PCI in SCLC

[Gfunk6]

I've always delivered PCI for CR in LS-SCLC and CR/PR in ES-SCLC. However, I'm hearing more and more from academic centers that this is not routinely being utilized anymore. Am curious to what everyone else's experience is.

I occasionally use hippocamapal-sparing WBRT in younger patients with diffuse brain met but have deferred doing so with PCI as there is an ongoing randomized trial.

---

Members don't see this ad.

 

[medgator]

I've heard the criticism regarding the ES slotmann trial (no pre pci MRI imaging required), but was unaware this was happening in LS disease.

Not sure why considering the data...

Sent from my SAMSUNG-SM-N910A using SDN mobile

 

[Neuronix]

I mostly stopped after this trial was reported:

Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-labe... - PubMed - NCBI

I don't see why that shouldn't apply to limited stage assuming routine MRI surveillance. The EORTC extensive stage data was flawed and the limited stage data was based off two meta-analyses of small trials. To me that wasn't particularly high level data to support it to begin with.

Japanese have been doing this for awhile even off protocol. Hence this retrospective paper:

An Error Occurred Setting Your User Cookie

 

[seper]

I've heard this argument re: new Japanese study, but I disagree with changing practice based on that.

 

[nkmiami]

.

 

[nkmiami]

I call Moffitt docs sometimes for advice in lung cancer- over the years they never agreed with prophylactic xrt in limited stage small cell- although I could be mistaken- based on the fact that original studies did not have MRI after chemorads, so the benefit may have been due to treating early overt disease. personally. I dont really have an opinion on this.

 

[seper]

For a some years I've worked in a severely undeserved area, and MRI surveillance was simply not feasible.

 

[deleted18755]

I mostly stopped after this trial was reported:

Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-labe... - PubMed - NCBI

I don't see why that shouldn't apply to limited stage assuming routine MRI surveillance. The EORTC extensive stage data was flawed and the limited stage data was based off two meta-analyses of small trials. To me that wasn't particularly high level data to support it to begin with.

Japanese have been doing this for awhile even off protocol. Hence this retrospective paper:

An Error Occurred Setting Your User Cookie

To be clear it's not really PCI vs no PCI but up front PCI vs regular MRI's to quickly salvage with WBRT... makes sense that they might be roughly equivocal given the systemic but relatively radiosensative nature of SCLC.

I have a lot of patients who can barely afford the extra gas in their tank to make it to a clinical follow-up and I'm sure the vast majority for one reason or another would not get the survellience MRI's so I'm sure I administer more PCI than the average radiation oncologist (just like I'm sure I administer RT in stage I seminoma more frequently than most, although come to think of it I don't think I've done so in at least 1.5-2 years).

 

[evilbooyaa]

The Japanese data Neuronix posted is the basis for omitting PCI in ES-SCLC. Similar thought process in LS-SCLC. Likely no difference between PCI and early salvage.

As long as you can do surveillance regularly, then it's fine. The above post brings up good points- if the patients aren't going to follow-up and get their surveillance MRIs with regularity, then do the PCI.

HS-WBRT for PCI for SCLC is currently in clinical trials (and an exclusion criteria for other HS-WBRT trials), and I wouldn't offer it off clinical trial at this time.

 

[Palex80]

We stopped giving PCI for ED-SCLC 2 years ago or so, when the Japanese data came out as practice. I've seen already 3 patients this year who developed massive tumor progression with cerebral mets, exactly because they didnt get PCI after chemo for ED-SCLC. 2 out of 3 also have tumor progression in the liver simultaneously. I presume that if they had gotten PCI they would not have been hospitalized because of seizures or declining PS from the brain mets. They would however still died probably a few weeks later due to extracerebral tumor progression.
I expect PCI for ED-SCLC to become interesting when extracerebral tumor remission for ED-SCLC starts getting better, perhaps with immunotherapy?
Currently we don't do any surveillance with MRI. We just do an MRI after chemo has ended and that's it.


We still regularly treat all LD-SCLC with PCI.

 

[evilbooyaa]

We stopped giving PCI for ED-SCLC 2 years ago or so, when the Japanese data came out as practice. I've seen already 3 patients this year who developed massive tumor progression with cerebral mets, exactly because they didnt get PCI after chemo for ED-SCLC. 2 out of 3 also have tumor progression in the liver simultaneously. I presume that if they had gotten PCI they would not have been hospitalized because of seizures or declining PS from the brain mets. They would however still died probably a few weeks later due to extracerebral tumor progression.
I expect PCI for ED-SCLC to become interesting when extracerebral tumor remission for ED-SCLC starts getting better, perhaps with immunotherapy?
Currently we don't do any surveillance with MRI. We just do an MRI after chemo has ended and that's it.


