Surgery in small cell lung cancer: some quantitative aspects: A commentary

Abstract

Surgery in treatment of small cell lung cancer (SCLC) was abandoned by many in the 1970’s because only about 7% were resectable [l] and because the vast majority of the patients died from recurrent and disseminated disease in spite of resection. Combination chemotherapy has improved the outlook for patients with SCLC, but long-term survival is still obtained in less than 10% of the patients [2]. The most important determinant of longevity is extent of disease at time of diagnosis. Less than 2% of patients with extensive disease become long survivors. Among the 4045% of the patients, who have limited disease, a ‘normal’ mediastinum at pretreatment staging is a significant, good prognostic sign [3]. Data from very select series of resected patients similarly reflect an influence of disease extent, usually categorized by the TNM-system. The pTNM thus refers to the sum of peroperative, and pathological findings. Preoperative, clinical attributes, resulting in the cTNMstage, are not associated with a similar differentiated influence on the prognosis - especially because the nodal status (N, and NJ) is important, but difficult to verify in detail without thoracotomy [4,5]. The cTNM includes information on operability and it is well defined in operated as well as non-operated patients. A treatment policy of surgery therefore has to rely on the cTNM. The pTNM may have similar importance for treatment options available after surgery - but pTNM characteristics cannot facilitate comparison of results from surgical and ‘non-surgical’ series. Surgery in SCLC is optional in the few primarily operable patients as well as in patients, who are potentially resectable after combination chemotherapy. In the Copenhagen group we made a retrospective investigation of the outcome of surgery followed by chemotherapy in a series of 874 consecutive patients [6,7]. Sixty-eight patients, in whom the diagnosis of SCLC was obtained at an explorative thoracotomy, were excluded. Among the residual