Pretreatment Staging Evaluation in Small Cell Lung Carcinoma* A New Approach to Medical Decision Making Franck Chauvin, M.D.; Veronique Triliet, M.D.; Isabelle Court-Fortune, M.D.; Brigitte Velay, M.D.; Gisele Mazoyer, M.D.; Bruno Girodet, At.D.; Frederic GomUlnd, M.D.; Paul Rebattu, M.D.; and Jean Francois Cordier, M.D. The real need for extensive staging at the time of diagnosis is discussed in regard to small cell lung carcinoma. We performed a decisional retrospective analysis on a series of 182 patients, based on three staging steps: the 6rst step included physical examination and routine biologic tests. The second step consisted of liver ultrasonography and needle aspiration of any clinically detectable tumor mass, and the third step included bone marrow examination, radionuclide bone scan, thoracic, abdominal, and brain CT scan. A stepwise multivariate logistic regression performed on 11 variables considered in the 6rst step shows that a four-parameter model can predict the spread of the disease (limited or extensive): weight loss, performance status, and elevated LDH or alkaline phosphatase levels. Limited disease can be predicted in two ways: (1) elevated LDU with normal alkaline phosphatases, no weight loss, and good performance status, or (2) normal LDH and alkaline phosphatases. In this series, 28 percent of patients can be predicted as having extensive disease and can be treated

with chemotherapy alone without chest irradiation. After the second step, the probability of disease being extensive is only 25 percent, and only 84 (46.15 percent) patients would need to undergo the third step of staging procedures (brain cr scan, bone marrow aspiration and biopsy, radionuclide bone scan) with this method. We conclude that a multistep approach represents a simple staging method and offers the advantage of harmlessness and lower costs for patients not to be evaluated in prospective clinical trials. (Chest 1992; 102:497-502)

cell lung cancer (SCLC) accounts for to Small percent of all lung cancers. It has been separated

has resulted in an increased proportion of patients with ED at the time of diagnosis. This might allow a better selection of patients with potentially curable nonmetastatic disease. However, despite the use of new radiologic and biologic examinations, treatment results have not been markedly improved in SCLC. The necessity of complete staging for all patients has to be discussed in order to rationalize expense, to minimize the delay bernreen diagnosis and treatment, and to avoid iatrogenic risks. To determine the informative weight of each component of the staging, we retrospectively performed a decision analysis on a series of 182 patients included in a chemoradiotherapy pilot study of the Croupe Lyonnaise d'Oncologie Thoracique (CLOT), a multicentric regional lung cancer study group.

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from other histologic types because of its early metastatic potential. At the time of diagnosis, roughly 70 percent of patients present with evidence of metastatic disease. 1 This has led to a classification of SCLC patients in rn'o subgroups: the limited disease (LD) group and the extensive disease (ED) group, depending on the absence or presence of extrathoracic neoplastic involvement. 2 The distinction bernreen the limited or extensive stage of the disease appears of significant clinical importance. From a therapeutic point of view, most of the investigators choose to add chest radiotherapy to their chemotherapy programs for LD patients only, in order to improve local control, even though the impact on survival is still discussed. 3-7 From a prognostic point of vie\\', all the series in the literature sho\v a significantly higher median survival time in the LD group. H-lO During the past ten years, the availability of more sensitive staging procedures

*From the Groupe Lyonnais d'Oncologie Thoradque (CLC)T), Lyon,

France. This \\'ork \\'as supported hy grants from the Ligue Nationale Contre Ie Cancer (Comite Departenlental du Rht>ne) and Hospices Civils de Lvon, France. Manuscript received August 30; revision accepted Novernher 26. Reprint requl'stS: Dr. Chauvin, Centre Leon Berard, 28 me Laennec, Lyon, Frll nee 69008

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ALAT alanine aminotransferase; ALK alkaline phosphatases; ASAT aspartate aminotransferase; AVI doxorubicin (Adriamycin), etoposide (VP16), and ifosfamide; CEA = carcinoembryonic antigen; ED = extensive disease; GLOT = Groupe Lyonnais d'Oncologie Thoracique; GGT = gamma glutamyltransferase; LD = limited disease; NPV negative predictive value; NSE neuron-specific enolase; PPV positive predictive value; RMD rate of metastasis detection; SCLC small cell lung cancer; US ultrasonography

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METHODS

Patients From January 1, 1986 to July 15, 1988, 182 patients entered the CLOT PC 8601 pilot study for SCLC. All of them completed the fi)lIowin~ inclusion criteria: a~e youn~er than 70 years, Karnofsky index superior to 50 percent, no prior treatment, histolo~cally proven SCLC, no feasible sur~cal resection, no cardiac, renal, or hepatic failure eontraindicating chemotherapy and possihle followup durin~ and after treatment. Histologic diagnosis was mandatory (cytopathology, 131 [72 percent]; hiopsy, 27 [14.8 percent]; sur~ery, CHEST / 102 / 2 / AUGUSt 1992

497

I EXTENSIVE DISEASE

LIMITED DISEASE

1 51 STEP

-- .. -- .. -- .. -- ..

If AU< .. 105 IfLDH .. SOO If Kamosky < 80 % If Weight loss .. 10 %

p.

e

P < 90 %

b1 .3.32 b2 • 2.50 b3 ~ 1.56 b4 ~ 1.08

bl + b2 + b3 + b4

e

III

I

bl + b2 + b3

I

b4

II P .. 90 %

I

TREATMENT

as extensive disease

2nd STEP

III

No positive

I

II

1 Positive

I

TREATMENT as extensive disease

8M Biopsy

3rd STEP

RadlOl1ucletd Bone Scan

CTScan

II No positive

I

III 1 Positive

I

I

TREATMENT

II [6 percent]; transparit'lal punctnre. 8 [4.4 percent); and bronchial hrushing, .'5 [2_7 perceutD_ 7h'atllU'llt

Tht, treatmt'nt plan (Fig I) started in all patients by filUr

Pretreatment staging evaluation in small cell lung carcinoma. A new approach to medical decision making.

The real need for extensive staging at the time of diagnosis is discussed in regard to small cell lung carcinoma. We performed a decisional retrospect...
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