Case discussion: extensive stage SCLC

[Gfunk6]

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58F never-smoker presented with acute SOB, DOE, and cough. X-ray revealed R pleural effusion --> CT Chest re-demonstrated effusion w/ R mediastinal + hilar mass --> biopsy = small cell lung cancer

Pt was referred to Med Onc and underwent a PET/CT + MRI Brain. No evidence of extra-thoracic disease on PET/CT but x3 brain mets noted (all less than 2 cm, asymptomatic).

Pt was treated with x4 cycles of CDDP + Etoposide with a PR (> 50% response) in the chest and a CR in the brain (NED on re-imaging).

Pt is now referred to you for consideration of consolidative XRT.

I would r/c 54 Gy to residual chest disease in 36 fractions with x2 concurrent cycles of C/E followed by x2 adjuvant cycles of CE with PCI (25 Gy in 10 fractions).

This is based a a Phase III randomized study from Yugoslavia published in the JCO in 1999 located here. Sadly OS is still < 10%.

Thoughts?

 

[medgator]

There is a current RTOG trial looking to answer this question (although it wouldn't actually apply in this patient's situation, as it specifically excludes patients with CNS mets from enrolling).

http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0937

 

[radiaterMike]

I am not sure if I would offer PCI as opposed to giving an extra few doses (i.e. palliative brain RT as opposed to prophylactic brain RT). I doubt those brain metastases truly disappeared, and I would fear that a subtherapeutic brain dose would result in increased risk of regrowth of those brain metastases.

I don't think the Yugoslavian study or the ongoing RTOG study would apply to this patient, since he/she has brain metastases (despite a post-chemo MRI suggesting otherwise). I would consider offering thoracic RT as you described. The survival benefit is not known, but arguably, you can delay symptomatic thoracic progression.

 

[TarHeelRadOnc]

I am not sure if I would offer PCI as opposed to giving an extra few doses (i.e. palliative brain RT as opposed to prophylactic brain RT). I doubt those brain metastases truly disappeared, and I would fear that a subtherapeutic brain dose would result in increased risk of regrowth of those brain metastases.

I don't think the Yugoslavian study or the ongoing RTOG study would apply to this patient, since he/she has brain metastases (despite a post-chemo MRI suggesting otherwise). I would consider offering thoracic RT as you described. The survival benefit is not known, but arguably, you can delay symptomatic thoracic progression.

Jeremic data not applicable to patient b/c of brain mets. Would probably do 30Gy/10 or 35Gy/14 to brain rather than PCI dose of 25Gy/10. No data to support thoracic RT, but not unreasonable based on first principles. Would probably do 45Gy/30 BID (Turrissi) rather than 54Gy/36 BID (Jeremic). Would be hard to keep cord dose below 36Gy with the later regimen, not to mention increased gr 3-4 esophagitis risk. Would definitely error on the side of caution given unproven benefit.

 

[Gfunk6]

Good points everyone and excellent discussion. Thanks for the input.

 

[Mandelin Rain]

Jeremic has a way of having every trial run, end up positive. Which makes me take everything with a grain of salt.

Treat the brain and palliate systemically as need be.

 

[Palex80]

Jeremic simply asked smart questions in rather simple trials.
I have met him and he's a very pleasant fellow.

I would treat the brain and the thorax. If you are having second thoughts about toxicity and since your patient did not have any other mets (other than the brain), you could perhaps ommit the chemo.

As far as the brain dose is concerned, I would give 30/2 or perhaps even 36/2 (I know, I know, the French trial was negative for higher dose, but this aint PCI).

 

[medgator]

Jeremic simply asked smart questions in rather simple trials.
I have met him and he's a very pleasant fellow.

I would treat the brain and the thorax. If you are having second thoughts about toxicity and since your patient did not have any other mets (other than the brain), you could perhaps ommit the chemo.

As far as the brain dose is concerned, I would give 30/2 or perhaps even 36/2 (I know, I know, the French trial was negative for higher dose, but this aint PCI).

Decreased OS was found in the group of pts assigned to the higher-dose PCI arm (36/2).

http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=55&abstractID=32942

 

[Palex80]

Decreased OS was found in the group of pts assigned to the higher-dose PCI arm (36/2).

http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=55&abstractID=32942

That's what I said, didn't I?
"The French trial was negative"

The problem in this particular case is, it isn't PCI. This patient has had brain metastasis already.

 

[medgator]

That's what I said, didn't I?
"The French trial was negative"

The problem in this particular case is, it isn't PCI. This patient has had brain metastasis already.

My point wasn't just that it was negative, but that there was a statistically-significant decrease in OS in that group, and until that issue is teased out, I (and others) would be somewhat hesitant to give that dose in the pure PCI setting. In this patient, it may not matter because of previous Hx of brain met+.

 

[Palex80]

The French trial's result can probably be explained as a "false negative" result.
There was no excessive CNS-mortality due to the higher brain dose and no higher rate of SAEs.
Therefore the case that 36/2 leads to more deaths is simply not explainable by the study.


I don't give 36/2 for PCI either, our standard is 30/2.