We still regularly treat all LD-SCLC with PCI.

In regards to bolded, that isn't a valid option for patients IMO. Either you do PCI or you do surveillance in this group. q3 months may be hard but that was what was studied. You cant just observe and wait for symptoms.

 

[medgator]

In regards to bolded, that isn't a valid option for patients IMO. Either you do PCI or you do surveillance in this group. q3 months may be hard but that was what was studied. You cant just observe and wait for symptoms.

Yeah that seems pretty messed up. I had a LS guy refuse pci and 6 months later he presented with LLE weakness from a large met, pretty much needed a cane to get around for awhile, ended up seeing my partner, was mad that I was right?

 

[Palex80]

In regards to bolded, that isn't a valid option for patients IMO. Either you do PCI or you do surveillance in this group. q3 months may be hard but that was what was studied. You cant just observe and wait for symptoms.

I do not agree. What was studied was a negative trial. The Japanese trial was designed to prove the superiority of the PCI arm and failed to do so (they speculated that 2y-OS would be 24% in PCI arm vs. 15% in observation arm).
It was not a non-inferiority trial.
If it had been a successful non-inferiority trial, then your argument would have been correct. Then you would have to perform follow-up MRIs as in the trial.
Since however it was failed superiority trial, you can only say that PCI effective. That's all.
You cannot state however that the observation arm should be standard of care.
I know it's statistics, but that's how it works.

There is not proven OS benefit if you monitor closely with MRIs every 3 months for ED-SCLC, which won't get PCI. No trial was ever done that tested this. In fact there is no cancer I am aware of, where regular MRIs of the brain have showed a proven OS benefit.

In my experience, many patients fail simultaneously in the CNS and with extracerebral mets, which is probably why the benefit of PCI is so little in ED-SCLC. You may see CNS-mets early on, but its only the tip of the iceberg.

 

[Neuronix]

I disagree with Palex strongly on this point. Without MRI surveillance Q3mo, I would not omit PCI. The reason EORTC ES-SCLC trial showed survival benefit where Japanese didn't is likely MRI surveillance in the Japanese trial. We can make arguments about power and primary endpoints all we want, but that's the conclusion I make from the data.

I do recommend regular MRIs even after WBRT as well, though I'm not as strict about it. Am I the only one? You're looking at 20-40% symptomatic in brain failure at 2 years after WBRT alone. That's worth preventing IMO.

 

[Palex80]

I disagree with Palex strongly on this point. Without MRI surveillance Q3mo, I would not omit PCI. The reason EORTC ES-SCLC trial showed survival benefit where Japanese didn't is likely MRI surveillance in the Japanese trial. We can make arguments about power and primary endpoints all we want, but that's the conclusion I make from the data.

That is one possible explanation.

The other explanation is:
The EORTC trial showed a (small) benefit in terms of OS because it did not perform a BASELINE MRI.
Which pretty much means that lots of patients in the EORTC trial probably entered the observation or PCI arm with undetected macroscopic metastases.
So the PCI-arm patients actually got therapeutic WBRT, while the non-PCI patients simply progressed further on.
Had the EORTC-trial also included a "screening" baseline MRI before randomization it's possible that the results would have been different. This is something the EORTC-trial has been criticized repeatedly before and which is not actually well presented in the Japanese paper, since they do not state the number of screening failures due to positive MRIs before study inclusion.

This is a common problem in trials looking at prevention of brain metastases.
For example the CEREBEL-trial looking at a possible superiority of lapatinib over transtuzumab in metastastic breast cancer in terms of CNS metastases prevention had problems recruiting because of positive MRIs at baseline in asymptomatic patients with no know history of brain metastases.
CEREBEL (EGF111438): A Phase III, Randomized, Open-Label Study of Lapatinib Plus Capecitabine Versus Trastuzumab Plus Capecitabine in Patients With... - PubMed - NCBI
30% of the enrolled patients in the trial dropped out at baseline because of a positive MRI.
And we are talking about breast cancer, not SCLC, where the incidence of asymptomatic brain metastases in non-screened ED patients is likely higher.


I would do one baseline MRI after completing chemo, but would not do further imaging.
If I detected metastases in the MRI, I would treat with WBRT (provided the patient had responded to chemo), if I didnt detect metastases, I'd follow up without MRI.

