Khreis T

Background: Immune checkpoint inhibitors (ICI) have tremendously changed the paradigm of management for advanced stage cancers such as lung malignancies. Two unique patterns of response to immunotherapy have recently been described: pseudoprogression and hyperprogression. Hyperprogression is defined as a 2-fold increase in the tumor growth rate within 8 weeks of ICI administration.

Case Presentation: A 58-year-old female presented with left-sided chest pain for two weeks. CT-chest with contrast showed an 8.6 × 6.1 × 7.6 cm3 left upper lobe mass. An endobronchial ultrasound (EBUS)-guided biopsy revealed poorly differentiated adenocarcinoma. Staging FDG-18 PET scan revealed no metastases, resulting in a stage IIIA Non-Small Cell Lung Cancer (T4N0M0) on presentation. Per NCCN guidelines, she received standard of care definitive concurrent chemoradiation. Follow-up scans showed significant response in local disease without distant metastases. The patient then received cycle 1 consolidation immunotherapy with Durvalumab. Two weeks after, she complained of fatigue, new-onset headache and worsening dyspnea. CT-chest revealed development of a right upper lobe opacity, MRI brain showed the development of multiple brain metastases and PET scan uncovered hypermetabolic activity in a left adrenal nodule. Biopsy of the adrenal nodule confirmed metastatic adenocarcinoma, consistent with hyperprogression. Molecular testing of the standard lung tumor markers was negative (EGFR(-) ALK(-) BRAF(-) ROS-1 (-) PD-L1 <1%). Given her hyperprogression on ICIs, we opted to treat her with systemic chemotherapy with Carboplatin and Pemetrexed.

Conclusion: We herein report the first case report of hyperprogression in the non-metastatic setting. As ICIs become more incorporated in oncology practice, physicians should be aware of hyperprogression and its diagnostic criteria. Current molecular predictors of hyperprogression include MDM2/4 and EGFR mutations. Further elucidation of predictors of hyperprogressive disease will help guide better selection of ICI candidates.

Background: Immune checkpoint inhibitors (ICI) have tremendously changed the paradigm of management for advanced stage cancers such as lung malignancies. Two unique patterns of response to immunotherapy have recently been described: pseudoprogression and hyperprogression. Hyperprogression is defined as a 2-fold increase in the tumor growth rate within 8 weeks of ICI administration.

Case Presentation: A 58-year-old female presented with left-sided chest pain for two weeks. CT-chest with contrast showed an 8.6 × 6.1 × 7.6 cm3 left upper lobe mass. An endobronchial ultrasound (EBUS)-guided biopsy revealed poorly differentiated adenocarcinoma. Staging FDG-18 PET scan revealed no metastases, resulting in a stage IIIA Non-Small Cell Lung Cancer (T4N0M0) on presentation. Per NCCN guidelines, she received standard of care definitive concurrent chemoradiation. Follow-up scans showed significant response in local disease without distant metastases. The patient then received cycle 1 consolidation immunotherapy with Durvalumab. Two weeks after, she complained of fatigue, new-onset headache and worsening dyspnea. CT-chest revealed development of a right upper lobe opacity, MRI brain showed the development of multiple brain metastases and PET scan uncovered hypermetabolic activity in a left adrenal nodule. Biopsy of the adrenal nodule confirmed metastatic adenocarcinoma, consistent with hyperprogression. Molecular testing of the standard lung tumor markers was negative (EGFR(-) ALK(-) BRAF(-) ROS-1 (-) PD-L1 <1%). Given her hyperprogression on ICIs, we opted to treat her with systemic chemotherapy with Carboplatin and Pemetrexed.

Conclusion: We herein report the first case report of hyperprogression in the non-metastatic setting. As ICIs become more incorporated in oncology practice, physicians should be aware of hyperprogression and its diagnostic criteria. Current molecular predictors of hyperprogression include MDM2/4 and EGFR mutations. Further elucidation of predictors of hyperprogressive disease will help guide better selection of ICI candidates.

Background: Immune checkpoint inhibitors (ICI) have tremendously changed the paradigm of management for advanced stage cancers such as lung malignancies. Two unique patterns of response to immunotherapy have recently been described: pseudoprogression and hyperprogression. Hyperprogression is defined as a 2-fold increase in the tumor growth rate within 8 weeks of ICI administration.

