Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission

Controlled clinical trial of prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission

We conducted a randomised clinical trial on 211 patients with small-cell lung cancer in complete remission (CR). The aim of this trial was to evaluate the effect of prophylactic cranial irradiation (PCI) on overall survival. Eligible patients were randomly assigned to receive either PCI (100 patients) or no PCI (111 patients). Each centre was allowed to use its own PCI protocol as long as the total dose was within the range of 24-30 Gy and delivered in less than 3 weeks with fractions of 3 Gy or less. The mean follow-up is 5 years. The survival curves do not differ significantly (P = 0.25) between the two groups. The 4-year overall survival rate (95% confidence interval) is 22% [15-32%] in the PCI group versus 16% [10-25%] in the control group. The relative risk of death in the PCI group compared to the control group is 0.84 (95% CI = [0.62-1.13]). The incidence of brain metastasis is lower in the PCI group, but the difference is not statistically significant (P = 0.14). The 4-year cumulative rate of brain metastasis is 44% [32-57%] in the PCI group compared to 51% [38-63%] in the control group. In conclusion, in this study, which had to be closed prematurely, no significant difference was found in terms of the incidence of brain metastases nor in survival.

Alternating radiotherapy and chemotherapy in limited disease small cell lung cancer

In a pilot study of 29 patients treated for localized small cell lung cancer, three new approaches were introduced, i.e. an increased initial drug dose, an early alternation of chemotherapy and thoracic radiotherapy and initial accelerated and hyperfractionated irradiation. The results were interesting. However, a high rate of fatal toxicity (21%) was observed.

Radiation therapy in the management of limited small cell lung cancer: when, where, and how much?

Progress in the treatment of patients with small cell lung cancer (SCLC) has come in two phases. In the first phase, SCLC was recognized, even when seemingly localized to the lung and intrathoracic lymph nodes, to be widely metastatic and to require effective systemic therapy from the outset. The development of active chemotherapeutic agents and combinations in the 1970s improved median survival from the 6 months seen with radiotherapy alone to about 1 year. In the second phase has come the recognition that local control of a disease, even one with systemic spread, is necessary for its cure. This has resulted both in a better appreciation of the role of radiation therapy in SCLC treatment and in efforts to optimize combined-modality regimens using radiotherapy and chemotherapy. With current treatment regimens involving concurrent or closely interdigitated administration of cisplatin and etoposide chemotherapy and radiation doses of 45 Gy given over 3 to 5 weeks, median survivals of 20 to 24 months have been reported by many single institutions and confirmed in large cooperative group trials. Issues remaining to be resolved include optimization of radiation dose, volume, and timing; the role of prophylactic cranial irradiation; and how to reduce acute and late toxic reactions of treatment. As we develop more specific therapies based on specific molecular and biological characteristics of SCLC, including its autocrine growth regulation, we will be challenged to integrate these successfully with current radiation and chemotherapeutic approaches.

Limited-stage small cell lung cancer: a case report

Because small cell lung cancer (SCLC) is very responsive to chemotherapy, an attempt at treatment is warranted even in poor-prognosis patients with limited-stage disease. Concurrent thoracic radiotherapy and prophylactic cranial irradiation should be considered in such cases. A case report of an elderly, debilitated patient with limited-stage SCLC is presented, and his management is discussed.

Prophylactic cranial irradiation is indicated following complete response to induction therapy in small cell lung cancer: results of a multicentre randomised trial. United Kingdom Coordinating Committee for Cancer Research (UKCCCR) and the European Organization for Research and Treatment of Cancer (EORTC)

Prophylactic cranial irradiation (PCI) reduces the risk of cranial metastasis in small cell lung cancer (SCLC), but the magnitude and value of this reduction, the risks of radiation morbidity and whether PCI influences survival are unclear. We conducted a randomised trial in patients with limited-stage SCLC who had had a complete response to induction therapy. Initially, patients were randomised equally to (1) PCI 36 Gy in 18 daily fractions, (2) PCI 24 Gy in 12 fractions and (3) no PCI; subsequently, to increase the rate of accrual, randomisation was to clinicians' choice of PCI regimen versus no PCI (at a 3:2 ratio). The endpoints were appearance of brain metastases, survival, cognitive function, and quality of life (QoL). Three hundred and fourteen patients (194 PCI, 120 No PCI) were randomised. In the revised design, the most commonly used PCI regimens were 30 Gy in 10 fractions and 8 Gy in a single dose. With PCI, there was a large and highly significant reduction in brain metastases (HR = 0.44, 95% CI 0.29-0.67), a significant advantage in brain-metastasis-free survival (HR = 0.75, 95% CI 0.58-0.96) and a non-significant overall survival advantage (HR = 0.86, 95% CI 0.66-1.12). In both groups, there was impairment of cognitive function and QoL before PCI and additional impairment at 6 months and 1 year, but no consistent difference between the two groups and thus no evidence over 1 year of major impairment attributable to PCI. PCI can safely reduce the risk of brain metastases. Further research is needed to define optimal dose and fractionation and to clarify the effect on survival. Patients with SCLC achieving a complete response to induction therapy should be offered PCI.