I do recommend regular MRIs even after WBRT as well, though I'm not as strict about it. Am I the only one? You're looking at 20-40% symptomatic in brain failure at 2 years after WBRT alone. That's worth preventing IMO.

At 24 months 80% of the patients in the Japanese trial were dead already mostly due to extracerebral tumor progression.

 

[Neuronix]

That is one possible explanation.

The other explanation is:
The EORTC trial showed a (small) benefit in terms of OS because it did not perform a BASELINE MRI.
Which pretty much means that lots of patients in the EORTC trial probably entered the observation or PCI arm with undetected macroscopic metastases.
So the PCI-arm patients actually got therapeutic WBRT, while the non-PCI patients simply progressed further on.

The way I justify what I do is based on the high lifetime risk of brain metastases after the SCLC diagnosis without PCI (~70% in the Japanese trial). This is on par with the distant failure risk after GK for NSCLC. I do Q3mo surveillance patients for those NSCLC patients s/p GK as well for at least the first year (as recommended by NCCN guidelines).

At 24 months 80% of the patients in the Japanese trial were dead already mostly due to extracerebral tumor progression.

Well I don't do MRIs on dead patients But, I do prevent brain death and disability with the MRIs and resultant SRS in those patients who need it.

I can never predict which patients are actually going to live 2 years at time of diagnosis. I like to give everyone the "benefit of the doubt" with best treatments for quality and quantity of life unless they are clearly declaring themselves to have a very short life expectancy.

 

[Palex80]

The way I justify what I do is based on the high lifetime risk of brain metastases after the SCLC diagnosis without PCI (~70% in the Japanese trial). This is on par with the distant failure risk after GK for NSCLC. I do Q3mo surveillance patients for those NSCLC patients s/p GK as well for at least the first year (as recommended by NCCN guidelines).

That's a different scenario.
NSCLC patients with macroscopic brain metastases can be cured with radiosurgery, neurosurgery, etc. Not many will be cured but some will and lots of them live quite a long time nowadays with immunotherapy, EGFR-/ALK-directed therapy.
ED-SCLC patients with macroscopic brain metastases cannot be cured. It's palliative.

People die due to ED-SCLC. Look at the EORTC-trial: 1.3 months of OS-benefit due to PCI. That's almost like erlotinib in pancreatic cancer...

 

[medgator]

.
ED-SCLC patients with macroscopic brain metastases cannot be cured.

All the more reason to offer pci in very good responders after chemo therapy +/- chest xrt.

I have an ES patient 4 years out from pci after a CR to platinum/vp-16 on PET, and ~2 years out for salvage chemo/xrt for isolated mediastinal relapse found on surveillance chest ct as he did not get consolidative TRT after PCI

I do recommend regular MRIs even after WBRT as well, though I'm not as strict about it. Am I the only one? You're looking at 20-40% symptomatic in brain failure at 2 years after WBRT alone. That's worth preventing IMO.

I only do that in nsclc pts typically not my sclc patients. Interesting idea though for small cell. I never do imaging after pci. It shouldn't come back hopefully unless there is relapse extra-cranially

 

[evilbooyaa]

I do not agree. What was studied was a negative trial. The Japanese trial was designed to prove the superiority of the PCI arm and failed to do so (they speculated that 2y-OS would be 24% in PCI arm vs. 15% in observation arm).
It was not a non-inferiority trial.
If it had been a successful non-inferiority trial, then your argument would have been correct. Then you would have to perform follow-up MRIs as in the trial.
Since however it was failed superiority trial, you can only say that PCI effective. That's all.
You cannot state however that the observation arm should be standard of care.
I know it's statistics, but that's how it works.

There is not proven OS benefit if you monitor closely with MRIs every 3 months for ED-SCLC, which won't get PCI. No trial was ever done that tested this. In fact there is no cancer I am aware of, where regular MRIs of the brain have showed a proven OS benefit.

In my experience, many patients fail simultaneously in the CNS and with extracerebral mets, which is probably why the benefit of PCI is so little in ED-SCLC. You may see CNS-mets early on, but its only the tip of the iceberg.

Fair enough, but I'm not saying observation is standard of care. If you're going to say the Japanese trial is negative, then you should be offering PCI to all of your ES-SCLCs.

I think surveillance in patients at extremely high risk for intracranial failure or intracranial relapse is important.