Case Presentation: A 58-year-old female presented with left-sided chest pain for two weeks. CT-chest with contrast showed an 8.6 × 6.1 × 7.6 cm3 left upper lobe mass. An endobronchial ultrasound (EBUS)-guided biopsy revealed poorly differentiated adenocarcinoma. Staging FDG-18 PET scan revealed no metastases, resulting in a stage IIIA Non-Small Cell Lung Cancer (T4N0M0) on presentation. Per NCCN guidelines, she received standard of care definitive concurrent chemoradiation. Follow-up scans showed significant response in local disease without distant metastases. The patient then received cycle 1 consolidation immunotherapy with Durvalumab. Two weeks after, she complained of fatigue, new-onset headache and worsening dyspnea. CT-chest revealed development of a right upper lobe opacity, MRI brain showed the development of multiple brain metastases and PET scan uncovered hypermetabolic activity in a left adrenal nodule. Biopsy of the adrenal nodule confirmed metastatic adenocarcinoma, consistent with hyperprogression. Molecular testing of the standard lung tumor markers was negative (EGFR(-) ALK(-) BRAF(-) ROS-1 (-) PD-L1 <1%). Given her hyperprogression on ICIs, we opted to treat her with systemic chemotherapy with Carboplatin and Pemetrexed.

Conclusion: We herein report the first case report of hyperprogression in the non-metastatic setting. As ICIs become more incorporated in oncology practice, physicians should be aware of hyperprogression and its diagnostic criteria. Current molecular predictors of hyperprogression include MDM2/4 and EGFR mutations. Further elucidation of predictors of hyperprogressive disease will help guide better selection of ICI candidates.

Background: Sarcomatoid carcinoma is an unusual form of non-small cell lung cancer (NSCLC) that comprises 0.1% to 0.4% of all pulmonary malignancy. Mean age of onset is around 65 years of age, male to female ratio is almost 4-to-1, and it is associated with a poor prognosis.

Case Report: We present a case of sarcomatoid carcinoma in a 37-year-old patient, with a history of Hodgkin’s lymphoma, treated with chemotherapy, and uncontrolled HIV, initially presenting with unresponsiveness, tachycardia, and hypoxia after several days of vaginal bleeding. Her serum beta-HCG was 93.0 on admission. Her obstetric vaginal ultrasound did not identify an intrauterine pregnancy but did not rule out an ectopic pregnancy. A follow-up Beta-HCG in 1 week showed B-HCG rising to 163. Chest CT on admission revealed a cavitary lesion in the right upper lobe, suspicious for tuberculosis. A lung biopsy performed revealed highly atypical spindle epithelial cells suspicious for sarcomatoid carcinoma. A week later, biopsy of the left iliac bone of a lesion identified on CT scan of the pelvis on admission revealed cells similar in morphology and immunohistochemistry to the lung specimen, consistent with metastatic sarcomatoid carcinoma. After lengthy discussions, the patient opted for hospice care secondary to her poor functional status.

Conclusions: This case highlighted the importance of a broad differential in the approach to patients with unconfirmed diagnosis and expands the metastatic profile of sarcomatoid carcinoma. This is, also to the best of our knowledge, the first case of metastatic sarcomatoid carcinoma in a young female patient and the second in a HIV patients.

Background: Sarcomatoid carcinoma is an unusual form of non-small cell lung cancer (NSCLC) that comprises 0.1% to 0.4% of all pulmonary malignancy. Mean age of onset is around 65 years of age, male to female ratio is almost 4-to-1, and it is associated with a poor prognosis.

Case Report: We present a case of sarcomatoid carcinoma in a 37-year-old patient, with a history of Hodgkin’s lymphoma, treated with chemotherapy, and uncontrolled HIV, initially presenting with unresponsiveness, tachycardia, and hypoxia after several days of vaginal bleeding. Her serum beta-HCG was 93.0 on admission. Her obstetric vaginal ultrasound did not identify an intrauterine pregnancy but did not rule out an ectopic pregnancy. A follow-up Beta-HCG in 1 week showed B-HCG rising to 163. Chest CT on admission revealed a cavitary lesion in the right upper lobe, suspicious for tuberculosis. A lung biopsy performed revealed highly atypical spindle epithelial cells suspicious for sarcomatoid carcinoma. A week later, biopsy of the left iliac bone of a lesion identified on CT scan of the pelvis on admission revealed cells similar in morphology and immunohistochemistry to the lung specimen, consistent with metastatic sarcomatoid carcinoma. After lengthy discussions, the patient opted for hospice care secondary to her poor functional status.

