Consolidative Thoracic Radiotherapy Research Articles

Metastatic location of extensive stage small-cell lung cancer: implications for thoracic radiation.

This study was designed to evaluate the role of thoracic radiotherapy (TRT) in a selected patient population with oligometastatic extensive stage small-cell lung cancer (ES-SCLC) without brain or liver involved. The underlying hypothesis was that TRT will improve outcomes in this favorable patient population. 305 patients were included in an institutional review board (IRB)-approved study, of which 105 received TRT after chemotherapy (ChT) and 200 received ChT alone. The survival outcomes were compared between ChT+TRT group and ChT-alone group in patients with oligometastasis without brain or liver involved and patients with brain/liver/multimetastasis, respectively. The 1-year, 2-year and 5-year overall survival (OS) for all patients were 60.3%, 23.9% and 1.6%, respectively. The addition of TRT significantly improved PFS in total patients than ChT alone (14.5months vs. 10.1months, p = 0.006), but the OS benefit was not significant (17.8months vs. 16.5months, p = 0.061). For patients with oligometastasis (n = 118), TRT offered significant progression free survival (PFS) (16.5months vs. 9.1months, p = 0.005) and OS (19.2months vs. 15.6months, p = 0.039) benefits. However, for patients with brain/liver/multimetastasis, the PFS and OS were not improved with TRT (p = 0.49, p = 0.811). TRT provided significant PFS and OS benefits in patients with oligometastatic ES-SCLC without brain or liver involved. The consolidative TRT is a reasonable treatment option for this favorable patient population.

Thoracic radiotherapy in a cohort study of patients with metastatic small-cell lung neoplasms.

e20093 Background: Thoracic radiotherapy (TRT) for extensive stage small-cell lung cancer (ES-SCLC) patients is controversial. Slotman et al. (2015) demonstrated a 2-year overall survival (OS) benefit for patients who received TRT after chemotherapy (CT) and prophylactic cranial irradiation (PCI), but obtaining a median OS of 8 months (m). We wanted to confirm results of Slotman’s work in a real-world setting with higher doses of TRT. Methods: We retrospectively reviewed 67 patients with ES-SCLC treated between 1995 and 2015, after completing CT administration. Patients with initial brain metastasis and those who rejected PCI were excluded. All of them received PCI. All patients were followed until death. Disease-specific survival (DSS), disease-free survival (DFS) and OS were analyzed and computed with Kaplan-Meier method, groups were compared with log-rank test. Adjusted hazard risk (HR) of death for TRT was estimated through multivariate Cox model. Results: Patients (59 male, 8 female) with median age 64 years (42-79) had a median Karnofsky performance status (KPS) of 80. Twenty-three patients received high doses TRT (mean dose: 45.4 Gy). No significant differences between groups were found in age, gender, KPS, number of metastatic sites, residual thoracic disease or smoke activity. Non-TRT patients had more metastatic lesions. Median OS for TRT-patients was 19.9 m and 11.2 m for non-TRT patients (p = 0.01). DSS was 23.4 m for TRT-patients and 13.5 m for non-TRT patients (p = 0.007). For TRT-patients and non-TRT patients, median DFS were 15.5 and 8.3 m (p = 0.001), respectively. In the multivariate analysis, TRT (p = 0.003, HR 0.35), KPS (p = 0.012, HR 0.95) and residual thoracic disease (p = 0.02, HR 3.30) were independent prognostic factors for survival. The best benefit was obtained for those patients with consolidative TRT (CTRT): OS of 24.7, DSS of 27.4 and DFS of 15.9 m, compared with 13.4 (p = 0.003), 13.9 (p = 0.003) and 8.5 m (p = 0.007), respectively, for patients not treated with CTRT. Conclusions: TRT impacts positively in OS, DSS and PFS and should be administered to ES-SCLC patients who complete CT and PCI. High TRT doses could achieve better results than those described for low TRT doses.