Yearly brain MRIs for metastatic NSCLC (and re-image at any progression) and q3 or at least q6 month MRI for SCLC assuming no PCI. Likely q6 month or q1 year if received PCI.

Once you HAVE intracranial disease, q3 month MRI for at least 2 years of intracranial disease free interval, regardless of histology.

The cost of an MRI is a lot less than an admission for symptomatic brain mets.

 

[Palex80]

Fair enough, but I'm not saying observation is standard of care. If you're going to say the Japanese trial is negative, then you should be offering PCI to all of your ES-SCLCs.

Excuse me?

The Japanese trial was a superiority trial, designed to prove that PCI was superior to observation. Since the trial was negative, the trial results are against PCI.

I think surveillance in patients at extremely high risk for intracranial failure or intracranial relapse is important.

If you think that reduction of metastases rate is an important thing, sure.
I'd rather go for OS.
Reduction of metastases has also been shown for NSCLC with PCI. Do we do it? No. Why? Because patients do not live longer with PCI.

 

[medgator]

.
Reduction of metastases has also been shown for NSCLC with PCI. Do we do it? No. Why? Because patients do not live longer with PCI.

Yet reduction in mets and decrease in neurological cause of death was seen in the patchell study (without clear OS benefit) causing adjuvant wbrt to becoming standard of care after craniotomy and resection of a solitary brain met.

I doubt the pci debate is that cut and dry. If I have an ES pt with good PS and a completely negative PET, I sure as heck am offering PCI... my 4+ year ES survivor would probably agree

 

[Palex80]

Yet reduction in mets and decrease in neurological cause of death was seen in the patchell study (without clear OS benefit) causing adjuvant wbrt to becoming standard of care after craniotomy and resection of a solitary brain met.

Which is again another scenario. Why?
Because a patient with a solitary metastasis from a NSCLC has a better prognosis than a patient with brain metastasis from an SCLC.
You can cure patients with solitary brain metastasis from an NSCLC using surgery/SRS +/- WBRT. You cannot cure patients with brain metastasis from an SCLC.

I don't the pci debate is that cut and dry. If I have an ES pt with good PS and a completely negative PET, I sure as heck am offering PCI... my 4+ year ES survivor would probably agree

Our decisions are often driven by single patient cases we have in mind. I have done this myself often enough. This is however unfortunately not evidence based medicine.

And I'd like to stress out something, which was not pointed out so far.
PCI is not exactly atoxic treatment. Patients remain bald for a further 3 months, fatigue is certainly an issue (especially since they are recovering from 4-6 cycles of chemo) and neurocognition can worsen.

 

[medgator]

You cannot cure patients with brain metastasis from an SCLC.

I've learned there are rarely absolutes in cancer. If that were true, that would make pci even more important in appropriately selected patients.

Our decisions are often driven by single patient cases we have in mind. I have done this myself often enough. This is however unfortunately not evidence based medicine.

And I'd like to stress out something, which was not pointed out so far.
PCI is not exactly atoxic treatment. Patients remain bald for a further 3 months, fatigue is certainly an issue (especially since they are recovering from 4-6 cycles of chemo) and neurocognition can worsen.

Neither is neuro sx from sclc in the brain.

I think we'll just have to agree to disagree here

 

[deleted18755]

This is a little tangential but the thread is deviating from the original question anyway (good discussion though) so I'll just post here:

Does anybody order surveillance MRI's after PCI? Of course the patient is still at risk for disease after PCI but I never order surveillance MRI's since I figure if they have asymptomatic mets the toxicity from repeat whole brain almost definitely outweighs the benefits, especially since they have so much else going on.

 

[BobbyHeenan]

This is a little tangential but the thread is deviating from the original question anyway (good discussion though) so I'll just post here:

Does anybody order surveillance MRI's after PCI? Of course the patient is still at risk for disease after PCI but I never order surveillance MRI's since I figure if they have asymptomatic mets the toxicity from repeat whole brain almost definitely outweighs the benefits, especially since they have so much else going on.

I don't order surveillance MRI's after PCI.

I do always re-image the brain if they have systemic progression though even if they don't have CNS symptoms.

 

[evilbooyaa]

Excuse me?

The Japanese trial was a superiority trial, designed to prove that PCI was superior to observation. Since the trial was negative, the trial results are against PCI.

But you can't take that study, claim it's negative, and do something that neither arm of that study did. There is no data to support observation with no surveillance MRIs.

The trial did not look at PCI versus wait for symptoms. It looked at PCI versus surveillance with early salvage and did not show superiority of PCI.

