Radiation Oncology/SCLC/Extensive Stage

Extensive Stage Small Cell Lung Cancer

Consensus guidelines

• American Radium Society Appropriate Use Criteria on Radiation Therapy for Extensive-Stage SCLC
  • 2020 PMID 33011389 – Higgins KA et al., J Thorac Oncol
  • Evidence-based guidelines for specific extensive-stage SCLC variants rated by multidisciplinary expert panel
  • Conclusions:
  • Current evidence supports either prophylactic cranial irradiation or surveillance with magnetic resonance imaging every 3 months for patients without evidence of brain metastases
  • Patients with brain metastases should receive whole-brain radiation with a recommended dose of 30 Gy in 10 fractions
  • Consolidative thoracic radiation can be considered in selected cases with the recommended dose ranging from 30 to 54 Gy

Consolidation Thoracic Radiotherapy

• Kragujevac, Yugoslavia (1988-1993) -- Consolidation chemoradiation vs consolidation cisplatin/etoposide
  • Randomized. 210 patients treated w/ 3 cycles of cisplatin/etoposide (PE). Pts w/ distant-CR + local-CR/PR randomized to RT (54 Gy in 36 fx over 18 days) with concurrent carboplatin/etoposide followed by 2 more cycles of PE vs 4 additional cycles of PE.
  • 1999 PMID 10561263 "Role of radiation therapy in the combined-modality treatment of patients with extensive disease small-cell lung cancer: A randomized study." (Jeremic B et al. J Clin Oncol. 1999 Jul;17(7):2092-9.)
    • Outcome: Median OS RT 17 months vs chemo 11 months (SS); 5-year OS 9% vs 4%. No difference in DMFS.
    • Conclusion: Patients with good response to initial chemo may have improved overall survival with consolidative RT

• Slotman (2009-2012) -- Consolidation chest RT vs no chest RT
  • Randomized. 498 patients, 42 hospitals in Europe, treated w/ 4-6 cycles cisplatin/etoposide (PE). Pts w/ any response randomized PCI + thoracic RT vs PCI alone. PCI 20Gy/5fxs, 25Gy/10fxs, 30Gy/10,12,15 fxs (institution allowed only one regimen). Thoracic RT 30Gy/10fxs. PTV post-chemo volume +15mm margin, hilar and mediastinal nodal stations involved pre-chemo always included
  • 2015 PMID: 25230595 "Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial" (Slotman BJ et al. Lancet 2015 Jan 3;385(9962):36-42)
    • Outcome: Median FU 24 months. 1 year OS thoracic RT 33% vs 28% no thoracic RT (p=0.066). 2 year OS 13% vs 3% (p=0·004). 6 month PFS 24% vs 7% (p=0·001)
    • Conclusion: "Thoracic radiotherapy in addition to prophylactic cranial irradiation should be considered for all patients with ES-SCLC who respond to chemotherapy."