Small cell lung cancer: state-of-the-art therapy in 1996

Small cell lung cancer (SCLC) occurs almost exclusively in smokers and represents 15 to 25% of all lung cancer histologic findings. It is distinguished from non-small cell lung cancer by its rapid tumor doubling time, high growth fraction, and early development of widespread metastases. Since patients with SCLC usually present with disseminated disease, treatment strategies have focused on systemic therapy. Single-agent and combination chemotherapy, as well as combined-modality therapy, have produced high response rates (80 to 100% for limited disease; 60 to 80% for extensive disease), but these tend to be short-lived (median duration, 6 to 8 months). Survival beyond 5 years occurs in only 3 to 8% of all patients with SCLC. At least 15 to 20 different chemotherapeutic agents have shown major activity against SCLC in both the untreated and relapsed settings, including etoposide, teniposide, cisplatin, carboplatin, ifosfamide, cyclophosphamide, vincristine, and doxorubicin. This paper reviews state-of-the-art treatment strategies being employed in the treatment of SCLC, including those incorporating high-dose intensive therapy, salvage therapy, new agents, thoracic radiotherapy, prophylactic cranial radiotherapy, surgical resection, and biologic response modifiers.

Central Nervous System Involvement and the Role of Prophylactic Cranial Irradiation in Small Cell Lung Cancer

This paper studies the frequency and manifestations of central nervous system (CNS) involvement and assesses the role of prophylactic cranial irradiation in small cell lung cancer (SCLC). All patients with confirmed diagnosis, admitted to our department within the last 15 years, were included. Patients were staged as having limited or extensive disease. Irradiation (40 Gy/20f) was offered to all complete responders immediately after polychemotherapy. There were 200 patients (176 men and 24 women, median age 58), 68 with limited and 132 with extensive disease. Twenty (10%) presented with CNS involvement, 14 (7%) developed it during chemotherapy and 47 (23.5%) during follow-up. In total, 81 (40.5%) developed CNS involvement, and in 57 (28.5%) it was the main manifestation. There was no relation to disease extent or type of response to therapy. The most frequent site of metastases was brain (33%), followed by leptomeninges (6%), spinal cord (1.5%), and pituitary (1.5%).

Of 79 complete responders, 51 (65%) received prophylactic cranial irradiation (PCI) and 28 (35%) did not. Frequency of CNS involvement was not significantly different (49% and 39%, respectively). Actuarial probabilities of developing CNS involvement were also not different. Nevertheless, 91% of complete responders without PCI relapsed only to CNS involvement, versus 48% with prophylactic irradiation. Cranioprophylaxis administration was followed by an improvement in overall survival, which was highly significant in limited disease. The actuarial survival of complete responders at two and four years was 46% and 26% with cranioprophylaxis versus 18% and 9% without, respectively.

CNS involvement in SCLC not only is a frequent complication, but also its frequency increases with lengthening survival. The necessity of routine use of brain CT scan during staging and follow-up is questioned in view of the present data. Administration of cranioprophylaxis did not reduce the frequency of CNS involvement in our series apparently because while it significantly delays CNS involvement, it does not abolish it. Nevertheless, survival of complete responders was prolonged with cranioprophylaxis and very significantly so in limited disease. This last finding, although clear cut, must await confirmation from randomized trials.

Small cell carcinoma of the esophagus: a case report

This article reports a case of primary undifferentiated small cell carcinoma of the esophagus with lymph node metastasis which invaded the stomach wall. The patient was treated with chemotherapy alone, consisting of CDDP and VP-16. The patient had a complete response to chemotherapy, with no evidence of disease for nine months, after six courses of the regimen. Small cell carcinoma of the esophagus is an aggressive tumor with an extremely poor prognosis. Because its characteristics are similar to small cell carcinoma of the lung, small cell carcinoma of the esophagus should be treated by multi-drug chemotherapy including CDDP, with or without radiation as the first line treatment. This chemotherapy regimen may achieve a long disease-free survival time.

Dose-intense therapy with etoposide, ifosfamide, cisplatin, and epirubicin (VIP-E) in 100 consecutive patients with limited- and extensive-disease small-cell lung cancer

BACKGROUND

We conducted a phase I/II trial to assess the feasibility and activity of VIP-E chemotherapy in small-cell lung cancer. End-points were treatment-related morbidity and mortality, response to treatment. duration of response, and survival.