Conclusions: This case highlighted the importance of a broad differential in the approach to patients with unconfirmed diagnosis and expands the metastatic profile of sarcomatoid carcinoma. This is, also to the best of our knowledge, the first case of metastatic sarcomatoid carcinoma in a young female patient and the second in a HIV patients.

Background: Sarcomatoid carcinoma is an unusual form of non-small cell lung cancer (NSCLC) that comprises 0.1% to 0.4% of all pulmonary malignancy. Mean age of onset is around 65 years of age, male to female ratio is almost 4-to-1, and it is associated with a poor prognosis.

Case Report: We present a case of sarcomatoid carcinoma in a 37-year-old patient, with a history of Hodgkin’s lymphoma, treated with chemotherapy, and uncontrolled HIV, initially presenting with unresponsiveness, tachycardia, and hypoxia after several days of vaginal bleeding. Her serum beta-HCG was 93.0 on admission. Her obstetric vaginal ultrasound did not identify an intrauterine pregnancy but did not rule out an ectopic pregnancy. A follow-up Beta-HCG in 1 week showed B-HCG rising to 163. Chest CT on admission revealed a cavitary lesion in the right upper lobe, suspicious for tuberculosis. A lung biopsy performed revealed highly atypical spindle epithelial cells suspicious for sarcomatoid carcinoma. A week later, biopsy of the left iliac bone of a lesion identified on CT scan of the pelvis on admission revealed cells similar in morphology and immunohistochemistry to the lung specimen, consistent with metastatic sarcomatoid carcinoma. After lengthy discussions, the patient opted for hospice care secondary to her poor functional status.

Conclusions: This case highlighted the importance of a broad differential in the approach to patients with unconfirmed diagnosis and expands the metastatic profile of sarcomatoid carcinoma. This is, also to the best of our knowledge, the first case of metastatic sarcomatoid carcinoma in a young female patient and the second in a HIV patients.

Background: Right-sided colon cancer (RC) is derived from the mid-gut, while left-sided colon cancer (LC) originates from the hindgut. LC has been associated with better survival compared to RC. The effect of primary tumor sidedness on colorectal cancer (CRC) survival rates has not been studied in VA hospitals.

Methods: Data from the National VA Cancer Cube Registry was studied. 65,940 cases of CRC were diagnosed between 2001 and 2015. ICD codes C18 to C20 were used to delineate patients with RC vs. LC. RC was defined as cancer from the cecum to the hepatic flexure, LC from the splenic flexure to the rectum with transverse cancer in between flexures. Local IRB approval was obtained.

Results: Of the total number of CRC, 30.3% were RC and 58.8% were LC. RC constituted 36.3% of cases in women and 30.1% of cases in men. RC was diagnosed after the age of 70 years in 51.8% of cases, compared with 38.5% of LC. LC constituted 56.0% of CRC in blacks, and 59.4% in whites. RC was more likely to be diagnosed at more advanced stage, with 60.84% of cases diagnosed at stage II-IV, compared to 51.82% of LC. Stage IV RC has worse one year survival as compared with LC (50.5% vs 42.2% surviving less than one year, respectively)

Conclusions: RC is associated with female gender, older age, poorer functional status, and more advanced stage at diagnosis. LC was associated with white race. Stage IV RC had worse one-year survival than LC colon cancer.

Background: Right-sided colon cancer (RC) is derived from the mid-gut, while left-sided colon cancer (LC) originates from the hindgut. LC has been associated with better survival compared to RC. The effect of primary tumor sidedness on colorectal cancer (CRC) survival rates has not been studied in VA hospitals.

Methods: Data from the National VA Cancer Cube Registry was studied. 65,940 cases of CRC were diagnosed between 2001 and 2015. ICD codes C18 to C20 were used to delineate patients with RC vs. LC. RC was defined as cancer from the cecum to the hepatic flexure, LC from the splenic flexure to the rectum with transverse cancer in between flexures. Local IRB approval was obtained.

