Evolving role of immunotherapy in small cell lung cancer

The role of nursing in enhancing quality of life for lung cancer patients receiving targeted and immunotherapy: Challenges, opportunities, and future directions

Targeted therapy and immunotherapy are two critical contemporary strategies in the management of lung cancer. Despite their success in extending survival and mitigating symptoms, they introduce complex nursing interventions. This narrative review examines the impact of these treatment strategies on patients' quality of life, assesses the efficacy of current nursing interventions, and proposes strategies for enhancing future nursing practices. A comprehensive analysis of existing literature, covering studies published between 2014 and 2024 in the databases of WOSCC- SCIE, PubMed, CINAHL, and Embase, underscores the pivotal role of nursing in managing treatment-related adverse effects, delivering psychosocial support, and educating patients. Nevertheless, challenges remain in the areas of nursing staff training, resource allocation, and the limited scope of nursing research. Future directions should focus on the development of individualized care plans, the integration of innovative nursing technologies, and the ongoing enhancement of care quality to optimize nursing practices.

Patterns and Differences in Lung Cancer Treatment: United States, 2015-2020

BACKGROUND

Treatment for lung cancer can improve prognosis, but 5-year survival remains low at 26%. An examination of treatment using data with higher population coverage, and among a broader number of treatment modalities and individual characteristics, would provide greater insight into differences in lung cancer treatment.

RESEARCH QUESTION

Among adults diagnosed with lung cancer, how does reported receipt of lung cancer treatment differ by sociodemographic characteristics?

STUDY DESIGN AND METHODS

We used 2015-2020 National Program of Cancer Registry data covering 89% of the US population to describe first-course treatment among people aged ≥ 20 years and diagnosed with lung and bronchus cancer. We performed multivariable logistic regression to examine associations between sociodemographic characteristics and treatment received.

RESULTS

Among 1,068,155 people diagnosed with lung cancer, 22% received surgery, 41% received chemotherapy, 40% received radiation, 13% received immunotherapy, and 75% received at least one of the four treatments. People who were aged ≥ 45 years (OR range, 0.08-0.67); were of American Indian or Alaska Native (OR, 0.82; 95% CI, 0.77-0.87), Black (OR, 0.82; 95% CI, 0.81-0.84), or Hispanic (OR, 0.80; 95% CI, 0.78-0.82) race/ethnicity; resided in a nonmetropolitan county (OR, 0.98; 0.96-0.99); resided in the bottom 25% (OR, 0.80; 95% CI, 0.78-0.81) and middle 50% (OR, 0.87; 95% CI, 0.86-0.88) of counties by economic status (considers unemployment rate, per capita market income, and poverty rate); and in the West US census region (OR, 0.95; 95% CI, 0.94-0.97) had significantly lower odds of receiving at least 1 of the 4 treatments.

INTERPRETATION

Chemotherapy and radiation were the most common types of first-course treatment reported. Receipt of at least one of the four treatments examined was lower among several groups, including certain racial and ethnic groups and those residing in counties with lower economic status. Future studies might further identify and intervene on factors underlying differences.

Immunochemotherapy for small cell lung cancer with paraneoplastic Cushing syndrome: A case report and literature review

RATIONALE

Paraneoplastic Cushing syndrome (PCS) is an adverse prognostic factor for small cell lung cancer (SCLC) patients. Retrospective studies have shown that the median survival of SCLC complicated with PCS was <7 months. No immunochemotherapy has been recorded in the treatment of SCLC with PCS. Previous preclinical and clinical studies have suggested glucocorticoid exposure may affect the efficacy of immunotherapy.

PATIENT CONCERNS AND DIAGNOSIS

A 60-year-old man was admitted for his irritability and palpitation. During hospitalization, a chest computed tomography scan revealed a lobar soft tissue shadow in his left lower lung. He was diagnosed as limited-stage SCLC (T2bN1M0 IIB) with PCS, ultimately.

INTERVENTIONS AND OUTCOME

The patient received 4 courses of immunochemotherapy of etoposide plus platinum with durvalumab and 1 adjuvant radiotherapy alone in 2022 for his limited-stage SCLC, and underwent 5 courses of immunochemotherapy of irinotecan plus platinum with serplulimab in 2023 for his extensive-stage SCLC. The patient achieved a long survival of 20 months.

