NCCN Small Cell Lung Cancer

Question 1

Workup of SCLC found on biopsy.

Answer 1

Big workup for SCLC: 
Path review. 
CT CAP w/ contrast.
Brain MRI.
PET.

Smoking cessation.
If never smoker w/ extensive stage (Stage IV, or T3/4 w/ multiple nodules that cannot be radiated), get molecular profiling.

Question 2

If SCLC has pleural effusion, what should be done?

Answer 2

Thoracentesis.

If inconclusive, do thoracoscopy.

Question 3

A SCLC pt has T1-2 N0M0 clinical staging (PET, brain MRI, CT CAP), what’s next?

Answer 3

Assess for clinical surgical candidacy (PFTs and clinical exam) ->
Pathological mediastinal staging (no need if not surgical candidate)

Question 4

A pt w/ SCLC has PET equivocal for bone mets, what’s next (workup)?

Answer 4

Bone imaging via XR or MRI.

If still equivocal, get biopsy.

Question 5

When should a pt w/ SCLC get bone MARROW biopsy?

Answer 5

Peripheral smear w/ nucleated RBCs, neutropenia, thrombocytopenia (suggest bone marrow infiltration)

Question 6

A pt w/ early, small SCLC gets clinical staging (PET, brain MRI, CT CAP; and thoracentesis, bone imaging, bone biopsy, or marrow biopsy as needed), then gets mediastinal staging, which is negative. What’s next?

Answer 6

Lobectomy is preferred.

Mediastinal lymph node dissection or sampling.

Question 7

A pt w/ SCLC gets clinical staging (PET, brain MRI, CT CAP; and thoracentesis, bone imaging, bone biopsy, or marrow biopsy as needed).
Mediastinal staging is negative.
Lobectomy w/ LN dissection/sampling done.
How does N status after resection change treatment?

Answer 7

N0 - systemic therapy (everyone gets systemic therapy)
N1/2 - systemic therapy and mediastinal RT

*if nodes are positive, add RT to mediastinum

Question 8

What are options for medically inoperable T1-2 N0M0 (stage I-IIa) SCLC?

Answer 8

SABR then systemic therapy.

Systemic therapy and concurrent RT.

Question 9

If a SCLC pt has limited stage IIB-IIIC (T3-4,N0,M0 or T1-4,N1-3,M0), what should be figured out next? What are treatment options?

Answer 9

Performance status AND if related to cancer:
Good is 0-2 -> systemic therapy AND concurrent RT.
Poor is 3-4 and from SCLC -> systemic therapy +/- either concurrent or sequential RT.
Poor (3-4) not from SCLC -> individualized treatment, including supportive care.

Question 10

What is extensive stage SCLC? How is it managed?

Answer 10

Extensive stage: stage IV, T3-4 b/c of multiple lung nodules that are too extensive or tumor/nodal volume too large to be encompassed in a tolerable radiation plan.

Tx Principles:

• Systemic therapy for all. Can basically keep giving until no response, unacceptable toxicity, or performance score 3-4.
• RT to symptomatic sites (SVC, lung, bone, brain) before systemic therapy

Question 11

For SCLC, what workup is needed after primary treatment (ie response assessment)?

Answer 11

CT CAP w/ contrast, brain MRI, labs

Question 12

A pt w/ limited stage SCLC gets lobectomy, then systemic therapy. Treatment response assessment (CT CAP w/ contrast, brain MRI, labs) shows complete response. What’s next?

Answer 12

Prophylactic cranial irradiation (PCI)

Question 13

What is surveillance for SCLC after tx?

Answer 13

Surveillance CT - chest +/- abd/pelvis x2-6 mo.
MRI brain

• New pulm nodule - workup for new primary
• PET is NOT recommended routinely