Lung - SCLC

Question 1

How is limited vs extensive stage small cell lung cancer defined

Answer 1

Limited - can be encompassed in one 10x10cm field
Practically, disease confined to one hemithorax and regional nodes

Extensive stage (90% of presentations)
Multiple lung nodules, SCF nodes, effusion

Question 2

What is the management for an early small cell lung cancer

Answer 2

If T1/2 - surgery (lobectomy) + adjuvant chemotherapy (cisplatin/etoposide) +/- PCI

If found to be node positive after surgery - give adjuvant CRT

Question 3

Management for T3/4 or N+ small cell lung cancer

Answer 3

Concurrent ChemoRT, followed by surveillance if response, or 2nd line treatment if progression

Less intense if sequential ChemoRT - if pt less fit or disease is not encompassable / too extensive

Question 4

What is the regimen for sequential chemoRT for small cell lung cancer

Answer 4

4 cycles cis/carboplatin & etoposide, followed by 40Gy/15# over 3wks

Question 5

What are the CRT regimes for small cell lung cancer

Answer 5

Either Turrisi regimen or Convert regimen
4x cisplatin and etoposide
RT starts with second cycle of chemo

Turrisi:
45Gy/30# treating bd, over 19 days
4% survival advantage to bd RT treatment - can instead treat daily

Convert
66Gy/33#, RT starting with cycle 2
45Gy/30# is SOC

Rescan 4-6wks after completion of cycle 4 chemotherapy, before considering PCI

Question 6

How should RT be planned for a small cell lung cancer

Answer 6

GTV = primary and nodes
CTV = GTV +5mm
PTV = CTV +10mm axillary and 15mm sup/inf, or 5mm throughout if planned using 4DCT

Question 7

What is the regimen for PCI in limited small cell lung cancer
Indications
What is the benefit

Answer 7

25Gy/10#/2wks

Indications:
Partial or complete response in limited disease, within 4-6wks of completing ChT
PS0-2 & age ≤70

Benefit:
Improves OS by 5% at 3yrs, from 15->20%
Reduces risk of CNS met by 50% (60->30%) at 3yrs

Question 8

What is the first line management of extensive stage small cell lung cancer

Answer 8

Carboplatin/etoposide + atezolizumab x6, followed by maintenance atezolizumab (needs PS 0-1)
Or cisplatin/carboplatin + etoposide + durvalumab x6, followed by maintenance durvalumab

If PS2-3 - consider platinum/etoposide only

Question 9

What is the mOS for extensive stage SCLC treated with carbo/etopo/atezo
and carbo/etopo/durvalumab

Answer 9

atezo: 12.3mths according to IMPower 133 trial

durval: 13mths - Caspian trial

Question 10

How should brain mets be managed as part of small cell lung cancer presentation

Answer 10

CNS RT, then wean off steroids before starting immunotherapy
Cannot use immunotherapy with uncontrolled / untreated intracranial disease

Question 11

How should a small cell cancer presenting as SVCO be managed

Answer 11

Stent only if doesn’t delay chemo
Urgent carboplatin/etoposide, and add ate once PS improves to 1.

Question 12

What are the indications for consolidation RT in SCLC?
What dose is given

What volumes
What was the benefit

Answer 12

Residual disease post chemotherapy / chemo-IO
Bulky mediastinal disease initially

Dose: 30Gy/10# / 20Gy/5#, 17/2, single 8 or 10

Volumes:
CTV lung - post chemo volume
CTV nodes - pre-chemo volume
PTV = CTV +15mm

Crest trial - 30Gy/10# - 2yr OS improved by 10% (13% vs 3%)

Question 13

When is PCI indicated in extensive stage SCLC
Dose?
Benefit
SE

Answer 13

If complete or partial response to treatment, age <75 and PS0-2
20Gy/5# or 25Gy/10# if fitter (same dose as limited stage)
And not already had WBRT

Increased mOS (27% vs 13%) and reduced occurrence of symptomatic brain mets (15% vs 40%)
based on Slotman trial, but no baseline imaging was done
Possible that MRI surveillance is as effective

SE: mild cognitive decline in 30%, headache, N/V. fatigue