LESSONS

The case preliminarily demonstrated the efficacy of immunochemotherapy in the management of SCLC complicated with PCS. The regime of serplulimab with irinotecan-based chemotherapy also indicated its satisfactory efficacy as a second-line treatment for extensive-stage SCLC. Furthermore, the case has highlighted that the management of hypercortisolism, the improvement of myelosuppression, and the prophylaxis against infection were 3 hinges for the continuation of immunochemotherapy and the holistic management of SCLC with PCS.

Novel Immunohistochemical Profiling of Small-Cell Lung Cancer: Correlations Between Tumor Subtypes and Immune Microenvironment

BACKGROUND/OBJECTIVES

Small-cell lung cancer (SCLC) is a highly aggressive malignancy with an emerging molecular classification based on the expression of the transcription factors ASCL1, NEUROD1, and POU2F3. This study aimed to explore the relationship between these novel subtypes and the tumor immune microenvironment (TIME), particularly CD8+ and CD4+ tumor-infiltrating lymphocytes (TILs).

METHODS

In 51 cases of patients with SCLC, immunohistochemical (IHC) stains for ASCL1, NEUROD1, POU2F3, CD56, Ki67, CD8, and CD4 were performed. H-scores for the novel transcription factors were calculated to determine tumor subtype. CD8+ and CD4+ TIL counts were averaged across 10 high-power fields. The Kruskal-Wallis test and subsequent post hoc Dunn tests were used to determine the differences in transcription factor expression and TILs across subtypes.

RESULTS

In our cohort, 68.62% of our cases were SCLC-A, 9.80% were SCLC-N, 7.84% were SCLC-P, and 13.72% were SCLC-I. Significant differences were observed in the expression of ASCL1, NEUROD1, and POU2F3 across subtypes. CD8+ TILs were more abundant in SCLC-P and SCLC-I. CD8+ TILs were negatively correlated with ASCL1 expression (p < 0.05) and positively correlated with POU2F3 expression (p < 0.005).

CONCLUSIONS

This study highlights the need to integrate the novel SCLC classification with data regarding the TIME to better inform patient prognosis and treatment.

Patients with Extensive-Stage Small Cell Lung Cancer Harboring Less Than 4 Metastatic Sites May Benefit from Immune Checkpoint Inhibitor Rechallenge by Reshaping Tumor Microenvironment

Background

Immune checkpoint inhibitors (ICIs) has prolonged survival in patients with extensive-stage small cell lung cancer (ES-SCLC) as first-line treatment. However, whether ICI rechallenge could bring survival benefit to patients with ES-SCLC following its failure as first-line treatment remains unknown. Therefore, we aim to address the issue and identify the cohort of patients that may derive such benefit.

Methods

Patients with ES-SCLC from both the IMpower133 study and Shandong Cancer Hospital and Institute (shanzhong cohort) who failed first-line ICI were included. Kaplan Meier analysis was performed to compare overall survival (OS). Both univariate and multivariate Cox regression analyses were conducted to identify factors affecting survival. Tumor immune cell infiltration was evaluated by the CIBERSORT algorithm and detected by multiplex immunofluorescence (mIF).

Results

A total of 125 ES-SCLC patients undergoing atezolizumab and 161 patients undergoing ICI as first-line treatment were recruited from IMpower133 and shanzhong cohort. Those receiving ICI rechallenge had a longer OS than those without in IMpower133 (P = 0.08) and shanzhong cohort (P = 0.013). In IMpower133 cohort, subgroup analyses found that patients with <4 metastatic sites derived more survival benefit from atezolizumab (P = 0.008). For patients with ES-SCLC harboring <4 metastatic sites, there was significant OS difference between atezolizumab versus non-atezolizumab as retreatment (P = 0.036). Moreover, for ES-SCLC patients with <4 metastatic sites, atezolizumab improved survival compared with non-atezolizumab (hazard ratio [HR]: 0.457; 95% CI: 0.256-0.817; P = 0.008). These findings were confirmed in shanzhong cohort. Those harboring <4 metastatic sites had fewer M2 macrophage and more CD4 naïve T cells infiltration, which was further confirmed by mIF of ES-SCLC samples from shanzhong cohort.

