Background and recommendations Flashcards
Dose limit to spinal cord?
37 Gy to Dmax with BID
45 Gy Dmax with QD
What are the RT dosing options for patients with limited stage disease?
- 45 Gy at 1.5 Gy/fx (30) BID
2. 66 Gy at 2 Gy/fx (33) QD
What imaging is needed for patients with small cell lung cancer?
- PET/CT scan
- MR brain
- Consider BM bx
What special studies are needed for patients with small cell lung cancer?
- PFTs
Follow up
H&P and Chest CT every 3 months for 2 years, then every 6 for year 3 years, then yearly.
CBC and CMP at each visit
Acute complications of RT
Esophagitis
Dermatitis
Cough
Fatigue
Subacute toxicities of RT
Radiation pneumonitis
Late complications of RT
Esophogeal stricture or perforation Pericarditis CAD Lhermittes syndrome Brachial plexopathy Rib fracture
Lung dose constraints?
V20 < 30%
MLD < 15 Gy
Esophagus dose constraints?
Mean dose < 34 Gy
V55:50%
Brachial plexus constraint?
Dmax 60 Gy
Heart constraint?
V40<40%
What is the dose for PCI?
25 at 2.5 Gy/fx
How to develop target volumes?
GTV = Gross tumor seen on CT planning scan
CTV= GTV + 1.5 cm margin including any initially involved nodal regions
Among patients with limited stage disease, who should get PCI?
All patients with CR or near CR, who have no sign of brain metastases.
What is the recommended treatment for patients with limited stage small cell lung cancer?
cT1-2 N0, medically operable
Lobectomy with mediastinal node sampling followed by adjuvant EP
cT3-4, N+, or medically inoperable
Cisplatin and etoposide every 3 weeks x 4 cycles.
Start RT during cycle 1 or 2 to the thorax.
Treatment with PCI for all patients who achieve either a CR or near CR.
What is the median OS for patients with limited stage SCLC? 5 year OS?
MS: 20 months
5 year OS: 20-26%
What is the median OS for patients with extensive stage SCLC?
12 months
5 year OS: <5%
What is extensive stage disease?
Any disease not meeting limited stage
What is limited stage disease?
Disease confined to to one hemithorax and regional nodes
How is a tissue diagnosis made?
Sputum cytology
Bronchoscopy with EBUS and FNA transbronchial biopsy of tumor and suspicious nodes
CT guided biopsy is reserved for peripheral lesions
BM BX if LDH is elevated and clinically appears to be limited stage
What counseling needs to be done at work up?
Smoking cessation counseling
What is the most important prognostic factors?
Staging and performance status
How to treat extensive stage in patients without brain metastases?
- Cisplatin and etoposide x 3 cycles s
- Reimage with CT scan of C/A/P, MR brain
- If CR peripherally, and atleast PR in the thorax, chest RT with concurrent cisplatin and etoposide. 54 Gy at 1.5 BID.
- Deliver PCI for all patients who have not progressed and have had atleast a PR.
What histologic features are present with small cell lung cancer?
Small round blue cells
Neuroendocrine differentiation
Increased mitotic count
Increased N/C ratio
What markers are commonly present with small cell lung cancer?
S100+ Synaptophysin+ Chromagranin+ Neurotensin+ EGFR-
What percentage of patients present with brain metastases?
10-15%
What percentage of patients eventually develop brain metastases?
50-80%
What did the pignon metaanalysis indicate about the benefit of RT to chemo?
5% improvement in OS
25-30% improvement in LC
What is grade 2 pneumonitis?
Symptomatic but not requiring oxygen
What is grade 3 pneumonitis?
Dyspnea at rest or oyxogen needed
What study indicated that PCI can benefit patients with extensive stage disease after chemo?
EORTC 08993
What study indicated that consolidative RT to the thorax improves OS for patients with extensive stage disease?
Jeremic et al
What study supported BID thoracic RT?
INT 0096
What labs are needed at work up?
CBC, CMP, LDH
What chemotherapy doses for limited stage?
- Cisplatin 60 mg/m2 day 1
- Etoposide 120 mg/m2 days 1,2,3
Every 21 days, for 4-6 cycles
What chemotherapy doses for extensive stage?
- Cisplatin 80 mg/m2 day 1
- Etoposide 80 mg/m2 days 1,2,3
Every 21 days, for 4-6 cycles
