SUPERIOR VENA-CAVA OBSTRUCTION IN SMALL-CELL LUNG-CANCER

Purpose: To identify prognostic or treatment factors influencing the r esponse of superior vena cava obstruction (SVCO), time to SVCO recurre nce, and overall survival of SCLC patients with SVCO at presentation; and to assess the role of retreatment in patients with SVCO at recurre nt or persistent disease. Methods and Materials: Between January 1983 and November 1993, 76 consecutive patients who had small-cell lung can cer (SCLC) with SVCO were treated in our institution. Analysis was don e according to the disease status at diagnosis of SVCO. The first anal ysis concerned a group of 50 patients who had SVCO at initial presenta tion. The second analysis concerned a group who had SVCO as a manifest ation of persistent or recurrent disease. Results: In the first analys is, 93% had significant improvement in symptoms of SVCO after chemothe rapy and 94% after mediastinal radiation. Response is almost universal despite a wide range of radiation fractionation and total dose used. Seventy percent remained SVCO-free before death. Thirty percent develo ped recurrence of SVCO symptoms 1-16 months (median 8) after the start of initial treatment. Those who received combined chemotherapy and ra diation had a longer time to SVCO recurrence (p = 0.018) compared to t hose who received chemotherapy alone. This effect is mainly seen in li mited-stage patients. The presence of SVCO recurrence tends to have an adverse effect on the overall survival (p = 0.077) irrespective of th e time when the recurrences occurred (p = 0.296). The median survival of this whole group of 50 patients in the first analysis was 9.5 month s, and the 2-year survival was 10%. Stage was strongly predictive of s urvival (p < 0.001). Sixteen percent (3 of 19) of the patients with li mited-stage diseases were long-term survivors (two patients survived 3 5 months and one survived 70 months). The early mortality from SVCO wa s 2%. In the second analysis, 85% had previously been treated with che motherapy alone. The response rate of SVCO in the analysable patients (n = 39) was 77%. There was no significant difference in the response rate of SVCO to treatment comparing patients treated by chemotherapy f irst or mediastinal radiation first (p = 0.653), but most patients [82 % (32 of 39)] received radiation as the initially treatment of SVCO. N inety-three percent (38 of 41) received mediastinal radiation as a par t of their ultimate retreatment regimen, and 68% (28 of 41) received m ediastinal radiation as their sole retreatment regimen. Thirty-two per cent (13 of 41) received chemotherapy as a part of their ultimate retr eatment regimen, and only 7% received chemotherapy alone as their sole retreatment regimen. Eighty-three percent (25 of 30) of those whose S VCO responded remained free of SVCO before death, with a median surviv al of 3 months after recurrent or persistent disease documented. Concl usion: Chemotherapy or mediastinal radiation is very effective as an i nitial treatment in SCLC patients with SVCO at presentation and at rec urrent or persistent disease. There is no obvious need to use big radi ation fraction sizes for the first few radiation treatment as was prev iously believed. In patients with recurrent or persistent SCLC with SV CO, especially in those who previously received chemotherapy only, we have more experience in incorporating mediastinal radiation as a major component of the palliative regimen with highly effective and durable palliation achieved. (C) 1997 Elsevier Science Inc.