Consolidative thoracic radiotherapy in stage IV small cell lung cancer: Selection of patients amongst European IASLC and ESTRO experts

BackgroundThe role of consolidative thoracic radiotherapy (TRT) in stage IV small cell lung cancer (SCLC) is not uniformly accepted. MethodsWe obtained a list of 13 European medical oncologists from the International Association for the Study of Lung Cancer (IASLC) and 13 European radiation oncologists from the European Society for Therapeutic Radiation Oncology (ESTRO). The strategies in decision making for TRT in stage IV SCLC were collected. Decision trees were created representing these strategies. Frequencies of recommending TRT were analysed for various parameter combinations based on the objective consensus methodology. ResultsThe factors associated with the recommendation for TRT included fitness of the patient, limited extrathoracic tumour burden, initial bulky thoracic disease and response to chemotherapy. The highest consensus for TRT was in fit patients with limited extrathoracic tumour burden and initial bulky disease with either a complete extrathoracic response or partial thoracic response (92% recommend TRT). For these patients the recommendations were the same for medical and radiation oncologists. In the setting of partial response (intra- and extra-thoracically) without initial bulky thoracic disease radiation oncologists were more likely to recommend TRT than medical oncologists. For unfit patients or for patients with poor overall response to chemotherapy, the majority did not recommend TRT. ConclusionEuropean radiation and medical oncologists specializing in lung cancer recommend TRT in selected patients with stage IV SCLC and restrict its use primarily to fit patients who responded to chemotherapy with limited extrathoracic tumour burden.

The role of PCI in extensive stage small cell lung cancer treated with palliative chemotherapy and consolidative thoracic radiotherapy

The role of PCI in extensive stage small cell lung cancer treated with palliative chemotherapy and consolidative thoracic radiotherapy

MA25.07 Effectiveness of Systemic Therapy Combined with Thoracic Radiotherapy for Patients with Oligometastatic NSCLC: A Pooled Analysis

Local therapy combined with systemic therapy for oligometastases or oligo-recurrence (≤ 5 lesions) in NSCLC has become one of the hottest spots in recent years. At present , there is lack of results from randomised phase III trial in this regard. Therefore, we performed a pooled analysis, aiming to evaluate the effectiveness of the combination of systemic therapy and local thoracic radiotherapy for patients with oligometastatic NSCLC. Computerized search of the Pubmed database was performed using the following key words: non-small cell lung cancer, metastasis, stage IV, thoracic radiation. Abstracts were ruled out. In addition, we also reviewed the references listed in the identified articles and included eligible studies for integrity of the literature search. Combination therapeutic modality should include systemic therapy (chemotherapy or targeted therapy) and thoracic radiotherapy. Authors with more than 1 publication involving the same study population were included only once, and the one with most relevant and complete data were included. Literature retrieval was terminated by April 2018. All the analysis was performed in the Stata/SE 12.0. A total of 32 articles with full text were retrieved in our initial literature search. After reviewing these articles and corresponding references, 16 studies (9 retrospective studies vs. 7 prospective phase II studies) with a total of 791 oligometastatic NSCLC patients were finally identified as eligible for this analysis. The median progression free survival (PFS) ranged from 6.6 to 16.0 months and median overall survival OS ranged from 10.0 to 27.1 months. Four studies involving 256 patients reported the post-radiotherapy response, resulting in a pooled objective response (CR + PR) rate of 58% (95% CI: 0.41, 0.76). A total of 3 studies involving 168 patients provided comparison data on PFS between systemic therapy alone and systemic therapy plus thoracic radiotherapy, leading to a pooled hazard ratio (HR) of 0.42 (95% CI: 0.28, 0.64) for the combined modality group. Consolidative thoracic radiotherapy in addition to systemic therapy may offer significant outcome benefits for oligometastatic NSCLC, leading to a numerically comparable response and survival to locally advanced NSCLC. Results from phase III randomized controlled trials are awaited.

