SCLC

1. SCLC Elshami M Elamin, MD Medical Director: Central Care Cancer Center Newton, Kansas USA

2. INTRODUCTION • Causes: • cigarette smoking • environmental factors • genetic factors • 15% of all lung cancers • 2/3 presents with mets • Rapid doubling time • Highly sensitive to initial chemo and RT • High recurrence rate

3. Clinical Presentation • Cough and dyspnea • Large central mass • hilar and bulky mediastinal LNs • Mets; • contra lung, liver, adrenals, brain, bones, BM • Paraneoplastic • SIADH • Cushing’s-like syndrome

4. INITIAL EVALUATION • H&P • Pathology review • Chest x-ray • CBC, electrolytes, liver function, LFT, LDH Chest/liver/adrenal CT • Head MRI (preferred) or CT • Bone scan • PET scan (optional) • Smoking cessation counseling

5. Staging • TNM sataging: • does not predict survival • used only for surgical staging • Limited stage: • confined to ipsi hemithorax, which can be safely encompassed within a tolerable radiation field • Contra mediastinal and ipsi SCV LN • Extensive Stage: • beyond ipsi hemithorax which may include malignant pleural or pericardial effusion or hematogenous metastases. • Contra hilar and SCV LN

6. LIMITED STAGEadditional work-up • BM aspiration/biopsy if low blood counts • Thoracentesis/thoracoscopy if indicated • if effusion is too small, pt should be considered to have limited-stage • PFTs (if clinically indicated) • Bone x-rays/MRI if +ve bone scan

7. Limited (T1-2, N0) • Should confirm with PET scan +/- Mediastinoscopy • Lobectomy (preferred) and mediastinal LN dissection or sampling: • LN –ve  Chemo • LN +ve  Concurrent ChemoRT

8. Limited (excess of T1-2, N0) • Good PS: • Concurrent ChemoRT • Poor PS due to SCLC: • Chemo +/- RT

9. Limited StageTreatment • Surgery or RT alone: • MS 3-4 m • 5YS 1%-2% • Rapid local recurrence and mets • Chemotherapy: • MS 12 m • 2YS 10%-15% • Maintenance chemo add little to survival • Concurrent ChemoRT: • RR 70% to 90% • MS 20m • 2YS 40%

10. Extensive stageadditional work-up • x-rays of bone scan abnormalities of weight-bearing areas

11. Extensive stageTreatment • Combination Chemo • Best Supporive Care • Palliative RT for symptomatic: • Brain mets • SVC syndrome • symptomatic Lobar obstruction • symptomatic Bone metastases • Concurrent Chemo + RT for: • Spinal cord compression

12. Extensive-stage: Survival • Combination Chemotherapy: • RR 60% to 70% • MS 9 to 11m • 2YS <5%

13. RESPONSE ASSESSMENTFOLLOWING INITIAL THERAPY • CT chest/liver/adrenal • MRI or CT brain if planning for PCI • X-rays/scan to assess prior sites of involvement • CBC, CMP • If CR or <10% of tumor: • Limited dz  PCI • Extensive dz  consider PCI • Partial Response: • surveillance • Progressive • 2nd line chemo, palliation or clinical trial

14. PCI • Limited disease in CR • ??Extensive disease in CR • 25-36 Gy: • Lower fraction are recommended; 1.8-2.0 Gy/fraction • Not recommended: • patients with multiple comorbidities • poor PS • impaired mental function.

15. SURVEILLANCE • H&P, chest imaging and bloodwork • every 2-3 m (1st y), every 3-4 m (2nd , 3rd y), every 4-6 m (y 4th 5th), then annually • New lung nodule after 2 y: • workup for potential new primary • Smoking cessation intervention

16. SECOND-LINE THERAPY/PALLIATION • Relapse: • Second-line chemo • Clinical trial • Best supportive care • Primary progressive disease: • Palliative e.g RT • Clinical trial • Second-line chemo (PS 0–2)

17. Paraneoplastic Syndrome • SIADH • Fluid restriction • Saline infusion for symptomatic patients • Demeclocycline • Antineoplastic therapy • Cushing’s syndrome • Consider ketoconazole • Try to control before of antineoplastic therapy

18. First Line Chemo • Limited stage (during RT): • Cisplatin + Etoposide x 4 cycles • Carboplatin + Etoposide x 4 cycles • Extensive stage: • Cisplatin + Etoposide x 4-6 cycles • Carboplatin + Etoposide x 4-6 cycles • Irinotecan + Cisplatin • Cytoxan + doxorubicin + vincristine (CAV)

19. 2nd Line Chemo • Clinical trial preferred • Relapse < 2-3 mo, PS 0-2: • ifosfamide, paclitaxel, docetaxel, gemcitabine, Topotecan • Relapse > 2-3 mo up to 6 mo: • topotecan, irinotecan, CAV, gemcitabine, taxane, oral etoposide, vinorelbine • Relapse > 6 mo: • original regimen

20. PRINCIPLES OF RADIATION THERAPY • Limited disease: • RT 45 Gy or 50-60 Gy • Start with chemotherapy cycle 1 or 2 • Review pre-chemo CT to include the originally involved LN in the treatment fields • PCI dose: • 25-36 Gy

21. Lung Neuroendocrine Tumors

22. NSCLC with neuroendocrine features (Large-cell neuroendocrine) • Work-up and Treatment: • Follow NSCLC guidelines

23. Carcinoidand Atypical Carcinoid • Chest/abd CT • Bronchoscopy • Mediastinoscopy • Octreotide scan • PET scan (optional)

24. Carcinoid(I-IIIA) • Surgery: • Lobectomy or other anatomic resection + mediastinal LN dissection • Typical Carcinoid or stage I Atypical  Observe • Stage II-III Atypical  Adj ChemoRT

25. Carcinoid(IIIB, IV or Unresectable) • Systemic therapy • Octreotide (Sandostatin): • If octreotide scan +ve or • Carcinoid syndrome

26. Combined SCLC and NSCLC • Work-up and Treatment: • Follow SCLC guidelines

27. MESOTHELIOMA • From cells lining the pleura and peritoneum • Asbestos exposure (3-4 decades) • C-x-ray/CT: • pleural thickening, pleural-based masses, effusion • Diagnosis: • Thoracentesis and thoracoscopy • May need IHC and electron microscopy • Survival: • 22 m (epithelial) • 6 m (sarcomatoid and mixed)

28. Mesothelioma Butchart Staging

29. Treatment • Palliative not curative • Surgery: • pleurodesis • Subtotal pleurectomy • Lung re-expansion • prevents effusion recurrence • extrapleural pneumonectomy with resection of the diaphragm and pericardium • followed by chemotherapy and radiotherapy

30. Chemotherapy • Unresectable Malignant Mesothelioma: • Cisplatin +/- pemetrexed (Alimta): • MS 12.1 m vs 9.3 m • Improves OS and Q of L • B12/folic acid supplement