Small Cell Lung Cancer
- Recommendations
Diagnosis and Risk Assessment
● Initial assessment should include smoking history, physical examination, complete blood count, liver enzymes, sodium, potassium, calcium, glucose, LDH and creatinine (pulmonary function tests if localized disease).
Good practice statement
● Attention drawn towards potential autoimmune-mediated paraneoplastic symptoms is advised.
Conditional recommendation, low grade evidence (9)
● Combined approach of using the AJCC TNM staging system (9th edition) and the older Veterans Administration (VA) Lung Study Group’s 2-stage classification VA scheme for SCLC staging should be used (appendix 1).
Good practice statement
● The effusion should be excluded as a staging element if: 1) multiple cytopathologic examinations of the pleural fluid are negative for cancer; 2) the fluid is not bloody and not an exudate; and 3) clinical judgment concludes that the effusion is not directly related to the cancer.
Good practice statement
● Pericardial effusions are classified using the same criteria mentioned in the above recommendation.
Good practice statement
● A contrast-enhanced CT of the chest and abdomen is recommended.
Strong recommendation, very low grade evidence (10)
● Brain MRI is recommended for all patients. However, contrast enhanced CT is an option when MRI is not available.
Strong recommendation, low grade evidence (10)
● FDG–PET–CT is optional for staging in limited-stage disease, and FDG–PET findings that modify treatment decisions should be pathologically confirmed.
Conditional recommendation, moderate grade evidence (11,12)
● FDG–PET–CT is advised to assist in RT volume delineation.
Conditional recommendation, low grade evidence (11,12)
● In limited-stage disease, additional bone scintigraphy is recommended when no FDG–PET–CT has been carried out.
Strong recommendation, very low grade evidence (11,12)
● In limited-stage disease, a bone marrow aspiration and biopsy are advised in the case of abnormal blood counts suggesting bone marrow involvement only if it changes clinical management..
Conditional recommendation, low grade evidence (11)
● The workup for SCLC should not delay the onset of treatment for >1 week because of the aggressive nature of SCLC.
Good practice statement
● Tobacco smoking cessation counseling and intervention should be strongly promoted in patients with SCLC.
Good practice statement
Treatment
● The WHO classification recognizes two types of SCLC: pure and combined SCLC, patients with combined SCLC should treated using regimens for SCLC, because it is the more aggressive cancer.
Strong recommendation, strong grade evidence (13)
· Surgery should be considered in patients with clinical stages I and II (cT1-2N0) SCLC in the context of a multimodal treatment concept and following a multidisciplinary board decision.
Strong recommendation, low grade evidence (14)
· The aim of surgical treatment should be achieving an R0 resection.
Strong recommendation, low grade evidence (15)
· When considering surgical treatment for SCLC, pathological mediastinal staging should be done.
Strong recommendation, very low grade evidence (16,17)
· Sublobular resection is not recommended for SCLC.
Conditional recommendation, low grade evidence (15)
· After surgical resection, in case of pT1-2N0-1, R0 resection, adjuvant chemotherapy should be given.
Strong recommendation, very low grade evidence (18)
· After surgical resection, in case of R1-R2 resection or positive mediastinal lymph nodes (N2), adjuvant chemotherapy should be combined with RT, preferably concurrently.
Strong recommendation, very low grade evidence (16)
· The preferred Chemotherapy for patients with limited-stage (stage I-III) SCLC is cisplatin plus etoposide.
Strong recommendation, high grade evidence (19)
· When cisplatin is contraindicated because of comorbidities, carboplatin plus etoposide is recommended.
Strong recommendation, high grade evidence (20)
· G-CSF is a treatment option to prevent haematological toxicity.
Good practice statement
· Patients with T1-4N0-3M0 tumours and a good PS (0-1) should be treated with concurrent platinum-salt based chemotherapy and thoracic RT.
Strong recommendation, high grade evidence (21,22)
· The recommended fractionation schedule is 66 Gy in 33 fractions or equivalent doses.
Strong recommendation, high grade evidence (21)
· Thoracic RT should be initiated as early as possible, starting on the first or second cycle of Chemotherapy.
Strong recommendation, high grade evidence (23)
· When the patient PS (≥2) or dose to the organs at risk do not allow for the early administration of thoracic RT, it should be postponed until the start of the third cycle of Chemotherapy.
Strong recommendation, high grade evidence (24,25)
· Sequential CRT is a preferred option for patients who are not candidates for concurrent CRT due to poor PS, comorbidities and/or disease volume.
Strong recommendation, low grade evidence (26)
· In case of response to Chemotherapy, the post-Chemotherapy primary tumour should be included in the radiation field.
Strong recommendation, low grade evidence (26)
· In case of response to Chemotherapy, the pre-Chemotherapy nodal stations should be included in the radiation field.
Strong recommendation, low grade evidence (26)
· In case of stable disease, surveillance is recommended until progression.
Good practice statement
· In case of disease progression treatment of extensive disease is recommended
Good practice statement
· Selective node irradiation is recommended (i.e. involved nodes defined as FDG avid on PET–CT, enlarged on CT and/or biopsy-positive).
Strong recommendation, high grade evidence (24)
· Patients with stage III SCLC with a response after treatment (CRT) and a PS of 0-1 should be offered PCI.
Strong recommendation, low grade evidence (27)
· PCI can be considered in patients with a PS of 2.
Conditional recommendation, low grade evidence (27)
· The role of PCI is not as well defined in patients with stage I-II SCLC or in those >70 years of age or who are frail. In such cases, shared decision making is advised.
Conditional recommendation, very low grade evidence (28)
· The recommended PCI regimen is 25 Gy/10 fractions.
Strong recommendation, high grade evidence (29)
Management of extensive-stage disease (i.e. stage IV or stage III SCLC not eligible for treatment of curative intent)
· The preferred first-line treatment of extensive-stage SCLC (PS 0-2) is four to six cycles of a platinum plus etoposide.
Strong recommendation, high grade evidence (19)
· Cisplatin with irinotecan or topotecan are alternative treatment options.
Conditional recommendation, moderate grade evidence (30,31)
· In poor prognosis patients, gemcitabine plus carboplatin is an alternative treatment option.
Conditional recommendation, moderate grade evidence (32)
· In patients achieving a response after Chemotherapy and a PS of 0-2, RT to the residual primary tumour and lymph nodes (30 Gy/10 fractions) is a treatment option.
Conditional recommendation, moderate grade evidence (33)
· PCI (20 Gy/5 fractions and 25 Gy/10 fractions) is justified without prior MRI staging or follow-up in patients <75 years of age and a PS of 0-2 who achieved a response after Chemotherapy.
Strong recommendation, high grade evidence (34)
· In patients with extensive-stage SCLC without brain metastases on brain MRI after Chemotherapy and who can be followed-up with regular brain MRI, PCI may be omitted.
Conditional recommendation, high grade evidence (35)
· Patients with platinum-refractory SCLC have a poor prognosis and BSC is recommended.
Strong recommendation, moderate grade evidence (36)
· Topotecan is recommended for patients with platinum-resistant or -sensitive relapse; CAV , Texans, Gemcitabine, oral etoposide are alternative options.
Strong recommendation, moderate grade evidence (37)
· In patients with platinum-sensitive SCLC, rechallenge with first-line platinum plus etoposide can be considered.
Strong recommendation, high grade evidence (38)