Dose escalation and associated predictors of survival with consolidative thoracic radiotherapy in extensive stage small cell lung cancer (SCLC): A National Cancer Database (NCDB) propensity-matched analysis

PurposeRandomized studies have demonstrated a survival benefit for consolidative thoracic radiotherapy (TRT) in extensive stage (ES) small cell lung cancer (SCLC), however the radiation dose and optimal selection criteria are often debated. MethodsWe analyzed 3280 stage IV SCLC treated with double-agent chemotherapy and TRT within the National Cancer Data Base (NCDB) and evaluated the differences in selection patterns and survival outcomes for patients who received at least 45 Gy of TRT and those who received <45 Gy. Univariable and multivariable analyses identified characteristics predictive of overall survival. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias between the two dose arms. ResultsThere were 1621 patients in the <45 Gy group (most common 30 Gy) and 1659 patients in the 45 Gy or higher group (most common 45 Gy). White patients, T1-T3 lesions, an absence of brain/liver/bone metastases, and starting TRT after 12 weeks of chemotherapy were associated with the higher dose group.With multivariable analysis, TRT to at least 45 Gy was an independent predictor of improved survival (HR = 0.78, P < 0.001) along with female gender, age <65, lower comorbidity score, starting TRT 12 weeks after chemotherapy, and the absence of brain/liver/bone metastases (P < 0.01). Propensity adjusted regression model showed a persistent correlation between a higher dose and survival (HR = 0.74, P < 0.001). Survival at 1 and 2 years for the 45 Gy or higher arm was 58.1% and 25.2% compared to 43.8% and 15.1% for the <45 Gy arm (P < 0.001). ConclusionIn the largest analysis of consolidative thoracic radiotherapy in ES-SCLC to date, dose escalation to at least 45 Gy was an independent predictor for increased survival. These findings may be validated in ongoing prospective studies.

PC 02.01 Thoracic Radiation - YES

Small cell lung cancer (SCLC) accounts for 15%–20% of all lung cancers, and the overwhelming majority (>95%) are associated with tobacco exposure. The incidence of all types of lung cancer, including SCLC, has been declining in the United States with the onset of tobacco smoking cessation programs, although this trend took nearly 20 years to become evident among men. Overall survival (OS) rates for patients with lung cancer have also increased by about 5% since the advent of low-dose spiral computed tomography (CT) scanning to detect early lung cancer. The prognosis for patients with SCLC continues to be poor but has improved with the advent of smoking cessation campaigns, more effective chemotherapy agents and radiation planning and delivery techniques, and the use of prophylactic cranial irradiation (PCI) for those who experience a complete response to therapy. Consolidation with chest radiotherapy has improved OS among patients with extensive-stage SCLC who achieved a complete response to chemotherapy. SCLC often presents as bulky symptomatic masses, and mediastinal involvement is common with or without pleural effusion and extrathoracic disease. Extrathoracic spread (i.e., extensive-stage disease) is also quite common, being present in 80%-85% of cases at diagnosis. Brain metastases are present in approximately 20% of patients at diagnosis; roughly half of these metastases are symptomatic and the other half are detected by imaging. Predictors of poor prognosis include poor performance status, older age, and being male. The pathologic subtypes of the disease (small cell carcinoma and combined small cell carcinoma) all carry a similarly poor prognosis. Current guidelines of the U.S. National Comprehensive Cancer Network recommend the use of positron emission tomography (PET), CT scanning, or fused PET/CT scanning of the chest, liver, adrenals, bone, and other areas of concern in the diagnosis and staging of SCLC (NCCN guideline-SCLC 2017). Thoracic radiotherapy has also become important for improving OS among patients with SCLC who achieved a complete response to chemotherapy. In one prospectively randomized study of 498 patients with extensive-stage SCLC (WHO performance status score 0-2) who achieved complete response to chemotherapy, patients who received consolidation thoracic radiotherapy (30 Gy in 10 fractions) had significantly better 2-year OS rates than did those who did not receive thoracic radiotherapy (13% vs. 3%, P=0.004). Thoracic radiotherapy further improved thoracic-only failure rates (19.8% vs. 46% without, P=0.001) (Slotman B et al, Lancet Oncol 2015;385:36-42). However, many patients with extensive-stage SCLC do not respond to the standard etoposide/cisplatin chemotherapy (Fig 1). Those patients may need to receive molecular-targeted therapies or immunotherapy with the consolidating thoracic radiotherapy. Several histologic and immunohistochemical markers have been evaluated for diagnosing or monitoring treatment response in SCLC, including transcription thyroid factor-1 (positive in >85% of SCLC cases); cytokeratin 7; deletions in chromosome 3; Leu-7; chromogranin A; synaptophysin; myc amplification; and p53 mutations (present in ∼75% of cases). Deletions in tumor-suppressor genes are also relatively common and include fragile histidine triad (FHIT) (80%); RAS effector homologue (RASSF1) (>90%); TP53 (>75%); retinoblastoma-1 (RB1) (>90%); and retinoic acid receptor-beta (72%). However, to date no biomarkers have been validated for use in diagnosing SCLC. Moreover, mutations that are often present in non-small cell lung cancer (such as epidermal growth factor receptor [EGFR] mutations and anaplastic lymphoma kinase [ALK]) are rare in SCLC. Several clinicopathologic features have been linked with worse prognosis, including poor performance status, significant weight loss, high lactate dehydrogenase levels, large numbers of metastatic sites, and the presence of paraneoplastic syndromes. Because SCLC has the among the highest rates of somatic driver mutations, and because more than 95% of patients with SCLC are former or current smokers, immunotherapy seems a reasonable approach, as high mutation burdens correlate with good response to chemoradiotherapy and sensitivity to immunomodulators (Peifer M et al., Nat Genet 2012;44(10):1104-10). At MD Anderson Cancer Center, an ongoing phase I/II study of patients with extensive-stage SCLC has been proposed to the NRG as a prospective randomized study (PI J Welsh) (Fig 2). Use of thoracic radiotherapy to consolidate a site at which SCLC is quite likely to recur is reasonable, given that recurrence considerably reduces quality of their life as well as OS. In summary, in most cases SCLC presents as extensive-stage disease, for which outcomes are very poor. Consolidation with thoracic radiotherapy for patients who achieve a complete response to chemotherapy can improve 2-year OS rates. However, less toxic and more effective systemic treatment is also required to derive the greatest benefit from consolidation thoracic radiotherapy. thoracic radiotherapy extensive small-cell lung cancer, immunotherapyFig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Metastasectomy of Solitary Adrenal Metastasis From Small Cell Lung Cancer.

