Help with SCLC Case

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napoleondynamite

napoleondynamite

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pt in mid 60's, excellent KPS. Was diagnosed with limited stage SCLC. Treated Turrisi style with BID to 45 and concurrent Cis/Etop followed by more chemo (4c total).

Restating shows decent partial response, but definitely not a CR with pet-avid and bulky nodal tissue remaining in the mediastinum. No distant mets. Brain negative.

Medonc not optimistic (nor am I) that additional chemo will produce a CR.

Would anyone retreat with say 5Gyx5? Other options? Topotecan data not exciting IMO and 2 more cycles of Cis/Etop will likely just add toxicity IMO.
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That is not behaving like small cell. You could re-biopsy to rule out mixed histology or residual NSCLC component (~10% of cases). Send genetics for possible targeted agent match if residual adenoCA. Not sure how much a radiation boost would help, but I guess thats as option as well, I would recommend conventional fractionation for mediastinum.
 
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Will be interesting to see the results of turrisi vs 70 Gy when the rtog trial results publish. I agree with phantom, would probably use conventional boost with chemo once you've confirmed its sclc vs nsclc. If the pt got cis/VP-16 with XRT, that's good chemo for either disease. Most med oncs get concerned about toxicity and give carbo/taxol for NSCLC.
 
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How long did you wait to get PET? If < 12 weeks, just disregard it and continue chemo.

napoleondynamite said:
pt in mid 60's, excellent KPS. Was diagnosed with limited stage SCLC. Treated Turrisi style with BID to 45 and concurrent Cis/Etop followed by more chemo (4c total).

Restating shows decent partial response, but definitely not a CR with pet-avid and bulky nodal tissue remaining in the mediastinum. No distant mets. Brain negative.

Medonc not optimistic (nor am I) that additional chemo will produce a CR.

Would anyone retreat with say 5Gyx5? Other options? Topotecan data not exciting IMO and 2 more cycles of Cis/Etop will likely just add toxicity IMO.
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seper said:
How long did you wait to get PET? If < 12 weeks, just disregard it and continue chemo.
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PET/CT was performed 12 weeks after chemoRT, which coincided with just a couple weeks after completion of chemo.
 
medgator said:
Will be interesting to see the results of turrisi vs 70 Gy when the rtog trial results publish. I agree with phantom, would probably use conventional boost with chemo once you've confirmed its sclc vs nsclc. If the pt got cis/VP-16 with XRT, that's good chemo for either disease. Most med oncs get concerned about toxicity and give carbo/taxol for NSCLC.
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How high would you guys go with a conventional boost? Keeping in mind it's now been 14 weeks since completion of chemoRT. My thought was to try to do a wimpy sort of SBRT approach with 5x5 - but that's probably less wimpy than any conventional boost I could deliver..I dunno.

We did biopsy him - confirmed SCLC. Weird, I haven't seen this before.
 
NCCN says PCI for SCLC-LS for CR/PR as category 1 recommendation. Still at risk for brain mets, and that's a killer for SCLC. I'd give the 25/10 to the brain.
Don't love the 5 Gy x 5 SBRT-esque approach, as SCLC doesn't seem to have a low a/b. How much did cord get and what was the V20? Keep it real tight, maybe boost to 20-30 Gy, depending on what cord got.
 
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Conventional didn't work the first time, so I'd be fine with a more hypofractionated approach like you mentioned. Get the dose in faster, prevent repopulation. I would not give PCI, as I would argue that they have had a poor up front response. I feel the evidence is strongest for PCI in a complete response, and that there is a gray area as to what you quantify as a partial response. If they truly have intensely PET avid gross disease, I would not qualify that as a "good response" and they are at high risk to reseed their brain despite PCI, then what will you do?

Gfunk is right, this is a very bad prognostic factor. Depending on the patient's goals of care though, I wouldn't throw in the towel just yet.
 
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radmonckey said:
Conventional didn't work the first time, so I'd be fine with a more hypofractionated approach like you mentioned. Get the dose in faster, prevent repopulation. I would not give PCI, as I would argue that they have had a poor up front response. I feel the evidence is strongest for PCI in a complete response, and that there is a gray area as to what you quantify as a partial response. If they truly have intensely PET avid gross disease, I would not qualify that as a "good response" and they are at high risk to reseed their brain despite PCI, then what will you do?

Gfunk is right, this is a very bad prognostic factor. Depending on the patient's goals of care though, I wouldn't throw in the towel just yet.
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yah, this was my thought process too..sneak in a few hypofractionated treatments, restage and then decide on PCI..or just go for PCI if he wants to do it instead of wait.

Sucky situation without great data-driven answers. He definitely is of the mindset to want to be as aggressive as possible, very highly functional executive type personality. I've never re-irradiated like this to the mediastinum, but my sense is that if I keep the volumes tight with breath hold it would be safe-ish..but certainly some risk to the adjacent great vessels and esophagus.
 
I'm not sure what the utility of a little more RT is going to do at this point. I agree with the other posters; this patient is likely not destined to do well and, in my opinion, and further radiotherapy should be palliative in nature. The odds of you inducing a cure at this point are essentially zero.
 
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napoleondynamite said:
How high would you guys go with a conventional boost? Keeping in mind it's now been 14 weeks since completion of chemoRT. My thought was to try to do a wimpy sort of SBRT approach with 5x5 - but that's probably less wimpy than any conventional boost I could deliver..I dunno.

We did biopsy him - confirmed SCLC. Weird, I haven't seen this before.
Click to expand...
Didn't realize it was that long of an interval, have to agree with others, not sure you can get the dose in at this point to cure him, so pci doesn't make sense as he will eventually reseed. Would hold further xrt for palliation
 
I would treat.
If you can spare the esophagus and have a small volume to treat, treat it now. He will most probably develop PD at that site, than anywhere else in the near future.
You will probably not going to cure this patient, but you may very well prolong the time to second line chemo.

