Prophylactic Cranial Irradiation Following Surgical Resection of Early-Stage Small-Cell Lung Cancer: A Review of the Literature.

Brooke C Bloom,Steven E Schild,Stephen G Chun,Alexander Augustyn,Sunil Patel,Boris Sepesi,Ritsuko U Komaki,Shalin J Shah

doi:10.3389/fonc.2017.00228

Abstract

With increasing use of low-dose screening CT scans, the diagnosis of early-stage small-cell lung cancer (SCLC) without evidence of mediastinal nodal or distant metastasis is likely to become more common, but the role of adjuvant therapies such as prophylactic cranial irradiation (PCI) are not well understood in this population. We performed a review of the literature pertaining to the impact of PCI in patients who underwent surgical resection of early-stage SCLC. Four studies were identified that were pertinent including three single-institution retrospective analyses and a National Cancer Database analysis. Based upon these studies, we estimate the rate of brain metastases to be 10–15% for Stage I and 15–25% for Stage II disease without PCI. However, the impact of PCI on the development of brain metastases and its ultimate impact on overall survival were not consistent across these studies. In summary, there is sparse evidence to guide recommendations for PCI following resection of early-stage SCLC. While it may be reasonable to offer PCI to maximize likelihood of cure, alternative strategies such as observation with close imaging follow-up can also be considered for the appropriate patient given the known neurocognitive side effects of PCI.

Highlights

Small-cell lung cancer (SCLC) is a common smoking-related malignancy that accounts for approximately 15% of all lung cancers [1, 2]
With increasing use of low-dose screening CT scans (LDCT), it is conceivable that patients with resected early-stage SCLC will become more common, in regions that have high rates of tobacco use. In this mini-review, we present the studies in the literature comparing outcomes of patients with and without prophylactic cranial irradiation (PCI) after surgical resection for early-stage (Stages I and II) SCLC
For Stage II SCLC, PCI was associated with an overall survival benefit on multivariable analysis (HR 0.54, p = 0.047), as well as a statistical trend toward reduction in brain metastases (22.4 vs. 12.8%, p = 0.094)

Summary

Introduction

Small-cell lung cancer (SCLC) is a common smoking-related malignancy that accounts for approximately 15% of all lung cancers [1, 2]. The brain has long been established to be a sanctuary site for SCLC where there is poor chemotherapy penetration and roughly 50% of patients develop brain metastases [2, 9]. In these studies, most patients had bulky and unresectable disease treated with chemoradiotherapy, and the applicability of this data to surgical resected early-stage SCLC is questionable. The absolute survival benefit (5.4%) seen in the meta-analysis by Auperin et al was small [4], suggesting that the benefit of PCI for surgically resected early-stage SCLC might be even smaller

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Conclusion