Optimal Radiation Therapy for Small Cell Lung Cancer
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Radiation therapy plays an important role in the management of both limited stage and extensive stage small cell lung cancer. For limited stage disease, there has been a trend toward reduced size of thoracic radiation fields, which has the potential to reduce toxicity. FDG-PET staging helps make this possible by more accurately identifying areas of nodal and metastatic involvement. Trials have demonstrated similar outcomes using a range of radiation fractionation schedules, allowing flexibility in individualizing treatment. Using advanced radiation therapy techniques such as intensity-modulated radiation therapy, it may be possible to deliver fewer, higher dose fractions and achieve similar results to the hyperfractionated regimen. For extensive stage disease, consolidative thoracic radiation therapy after chemotherapy was recently shown to improve overall survival in certain patient subsets. Prophylactic cranial irradiation continues to play an important role in management of all stages of small cell lung cancer. Debate continues about the neurocognitive effects of this treatment, and whether MRI surveillance is an acceptable alternative. Strategies such as hippocampal avoidance may reduce the cognitive effects of prophylactic cranial irradiation in the future. Finally, in the last few years stereotactic ablative radiation therapy followed by chemotherapy has emerged as a promising treatment for stage I small cell lung cancer. This radiation treatment is usually given over 1–5 fractions and appears to provide a good rate of local control with a low rate of serious toxicity.
KeywordsSmall cell lung cancer Radiation therapy Intensity-modulated radiation therapy
Compliance with Ethical Standards
Conflict of Interest
Michael F. Gensheimer has received research support through a grant from the Varian Medical Systems.
Billy W. Loo, Jr. has received research support through grants from the Varian Medical Systems and RaySearch Laboratories and educational lecture honoraria from the Varian Medical Systems. Dr. Loo is also a board member of TibaRay, Inc.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
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- 3.•• Slotman BJ, van Tinteren H, Praag JO, Knegjens JL, El Sharouni SY, Hatton M, et al. Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial. Lancet. 2015;385(9962):36–42. Large trial that showed benefit of consolidative thoracic RT for extensive stage SCLC patients with response to chemotherapyCrossRefPubMedGoogle Scholar
- 4.Zelen M. Keynote address on biostatistics and data retrieval. Cancer Chemother Rep (Part 3). 1973;4:31–42.Google Scholar
- 5.Shepherd FA, Crowley J, Van Houtte P, Postmus PE, Carney D, Chansky K, et al. The International Association for the Study of Lung Cancer lung cancer staging project: proposals regarding the clinical staging of small cell lung cancer in the forthcoming (seventh) edition of the tumor, node, metastasis classification for lung cancer. J Thorac Oncol. 2007;2(12):1067–77.CrossRefPubMedGoogle Scholar
- 6.National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Small Cell Lung Cancer, version 2.2017. https://www.nccn.org/professionals/physician_gls/pdf/sclc.pdf. Accessed 1/14/2017.
- 8.Auperin A, Arriagada R, Pignon JP, Le Pechoux C, Gregor A, Stephens RJ, et al. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic cranial irradiation overview collaborative group. N Engl J Med. 1999;341(7):476–84.CrossRefPubMedGoogle Scholar
- 10.Choi NC, Herndon JE, Rosenman J, Carey RW, Chung CT, Bernard S, et al. Phase I study to determine the maximum-tolerated dose of radiation in standard daily and hyperfractionated-accelerated twice-daily radiation schedules with concurrent chemotherapy for limited-stage small-cell lung cancer. J Clin Oncol. 1998;16(11):3528–36.CrossRefPubMedGoogle Scholar
- 11.• Faivre-Finn C, Snee M, Ashcroft L, Appel W, Barlesi F, Bhatnagar A, et al. CONVERT: An international randomised trial of concurrent chemo-radiotherapy (cCTRT) comparing twice-daily (BD) and once-daily (OD) radiotherapy schedules in patients with limited stage small cell lung cancer (LS-SCLC) and good performance status (PS). J Clin Oncol 2016:34:abstr. 8504. Abstract from an important study that compares commonly used RT fractionation schedules for limited stage SCLCGoogle Scholar
- 12.Gronberg BH, Halvorsen TO, Flotten O, Brustugun OT, Brunsvig PF, Aasebo U, et al. Randomized phase II trial comparing twice daily hyperfractionated with once daily hypofractionated thoracic radiotherapy in limited disease small cell lung cancer. Acta Oncol. 2016;55(5):591–7.CrossRefPubMedGoogle Scholar
- 14.Hu X, Bao Y, Zhang L, Guo Y, Chen YY, Li KX, et al. Omitting elective nodal irradiation and irradiating postinduction versus preinduction chemotherapy tumor extent for limited-stage small cell lung cancer: interim analysis of a prospective randomized noninferiority trial. Cancer. 2012;118(1):278–87.CrossRefPubMedGoogle Scholar
- 17.Chun SG, Hu C, Choy H, Komaki RU, Timmerman RD, Schild SE, et al. Impact of intensity-modulated radiation therapy technique for locally advanced non-small-cell lung cancer: a secondary analysis of the NRG oncology RTOG 0617 randomized clinical trial. J Clin Oncol. 2017;35(1):56–62.CrossRefPubMedGoogle Scholar
- 18.Movsas B, Hu C, Sloan J, Bradley J, Komaki R, Masters G, et al. Quality of life analysis of a radiation dose-escalation study of patients with non-small-cell lung cancer: a secondary analysis of the radiation therapy oncology group 0617 randomized clinical trial. JAMA Oncol. 2016;2(3):359–67.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.• Verma V, Simone 2nd CB, Allen PK, Gajjar SR, Shah C, Zhen W, et al. Multi-institutional experience of stereotactic ablative radiation therapy for stage I small cell lung cancer. Int J Radiat Oncol Biol Phys. 2017;97(2):362–71. Some of the first data on SABR for very early stage SCLC, showing encouraging disease control and toxicity profileCrossRefPubMedGoogle Scholar
- 26.Brown PD, Jaeckle K, Ballman KV, Farace E, Cerhan JH, Anderson SK, et al. Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases: a randomized clinical trial. JAMA. 2016;316(4):401–9.CrossRefPubMedPubMedCentralGoogle Scholar
- 28.Seto T, Takahashi T, Yamanaka T, Harada H, Nokihara H, Saka H, Nishio M, et al. Prophylactic cranial irradiation (PCI) has a detrimental effect on the overall survival (OS) of patients (pts) with extensive disease small cell lung cancer (ED-SCLC): results of a Japanese randomized phase III trial. J Clin Oncol 2014:32:5 s:abstr 7503.Google Scholar