Most extensive-stage small cell lung cancers have disseminated disease at diagnosis, and solitary adrenal metastasis from small cell lung cancer is rare. We report the case of a 51-year-old man with extensive-stage small cell lung cancer with solitary right adrenal metastasis (T2N0M1), who was cured with resection of primary tumor, chemotherapy (cisplatin, etoposide), adrenalectomy, consolidative thoracic radiotherapy, and prophylactic cranial irradiation. He remained cancer free, 7.5 years since diagnosis. For small cell lung cancer with solitary adrenal gland metastasis, metastasectomy combined with chemotherapy and radiotherapy can be curative and enable long-term survival. This treatment approach should be further studied, and similar cases should be reported.

Results of a Phase 2 Study of Consolidative Thoracic Radiotherapy and/or Stereotactic Body Radiotherapy for Oligometastatic NSCLC

Results of a Phase 2 Study of Consolidative Thoracic Radiotherapy and/or Stereotactic Body Radiotherapy for Oligometastatic NSCLC

Recent developments in radiotherapy for small-cell lung cancer: a review by the Oncologic Group for the Study of Lung Cancer (Spanish Radiation Oncology Society)

Small-cell lung cancer (SCLC) accounts for 13% of all lung tumours. The standard treatment in patients with limited-stage disease is radiotherapy combined with chemotherapy. In extensive SCLC, the importance of consolidation thoracic radiotherapy in patients with a good treatment response has become increasingly recognized. In both limited and extensive disease, prophylactic cranial irradiation is recommended in patients who respond to treatment. New therapeutic approaches such as immunotherapy are being increasingly incorporated into the treatment of SCLC, although more slowly than in non-small cell lung cancer (NSCLC). Diverse radiation dose and fractionation schemes, administered in varying combinations with these new drugs, are being investigated. In the present study we review and update the role of radiotherapy in the treatment of SCLC. We also discuss the main clinical trials currently underway in order to identify future trends.

Consolidative thoracic radiotherapy for extensive stage small cell lung cancer.

