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Small Cell Lung Cancer

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In small cell lung cancer, the use of prophylactic cranial irradiation (PCI) for ... Regarding lung cancer patients: (True or False? ... – PowerPoint PPT presentation

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Title: Small Cell Lung Cancer


1
Small Cell Lung Cancer
  • Sam Wang

2
Outline
  • Small Cell Lung Cancer

3
SCLC - Background
  • SCLC Incidence
  • ACS 2007 All Lung CA incidence 213,000
  • 13 of all lung CA (27,000)

4
Natural History of SCLC
  • SCLC is distinguished from NSCLC by its rapid
    doubling time, high growth fraction, and the
    early development of widespread metastases
  • Although considered highly responsive to
    chemotherapy and radiotherapy, SCLC usually
    relapses within two years despite treatment
  • Overall, only three to eight percent of all
    patients with SCLC (10 to 13 percent of those
    with limited disease) survive beyond five years

5
SCLC Histology
  • SCLC is a small blue round cell tumor from
    neuroendocrine cells
  • Classifications
  • oat cell (lymphocyte-like), fusiform, polygonal
  • OR classical, large cell neuroendocrine, combined
    SCLC/NSCLC
  • crush artifact
  • Immunohisto tests
  • TTF1 (adeno SCLC)

6
Lymph Node Stations
  • 1
  • 2
  • 3a
  • 3b
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11-14
  • highest mediastinal
  • upper paratracheal
  • pretracheal
  • retrotracheal
  • lower paratracheal
  • AP window
  • Para-Aortic (above 5)
  • subcarinal
  • esophageal
  • pulmonary ligament
  • hilar
  • interlobar, lobar, segmental, subsegmental

7
Lymph Node Stations
8
(No Transcript)
9
Clinical Presentation of SCLC
  • Smokers (almost exclusively)
  • Cough 75
  • Hemoptysis in 50
  • Dyspnea and chest pain 40
  • Constitutional symptoms 10 to 15
  • Clubbing 16 to 29
  • pneumonia, weight loss

10
SCLC Paraneoplastic Syndromes
  • SIADH
  • ectopic ACTH production- Cushings synd
  • Eaton-Lambert Myasthenic syndrome
  • proximal muscle weakness that improves on
    repetition (facilitation)
  • Hypercalcemia
  • Peripheral Neuropathy

11
Workup
  • Labs CBC, chem, LFTs, LDH
  • CT chest/abd/pelvis
  • Brain imaging (CT or MRI) (up to 30 have brain
    mets at presentation)

12
SCLC Staging
  • Limited Stage (1/3)
  • confined to 1 hemithorax
  • disease fits within a tolerable radiation port
  • Extensive Stage (2/3)
  • doesnt fit
  • Recommend also use TNM staging, as for NSCLC

13
Where does SCLC metastasize to? BALLS
  • Brain (30)
  • Adrenal (20-40)
  • Liver (25)
  • Lung
  • Skeleton (35)

14
Prognostic Factors
  • The host factors of poor performance status and
    weight loss
  • Stage (limited versus extensive).
  • In extensive disease, the number of organ sites
    involved is inversely related to prognosis
  • Metastatic involvement of the central nervous
    system, the marrow, or the liver is unfavorable
    compared to other sites, although these variables
    are confounded by the number of sites of
    involvement.
  • In most trials, women fare better than men,
    although the reasons for this are not known.
  • The presence of paraneoplastic syndromes is
    generally unfavorable

15
Survival
  • Limited Stage
  • Median OS 14-24 months
  • 5-yr OS 20
  • Extensive Stage
  • MedianOS 6-11 months
  • 5-yr OS 2

16
Treatment Limited Stage SCLC
  • Concurrent chemoradiation
  • Chemo cisplatin/etoposide q3wks
  • Radiation 150 cGy BID to 4500 cGy (Turrisi)
  • OR 180 QD to 50-70Gy. (54Gy?)
  • Sequential chemo, then RT.
  • If CR, then PCI
  • 2500/10, 3000/15, or 2400/8
  • Auperin (NEJM 99)

17
Treatment Extensive Stage
  • Chemo
  • RT for palliation only

18
Treatment Fields for SCLC
  • Cover primary disease known positive LNs w/
    1.5-2cm margin.
  • Do you cover elective mediastinal nodes for SCLC?
  • Cord limit _at_ BID
  • Lung V20
  • Heart D50

19
Turrisi (NEJM 340(4)265-271, 1999)
  • Twice-Daily Compared With Once-Daily Thoracic
    Radiotherapy In Limited Small-Cell Lung Cancer
    Treated Concurrently With Cisplatin and Etoposide

