Choice for SCLC with lobectomy?

[jinbo]

Female, 62yr, diagnosed as right lung cancer with CT when annual check up.
Sputum cytology ,brain MRI, bone ECT negative. Without biopsy, she went lobectomy and complete lymph node dissection. Postoperative pathology showed small cell lung cancer with 4/30 lymph nodes positive, including 4R, 7 ,10 regional lymph nodes metastasis. The diameter of the tumor is 3cm.
Do she need thoracic RT? when to deliver RT?
How to do RT, concurrent with Chemo? or sequential after Chemo?
Target should include?
When to give PCI?

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[BraggPeak]

Since the patient is node positive, concurrent chemo + mediastinal RT, followed by response assessment as you would have done in a definitive chemoRT case--> if CR/PR -->PCI

 

[Palex80]

Since the patient is node positive, concurrent chemo + mediastinal RT, followed by response assessment as you would have done in a definitive chemoRT case--> if CR/PR -->PCI

Precisely!


Some say that only if N2 nodes are involved one should offer RT, others say that if N1 nodes are positive, it's also justified to offer RT.
What do you think?

We treat if node positive (regardless whether it was N1 or N2), but I can see the point of ommiting RT if you only had a small positive N1 node, the complete mediastinal nodes were resected and found to be negative.

 

[deleted4401]

N2- concurrent chemoRT, adjuvant chemo, PCI
N1- +/- concurrent chemoRT, adjuvant chemo, PCI
N0- adjuvant chemo, PCI

Treat the mediastinum (affected area vs. whole) and omit primary unless high risk features (close/positive margins)
I've never seen a SCLC have less than a PR, so since we give it for PRs in ES-SCLC, no reason to withhold for LS-SCLC. And, if brain scan is positive, need WBRT anyhow.

 

[Palex80]

N2- concurrent chemoRT, adjuvant chemo, PCI
N1- +/- concurrent, adjuvant chemo, PCI
N0- adjuvant chemo, PCI

What do you mean by "N1- +/- concurrent, adjuvant chemo, PCI"?
What factors do you take into account. I just checked out NCCN and they propose RCT if N+.

 

[deleted4401]

Sorry made edit ... I'm just saying the treatment of this situation isn't really well defined, and that there is likely agreement that N2 patients should get RT and likely agreement N0 patients shouldn't, but N1 is not as obvious. There isn't great data on recurrence patterns and efficacy of treatment in any of these situations, so it's just rampant speculation, but anecdotally, I think this is what most people do. I think you're right, if N1, you can make a good case to treat, but for NCCN to say this is Category 2A is a stretch. They don't even quote "low-level evidence".