Conclusion

Our study provides rationale for ICI rechallenge among ES-SCLC patients with <4 metastatic sites, suggesting beneficial outcome by reshaping TME.

Overcoming resistance in small-cell lung cancer

INTRODUCTION

Small-cell lung cancer (SCLC) accounts for 15% of lung cancers and has a dismal prognosis due to early dissemination and acquired chemoresistance. The initial good response to chemotherapy is followed by refractory relapses within 1-2 years. Mechanisms leading to chemoresistance are not clear and progress is poor.

AREAS COVERED

This article reviews the current evidence of the resistance of SCLCs at the cellular level including alteration of key proteins and the possible presence of cancer stem cells (CSCs). Without compelling evidence for cellular mechanisms and clinical failures of novel approaches, the study of SCLC has advanced to the role of 3D tumor cell aggregates in chemoresistance.

EXPERT OPINION

The scarcity of viable tumor specimen from relapsed SCLC patients has hampered the investigations of acquired chemoresistance but a panel of nine SCLC circulating tumor cell (CTC) cell lines have revealed characteristics of SCLC in the advanced refractory states. The chemoresistance of relapsed SCLC seems to be linked to the spontaneous formation of large spheroids, termed tumorospheres, which contain resistant quiescent and hypoxic cells shielded by a physical barrier. So far, drugs to tackle large tumor spheroids are in preclinical and early clinical development.

Management of patients with extensive small-cell lung cancer in the immunotherapy era: An Italian consensus through a Delphi approach

BACKGROUND

Immunotherapy represented a turning point for treating extensive small-cell lung cancer (ES-SCLC). Although, many issues remain debated.

METHODS

A group of Italian medical and radiation oncologists with expertise in managing patients with ES-SCLC developed a list of statements divided in six areas of interest. The Delphi method was used to assess the consensus on the defined list of statements.

RESULTS

32 statements were included in the final list to be voted by the Delphi panel, and 26 reached a consensus on the agreement. A prompt involvement of a multidisciplinary team is a priority to provide an integrated treatment strategy. First-line recommended treatment is immunotherapy in combination with platinum-based chemotherapy and etoposide for four cycles followed by maintenance immunotherapy.

CONCLUSIONS

While awaiting new data from clinical trials and real-world studies, these recommendations can represent a useful tool to guide the management of ES-SCLC patients in daily practice.

Durable Response to Atezolizumab in Extensive-Stage Small-Cell Lung Cancer Leading to 60 Months Overall Survival: A Case Report

Small-cell lung cancer (SCLC) remains a disease with poor prognosis, particularly in extensive-stage SCLC (ES-SCLC). Current standard-of-care treatment includes chemotherapy with platinum agents and etoposide plus immunotherapy with atezolizumab or durvalumab, which has achieved a mean overall survival of 12-13 months in clinical trials. However, long-term survival in ES-SCLC, even with the addition of immunotherapy, continues to be rare. We present the case of a middle-aged male patient diagnosed with ES-SCLC who was treated with four cycles of induction chemotherapy (carboplatin and etoposide) and atezolizumab, starting maintenance atezolizumab every 21 days thereafter, and thoracic radiotherapy. After 9 months, he experienced mild disease progression and was rechallenged with six cycles of carboplatin and etoposide with continued atezolizumab. Subsequent imaging showed near-complete disease resolution which has been sustained since. He has continued on maintenance atezolizumab since diagnosis and has achieved 60 months overall survival and 44 months progression-free survival. Throughout treatment, he has maintained a high functional capacity and only experienced one immune-related adverse event. Our patient is representative of a small subset who are capable of achieving durable responses to immunotherapy and his case highlights the need for further research to elucidate the clinical and biological factors driving this response.

The Biological Role of Macrophage in Lung and Its Implications in Lung Cancer Immunotherapy

The lungs are the largest surface of the body and the most important organ in the respiratory system, which are constantly exposed to the external environment. Tissue Resident Macrophages in lung constitutes the important defense against external pathogens. Macrophages connects the innate and adaptive immune system, and also plays important roles in carcinogenesis and cancer immunotherapy. Lung cancer is the leading cause of cancer-related death worldwide, with an overall five-year survival rate of only 21%. Macrophages that infiltrate or aggregate in lung tumor microenvironment are defined as tumor-associated macrophages (TAMs). TAMs are the main components of immune cells in the lung tumor microenvironment. The differentiation and maturation process of TAMs can be roughly divided into two different types: classical activation pathway produces M1 tumor-associated macrophages, and bypass activation pathway produces M2 tumor-associated macrophages. Studies have found that TAMs are related to tumor invasion, metastasis, and treatment resistance, and show potential as a new target for tumor immunotherapy. Therefore, the biological function of macrophages in lung and the role of TAMs in the occurrence, development, and treatment of lung cancer are discussed in this paper.