20
Turrisi - Methods
  • 419 pts (89-92) with LS-SCLC
  • Concurrent Chemo x4c (cis/etopo) q3w
  • Radiation
  • Group 1 1.8 Gy QD to 45 Gy
  • Group 2 1.5 Gy BID to 45 Gy
  • Bilateral mediastinal and ipsilateral hilar
    adenopathy
  • Prophylactic Cranial Irradiation if CR
  • 25 Gy/ 10 fx

21
Turrisi - Esophagitis worse in BID arm
22
Turrisi Survival
23
Turrisi Overall Survival
24
Turrisi Local Distant Failure
  • Local Failure
  • QD RT 52
  • BID RT 36 (p0.06)
  • Local and Distant Failure
  • QD RT 23
  • BID RT 6 (p0.01)

25
Turrisi - Conclusions
  • BID more effective than QD
  • Benefit 10 absolute increase in overall
    survival _at_ 5yrs
  • Cost 15 increase in high grade esophagitis

26
Turrisi - Criticisms
  • QD only went to 45 Gy
  • Fractionation still open question
  • New CONVERT trial 66 Gy QD vs 45 BID
  • Starts Jan 2008.

27
Auperin Meta-Analysis of PCI (NEJM 1999)
  • PCI for LS-SCLC if CR after chemo
  • Meta-analysis of 7 trials (1965-95)
  • Dose Fx 800x1 to 4000/20.
  • Improved 3yr OS 20.7 v 15.3.
  • Incidence of brain mets decreased from 58 to 33
    _at_ 3yrs.
  • Better if PCI
  • No assessment of neurocognitive fxn

28
But what about PCI for ES-SCLC?
  • Slotman, EORTC, ASCO 2007
  • RCT, 286 pts w/ ES-SCLC
  • If any response to chemo x4c, then randomized to
    /- PCI
  • PCI reduced risk of symptomatic brain mets 14.6
    v 40.4 at 1 yr.
  • Improved 1-yr OS 27.1 vs 13.3.

29
Quiz
30
  • According to the original VA definition, which of
    the following patient presentations would be
    classified as limited-stage small cell lung
    cancer?
  • A. A 3-cm left upper-lobe lung tumor and a right
    hilar lymph node
  • B. A 3-cm left lower-lobe tumor with a malignant
    pleural effusion
  • C. A 7-cm right upper-lobe lung tumor with a
    right hilar lymph node
  • D. A 7-cm right upper-lobe lung tumor with a
    right anterior cervical lymph node

31
  • According to the original VA definition, which of
    the following patient presentations would be
    classified as limited-stage small cell lung
    cancer?
  • A. A 3-cm left upper-lobe lung tumor and a right
    hilar lymph node
  • B. A 3-cm left lower-lobe tumor with a malignant
    pleural effusion
  • C. A 7-cm right upper-lobe lung tumor with a
    right hilar lymph node
  • D. A 7-cm right upper-lobe lung tumor with a
    right anterior cervical lymph node

32
  • Which of the following statements does NOT
    describe a feature of small cell lung carcinoma?
  • A. Most patients are smokers.
  • B. Abundant mucin production is associated.
  • C. Paraneoplastic syndromes are associated.
  • D. A majority of cases have neurosecretory-type
    granules.

33
  • Which of the following statements does NOT
    describe a feature of small cell lung carcinoma?
  • A. Most patients are smokers.
  • B. Abundant mucin production is associated.
  • C. Paraneoplastic syndromes are associated.
  • D. A majority of cases have neurosecretory-type
    granules.

34
  • A patient presents with a 3-cm solitary small
    cell lung tumor in the right upper lobe. Results
    of other imaging studies are negative for
    metastatic or nodal disease. Mediastinal biopsy
    specimens are nondiagnostic. Which of the
    following statements about management options is
    FALSE?
  • A. Surgery is contraindicated.
  • B. Chemotherapy has a role.
  • C. Radiation therapy may have a role.
  • D. Concurrent chemoradiation therapy is an
    option.

35
  • A patient presents with a 3-cm solitary small
    cell lung tumor in the right upper lobe. Results
    of other imaging studies are negative for
    metastatic or nodal disease. Mediastinal biopsy
    specimens are nondiagnostic. Which of the
    following statements about management options is
    FALSE?
  • A. Surgery is contraindicated.
  • B. Chemotherapy has a role.
  • C. Radiation therapy may have a role.
  • D. Concurrent chemoradiation therapy is an
    option.

