ROLE OF RADIATION IN SMALL CELL LUNG CANCERDr Bharti Devnani

Moderator:- Dr Sheh Rawat

Staging of SCLC depends on radiation portals(Veteran’s administration lung group)

Limited Stage Disease confined to I/L hemithorax which

could be safely encompassed with in a tolerable RT field. T1, T2, nonmetastatic

Contralateral mediastinal and I/L SCF

Extensive stageBeyond I/L hemithorax T3,T4 and metastatic disease

Definitive (For LS)Thoracic radiation as a part of CCRT

Adjuvant RTNode positive cases after lobectomy

Prophylactic cranial irradiation

Palliative EXRTThoracicBrain metsBone mets

Oncologic emergenciesSVCOSpinal cord compression

Palliative brachytherapyEndobronchial brachytherapy: Hemoptysis

ROLE OF THORACIC RADIATION IN LIMITED STAGE

EVOLUTION

Before the introduction of chemo in 1970, RT was the mainstay of treatment

CT

More local recurrences with chemo alone

CT+RT-Standarad of care

EVIDENCE FOR THORACIC RADIOTHERAPY

25-30% reduction in the local recurrence with 5-7% increase in 2 year survival with addition of radiotherapy

Pignon et al NEJM 1992 327;1618-24

ISSUES IN THORACIC RT OF SCLC

Sequencing with chemotherapy (concurrent v/s sequential)

Timing of RT (Early v/s late)

Portals (before chemotherapy v/s shrinking field)

Dose and fractionation schedules(conventional v/s hyperfractionation)

ISSUES IN THORACIC RT OF SCLC

Sequencing with chemotherapy (concurrent v/s sequential)

Timing of RT (Early v/s late)

Portals (before chemotherapy v/s shrinking field)

Dose and fractionation schedules(conventional v/s hyperfractionation)

Takada et al.J Clin Oncol 2002; 20:3054-60.

Better outcome with CCT with a trend towards improved OS.Concurrent RT reduces the risk of tumor repopulation and development of resistant clones. Radiosensitizing effect

ISSUES IN THORACIC RT OF SCLC

Sequencing with chemotherapy (concurrent v/s sequential)

Timing of RT (Early v/s late)

Portals (before chemotherapy v/s shrinking field)

Dose and fractionation schedules(conventional v/s hyperfractionation)

Benefit in 2 year survival rate with early RT(within 9 weeks or before 3rd cycle)

Factors which have significant impact on the benefit of early RT were:-

Type of chemotherapy The fractionation scheme

Concept of SER

Start of any treatment until the end of radiotherapy

Cancer Treat Rev 2007; 33:461-73.

Significant 2 & 5 years improvement in survival when RT was started within 30 days of platinum based chemo (2-year survival: HR: 0.73, 5-year survival: HR: 0.65).

This was even more pronounced when the overall treatment time of chest radiotherapy was less than 30 days.

Early and concurrent chemoradiation is preferred over late and sequential schedule.

ISSUES IN THORACIC RT OF SCLC

Sequencing with chemotherapy (concurrent v/s sequential)

Timing of RT (Early v/s late)

Dose and fractionation schedules (conventional v/s hyperfractionation)

Portals (before chemotherapy v/s shrinking field)

High chances of local recurrence with conventional RT, attempts made to improve the outcome by:-

Hyperfractionated Accelerated

radiotherapy Dose escalation

417 patients LS-SCLC

45 Gy at 1.5 Gy/#B.D.x3week

s

45 Gy/25# at 1.8 Gy/# x5 weeks

Grade -3 Esophagitis

(27%v/s 11%)P<0.001

ONGOING TRIALS (HYPERFRACTIONATION & DOSE ESCALATION)

ISSUES IN THORACIC RT OF SCLC

Sequencing with chemotherapy (concurrent v/s sequential)

Timing of RT (Early v/s late)

Dose and fractionation schedules(conventional v/s hyperfractionation)

Portals (before chemotherapy v/s shrinking field)

RT PORTALS

PET based planning should be used. (PET at the time of radiotherapy planning or within 4 weeks)

GTV = Post induction chemotherapy volume

Omission of elective nodal irradition.

Low rates of local recurrence(11% with only CT based planning, 3 % with PET based planning)

Decreases the esophageal toxicity significantly.

ROLE OF THORACIC RT IN EXTENSIVE STAGE

CR at distant sites and any response at

local site (n=210)

CT+

RT= 54 Gy/36#

CT alone

Median survival-17 months v/s 11 monthsSurvival rate at 3 years-22% v/s 13%Survival rate at 5 years-9% v/s 4%

PROPHYLACTIC CRANIAL IRRADIATION

Rationale Frequent brain mets in SCLC

20 %- at diagnosis

80%- during the course of the disease

Once symptomatic- results have been poor.

Incidence of brain metastasis decreased by 25% at 3 years (58.6% v/s 33.3%)

5.4 % survival benefit with addition of PCI

PCI IN EXTENSIVE STAGE DISEASE

14.6 % v/s 40.4%

27.1% v/s 13.3% at 1 yr

DOSE OF PCI

Limited stage25 Gy/10#24 Gy/8#30Gy/15#Extensive stage25 Gy/10#Shorter fractionation scheme of 20 Gy/5# can

be used.

Dose>30 Gy should be avoided due to high risk of neurotoxicity

ROLE OF RT IN ADJUVANT SETTING

ROLE OF RT IN PALLIATION (EXRT)

RADIATION FOR BRAIN METASTASIS

WBRT- 30Gy/10#

BONE METS & PATHOLOGICAL FRACTURE

30 Gy/10#

20Gy/5#

24Gy/6#

8 Gy single fraction

ROLE OF RADIATION IN ONCOLOGIC EMERGENCIES IN SCLC

SPINAL CORD COMPRESSION

30Gy/10#

SUPERIOR VENA CAVA OBSTRUCTION

Symptomatic relief in 70-90% cases with radiotherapy alone.

Dose- initial high dose fractionation of 3- 4 Gy followed by 1.8 Gy fractionation

ROLE OF ENDOBRONCIAL BRACHYTHERAPY - HEMOPTYSIS

TAKE HOME MESSAGE

LS-SCLCConcurrent CCT/RTEarly(1st or 2nd cycle)Dose-45 Gy @1.5 Gy bd or 50-60 Gy @1.8 Gy once

dailyAny response to chemo-PCI to a dose of 25 Gy/10#

ES-SCLCAny response to chemo- PCI-25 Gy/10# or shorter 20

Gy/5# can be used.Possible value of local RT are the subject of ongoing

investigation.

Palliation

Thank U

Santa air hostess se-aapki shakal meri biwi se milti hai

Air hostess ne zordar thappad santa k muh pe mara

Santa- Kamal hai, Aadat bhi milti hai

Very Touchy story:"Husband forgot to wish her on his Wife's birthday.

He came home late at night from the office .....His wife shouted: How would u feel if u dont see

me for next few days?He couldnt believe his luck. He replied at once.''

Wowww.....That would be great..!''Monday passed & he didn't see her. Tuesday he didnt see her

.

.& wednesday passed too

.

.On Thursday the swelling was better & he could

see her from the corner of his left eye...