SCLCSCLCElshami M Elamin, MD

Medical Director: Central Care Cancer CenterNewton, Kansas USA

INTRODUCTIONINTRODUCTION 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

Clinical PresentationClinical Presentation

Cough and dyspnea Large central mass

hilar and bulky mediastinal LNsMets;

contra lung, liver, adrenals, brain, bones, BMParaneoplastic

SIADH Cushing’s-like syndrome

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

StagingStaging 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

LIMITED STAGELIMITED STAGEadditional work-upadditional work-up

BM aspiration/biopsy if low blood countsThoracentesis/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

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

Limited (excess of T1-2, N0)

Good PS: Concurrent ChemoRT

Poor PS due to SCLC: Chemo +/- RT

Limited StageLimited StageTreatmentTreatment

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%

Extensive stageadditional work-up

x-rays of bone scan abnormalities of weight-bearing areas

Extensive stageExtensive stageTreatmentTreatment

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

Extensive-stage: SurvivalExtensive-stage: Survival

Combination Chemotherapy:• RR 60% to 70% • MS 9 to 11m • 2YS <5%

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

PCIPCILimited disease in CR??Extensive disease in CR25-36 Gy:

Lower fraction are recommended; 1.8-2.0 Gy/fraction

Not recommended: patients with multiple comorbidities poor PS impaired mental function.

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

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)

Paraneoplastic SyndromeParaneoplastic SyndromeSIADH

Fluid restriction Saline infusion for symptomatic patients Demeclocycline Antineoplastic therapy

Cushing’s syndrome Consider ketoconazole Try to control before of antineoplastic therapy

First Line ChemoFirst 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)

22ndnd Line Chemo Line ChemoClinical trial preferredRelapse < 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, vinorelbineRelapse > 6 mo:

original regimen

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 fieldsPCI dose:

25-36 Gy

Lung Neuroendocrine

Tumors

NSCLC with neuroendocrine features

(Large-cell neuroendocrine)

Work-up and Treatment:Follow NSCLC guidelines

Carcinoidand Atypical Carcinoid

Chest/abd CTBronchoscopyMediastinoscopyOctreotide scan PET scan (optional)

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

Carcinoid(IIIB, IV or Unresectable)

Systemic therapyOctreotide (Sandostatin):

If octreotide scan +ve or Carcinoid syndrome

Combined SCLC and NSCLC

Work-up and Treatment:Follow SCLC guidelines

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)

Mesothelioma Mesothelioma Butchart StagingButchart Staging

Stage Description I confined within parietal pleura

II invades chest wall or involves mediastinal structures

III penetrates the diaphragm to peritoneum; involves opposite pleura, LN outside the chest

IV Distant blood-borne metastases

Treatment

Palliative not curativeSurgery:

pleurodesis Subtotal pleurectomy

• Lung re-expansion • prevents effusion recurrence

extrapleural pneumonectomy with resection of the diaphragm and pericardium

• followed by chemotherapy and radiotherapy

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