36
  • The addition of radiation therapy to the thorax
    improves survival for patients with
    limited-stage, small cell lung cancers. The
    median survival time for patients is how many
    months?
  • A. 9 to 12
  • B. 14 to 18
  • C. 20 to 24
  • D. 26 to 30

37
  • The addition of radiation therapy to the thorax
    improves survival for patients with
    limited-stage, small cell lung cancers. The
    median survival time for patients is how many
    months?
  • A. 9 to 12
  • B. 14 to 18
  • C. 20 to 24
  • D. 26 to 30

38
  • Which of the following statements about
    prophylactic cranial irradiation (PCI) for
    patients with small cell lung cancer is true?
  • A. It may be considered for patients with a
    complete response to treatment.
  • B. It should be delivered concurrently with
    chemotherapy.
  • C. It is commonly administered at 2 Gy per
    fraction to 40 Gy in 4 weeks.
  • D. There is no decrease in CNS failure for
    patients who receive PCI.

39
  • Which of the following statements about
    prophylactic cranial irradiation (PCI) for
    patients with small cell lung cancer is true?
  • A. It may be considered for patients with a
    complete response to treatment.
  • B. It should be delivered concurrently with
    chemotherapy.
  • C. It is commonly administered at 2 Gy per
    fraction to 40 Gy in 4 weeks.
  • D. There is no decrease in CNS failure for
    patients who receive PCI.

40
  • Which of the following symptoms is most common in
    patients presenting with primary tracheal
    malignancies?
  • A. Dyspnea
  • B. Hemoptysis
  • C. Hoarseness
  • D. Pneumonia

41
  • Which of the following symptoms is most common in
    patients presenting with primary tracheal
    malignancies?
  • A. Dyspnea
  • B. Hemoptysis
  • C. Hoarseness
  • D. Pneumonia

??? NOT SCORED
42
  • True or False Abnormalities in p53 are moerree
    common in small cell lung cancer than in
    non-small cell lung cancer.

43
  • True or False Abnormalities in p53 are moerree
    common in small cell lung cancer than in
    non-small cell lung cancer.
  • TRUE

44
  • When hyperfractionated radiotherapy is delivered
    concurrently with chemotherapy for limited stage
    small
  • cell lung cancer, which one of the following is
    CORRECT?
  • A. Local control is improved.
  • B. Survival is improved.
  • C. Brain metastasis is decreased
  • D. Local control and survival are improved.
  • E. Local control and survival are improved, while
    brain metastasis is decreased.

45
  • When hyperfractionated radiotherapy is delivered
    concurrently with chemotherapy for limited stage
    small
  • cell lung cancer, which one of the following is
    CORRECT?
  • A. Local control is improved.
  • B. Survival is improved.
  • C. Brain metastasis is decreased
  • D. Local control and survival are improved.
  • E. Local control and survival are improved, while
    brain metastasis is decreased.

46
  • In small cell lung cancer, the use of
    prophylactic cranial irradiation (PCI) for
    patients with a complete response to induction
    therapy has been shown to improve the absolute
    overall survival by which one of the following?
  • A. 9.1 at 5 years
  • B. 9.8 at 3 years
  • C. 7.4 at 5 years
  • D. 5.4 at 3 years
  • E. 10.1 at 7 years

47
  • In small cell lung cancer, the use of
    prophylactic cranial irradiation (PCI) for
    patients with a complete response to induction
    therapy has been shown to improve the absolute
    overall survival by which one of the following?
  • A. 9.1 at 5 years
  • B. 9.8 at 3 years
  • C. 7.4 at 5 years
  • D. 5.4 at 3 years
  • E. 10.1 at 7 years

48
  • Identify each of the nodal stations for lung
    cancers listed below
  • 401. 4
  • 402. 7
  • 403. 10
  • A. High mediastinal.
  • B. Low paratracheal.
  • C. Subcarinal
  • D. Hilar
  • E. Subaortic

49
  • Identify each of the nodal stations for lung
    cancers listed below
  • 401. 4 Low paratracheal
  • 402. 7 Subcarinal
  • 403. 10 Hilar
  • A. High mediastinal.
  • B. Low paratracheal.
  • C. Subcarinal
  • D. Hilar
  • E. Subaortic

50
  • Regarding lung cancer patients (True or False?)
  • 404. The most common second cancer for non-small
    cell lung cancer patients is lymphoma.
  • False
  • 405. The most common second cancer for small cell
    lung cancer patients is liver cancer.
  • False
  • 406. The incidence rate for non-smell cell lung
    cancer patients developing another lung cancer is
    1-2 per year.
  • True

51
  • Regarding lung cancer patients (True or False?)
  • 407. To treat the second primary lung cancer,
    surgery is not a viable modality.
  • False
  • 408. Aerodigestive cancers do occur among smokers
    who have lung cancers.
  • True
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