I think we'll have to agree to disagree on this matter.

I don't order surveillance MRI's after PCI.

I do always re-image the brain if they have systemic progression though even if they don't have CNS symptoms.

In answer to oldking's question, I think this is reasonable. At my institution we do surveillance and consider SRS for recurrent focal intracranial disease vs repeat whole brain, but that's like more of an academics thing and not something I would feel is necessarily standard.

 

[Palex80]

But you can't take that study, claim it's negative, and do something that neither arm of that study did. There is no data to support observation with no surveillance MRIs.

The trial did not look at PCI versus wait for symptoms. It looked at PCI versus surveillance with early salvage and did not show superiority of PCI.

I think we'll have to agree to disagree on this matter.

That's a point.
However before the EORTC study noone did 3-monthly MRIs either.
MRI surveillance by itself is not evidence based. That's the argument.

Like you said, we will agree to disagree.

 

[RadOncDoc21]

I disagree to agree! Carry on.

 

[Neuronix]

This is a little tangential but the thread is deviating from the original question anyway (good discussion though) so I'll just post here:

Does anybody order surveillance MRI's after PCI? Of course the patient is still at risk for disease after PCI but I never order surveillance MRI's since I figure if they have asymptomatic mets the toxicity from repeat whole brain almost definitely outweighs the benefits, especially since they have so much else going on.

I do order surveillance MRIs after PCI with the intent of SRS for limited metastatic brain disease. I do repeat whole brain radiation, but only as a last resort.

 

[Cancerdancer]

Palex's argument that "PCI was not superior to observation with 3 month MRIs, so I do neither" would be the equivalent of not recommending PSA surveillance after a prostatectomy for T3 disease with a positive margin if the first PSA is negative.
Trimodality therapy (with surgery inclusion) isn't superior to chemoRT for stage III lung cancer in RCTs...so do you just not treat those patients at all either? "Since neither is superior, I choose neither!"
The close surveillance in the Japanese resulted in 60% of the observation patients getting WBRT at some point, presumably for radiographic (asymptomatic) progression; hence the lack of survival benefit to upfront PCI.
I push people with LS-SCLC to PCI because I suspect you do cure a few people where you sterilize microscopic disease and if they were observed they wouldn't be curable with macroscopic CNS disease. I don't think that proportion is high, but a few long-term disease free patients are worth some small neurocognitive impact in a lot of patients who will pass away regardless.
In ES-SCLC I favor observation q 3 mo now with the Japanese data, especially if patient reliable. I offer but never push PCI in these patients; they all opt for observation, and many never f/u because it ends up not being relevant due to extracranial disease.
I'd argue that not recommending MRI surveillance in the absence of PCI is malpractice.

 

[scarbrtj]

For discussion: prophylactic cranial irradiation is not prophylactic

 

[Palex80]

Palex's argument that "PCI was not superior to observation with 3 month MRIs, so I do neither" would be the equivalent of not recommending PSA surveillance after a prostatectomy for T3 disease with a positive margin if the first PSA is negative.
Trimodality therapy (with surgery inclusion) isn't superior to chemoRT for stage III lung cancer in RCTs...so do you just not treat those patients at all either? "Since neither is superior, I choose neither!"
The close surveillance in the Japanese resulted in 60% of the observation patients getting WBRT at some point, presumably for radiographic (asymptomatic) progression; hence the lack of survival benefit to upfront PCI.
I push people with LS-SCLC to PCI because I suspect you do cure a few people where you sterilize microscopic disease and if they were observed they wouldn't be curable with macroscopic CNS disease. I don't think that proportion is high, but a few long-term disease free patients are worth some small neurocognitive impact in a lot of patients who will pass away regardless.
In ES-SCLC I favor observation q 3 mo now with the Japanese data, especially if patient reliable. I offer but never push PCI in these patients; they all opt for observation, and many never f/u because it ends up not being relevant due to extracranial disease.
I'd argue that not recommending MRI surveillance in the absence of PCI is malpractice.

I didn't want to discuss this further, but now I feel I must.

Performing imaging for follow-up in a palliative setting is only important if any early detection of disease progression will change a relevant endpoint for the patient.
This is why patients in a palliative setting do not need regular scans if they are not under treatment. You do the scans while under treatment to know if your treatment works, because if it doesn't you can stop/switch it. No reason to expose the patient to an ineffective treatment.
You do not however do regular imaging for asymptomatic patients in a palliative setting.