Extensive stage small cell lung cancer (ES-SCLC) represents approximately half of all diagnosed small cell lung cancer worldwide. It is notorious for a high risk of local recurrence although it’s sensitive to chemotherapy. Nearly 90% of intrathoracic failures happen in the first year after diagnosis. The cornerstone of treatment for ES-SCLC is etoposide-platinum based chemotherapy. Consolidative radiotherapy to thorax has diminished the incidence of local relapse, therefore it should be offered to patients with excellent response to induction first-line chemotherapy. This review centers on the clinical evidence for the use of thoracic radiotherapy (TRT) and current modalities of TRT delivery, then tries to determine a feasible way to conduct TRT in a selective group of cases.

P1.07-021 Impact on Survival of High Dose Consolidative Thoracic Radiotherapy in Extensive Stage Small Cell Lung Cancer

Consolidative thoracic radiotherapy for metastatic small cell lung cancer patients who have responded to chemotherapy is controversial. Some publications suggest improved local control which could influence survival. Slotman et al. have recently published a randomized study that showed that thoracic radiotherapy improves long term survival for patients with extensive stage small cell lung cancer (ES-SCLC) who have responded to chemotherapy. Slotman also demonstrated in 2007 that prophylactic cranial irradiation in metastatic small-cell lung cancer with response to initial chemotherapy, reduces the incidence of symptomatic brain metastases and prolongs disease-free and overall survival. In our Radiation Oncology Department we have reviewed those patients with ES-SCLC (disseminated disease excluding brain metastases) who have achieved an objective response after chemotherapy, received prophylactic cranial irradiation and, after that, some of them treated with consolidative thoracic radiotherapy (CRT). Between 1995 and 2015 we have treated 68 patients, 59 men and 9 women (median age 63 years, range 42-79), with the characteristics mentioned above. Prophylactic cranial irradiation was administered at median doses of 24 Gy (range 24-36 Gy). Thoracic radiotherapy consolidation was delivered to 23 patients (33.8 %), with a median total dose of 46 Gy (range 20-54 Gy). We compared this group with the 45 patients (66.2%) who did not receive CRT. Among those patients treated with CRT, 17 patients (74%) had residual disease after chemotherapy, 4 patients (17.4%) had chest progression and 2 patients (8.7%) achieved complete response. No grade 3 toxicity has been reported. Median overall survival (OS) is 18 months in patients who received CRT, compared to 10 months in those patients who have not CRT. OS after one year was 78.3% in the group of patients with CRT and 41.3% when CRT was not performed. OS after two years was 34.8% with CRT and 6.9% without CRT. We have found a benefit (p=0.002) in the group of patients who received CRT, compared with patients who did not, obtaining significant differences in median survival and overall survival, taking into account that a bias selection could have affected the results. In comparison with Slotman study, we have found an improved survival with higher doses of CRT, without additional severe toxicity.

Research progress in the treatment of small cell lung cancer.

Small cell lung cancer (SCLC) accounts for approximately 10-15% of all lung cancers. No significant improvement has been made for patients with SCLC in the past several decades. The main progresses were the thoracic radiation and prophylactic cranial irradiation (PCI) that improved the patient survival rate. For patients with limited disease and good performance status (PS), concurrent chemoradiotherapy (CCRT) followed by PCI should be considered. For extensive disease, the combination of etoposide and platinum-based chemotherapy remains the standard treatment and consolidative thoracic radiotherapy is beneficial for patients who have a significant respond to initial chemotherapy. However, the prognosis still remains poor. Recently, efforts have been focused on molecular targets and immunotherapy. But numerous molecular targets methods have failed to show a significant clinical benefit in patients with SCLC. It is anticipated that further development of research will depend on the on-going trials for molecular targeted therapy and immunotherapy which are promising and may improve the outcomes for SCLC in the next decade.

Management of small-cell lung cancer with radiotherapy-a pan-Canadian survey of radiation oncologists.

