What is the management of residual small cell lung cancer (SCLC) in limited stage after concurrent chemoradiation therapy (CCRT)?

From the Guidelines

Management of Residual Small Cell Lung Cancer (SCLC) in Limited Stage after Concurrent Chemoradiation Therapy (CCRT)

The management of residual small cell lung cancer (SCLC) in limited stage after concurrent chemoradiation therapy (CCRT) involves a multidisciplinary approach, with prophylactic cranial irradiation (PCI) being a key consideration for patients with residual disease 1.

• PCI is recommended with a total dose of 25 Gy in 10 fractions for patients in a reasonably good performance status (PS) without progression 1.
• For patients with a partial response to CCRT, additional chemotherapy may be considered, such as topotecan or etoposide, to further reduce tumor burden 1.
• Surgical resection may be an option for patients with residual disease, if feasible, followed by adjuvant chemotherapy to reduce the risk of recurrence 1.
• The choice of treatment should be individualized based on the patient's performance status, tumor response to CCRT, and other clinical factors, with consideration of the potential benefits and risks of each approach 1.

Key Considerations

• The optimal timing of PCI and additional chemotherapy should be determined based on the patient's response to CCRT and their overall clinical condition 1.
• The use of growth factors, such as G-CSF, may be considered to reduce the risk of chemotherapy-induced myelosuppression, but their routine use is not recommended for patients with limited-stage SCLC 1.
• Multidisciplinary care involving medical oncology, radiation oncology, and surgery is essential for optimizing outcomes in patients with residual SCLC after CCRT 1.

From the FDA Drug Label

1.2 Small Cell Lung Cancer Topotecan hydrochloride for injection, as a single agent, is indicated for the treatment of patients with small cell lung cancer (SCLC) with platinum-sensitive disease who progressed at least 60 days after initiation of first-line chemotherapy.

The management of residual small cell lung cancer (SCLC) in limited stage after concurrent chemoradiation therapy (CCRT) is not directly addressed in the provided drug label. Key points:

• The label indicates topotecan is used for SCLC with platinum-sensitive disease who progressed after first-line chemotherapy.
• It does not provide information on the management of residual SCLC in limited stage after CCRT. 2

From the Research

Management of Residual Small Cell Lung Cancer (SCLC) in Limited Stage after Concurrent Chemoradiation Therapy (CCRT)

• The management of residual SCLC in limited stage after CCRT typically involves prophylactic cranial irradiation (PCI) for patients without progression 3, 4.
• PCI is recommended for patients who have responded to CCRT, as it has been shown to improve overall survival and reduce the risk of brain metastases 4, 5.
• The use of hippocampal avoidance cranial irradiation and stereotactic radiosurgery (SRS) may also be considered in the management of residual SCLC, although these approaches are still being studied and are not yet widely adopted 4, 5.
• In some cases, consolidation thoracic RT may be considered for patients with residual disease after CCRT, although the evidence for this approach is limited 4.
• The role of surgery in the management of residual SCLC is not well established, and the current evidence does not support its use as a standard treatment approach 6.

Treatment Approaches

• Concurrent chemoradiotherapy with oral etoposide and cisplatin has been shown to improve survival compared to sequential chemoradiotherapy in patients with LS-SCLC and bulky tumor 7.
• The use of immunotherapy, such as atezolizumab and durvalumab, in combination with chemotherapy has been shown to improve outcomes in patients with ES-SCLC, and may also be considered in the management of residual SCLC 3, 4.

Radiation Therapy

• Thoracic radiotherapy is typically performed using intensity-modulated radiation therapy (IMRT) with a dose of 60Gy/30 times 7.
• The use of whole-brain prophylactic cranial irradiation is recommended for patients who have responded to CCRT, although the use of hippocampal avoidance cranial irradiation and SRS may also be considered 4, 5.