If you have a patient with localized prostate cancer after definitive RT who shows PSA progression, you don't do regular scans. There is no reason to.
You will do PSA tests every now and then just to know what the doubling time is and maybe plan when to start your ADT. But you are not going to do bone scans every 6 months.

Even in the curative treatment setting you don't have to do scans, even when the risk for recurrence is very high, because they are not evidence based.
A tripple negative, nodal positive breast cancer patient who has undergone chemotherapy, mastectomy and RT is not going to get regular scans of the liver, even if the risk of recurrence is high.
It's just not evidence based.

The whole point I am trying to make is that if you take 200 patients with extensive disease SCLC who have undergone 4 cycles of chemo, consolidative thoracic irradiation, MRI showing no brain mets but not PCI and then decide to:
a) do 3 monthy MRIS in 100 patients
b) do clinical follow ups in 100 patients
It is not known if group a) will live longer.
I agree that in group a) there is quite a good chance that you will pick up a lot of brain mets before they become symptomatic and probably deliver palliative WBRT earlier on. Will that enhance OS? Good question. We know that in poor-prognosis NSCLC patients WBRT does not really works well (QUARTZ-trial), so I am not sure we can safely say that early WBRT in asymptomatic SCLC patients will provide an OS benefit over WBRT in symptomatic SCLC patients.
It is quite probably that a lot of patients are going to show progression outside of the brain as well. This happens a lot of ED-SCLC and it happens early on. And when that happens prognosis is not good and a lot of patients die within a few months.

If any of you can offer me solid data, why surveillance with MRI is a must and evidence-based, then fine. But calling omission of MRI scans malpractice is just crazy.

 

[scarbrtj]

Just like Dr. Hurst once told me while pointing at his stethoscope, "Who needs a Swan-Ganz when you have this?"... who needs routine surveillance MRIs when you have the complete neurological examination (being a bit facetious, but in all non-seriousness... http://gomerblog.com/2015/09/mri-brain/).

 

[evilbooyaa]

I'd argue that not recommending MRI surveillance in the absence of PCI is malpractice.

I agree with the rest of your post, but I wouldn't go as far as making that statement.

Some people don't do things for LRC or decreased admission benefit and only look at survival numbers, and whether that will be improved with a proposed treatment. We do not officially have data on that, Palex is correct. While I do not agree with that approach, I also do not think malpractice is a term that should be thrown around lightly by physicians, even on anonymous message boards.

There will never be a trial like Palex requests, and he knows it, because nobody would be willing to run a trial like that. I strongly maintain that if he's not doing surveillance then he should be strongly recommending PCI to all of his ES-SCLC patients as there was a survival benefit.

However, that is the variation in practice present within our community.

 

[Cancerdancer]

Fair point Evil; I agree. I shouldn't toss that around.
To Palex, arguing that no MRIs should be used for palliative patients--do you argue with your med oncs for every scan they order in metastatic patients?
We have data in ES-SCLC that PCI improves OS in absence of high-quality imaging.
We have data that it doesn't in the setting of using high-quality imaging.
So if you're not gonna use it (which I don't) then using high-quality imaging.
WBRT upon radiographic progression is a simple intervention with relatively low morbidity for small lesions vs craniotomies and neurologic decline (still followed by whole brain) if you don't. It certainly makes more sense than the med oncs rescanning until the cows come home so they can give toxic 3rd line chemo. The MRI is the least of the worries for these patients.

 

[Palex80]

To Palex, arguing that no MRIs should be used for palliative patients--do you argue with your med oncs for every scan they order in metastatic patients?

Ordering scans in patients undergoing palliative systemic treatment is important. You can judge if the treatment you deliver is working or not. If it's not, you can stop it, saving the patients from toxicity and costs.
I guess that pretty logical, right?
Ordering regular scans in asymptomatic metastatic patients who do not undergo treatment is not something anyone should be doing.

We have data in ES-SCLC that PCI improves OS in absence of high-quality imaging.

You mean in the absence of any imaging. Slotman didn't even do a CT brain scan before randomizing the patients to PCI or observation.

We have data that it doesn't in the setting of using high-quality imaging.

MRI is common in the developed world.

WBRT upon radiographic progression is a simple intervention with relatively low morbidity for small lesions vs craniotomies and neurologic decline (still followed by whole brain) if you don't.

I have seldom seen craniotomy for SCLC in the brain. Only in rare cases of extreme symptoms from compression in the posterior fossa. SCLC is something you dont regularly do surgery for.

