, and vincristine; and (3) ifosfamid and etoposide. In 47 patients the diagnosis was known preoperatively and in 65 it was not confirmed until the resected specimen was examined (all diagnoses were reviewed by a referee pathologist). Each patient was classified by the pathologic TNM characteristics. There were 38 patients with stage I disease, 39 patients with stage II, and 35 patients with stage IIIa disease. In stage IIIa there were nine patients with T3 N0-1 disease and 26 with T1-3 N2 disease (most N2 disease was clinically undetected until thoracotomy or was discovered only by routine histologic examination of the resected mediastinal nodes). Early survival rates at 24 months calculated by the life table method are as follows: stage I, 76%; stage II, 56%; and stage IIIa, 49% (T3 N0-1, 89%; T1-3 N2, 35%). Survival rates at 36 months are 62%, 50%, and 41% (74% and 29%), respectively. The projected 36-month survival rate for 43 patients with N0 disease is 65%; for 43 with N1 disease, 52%; and for 26 with N2 disease, 29%. No difference in survival has been noted in either chemotherapy treatment group. It is concluded that initial surgical resection for limited small cell cancer (stage I, II, and T3 N0-1) followed by intensive chemotherapy is an appropriate therapeutic approach. For T1-3 N2 disease the results are inconclusive.