ES small cell volumes

[Reaganite]

Ah, since my mediastinal CTV question spurred such an interesting debate , I'll pose another question for you all:

Extensive stage small cell s/p chemo with CR at distant sites and in the chest. Do you offer consolidative RT and, if so, what is your actual target in the chest? Dose? Is anyone here consolidating metastatic sites as per RTOG 0937?

(Regarding the chest therapy, if your answer is treat the pre-chemo volume, what would you treat in the instance of a PR?)

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[Palex80]

The problem here is that "good evidence" only comes in the form of the Jeremic randomized trial, which utilized intensive consolidative radiochemotherapy.

In every day practice we give consolidative moderately dosed RT alone to the chest if CR at distant sites and PR/CR at the chest is achieved. Usually we combine it with PCI.

The actual target are the initially involved lymph node stations.
In cases of central tumors we include the hilus region into the target volume as well.

Dose is in the range of 46-50 Gy, given in 2 Gy/d. If PR is present, we may boost up to 54 Gy, but seldom go higher than that.

It's a very complicated area, since evidence is little. I've heard that a randomized trial in the UK (?) is currently testing 10 x 3 Gy as consolidative treatment, without chemo.

 

[deleted4401]

Areas of prior involvement if CR, sort of following lymphoma guidelines. Similar policy for PR, with margin for residual disease. 45 Gy in 30 Fx BID or hypofx.

I've done it on 2 patients recently, one I did 40 Gy in 15, one BID. Don't believe Jeremic, but if they are in good shape, might be good for local control/Pre-palliation.

S

 

[Brim]

Don't believe Jeremic, but if they are in good shape, might be good for local control/Pre-palliation.

I like that term Pre-palliation.

 

[medgator]

I like that term Pre-palliation.

Yeah, I'll add that to my other favorite word, Definito-palliative

 

[TarHeelRadOnc]

Yeah, I'll add that to my other favorite word, Definito-palliative

I have treated two patients with ES-SCLC with thoracic chemoRT. Both had low volume, single site extra-thoracic disease and both had CR at distant sites, PR in chest and no brain metastases (met criteria for Jeremic). Treated with Turrisi regimen (45Gy in 1.5 BID) concurrent with cycle 4, followed by PCI. Both subsequently progressed, but lived >18mo. One of the patients had asymptomatic progression in the chest, in the setting of widespread metastatic disease, 21mo after chemoRT. I think that chest tx was likely beneficial in both cases.

Definitely would not use the Jeremic dose (54Gy), and definitely would not advocate for thoracic chemoRT as standard for the most pts with ES-SCLC. I will only treat if CR at distant sites and would not advocate for the treatment of extra-thoracic sites outside of a clinical trial.

Palex, just out of curiosity, why do you boost sites of PR after chemo to 54Gy BID for (incurable) ES-SCLC, when we only treat to 45Gy BID in the definitive (?) treatment of LS-SCLC?

 

[TarHeelRadOnc]

I have treated two patients with ES-SCLC with thoracic chemoRT. Both had low volume, single site extra-thoracic disease and both had CR at distant sites, PR in chest and no brain metastases (met criteria for Jeremic). Treated with Turrisi regimen (45Gy in 1.5 BID) concurrent with cycle 4, followed by PCI. Both subsequently progressed, but lived >18mo. One of the patients had asymptomatic progression in the chest, in the setting of widespread metastatic disease, 21mo after chemoRT. I think that chest tx was likely beneficial in both cases.

Definitely would not use the Jeremic dose (54Gy), and definitely would not advocate for thoracic chemoRT as standard for the most pts with ES-SCLC. I will only treat if CR at distant sites and would not advocate for the treatment of extra-thoracic sites outside of a clinical trial.

Palex, just out of curiosity, why do you boost sites of PR after chemo to 54Gy BID for (incurable) ES-SCLC, when we only treat to 45Gy BID in the definitive (?) treatment of LS-SCLC?

Sorry Palex, just realized that I read your post wrong... You were talking about 2Gy/day to 54Gy... Please disregard my question

 

[Palex80]

No problem. I just prefer 2 Gy/d since it's pre-palliative (I love this term! May I use it too? ) and don't want to risk the theoretical additional acute toxicity due to accelerated treatment.

On the other hand 45/1.5 bid is probably not a lot worse than 54/2 in terms of acute toxicity.




Current case (finished treatment last week):
A 72 year old lady with a KI of 70 was presented to me last month. She had received 4x Carbo/Eto for ED-SCLC with bilateral adrenal mets, a rather small primary in the left lower lobe and multiple hilar/mediastinal nodes. She achieved a CR in the thorax, but a SD in the adrenal mets. I talked to her about PCI and considered offering her thoracic RT. The problem was, that she had only achieved SD in her adrenal mets and she was rather in not very good shape. So, she wouldn't meet the Jeremic eligibility criteria for the trial. I sticked to PCI only.
Two sessions before completion of her PCI she complained about back pain and a bit of breathlessness.
A CT scan revealed progression of a hilar mass (which was initially involved) with consecutive atelectasis. The adrenals mets were SD, no new mets had developed. The med oncs didn't want to give her a second line treatment, since she had PD barely 3 months after the last Carbo/Eto. I gave her 5 x 5 Gy to the left hilar mass.
That's a good example of a patient, which perhaps may have benefited from consolidative thoracic RT, but wouldn't be a candidate for it based on our current level of evidence.

 

[TarHeelRadOnc]

No problem. I just prefer 2 Gy/d since it's pre-palliative (I love this term! May I use it too? ) and don't want to risk the theoretical additional acute toxicity due to accelerated treatment.

On the other hand 45/1.5 bid is probably not a lot worse than 54/2 in terms of acute toxicity.

Yeah, Jeremic was 54Gy in 1.5BID... That's a little aggressive IMO

 

[Palex80]

Yeah, Jeremic was 54Gy in 1.5BID... That's a little aggressive IMO

Indeed. With concurrent chemo on top of that.

 

[user_name]

My favorite term use by an attending in residency, besides preemptive pallaition, was actually written in the "goal" section of the prescription on the chart. Your choices are definitive, adjuvant, palliative, etc. He actually wrote "aggressive palliation". That gave me quite the giggle during chart rounds.