Small Cell Lung Cancer

Recommendation

Strength of recommendation

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

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 above.

Good practice statement

A contrast-enhanced CT of the chest and abdomen is recommended.

Strong

Brain MRI is recommended for all patients. However, contrast enhanced CT is an option when MRI is not available.

Strong

FDG–PET–CT is optional for staging in limited-stage disease, and FDG–PET findings that modify treatment decisions should be pathologically confirmed.

Conditional

FDG–PET–CT is advised to assist in RT volume delineation.

Conditional

In limited-stage disease, additional bone scintigraphy is recommended when no FDG–PET–CT has been carried out.

Strong

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

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 and patients who previously smoked tobacco should be strongly encouraged to remain abstinent.

Good practice statement

Treatment

Management of limited-stage disease (i.e. stages I-III SCLC eligible for treatment of curative intent)

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

The aim of surgical treatment should be achieving an R0 resection.

Strong

When considering surgical treatment for SCLC, pathological mediastinal staging should be done.

Strong

Sublobular resection is not recommended for SCLC.

 Conditional

After surgical resection, in case of pT1-2N0-1, R0 resection, adjuvant chemotherapy should be given.

Strong

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

The preferred Chemotherapy for patients with limited-stage (stage I-III) SCLC is platinum plus etoposide.

Strong

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

The recommended dose fractionation schedule is 66 Gy. in 33 fractions or equivalent doses

 Strong

Thoracic RT should be initiated as early as possible, starting on the first or second cycle of Chemotherapy.

 Strong

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

Sequential CRT is the preferred option for patients who are not candidates for concurrent CRT due to poor PS, comorbidities and/or disease volume.

 Strong

In case of response to Chemotherapy, the post-Chemotherapy primary tumour should be included in the radiation field.

 Strong

In case of response to Chemotherapy, the pre-Chemotherapy nodal stations should be included in the radiation field.

 Strong

Selective node irradiation is recommended (i.e. involved nodes defined as FDG avid on PET–CT, enlarged on CT and/or biopsy-positive).

 Strong

Patients with stage III SCLC with a response after treatment (CRT) and a PS of 0-1 should be offered PCI.

 Strong

PCI can be considered in patients with a PS of 2.

Conditional

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

The recommended PCI regimen is 25 Gy/10 fractions.

 Strong

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

Cisplatin with irinotecan or topotecan are alternative treatment options.

 Conditional

In poor prognosis patients, gemcitabine plus carboplatin is an alternative treatment option.

 Conditional

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

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

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.

Strong

Patients with platinum-refractory SCLC have a poor prognosis and BSC is recommended.

 Conditional

Topotecan is recommended for patients with platinum-resistant or -sensitive relapse; CAV , texans, gemcitabine, and oral etoposide are alternative options.                      

Strong

In patients with platinum-sensitive SCLC, rechallenge with first-line platinum plus etoposide can be considered.

Strong