Prognostic Nutritional Index Predicts Efficacy and Immune-Related Adverse Events of First-Line Chemoimmunotherapy in Patients with Extensive-Stage Small-Cell Lung Cancer

Background

Currently, there is a lack of well-established markers to predict the efficacy of chemoimmunotherapy in small-cell lung cancer (SCLC). Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), advanced lung cancer inflammation index (ALI) and prognostic nutritional index (PNI) are associated with prognosis in several tumors, whereas their predictive role in SCLC remains unclear.

Methods

A retrospective study was conducted at Sun Yat-sen University Cancer Center, involving extensive-stage SCLC (ES-SCLC) patients who received first-line chemoimmunotherapy between January 2020 and December 2021. Peripheral blood biomarkers were extracted from medical records and their correlation with prognosis and immune-related adverse events (IRAEs) was analyzed.

Results

A total of 114 patients were included. Patients with a low PLR, high ALI and high PNI had prolonged progression-free survival (PFS) compared to those with a high PLR, low ALI and low PNI. Patients with a low NLR, low PLR, high ALI and high PNI had prolonged overall survival (OS) compared to those with a high NLR, high PLR, low ALI and low PNI. Cox regression model showed that PNI was an independent risk factor for both PFS and OS. ROC curve showed that PNI outperforms NLR, PLR and ALI in predicting both PFS and OS. The PNI-based nomogram demonstrated strong predictive capability for both PFS and OS. In addition, there was a significant correlation between PNI and IRAEs.

Conclusion

A high baseline PNI might be associated with improved prognosis and the occurrence of IRAEs in ES-SCLC patients treated with first-line chemoimmunotherapy.

Management of small cell lung cancer complicated with paraneoplastic Cushing's syndrome: a systematic literature review

Paraneoplastic Cushing's syndrome (PCS) is a rare, but clinically important feature of small cell lung cancer (SCLC) that is associated with even worse prognosis. To identify key considerations in comprehensive management of SCLC patients complicated with PCS, we conducted a systematic review of relevant reports on PubMed and Web of Science, focusing on SCLC with PCS cases. The systematic review analyzed 61 reports published between 1985 and 2022 with a total of 157 SCLC patients included. Out of the 157 patients, 132 (84.1%) patients across 58 (95.1%) reports were diagnosed with ectopic Cushing's syndrome. The immunohistochemical (IHC) staining for adrenocorticotropic hormone (ACTH) was performed on 30 (19.1%) patients across 22 (36.1%) reports and demonstrated encouraging performance. For treatment, chemotherapy and ketoconazole were utilized in 50 (81.97%) and 24 (39.34%) reports, respectively. Regarding cause of death, infection and cancer were equally frequent, each being recorded in 17 (27.87%) reports. To conclude, the majority of PCS cases in SCLC patients were caused by ectopic hormone secretion. In order to make a differential diagnosis, it is recommended to utilize IHC staining for a specific hormone such as ACTH or corticotropin-releasing hormone. In the comprehensive treatment of SCLC with PCS patients, effective management of hypercortisolism and potent safeguarding against infection play two crucial roles. Ultimately, further confirmations are required regarding the specificity and accuracy of IHC staining technique as well as the efficacy and safety of immunotherapy in the treatment of SCLC with PCS patients.

Comparation between novel online models and the AJCC 8th TNM staging system in predicting cancer-specific and overall survival of small cell lung cancer

Background

Most of previous studies on predictive models for patients with small cell lung cancer (SCLC) were single institutional studies or showed relatively low Harrell concordance index (C-index) values. To build an optimal nomogram, we collected clinicopathological characteristics of SCLC patients from Surveillance, Epidemiology, and End Results (SEER) database.