The MRI is the least of the worries for these patients.

That's your perception. It certains costs and it certainly creates stress for the patients. We know that repeat imaging does that.

 

[evilbooyaa]

Ordering regular scans in asymptomatic metastatic patients who do not undergo treatment is not something anyone should be doing.

Palex - Adjunctive question for you. Let's get away from SCLC for a second.

Let's say you have a 60 year old female with EGFR mutated metastatic NSCLC, controlled extracranially. She hasn't had a brain MRI in 2 years since it was negative at diagnosis 2 years ago. She has some progression on Tarceva after 2 years and comes to you for a painful bone met somewhere. Pelvis, spine, wherever, pick your favorite.

She's never been treated before.

Any role for an MRI brain, in your opinion?

 

[Palex80]

Palex - Adjunctive question for you. Let's get away from SCLC for a second.

Let's say you have a 60 year old female with EGFR mutated metastatic NSCLC, controlled extracranially. She hasn't had a brain MRI in 2 years since it was negative at diagnosis 2 years ago. She has some progression on Tarceva after 2 years and comes to you for a painful bone met somewhere. Pelvis, spine, wherever, pick your favorite.

She's never been treated before.

Any role for an MRI brain, in your opinion?

I wouldn't do one. Not in an asymptomatic patient.

 

[Gfunk6]

I wouldn't do one. Not in an asymptomatic patient.

I would agree with this. Typically I get serial MRI Brains only for patients with known intracranial disease that we are following. Otherwise, would only do so initially for screening purposes (e.g. NSCLC >= Stage IIB). If that screening MRI was negative would only reimage for symptoms.

 

[medgator]

I would agree with this. Typically I get serial MRI Brains only for patients with known intracranial disease that we are following. Otherwise, would only do so initially for screening purposes (e.g. NSCLC >= Stage IIB). If that screening MRI was negative would only reimage for symptoms.

I feel the same way.

Some med oncs will order mris in their asymptomatic stage IV patients getting avastin, as untreated brain mets is a relative contraindication to that

 

[evilbooyaa]

Interesting to see the agreement on that. Maybe my institution's yearly MRI on mNSCLC is the outlier?

 

[Palex80]

If you are going to screen metastatic NSCLC (without known history for brain mets) periodical brain MRIs during palliative systemic treatment, then you should be doing that for metastatic melanoma and Her2-positive breast cancer too.
Like I said, I'm not doing it. But if you do, you should be doing it in all metastatic cancers with high risk of brain involvement down the road.

 

[Palex80]

Interesting to see the agreement on that. Maybe my institution's yearly MRI on mNSCLC is the outlier?

Well, if you are intetested in making money, that's an excellent way to achieve that goal.

You probably treat several more patients with SRS because you pick up brain mets earlier on. You also probably treat some patients that would never have developed clinically symptomatic brain mets.

I'm not saying it's bad. It's simply not evidence based that you influence any relevant end point for the patient with such an approach.

It happens often by chance in every day life. I ordered an MRI of the C-spine for a patient with bone mets last week which I wanted to treat and picked up a cerebellar met. Of course I treated it that too.

 

[evilbooyaa]

I'd like to think that for mNSCLC if you pick up something with a screening MRI and treat it before they become symptomatic, you're doing them a service. Even if it's one big lesion you're saving them a craniotomy. If it's multiple lesions you're saving them from WBRT, or earlier enrollment into hospice if you go with the QUARTZ data. Of course, who knows what the NNT would be. But I see your point.

 

[scarbrtj]

I'd like to think that for mNSCLC if you pick up something with a screening MRI and treat it before they become symptomatic, you're doing them a service. Even if it's one big lesion you're saving them a craniotomy. If it's multiple lesions you're saving them from WBRT, or earlier enrollment into hospice if you go with the QUARTZ data. Of course, who knows what the NNT would be. But I see your point.

It's likely that if you pick up a breast cancer early by screening mammography we don't do women "a service" (just ask the Swiss) so I can almost guarantee that picking up *metastatic, incurable* CNS disease in lung cancer "early" does no patient a service either. Also, the logic for PCI replacing the need for ongoing screening MRIs (if you believe you need screening MRIs in lieu of PCI) would be specious, because all "prophylactic" cranial XRT can do is treat subclinical mets already present; it is never prophylactic (unless I missed something in Hall that irradiated tissues become resistant to metastatic deposits)... PCI can't "prevent" mets from seeding & appearing 6 months or 12 months, or more months, later.