The management of small-cell lung cancer (sclc) with radiotherapy (rt) varies, with many treatment regimens having been described in the literature. We created a survey to assess patterns of practice and clinical decision-making in the management of sclc by Canadian radiation oncologists (ros). A 35-item survey was sent by e-mail to Canadian ros. The questions investigated the role of rt, the dose and timing of rt, target delineation, and use of prophylactic cranial irradiation (pci) in limited-stage (ls) and extensive-stage (es) sclc. Responses were received from 52 eligible ros. For ls-sclc, staging (98%) and simulation or dosimetric (96%) computed tomography imaging were key determinants of rt suitability. The most common dose and fractionation schedule was 40-45 Gy in 15 once-daily fractions (40%), with elective nodal irradiation performed by 31% of ros. Preferred management of clinical T1/2aN0 sclc favoured primary chemoradiotherapy (64%). For es-sclc, consolidative thoracic rt was frequently offered (88%), with a preferred dose and fractionation schedule of 30 Gy in 10 once-daily fractions (70%). Extrathoracic consolidative rt would not be offered by 23 ros (44%). Prophylactic cranial irradiation was generally offered in ls-sclc (100%) and es-sclc (98%) after response to initial treatment. Performance status, baseline cognition, and pre-pci brain imaging were important patient factors assessed before an offer of pci. Canadian ros show practice variation in sclc management. Future clinical trials and national treatment guidelines might reduce variability in the treatment of early-stage disease, optimization of dose and targeting in ls-sclc, and definition of suitability for pci or consolidative rt.

Prophylactic cranial irradiation (PCI) and consolidation thoracic radiotherapy (TRT) for extensive stage small cell lung cancer (ES-SCLC): A systematic review and meta-analysis.

7568 Background: The role of PCI and TRT in ES-SCLC is controversial. We performed a systematic review of all comparative studies to investigate the benefits and harms of PCI and TRT in ES-SCLC. Me...

Clinical trial of post-chemotherapy consolidation thoracic radiotherapy for extensive-stage small cell lung cancer

Background and purposeTo define the rate of development of symptomatic chest failures in extensive stage small cell lung cancer (ES-SCLC) after undergoing post-chemotherapy chest radiotherapy (RT). Materials and methodsPatients had ES-SCLC, attained an objective response to chemotherapy and signed study consent. Target accrual was 33 patients. Patients were offered prophylactic cranial irradiation (PCI) as per department policy. PCI (25Gy/10 fractions) and chest RT (40Gy/15 fractions) were given simultaneously 4–8weeks after chemotherapy completion. Thoracic target volume was the post-chemotherapy residual chest disease plus margin. Patients were evaluated for RT toxicities, local control, disease-free and overall survival. ResultsThirty-two patients were evaluable. Twenty-nine patients completed RT without delay. There were 4 complete responses and 28 partial responses to chemotherapy. All study patients received PCI. Maximal acute RT toxicity was grade 2 esophagitis (18 patients). There were no RT-related deaths. Median time to disease progression and overall survival were 4.2 and 8.3months, respectively (median follow-up=21.8months). Of 16 chest recurrences, 7 were in the irradiated region and 5 were symptomatic. ConclusionsPost-chemotherapy consolidation chest RT for ES-SCLC patients on this trial was well tolerated and associated with symptomatic chest recurrences in only 5/32 treated patients.

Clinical Outcomes of Extensive Stage Small Cell Lung Carcinoma Patients Treated With Consolidative Thoracic Radiotherapy

ObjectivesTo determine the rates of loco-regional (LR) failure and toxicity in extensive-stage small cell lung carcinoma (ES-SCLC) patients treated with consolidative thoracic radiotherapy (TRT). MethodsA retrospective review was conducted on SCLC patients treated from January 2005 to July 2009. Patients with ES-SCLC who received consolidative TRT ≥30Gy were identified. Sites of disease failure, toxicity Common Terminology Criteria for Adverse Events version 3.0, incidence, and cause of treatment delays and vital status were determined. The cumulative LR and distant failure rates were calculated. Progression-free and overall survivals (OS) were determined by the Kaplan-Meier method. ResultsThree hundred thirty-six patients were identified with a diagnosis of SCLC and 215 patients had ES-SCLC. Nineteen (9%) patients were identified as receiving ≥30Gy consolidative TRT. Of this subgroup, the median age was 60 years (range 47 years to 82 years) and the median follow-up was 13 months (range 8 months to 32 months). Consolidative TRT was 40Gy/15 fractions (n = 16), 45Gy/30 fractions delivered twice daily (n = 2) and 36Gy/12 fractions (n = 1). Chemotherapy was sequential (n = 11) or concurrent (n = 8) with consolidative TRT. The incidence of LR failure was 26% and 39% at 1 and 2 years, respectively. The incidence of distant failure was 58% and 74% at 1 and 2 years, respectively. The median OS was 14 months. The 1-year and 2-year OS was 58% and 14%, respectively. No patients experienced clinical pneumonitis requiring treatment. ConclusionsConsolidative TRT controlled LR disease in most patients with minimal acute toxicity, though distant failure remained a significant problem.