Methods

24,055 samples with SCLC from 2010 to 2016 in the SEER database were analyzed. The samples were grouped into derivation cohort (n=20,075) and external validation cohort (n=3,980) based on America's different geographic regions. Cox regression analyses were used to construct nomograms predicting cancer-specific survival (CSS) and overall survival (OS) using derivation cohort. The nomograms were internally validated by bootstrapping technique and externally validated by calibration plots. C-index was computed to compare the accuracy and discrimination power of our nomograms with the 8th of version AJCC TNM staging system and nomograms built in previous studies. Decision curve analysis (DCA) was applied to explore whether the nomograms had better clinical efficiency than the 8th version of AJCC TNM staging system.

Results

Age, sex, race, marital status, primary site, differentiation, T classification, N classification, M classification, surgical type, lymph node ratio, radiotherapy, and chemotherapy were chosen as predictors of CSS and OS for SCLC by stepwise multivariable regression and were put into the nomograms. Internal and external validations confirmed the nomograms were accurate in prediction. C-indexes of the nomograms were relatively satisfactory in derivation cohort (CSS: 0.761, OS: 0.761) and external validation cohort (CSS: 0.764, OS: 0.764). The accuracy of the nomograms was superior to that of nomograms built in previous studies. DCA showed the nomograms conferred better clinical efficiency than 8th version of TNM staging system.

Conclusions

We developed practical nomograms for CSS (https://guowei2020.shinyapps.io/DynNom-CSS-SCLC/) and OS (https://drboidedwater.shinyapps.io/DynNom-OS-SCLC/) prediction of SCLC patients which may facilitate clinicians in individualized therapeutics.

Toripalimab combined with anlotinib for recurrent extensive‑stage small‑cell lung cancer: A case report

The 5-year survival rate of patients with extensive-stage small cell lung cancer (ES-SCLC) is <8%; therefore there is an urgent need for more effective treatment. Although immune checkpoint inhibitors have been widely used to treat lung cancer, the efficacy of anti-programmed death 1 therapy for SCLC is limited due to the abnormal vascular state of the tumour microenvironment. A 66-year-old man who was diagnosed with ES-SCLC and performance status (PS) 3 received first-line chemotherapy but experienced recurrence. Repeated stage IV thrombocytopenia hindered completion of second-line chemotherapy. Therefore, the patient was treated with a combination of toripalimab and anlotinib. After two cycles, the patient showed a partial response to therapy; a long-lasting curative benefit extending 20 months was achieved with PS 1. This novel and effective combined immune/anti-angiogenic therapy paradigm for patients with relapsed ES-SCLC and poor PS requires prospective clinical trials.

Long non-coding RNAs: an overview on miRNA sponging and its co-regulation in lung cancer

Lung cancer is the most devastating cause of death among all cancers worldwide, and non-small cell lung cancer (NSCLC) accounts for 80% of all the lung cancer cases. Beyond common genetic research and epigenomic studies, the extraordinary investigations of non-coding RNAs have provided insights into the molecular basis of cancer. Existing evidence from various cancer models highlights that the regulation of non-coding RNAs is crucial and that their deregulation may be a common reason for the development and progression of cancer, and competition of cancer therapeutics. Non-coding RNAs, such as long non-coding RNAs (lncRNAs) and microRNAs (miRNAs), are increasingly recognized as potential cancer biomarkers for early detection and application of therapeutic strategies. The miRNAs have gained importance as master regulators of target mRNAs by negatively regulating their expression. The lncRNAs function as both tumor suppressors and oncogenes, and also compete with miRNAs that influence the translational inhibition processes. This review addresses the role of lncRNAs in lung cancer development, highlights their mechanisms of action, and provides an overview of the impact of lncRNAs on lung cancer survival and progression via miRNA sponging. The improved understanding of lung cancer mechanisms has opened opportunities to analyze molecular markers and their potential therapeutics.