Results: Of the total number of CRC, 30.3% were RC and 58.8% were LC. RC constituted 36.3% of cases in women and 30.1% of cases in men. RC was diagnosed after the age of 70 years in 51.8% of cases, compared with 38.5% of LC. LC constituted 56.0% of CRC in blacks, and 59.4% in whites. RC was more likely to be diagnosed at more advanced stage, with 60.84% of cases diagnosed at stage II-IV, compared to 51.82% of LC. Stage IV RC has worse one year survival as compared with LC (50.5% vs 42.2% surviving less than one year, respectively)

Conclusions: RC is associated with female gender, older age, poorer functional status, and more advanced stage at diagnosis. LC was associated with white race. Stage IV RC had worse one-year survival than LC colon cancer.

Background: Right-sided colon cancer (RC) is derived from the mid-gut, while left-sided colon cancer (LC) originates from the hindgut. LC has been associated with better survival compared to RC. The effect of primary tumor sidedness on colorectal cancer (CRC) survival rates has not been studied in VA hospitals.

Methods: Data from the National VA Cancer Cube Registry was studied. 65,940 cases of CRC were diagnosed between 2001 and 2015. ICD codes C18 to C20 were used to delineate patients with RC vs. LC. RC was defined as cancer from the cecum to the hepatic flexure, LC from the splenic flexure to the rectum with transverse cancer in between flexures. Local IRB approval was obtained.

Results: Of the total number of CRC, 30.3% were RC and 58.8% were LC. RC constituted 36.3% of cases in women and 30.1% of cases in men. RC was diagnosed after the age of 70 years in 51.8% of cases, compared with 38.5% of LC. LC constituted 56.0% of CRC in blacks, and 59.4% in whites. RC was more likely to be diagnosed at more advanced stage, with 60.84% of cases diagnosed at stage II-IV, compared to 51.82% of LC. Stage IV RC has worse one year survival as compared with LC (50.5% vs 42.2% surviving less than one year, respectively)

Conclusions: RC is associated with female gender, older age, poorer functional status, and more advanced stage at diagnosis. LC was associated with white race. Stage IV RC had worse one-year survival than LC colon cancer.

Background: CONCORD is a global program for worldwide surveillance of cancer survival. A recent analysis of the CONCORD-2 study shows a 9-10% lower survival rates for blacks affected by colon cancer (CC) as compared to whites in the US between 2001 and 2009.

Methods: We aim to investigate the differences in the survival of blacks and whites affected by CC in the National VA Cancer Cube Database in the same time-period. Overall, 30,196 CC cases between 2001 and 2009 were examined.

Results: 66.12% (19,967) of CC patients identified as white and 16.32% (4929) identified as black. The distribution of stages in blacks was the following: Stage 0: 10.49% (517), I: 25.10% (1237), II: 18.58% (916), III: 17.73% (874) and IV: 17.91% (883). By comparison, CC cases in whites presented as Stage 0: 8.92% (1781), I: 26.62% (5316), II: 22.29% (4450), III 18.75% (3744) and IV 13.71% (2738) (P value for X2 trend test = .021). Interestingly, in contrast to the results of the CONCORD study, the overall 5-year survival for all stages of CC in blacks and whites was similar [blacks: 2,854 (57.90%); whites 11,897 (59.58%); P = .2750]. The same holds true for the 5-year survival for Stage 0 [blacks: 423 (81.82%) whites: 1391 (78.10%); P = .5338], Stage I [blacks: 932 (75.34%) whites: 3973 (74.74%); P = .8667], Stage II [blacks: 605(66.05%) whites:2927 (65.78%); P = .9427], Stage III [blacks:509 (58.24%) whites:2138 (57.10%); P = .7513], Stage IV blacks:101 (11.44%) whites:364 (13.29%); P = .2058].

Conclusions: The racial disparity in survival highlighted in CONCORD-2 (9-10% lower 5-year survival for blacks) is not replicable in the VA system. This difference is likely due to the uniformity of the VA in providing screening and treatment services and in leveling the playing field in terms of access to care. We believe these results should be taken into consideration in the current discussion of the shape of the healthcare system the US should adopt.

Background: CONCORD is a global program for worldwide surveillance of cancer survival. A recent analysis of the CONCORD-2 study shows a 9-10% lower survival rates for blacks affected by colon cancer (CC) as compared to whites in the US between 2001 and 2009.