 

[scarbrtj]

If you are going to screen metastatic NSCLC (without known history for brain mets) periodical brain MRIs during palliative systemic treatment, then you should be doing that for metastatic melanoma and Her2-positive breast cancer too.
Like I said, I'm not doing it. But if you do, you should be doing it in all metastatic cancers with high risk of brain involvement down the road.

This kind of reminds me of the people who say that you should be doing a (screening) digital rectal exam for all prostate CA guys (who've had DREs by their urologist, and biopsy, and imaging) at consult and in followup because "I occasionally catch an anal or a rectal cancer." So I'm like, well, you better be doing DREs on all your breast patients, your lung CA patients, etc., because you're missing all these undiagnosed anal and rectal cancers!

 

[evilbooyaa]

It's likely that if you pick up a breast cancer early by screening mammography we don't do women "a service" (just ask the Swiss) so I can almost guarantee that picking up *metastatic, incurable* CNS disease in lung cancer "early" does no patient a service either. Also, the logic for PCI replacing the need for ongoing screening MRIs (if you believe you need screening MRIs in lieu of PCI) would be specious, because all "prophylactic" cranial XRT can do is treat subclinical mets already present; it is never prophylactic (unless I missed something in Hall that irradiated tissues become resistant to metastatic deposits)... PCI can't "prevent" mets from seeding & appearing 6 months or 12 months, or more months, later.

Our opinions seem to differ on this, but to me there is a lot more to 'service' than just OS. Prevention of hospitalization, surgery, morbidity, symptomology, etc. I can't read that article you posted - got a pubmed link?

 

[Palex80]

Also, the logic for PCI replacing the need for ongoing screening MRIs (if you believe you need screening MRIs in lieu of PCI) would be specious, because all "prophylactic" cranial XRT can do is treat subclinical mets already present; it is never prophylactic (unless I missed something in Hall that irradiated tissues become resistant to metastatic deposits)... PCI can't "prevent" mets from seeding & appearing 6 months or 12 months, or more months, later.

Well you are absolutely correct when it comes to extensive disease SCLC.
However in limited disease SCLC, PCI can eliminate microscopic metastatic deposits and aid to the cure of the patient.

 

[medgator]

Well you are absolutely correct when it comes to extensive disease SCLC.
However in limited disease SCLC, PCI can eliminate microscopic metastatic deposits and aid to the cure of the patient.

What do I tell my 4+ year es sclc survivor who had a CR after initial EP, PCI and then went on to chemoradiation for salvage for isolated mediastinal recurrence 2 years ago?

Pretty sure the pci eradicated micromets intracranially as well as the carbo/VP-16 did extra-cranially

 

[scarbrtj]

What do I tell my 4+ year es sclc survivor who had a CR after initial EP, PCI and then went on to chemoradiation for salvage for isolated mediastinal recurrence 2 years ago?

To buy a lottery ticket!* But... PCI could or could not have been the key to her long survival. (Chemo eliminates mets in the brain, too; I'm sure we have all seen this for macromets in small cell.) I mean these are almost fruitless arguments obviously. Did she get chest RT upfront? 'Cause the chest RT data in ES-SCLC looks (BAM) pretty (POW) good (WHACK); its effects I think probably "trump" the literature's wishy-washy track record re: PCI effects in ES-SCLC (there's also some additional chest RT data in ES-SCLC which I annoyingly can't find). But it seems she got chest RT at recurrence. To treat at recurrence vs upfront maybe could have been an approach for her CNS as well, what with the CNS arguably being a site at less risk for recurrence than her chest.

This is all wild-ass conjecture of course. I give PCI to all LS-SCLC, and all CR/PR patients in ES-SCLC, and I give chest RT to ES-SCLC patients who have PR/CR as well. Because the data support all these approaches. I have no data about ongoing routine MRIs in ES or LS SCLC doing anything. I have opinions, but no great data. So I can't make any claims that ongoing routine chest imaging, or routine brain imaging, for any patient in the small or non-small metastatic setting, does anything. It "feels good" to say you're saving money or anxiety or preventing paralysis or SVC syndromes... but I just don't know! Maybe?

*-or that she had a mixed small/non-small tumor, which is quite common... the pathologists call it "small cell" no matter how much non-small is there, and it's quite probable based on some emerging data that a "single lung cancer" in a patient can have varying phenotypic behaviors and these long-term small-cell survivals were cured of localized small cell and we are witnessing perhaps the more indolent natural history of remaining non-small variants... again, conjecture!