Monitoring Blood Immune Cells in Patients with Advanced Small Cell Lung Cancer Undergoing a Combined Immune Checkpoint Inhibitor/Chemotherapy

In this exploratory prospective observational study on 40 small cell lung cancer (SCLC) patients treated with a combination of chemotherapy and immune checkpoint inhibitors, blood immune cells were characterized by multi-color flow cytometry at the baseline and at the third therapy cycle. The numbers of neutrophils and of T-, B-, and NK cells, as well as the frequency of HLA-DR^low monocytes, 6-SulfoLacNAc (slan)+ non-classical monocytes and circulating dendritic cell (DC) subtypes were determined. The prognostic value of the parameters was evaluated by the patient's survival analysis with overall survival (OS) as the primary endpoint. In addition, blood cell parameters from SCLC patients were compared to those from non-SCLC (NSCLC). The global median OS of patients was 10.4 ± 1.1 months. Disease progression (15% of patients) correlated with a higher baseline neutrophil/lymphocyte ratio (NLR), more HLA-DR^low monocytes, and lower NK cell and DC numbers. The risk factors for poor OS were the presence of brain/liver metastases, a baseline NLR ≥ 6.1, HLA-DR^low monocytes ≥ 21% of monocytes, slan+ non-classical monocytes < 0.12%, and/or CD1c+ myeloid DC < 0.05% of leukocytes. Lymphocytic subpopulations did not correlate with OS. When comparing biomarkers in SCLC versus NSCLC, SCLC had a higher frequency of brain/liver metastases, a higher NLR, the lowest DC frequencies, and lower NK cell numbers. Brain/liver metastases had a substantial impact on the survival of SCLC patients. At the baseline, 45% of SCLC patients, but only 24% of NSCLC patients, had between three and five risk factors. A high basal NLR, a high frequency of HLA-DR^low monocytes, and low levels of slan+ non-classical monocytes were associated with poor survival in all lung cancer histotypes. Thus, the blood immune cell signature might contribute to a better prediction of SCLC patient outcomes and may uncover the pathophysiological peculiarities of this tumor entity.

Camrelizumab plus platinum-irinotecan followed by maintenance camrelizumab plus apatinib in untreated extensive-stage small-cell lung cancer: a nonrandomized clinical trial

Background

Programmed cell death-ligand 1 (PD-L1) inhibitors plus chemotherapy have made substantial progress in extensive-stage small-cell lung cancer (ES-SCLC), but the survival benefit is still limited. This study aimed to evaluate the preliminary efficacy and safety of camrelizumab plus platinum-irinotecan (IP/IC) followed by maintenance camrelizumab plus apatinib in patients with untreated ES-SCLC.

Methods

In this non-randomized clinical trial (NCT04453930), eligible patients with untreated ES-SCLC received 4-6 cycles of camrelizumab plus IP/IC, followed by maintenance with camrelizumab plus apatinib until disease progression or unmanageable toxicity. The primary endpoint was progression-free survival (PFS). Patients who received PD-L1 inhibitors (atezolizumab or durvalumab) plus platinum-etoposide (EP/EC) were selected as the historical control.

Results

Nineteen patients received IP/IC plus camrelizumab and 34 patients received EP/EC plus PD-L1 inhibitor. At a median follow-up time of 12.1 months, the median PFS was 10.25 months (95% CI: 9.40-NA) in the IP/IC plus camrelizumab group and 7.10 months (95% CI 5.79-8.40) in the EP/EC plus PD-L1 inhibitor group, respectively (HR=0.58, 95% CI 0.42-0.81). The objective response rate of IP/IC plus camrelizumab and EP/EC plus PD-L1 inhibitor was 89.6% and 82.4%, respectively. The most common treatment-related adverse events in the IP/IC plus camrelizumab group was neutropenia, followed by reactive cutaneous capillary endothelial proliferation (RCCEP) and diarrhea. The occurrence of immune-related adverse event was found to be associated with a prolonged PFS (HR=4.64, 95% CI 1.92-11.18).

Conclusions

IP/IC plus camrelizumab followed by maintenance camrelizumab plus apatinib showed preliminary efficacy and acceptable safety profile in patients with untreated ES-SCLC.

DLL3 regulates Notch signaling in small cell lung cancer

Tumor heterogeneity plays a critical role in tumor development and response to treatment. In small-cell lung cancer (SCLC), intratumoral heterogeneity is driven in part by the Notch signaling pathway, which reprograms neuroendocrine cancer cells to a less/non-neuroendocrine state. Here we investigated the atypical Notch ligand DLL3 as a biomarker of the neuroendocrine state and a regulator of cell-cell interactions in SCLC. We first built a mathematical model to predict the impact of DLL3 expression on SCLC cell populations. We next tested this model using a single-chain variable fragment (scFv) to track DLL3 expression in vivo and a new mouse model of SCLC with inducible expression of DLL3 in SCLC tumors. We found that high levels of DLL3 promote the expansion of a SCLC cell population with lower expression levels of both neuroendocrine and non-neuroendocrine markers. This work may influence how DLL3-targeting therapies are used in SCLC patients.