Methods: We aim to investigate the differences in the survival of blacks and whites affected by CC in the National VA Cancer Cube Database in the same time-period. Overall, 30,196 CC cases between 2001 and 2009 were examined.

Results: 66.12% (19,967) of CC patients identified as white and 16.32% (4929) identified as black. The distribution of stages in blacks was the following: Stage 0: 10.49% (517), I: 25.10% (1237), II: 18.58% (916), III: 17.73% (874) and IV: 17.91% (883). By comparison, CC cases in whites presented as Stage 0: 8.92% (1781), I: 26.62% (5316), II: 22.29% (4450), III 18.75% (3744) and IV 13.71% (2738) (P value for X2 trend test = .021). Interestingly, in contrast to the results of the CONCORD study, the overall 5-year survival for all stages of CC in blacks and whites was similar [blacks: 2,854 (57.90%); whites 11,897 (59.58%); P = .2750]. The same holds true for the 5-year survival for Stage 0 [blacks: 423 (81.82%) whites: 1391 (78.10%); P = .5338], Stage I [blacks: 932 (75.34%) whites: 3973 (74.74%); P = .8667], Stage II [blacks: 605(66.05%) whites:2927 (65.78%); P = .9427], Stage III [blacks:509 (58.24%) whites:2138 (57.10%); P = .7513], Stage IV blacks:101 (11.44%) whites:364 (13.29%); P = .2058].

Conclusions: The racial disparity in survival highlighted in CONCORD-2 (9-10% lower 5-year survival for blacks) is not replicable in the VA system. This difference is likely due to the uniformity of the VA in providing screening and treatment services and in leveling the playing field in terms of access to care. We believe these results should be taken into consideration in the current discussion of the shape of the healthcare system the US should adopt.

Background: CONCORD is a global program for worldwide surveillance of cancer survival. A recent analysis of the CONCORD-2 study shows a 9-10% lower survival rates for blacks affected by colon cancer (CC) as compared to whites in the US between 2001 and 2009.

Methods: We aim to investigate the differences in the survival of blacks and whites affected by CC in the National VA Cancer Cube Database in the same time-period. Overall, 30,196 CC cases between 2001 and 2009 were examined.

Results: 66.12% (19,967) of CC patients identified as white and 16.32% (4929) identified as black. The distribution of stages in blacks was the following: Stage 0: 10.49% (517), I: 25.10% (1237), II: 18.58% (916), III: 17.73% (874) and IV: 17.91% (883). By comparison, CC cases in whites presented as Stage 0: 8.92% (1781), I: 26.62% (5316), II: 22.29% (4450), III 18.75% (3744) and IV 13.71% (2738) (P value for X2 trend test = .021). Interestingly, in contrast to the results of the CONCORD study, the overall 5-year survival for all stages of CC in blacks and whites was similar [blacks: 2,854 (57.90%); whites 11,897 (59.58%); P = .2750]. The same holds true for the 5-year survival for Stage 0 [blacks: 423 (81.82%) whites: 1391 (78.10%); P = .5338], Stage I [blacks: 932 (75.34%) whites: 3973 (74.74%); P = .8667], Stage II [blacks: 605(66.05%) whites:2927 (65.78%); P = .9427], Stage III [blacks:509 (58.24%) whites:2138 (57.10%); P = .7513], Stage IV blacks:101 (11.44%) whites:364 (13.29%); P = .2058].

Conclusions: The racial disparity in survival highlighted in CONCORD-2 (9-10% lower 5-year survival for blacks) is not replicable in the VA system. This difference is likely due to the uniformity of the VA in providing screening and treatment services and in leveling the playing field in terms of access to care. We believe these results should be taken into consideration in the current discussion of the shape of the healthcare system the US should adopt.

Background: Small cell lung cancer (SCLC) carries a dismal prognosis with a 5-year survival of about 10%. Progress in treatment of SCLC has been poor and overall survival of SCLC has remained stagnant since the late 1970s. Limited-stage SCLC (LS-SCLC) is defined as a tumor confined into one hemithorax with or without lymphadenopathies included in a single radiation field. LS-SCLC frequently metastasizes to the brain. The administration of preventive radiation to the brain, a process known as prophylactic cranial irradiation (PCI) has been the major change in the management of SCLC. There is currently a paucity of data on sites of metastasis of SCLC after PCI has been performed. We aim to describe the pattern of recurrence post-PCI in SCLC.

