I am often asked whether my 8mm nodules can be cured, and whether my 2cm lesions will recur after surgery. When I encounter such questions, it is often difficult for me to answer them, because if I say it is light, I am afraid that the patient will not take it seriously and think it will be fine after surgery, and dragging it for a long time to take a review and follow up. Often say a cure rate, and then tell him that this is only for a group, not everyone will use, but still have to closely observe the changes in the disease.
All replies come from my own experience. After so many years of medical practice, most early stage lung cancer patients are cured after surgery, but a few of them have recurrence after surgery, and the speed of recurrence varies from person to person, some of them have slower recurrence, some of them have fast recurrence, even some early stage lung cancer has metastasized all over the body three months after surgery, and can only be treated conservatively.
This is the case of a recently admitted post-operative lung nodule patient who was admitted to the hospital with chest tightness and shortness of breath. This elderly patient, 73 years old, with a history of heavy smoking, was found to have a 2.5 cm nodule in the upper lobe of the left lung during a physical examination six months ago, and considering that the lesion was not large and the patient was in good health, she underwent minimally invasive lumpectomy at a local hospital to remove the upper lobe of the left lung.
The patient’s stage was relatively early, and she was routinely treated with 4 cycles of chemotherapy with EP regimen after surgery. Half a month after chemotherapy, when the family was ready to take the patient for local radiotherapy, the patient started to have chest tightness and left-sided chest pain, which gradually worsened, and the re-examination of CT revealed a moderate amount of pleural effusion on the left side, multiple nodules in the pleura, and metastases in the liver and brain.
Why did such an early lung cancer develop extensive metastasis in just half a year?
The reason is that the patient’s lung cancer type is small cell lung cancer! Although small cell lung cancer grows in the lung, it has very different characteristics from the common non-small cell lung cancer. Strictly speaking, small cell lung cancer is a systemic disease, which is the “evil of the evil”. Except for the very early stage, surgery is generally not considered, and most of them choose chemotherapy-based comprehensive treatment.
According to the staging criteria proposed by the VA hospital, small cell lung cancer is divided into limited stage and extensive stage. The so-called limited stage means that the tumor is limited to one side of the chest cavity, or there are only lymph node metastases in the surrounding area. Extensive stage means that the lesion is beyond one side of the chest cavity, and most patients with extensive stage will eventually develop metastasis to the liver, bone, brain and other areas. Because of the very obvious tendency of neuroendocrine differentiation of tumor cells, the incidence of tumor-associated syndrome is high.
Although small cell lung cancer is more sensitive to chemotherapy and has good results in recent treatment, the remission period is often short due to the short time of cancer cell multiplication, and many patients maintain for a few months and then progress again. Therefore, even after early radical surgery patients still need chemotherapy and radiotherapy to prevent recurrence and metastasis. Otherwise, if so few cells escape before surgery or during surgery, after a while, “a single spark can start a prairie fire.” Overall, most patients with small cell lung cancer have rapidly progressing symptoms and disease and die within a short period of time from tumor progression.
While the traditional treatment paradigm for small cell lung cancer relied on chemotherapy and radiation therapy, the treatment paradigm for small cell lung cancer has changed somewhat with the development of immunotherapy. The current guidelines recommend three PD1 immunotherapeutics and one anti-angiogenic oral targeted agent for extensive stage small cell lung cancer. They are the imported PD-L1 inhibitor dulvalizumab (Infiban), the imported PD-L1 inhibitor atelelizumab (Taishengqi), and the domestic PD-1 inhibitors solutumab and anlotinib, respectively.
Immunotherapy and targeted therapy offer some hope for patients with small cell lung cancer, but in fact, together with immunotherapy, the overall results are poor, for example, in the IMpower133 study, atelizumab + carboplatin + etoposide prolonged median OS (12.3 vs 10.3 months) and median PFS (5.2 vs 4.3 months) compared to placebo + carboplatin + etoposide . The results showed that overall survival was prolonged by only 2 months and disease progression was delayed by just under 1 month. As we can see, there is a long way to go in the treatment of small cell lung cancer, and we hope that better drugs and treatment modalities will be available in the future.
