Elective nodes in LS SCLC

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ramsesthenice

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Just curious, in limited stage small cell patients with PET negative and mediastinoscopy proven disease free mediastinum does anyone ever skip on mediastinal irradiation? There is a tiny Dutch study that skiped mediastinal nodes in PET neg LS patients with few mediastinal failures. We generally treat most everyone BID and it makes sense that leaving the mediastinum alone in select patients could reduce esophageal toxicity. Some of our senior faculty are weary of doing so since truly limited stage patients are so rare they don't want to blow a curative opportunity. Thoughts?

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Both schools of thought have their reasoning. The rtog/calgb protocol has eni in the initial 44 gy phase of treatment. I don't do it personally, but quite frankly, these pts present with such extensive central LAD, you end up kind of doing it anyways. The rationale for not doing it is based off some studies and the idea that the chemo will address micromets
 
You could always extrapolate data from the surgical series of very limited disease SCLC.
In patients with pT1-2 pN0 NSCLC you can ommit adjuvant RT alltogether, if the mediastinal and hilar lymph node regions have been resected.
Chemo seems to be able to control possible micro-mets in that case.
Thus if you have a true negative mediastinum on PET and on mediastinoscopy, why not ommit elective mediastinal radiation therapy in a cT1 cN0 SCLC?
The problem will probably be the hilar lymph nodes, which you can't address with mediastinoscopy and you will have to base your decision to treat or not solely on PET. I would treat those.
 
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