The Role of Radiotherapy in Extensive Stage Small Cell Lung Cancer (ED SCLC): Prophylactic Cranial Irradiation (PCI) and Consolidation Thoracic Radiotherapy

The Role of Radiotherapy in Extensive Stage Small Cell Lung Cancer (ED SCLC): Prophylactic Cranial Irradiation (PCI) and Consolidation Thoracic Radiotherapy

Radiochemotherapy in small-cell lung cancer

Thoracic radiotherapy and prophylactic cranial irradiation (PCI) in combination with chemotherapy is an established standard of treatment of limited-disease (LD) small-cell lung cancer (SCLC). Both types of radiotherapy increase 3-year survival by approximately 5%, as shown in the meta-analyses. There is some evidence that earlier commencement of thoracic radiotherapy for good performance status LD-SCLC patients results in better outcome. Total dose, fractionation type and irradiation volume are still matter of debate. The ongoing Phase III randomized trials aim to answer the question of total dose in LD-SCLC. For PCI, in LD-SCLC a standard dose of 25 Gy in ten fractions should remain a standard, as has recently been demonstrated. The PCI in extensive-disease SCLC improves survival at the expense of worsening of short-term health-related quality of life. There is evidence that consolidation thoracic radiotherapy may be of value in extensive-disease SCLC. The recently initiated prospective trials may answer this question.

Current trends in prophylactic cranial irradiation (PCI) for extensive-disease small cell lung cancer (EDSCLC): Results of a UK survey

19040 Background: The EORTC 08993–22993 trial published in 2007 showed a survival benefit for PCI in patients who respond to initial systemic therapy for EDSCLC. This questionnaire-based study assesses the uptake of PCI in this setting in the UK. Methods: A 10 item questionnaire was sent to clinical oncologists involved in the treatment of small-cell lung cancer in 52 radiotherapy centres in the UK in December 2007. We asked if and when PCI became routine practice for the treatment of EDSCLC, the dose/fractionation regimens used, and if they had treated patients outside of the inclusion criteria for the EORTC trial. As a secondary point of interest we asked if patients were routinely treated with consolidation thoracic radiotherapy following systemic therapy for EDSCLC. Results: Completed questionnaires were returned from 39 centres (75.0% response). PCI is used in 89.7% of centres after a response to systemic therapy in EDSCLC. Before the results of the EORTC trial were available, 5 centres were routinely using PCI in this setting. 13 centres started using PCI after the results were presented at the 2007 ASCO annual meeting in June, and 16 centres began after the results were published in August 2007. The latest implementation of PCI in an oncology centre was in October 2007. No centre is treating more than 5 patients per month. The most common dose/fractionation regimens in use are 20 Gy/5 fractions (60%), 25 Gy/10 fractions (25.7%), and 30 Gy/10 fractions (28.6%). Of the centres using PCI for EDSCLC, 28.6% have treated patients over 75 years old despite these patients having been excluded from the EORTC trial, and 80% have treated patients with a World Health Organisation (WHO) performance status (PS) of 2. No centres have treated patients with WHO PS > 2. Consolidation thoracic radiotherapy is routinely given in 35.9% of centres. Most centres (79.5%) would be interested in taking part in a randomised controlled trial to assess the role of consolidation thoracic radiotherapy following systemic therapy in EDSCLC. Conclusions: Radiotherapy centres in the UK have been quick in the implementation of PCI in patients with EDSCLC. Most centres are following the EORTC trial protocol with respects to inclusion criteria and radiation dose/fractionation. No significant financial relationships to disclose.