More than a third of all Turrisi patients had isolated recurrences at the initial involved sites. 45/1.5 bid is simply not enough for quite a big portion of all patients.
I regularly boost patients to higher doses by replanning them at 36-40 Gy. Most of them show remission 2 weeks into treatment. I often do SBRT as boost in N1/small N2 SCLC, but sometimes in bulky N2-3 I just go higher with total dose (51-54 Gy), that's an extra 2-3 days of Turrisi.
 
Palex80 said:
I would treat.
If you can spare the esophagus and have a small volume to treat, treat it now. He will most probably develop PD at that site, than anywhere else in the near future.
You will probably not going to cure this patient, but you may very well prolong the time to second line chemo.

More than a third of all Turrisi patients had isolated recurrences at the initial involved sites. 45/1.5 bid is simply not enough for quite a big portion of all patients.
I regularly boost patients to higher doses by replanning them at 36-40 Gy. Most of them show remission 2 weeks into treatment. I often do SBRT as boost in N1/small N2 SCLC, but sometimes in bulky N2-3 I just go higher with total dose (51-54 Gy), that's an extra 2-3 days of Turrisi.
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Wow, interesting to see the whole spectrum of opinions spanning the globe =)

What dosing have you used for SBRT boost in SCLC?
 
I don't think you should be worried about the safety of this
 
This would be that one lawyer you managed to save despite all the odds. Instead of being thankful, he decides to sue you for developing a dry cough that went away on its own.
 
4x5 Gy was the boost dose for SBRT, I didn't do a break though and delivered it immediately after the 45/1.5
 
Palex80 said:
.

More than a third of all Turrisi patients had isolated recurrences at the initial involved sites. 45/1.5 bid is simply not enough for quite a big portion of all patients.
.
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Totally agree. Plus the standard arm was just ridiculous. Who would ever treat sclc 45 in 5 weeks?
 
The problem in LD SCLC and Turrisi is esophagitis. As soon as you have involved nodes in station 7 or other bulky N2 disease close to the esophagus many patiens get grade III esophagitis on the third week, making dose escalation challenging.
IMRT can help, but can't prevent this.
The esophagus is in the PTV when you are treating station 7 (subcarinal nodes).
 
napoleondynamite said:
pt in mid 60's, excellent KPS. Was diagnosed with limited stage SCLC. Treated Turrisi style with BID to 45 and concurrent Cis/Etop followed by more chemo (4c total).

Restating shows decent partial response, but definitely not a CR with pet-avid and bulky nodal tissue remaining in the mediastinum. No distant mets. Brain negative.

Medonc not optimistic (nor am I) that additional chemo will produce a CR.

Would anyone retreat with say 5Gyx5? Other options? Topotecan data not exciting IMO and 2 more cycles of Cis/Etop will likely just add toxicity IMO.
Click to expand...

I have a very similar case now. 69 year old female, very good KPS with a small RUL small cell tumor with bulky 4R node, treated on study (BID 45 vs. 70 Gy) with BID. Had a CR on follow up CT/PET and subsequently got PCI.

Now 10 months from her treatment she has an in-field recurrence in that level 4R node - node hot on PET and ~2 cm. no other distant sites of disease. EBUS biopsy confirmed small cell. Brain MRI negative, no other sites on PET.

She doesn't want chemo now but wants to be aggressive otherwise. I'm thinking 25 Gy in 5 fractions SBRT. It's far from the esophagus, but is in the full dose at 45 BID.

I'm open to suggestions though.
 
BobbyHeenan said:
I have a very similar case now. 69 year old female, very good KPS with a small RUL small cell tumor with bulky 4R node, treated on study (BID 45 vs. 70 Gy) with BID. Had a CR on follow up CT/PET and subsequently got PCI.

Now 10 months from her treatment she has an in-field recurrence in that level 4R node - node hot on PET and ~2 cm. no other distant sites of disease. EBUS biopsy confirmed small cell. Brain MRI negative, no other sites on PET.

She doesn't want chemo now but wants to be aggressive otherwise. I'm thinking 25 Gy in 5 fractions SBRT. It's far from the esophagus, but is in the full dose at 45 BID.

I'm open to suggestions though.
Click to expand...

SBRT makes sense but recurrent SCLC treated without chemo will recur somewhere else fairly quickly so a palliative dose of 5 Gy x 5 is is reasonable.
 
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would you consider starting opdivo before 5 x 5? It does have a benefit in small cell. Maybe you could get some synergy with the opdivo by having it on board pior to hypofracionated XRT - a lot of preclinical work on this.
 
nkmiami said:
would you consider starting opdivo before 5 x 5? It does have a benefit in small cell. Maybe you could get some synergy with the opdivo by having it on board pior to hypofracionated XRT - a lot of preclinical work on this.
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Has it been FDA approved yet? I know it's coming but without that, you aren't going to get it paid for
 
it is not approved, but BM has been good about compassionate use in multiple disease sites.
 
nkmiami said:
would you consider starting opdivo before 5 x 5? It does have a benefit in small cell. Maybe you could get some synergy with the opdivo by having it on board pior to hypofracionated XRT - a lot of preclinical work on this.
Click to expand...

Yes - that was discussed but med onc said they've been having issues getting it approved for small cell. Thus, second line CPT-11 was considered and the pateint/med onc weren't enthusiastic about that - though they both understand she's likely to relapse and need chemo at some point.
 
In today's news... dog bites man! Man bites dog. Some lung cancer cases are incurable. Back to you, Connie.
 
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