Methods: A retrospective chart review of all LS-SCLC (stages IA to IIIB) patients who presented to the Stratton Veteran Affairs Medical Center (SVAMC) between January 2006 and January 2017 was performed. Exclusion criteria included other types of lung cancer and stage IV SCLC.

Results: Of the 31 LS-SCLC patients, 12 received PCI. Reasons for not receiving PCI included rapid progression of the disease/metastasis to the brain (8), patient refusal (5), loss to follow-up (4) and existing co-morbidities/poor performance status (2). Of the 12 that received PCI, 8 patients had recurrences, with most recurrences affecting more than one organ. Sites of recurrences included: lung (6), liver (4), lymph nodes (3), bone (2), soft tissue (1).

Conclusions: Post-PCI, LS-SCLC is likely to recur at the site of the tumor itself or metastasize to the liver and lymph nodes. Given the rarity of SCLC presenting at the limited stage, larger scale studies are needed to further delineate the pattern of metastasis of SCLC.

Background: Small cell lung cancer (SCLC) carries a dismal prognosis with a 5-year survival of about 10%. Progress in treatment of SCLC has been poor and overall survival of SCLC has remained stagnant since the late 1970s. Limited-stage SCLC (LS-SCLC) is defined as a tumor confined into one hemithorax with or without lymphadenopathies included in a single radiation field. LS-SCLC frequently metastasizes to the brain. The administration of preventive radiation to the brain, a process known as prophylactic cranial irradiation (PCI) has been the major change in the management of SCLC. There is currently a paucity of data on sites of metastasis of SCLC after PCI has been performed. We aim to describe the pattern of recurrence post-PCI in SCLC.

Methods: A retrospective chart review of all LS-SCLC (stages IA to IIIB) patients who presented to the Stratton Veteran Affairs Medical Center (SVAMC) between January 2006 and January 2017 was performed. Exclusion criteria included other types of lung cancer and stage IV SCLC.

Results: Of the 31 LS-SCLC patients, 12 received PCI. Reasons for not receiving PCI included rapid progression of the disease/metastasis to the brain (8), patient refusal (5), loss to follow-up (4) and existing co-morbidities/poor performance status (2). Of the 12 that received PCI, 8 patients had recurrences, with most recurrences affecting more than one organ. Sites of recurrences included: lung (6), liver (4), lymph nodes (3), bone (2), soft tissue (1).

Conclusions: Post-PCI, LS-SCLC is likely to recur at the site of the tumor itself or metastasize to the liver and lymph nodes. Given the rarity of SCLC presenting at the limited stage, larger scale studies are needed to further delineate the pattern of metastasis of SCLC.

Background: Small cell lung cancer (SCLC) carries a dismal prognosis with a 5-year survival of about 10%. Progress in treatment of SCLC has been poor and overall survival of SCLC has remained stagnant since the late 1970s. Limited-stage SCLC (LS-SCLC) is defined as a tumor confined into one hemithorax with or without lymphadenopathies included in a single radiation field. LS-SCLC frequently metastasizes to the brain. The administration of preventive radiation to the brain, a process known as prophylactic cranial irradiation (PCI) has been the major change in the management of SCLC. There is currently a paucity of data on sites of metastasis of SCLC after PCI has been performed. We aim to describe the pattern of recurrence post-PCI in SCLC.

Methods: A retrospective chart review of all LS-SCLC (stages IA to IIIB) patients who presented to the Stratton Veteran Affairs Medical Center (SVAMC) between January 2006 and January 2017 was performed. Exclusion criteria included other types of lung cancer and stage IV SCLC.

Results: Of the 31 LS-SCLC patients, 12 received PCI. Reasons for not receiving PCI included rapid progression of the disease/metastasis to the brain (8), patient refusal (5), loss to follow-up (4) and existing co-morbidities/poor performance status (2). Of the 12 that received PCI, 8 patients had recurrences, with most recurrences affecting more than one organ. Sites of recurrences included: lung (6), liver (4), lymph nodes (3), bone (2), soft tissue (1).

Conclusions: Post-PCI, LS-SCLC is likely to recur at the site of the tumor itself or metastasize to the liver and lymph nodes. Given the rarity of SCLC presenting at the limited stage, larger scale studies are needed to further delineate the pattern of metastasis of SCLC.