The role of stem cells in small-cell lung cancer: evidence from chemoresistance to immunotherapy

Small cell lung cancer (SCLC) is the most aggressive subtype of lung cancer, accounting for approximately 15% among all lung cancers. Despite the ability of chemotherapy, the first-line treatment for SCLC, to rapidly shrink tumors, nearly all patients experience recurrence and metastasis within a few months. Cancer stem cells (CSCs) are a small population of tumor cells responsible for tumorigenesis, metastasis, and recurrence after treatment, which play a crucial role in chemoresistance by promoting DNA repair and expression of drug resistance-associated proteins. Thus, targeting CSCs has been successful in certain malignancies. Tumor therapy has entered the era of immunotherapy and numerous preclinical trials have demonstrated the effectiveness of immunotherapeutic approaches targeting CSCs, such as tumor vaccines and chimeric antigen receptor (CAR) T cell, and the feasibility of combining them with chemotherapy. Therefore, a deeper understanding of the interaction between CSCs and immune system is essential to facilitate the advances of new immunotherapies approaches targeting CSCs as well as combination with standard drugs such as chemotherapy. This narrative review summarizes the mechanisms of chemoresistance of CSCs in SCLC and the latest advances in targeted therapies. Thereafter, we discuss the effects of CSCs on tumor immune microenvironment in SCLC and corresponding immunotherapeutic approaches. Eventually, we propose that the combination of immunotherapy targeting CSCs with standard drugs is a promising direction for SCLC therapies.

Non-coding genome in small cell lung cancer between theoretical view and clinical applications

Small cell lung cancer (SCLC) is a highly aggressive cancer of the neuroendocrine system, characterized by poor differentiation, rapid growth, and poor overall survival (OS) of patients. Despite the recent advances in the treatment of SCLC recently, the 2-year survival rate of patients with the cancer is only 14-15%, occasioned by the acquired resistance to drugs and serious off-target effects. In humans, the coding region is only 2% of the total genome, and 20% of that is associated with human diseases. Beyond the coding genome are RNAs, promoters, enhancers, and other intricate elements. The non-coding regulatory regions, mainly the non-coding RNAs (ncRNAs), regulate numerous biological activities including cell proliferation, metastasis, and drug resistance. As such, they are potential diagnostic or prognostic biomarkers, and also potential therapeutic targets for SCLC. Therefore, understanding how non-coding elements regulate SCLC development and progression holds significant clinical implications. Herein, we summarized the recent discoveries on the relationship between the non-coding elements including long non-coding RNAs (lncRNA), microRNAs (miRNAs), circular RNA (circRNA), enhancers as well as promotors, and the pathogenesis of SCLC and their potential clinical applications.

Small cell lung cancer: Novel treatments beyond immunotherapy

Small cell lung cancer (SCLC) arises in peribronchial locations and infiltrates the bronchial submucosa, including about 15% of lung cancer cases. Despite decades of research, the prognosis for SCLC patients remains poor because this tumor is characterized by an exceptionally high proliferative rate, strong tendency for early widespread metastasis and acquired chemoresistance. Omics profiling revealed that SCLC harbor extensive chromosomal rearrangements and a very high mutation burden. This led to the development of immune-checkpoint inhibitors as single agents or in combination with chemotherapy, which however resulted in a prolonged benefit only for a small subset of patients. Thus, the present review discusses the rationale and limitations of immunotherapeutic approaches, presenting the current biological understanding of aberrant signaling pathways that might be exploited with new potential treatments. In particular, new agents targeting DNA damage repair, cell cycle checkpoint, and apoptosis pathways showed several promising results in different preclinical models. Epigenetic alterations, gene amplifications and mutations can act as biomarkers in this context. Future research and improved clinical outcome for SCLC patients will depend on the integration between these omics and pharmacological studies with clinical translational research, in order to identify specific predictive biomarkers that will be hopefully validated using clinical trials with biomarker-selected targeted treatments.

Ferroptosis, necroptosis, and pyroptosis in the tumor microenvironment: Perspectives for immunotherapy of SCLC

Small cell lung cancer (SCLC) is an aggressive form of lung cancer characterized by dismal prognosis. Although SCLC may initially respond well to platinum-based chemotherapy, it ultimately relapses and is almost universally resistant to this treatment. Immune checkpoint inhibitors (ICIs) have been approved as the first- and third-line therapeutic regimens for extensive-stage or relapsed SCLC, respectively. Despite this, only a minority of patients with SCLC respond to ICIs partly due to a lack of tumor-infiltrating lymphocytes (TILs). Transforming the immune "cold" tumors into "hot" tumors that are more likely to respond to ICIs is the main challenge for SCLC therapy. Ferroptosis, necroptosis, and pyroptosis represent the newly discovered immunogenic cell death (ICD) forms. Promoting ICD may alter the tumor microenvironment (TME) and the influx of TILs, and combination of their inducers and ICIs plays a synergistical role in enhancing antitumor effects. Nevertheless, the combination of the above two modalities has not been systematically discussed in SCLC therapy. In the present review, we summarize the roles of distinct ICD mechanisms on antitumor immunity and recent advances of ferroptosis-, necroptosis- and pyroptosis-inducing agents, and present perspectives on these cell death mechanisms in immunotherapy of SCLC.

Genetic Alteration and Their Significance on Clinical Events in Small Cell Lung Cancer

Introduction

Small cell lung cancer (SCLC), an aggressive subtype of lung cancer characterized by the development of neuroendocrine tumors, is prone to distant metastasis, resistant to platinum-based drugs and has a poor prognosis. The development of next-generation sequencing technology (NGS) has led to the identification of many genetic alterations in SCLC. Few druggable targeted molecules can be used in clinical practice. Currently, NGS is widely employed in routine clinical practice of non-small cell lung cancer to assist in therapeutic options and prognosis evaluation. This study aims to investigate genes involved in small cell lung cancer (SCLC), their occurrence and their significance in clinical events.

Methods

Tumor tissue specimens from 18 Chinese SCLC patients were collected through a 520 cancer‐related genes panel for next-generation sequencing. First, the association between sequence results and clinical outcomes was examined. Subsequently, data on clinical pathology and sequencing results were analyzed.

Results

The Kaplan–Meier curve displayed a significant reduction in PFS for SCLC patients with LRP1B or MAP3K13 mutations. Overall survival (OS) of SCLC patients with MSH6 mutation was significantly higher than those with SPEN mutation.

Conclusion

Next-generation sequencing demonstrates that the genetic landscape of SCLC. Mutation status of LRP1B, MAP3K13, MSH6 and SPEN has prognostic significance, which might be potential therapeutic targets. We found possible genes and related signaling pathways that affect metastasis. These results can improve our understanding of the mutation characteristics of SCLC and identify potential biomarkers to guide targeted therapies.

Small cell lung cancer transformation: From pathogenesis to treatment

Small cell lung cancer (SCLC) is a type of neuroendocrine tumor with high malignancy and poor prognosis. Besides the de novo SCLC, there is transformed SCLC, which has similar characteristics of pathological morphology, molecular characteristics, clinical manifestations and drug sensitivity. However, de novo SCLC and transformed SCLC have different pathogenesis and tumor microenvironment. SCLC transformation is one of the mechanisms of resistance to chemotherapy, immunotherapy, and targeted therapy in NSCLC. Two hypotheses have been used to explain the pathogenesis of SCLC transformation. Although SCLC transformation is not common in clinical practice, it has been repeatedly identified in many small patient series and case reports. It usually occurs in epidermal growth factor receptor (EGFR) mutant lung adenocarcinoma after treatment with tyrosine kinase inhibitors (TKIs). SCLC transformation can also occur in anaplastic lymphoma kinase (ALK)-positive lung cancer after treatment with ALK inhibitors and in wild-type EGFR or ALK NSCLC treated with immunotherapy. Chemotherapy was previously used to treat transformed SCLC, yet it is associated with an unsatisfactory prognosis. We comprehensively review the advancements in transformed SCLC, including clinical and pathological characteristics, and the potential effective treatment after SCLC transformation, aiming to give a better understanding of transformed SCLC and provide support for clinical uses.