PATIENTS AND METHODS

Two cycles of combination chemotherapy followed by granulocyte colony-stimulating factor (G-CSF) were given at a dose of etoposide (500 mg/m2), ifosfamide (4000 mg/m2), cisplatin (50 mg/m2), and epirubicin (50 mg/m2) to 100 consecutive patients with SCLC. Thirty patients (19 with LD, and 11 with ED SCLC) proceeded to VIC-E high-dose chemotherapy with autologous peripheral blood stem cell transplantation (PBSCT) at a cumulative dose of etoposide 1500 mg/m2, ifosfamide 12,000 mg/m2, carboplatin 750 mg/m2 and epirubicin 150 mg/m2 (VIC-E). Surgical resection of primary tumor was attempted at the earliest feasible point. Thoracic irradiation was given after completion of chemotherapy. RESULTS of conventional-dose VIP-E: 97 patients were evaluable for response. Objective response rate was 81% in LD-SCLC (33% CR, 48% PR; excluding patients in surgical CR) and 77% in ED-SCLC (18% CR, 58% PR). Treatment mortality was 2%. Median survival was 19 months in LD-SCLC and 6 months in ED-SCLC. Two-year survival was 36% in LD and 0% in ED SCLC. RESULTS OF HIGH-DOSE VIC-E: All 30 patients improved on or maintained prior responses. Four patients (13%) died of treatment-related complications. Median survival was 26 months in LD-SCLC and 8 months in ED-SCLC. Two-year survival was 53% in LD and 9% in ED SCLC.

CONCLUSION

VIP-E chemotherapy is an effective induction therapy for SCLC. Compared with traditional protocols such as ACO or carboplatin/etoposide, response rates are slightly improved, while survival is not different. In the LD SCLC subgroup, high-dose chemotherapy improved response rates and survival, especially for patients in surgical CR prior to high-dose therapy. In ED SCLC, however, higher response-rates did not translate into improved survival. Selected LD-SCLC patients with good partial or complete remissions after prior therapy may benefit from HDC and PBSCT.

[Biological basis of combined chemo-radiotherapy. Applications to lung cancers]

Radiation therapy has been for years the treatment of choice of locally advanced non small cell lung cancer. Improvement due to the combination of radiation and chemotherapy has been shown recently through several randomized trials and a recent meta-analysis. These results may be explained by biological mechanisms, yet uncompletely explored, which are detailed in this review and applied to lung cancer. The optimal combination scheme is not yet defined, even though the concurrent approach is promising, at the expense of an increased toxicity which is the limiting factor of treatment escalation doses. Biological findings and future results of randomized trials will hopefully open new avenues in the therapeutic strategy of this poor prognosis disease.

Management of Toxicities of Combined Modality Therapy for Intrathoracic Malignancies

BACKGROUND: Combined radiation and chemotherapy for intrathoracic tumors can produce appreciable morbidity. Apprehension about the severity of these toxicities may inhibit optimal patient care. METHODS: The literature on recognition, diagnosis, prophylaxis, and management of these toxicities is reviewed and combined with the experiences of the authors to produce management recommendations. RESULTS: Toxicities include acute and chronic esophagitis, early and late pneumonitis with fibrosis, myelosuppression, and neurologic deficits. Measures are available to minimize their severity and to reduce their impact on the patient. CONCLUSIONS: The morbidity of combined radiation and chemotherapy patients with intrathoracic tumors can be minimized by recognizing potential toxicities and by applying appropriate prophylactic and management measures.

Indications, Results and Techniques of Radiotherapy in the Treatment of Small-Cell Lung Cancer

Aims and background

To define the role of radiotherapy in the treatment of small-cell lung cancer (SCLC) on the basis of clinical data reported in the medical literature.

Methods

Published reports are critically reviewed, with particular attention to randomized trials.

Results

Thoracic radiotherapy has an important role in improving local control and 3-year survival in limited-stage SCLC; radiation should be delivered early in the course of the chemotherapy program, avoiding large volumes and total doses exceeding 40-50 Gy. Thoracic radiotherapy probably has no role in resected patients treated with adjuvant chemotherapy and may even be detrimental in patients with extensive SCLC. Prophylactic cranial irradiation has been shown to reduce the risk of brain relapse, but it is not associated with a consistent increase in survival or cure rate: its use in clinical practice is therefore not advised.

Conclusions

Survival rates approaching 50% at 2 years are now possible in limited SCLC with the integrated effort of the surgeon, the medical oncologist and the radiation oncologist; their strict cooperation appears to be of the utmost importance in the earliest phase of treatment planning.

Paclitaxel, carboplatin, and extended schedule etoposide in the treatment of small cell lung carcinoma

BACKGROUND

Paclitaxel is an active agent in the initial treatment of patients with small cell lung carcinoma. The authors evaluated the toxicity and efficacy of paclitaxel (1-hour infusion) added to a standard combination regimen of carboplatin and etoposide in a Phase II trial for the treatment of patients with small cell lung carcinoma.

METHODS

Thirty-eight patients with previously untreated small cell lung carcinoma were treated with a combination regimen including paclitaxel, 135 mg/m2 by 1-hour intravenous (i.v.) infusion, on Day 1; carboplatin at AUC 5, on Day 1; and oral etoposide, 100 mg alternated with 50 mg, on days 1-10. Prior to availability of reimbursement for oral etoposide, 13 patients received etoposide, 25 mg/m2 i.v. on Days 1-5 and 8-12. Treatment courses were repeated every 21 days for a total of 4 courses. Patients with limited stage disease received radiation therapy (4500 centrigray in 25 fractions) concurrently with the last 2 courses of chemotherapy.

RESULTS

This combination chemotherapy regimen was easily tolerated. Eleven episodes of Grade 3 or 4 leukopenia occurred in 9 patients (8% of courses); Grade 3 and 4 thrombocytopenia and anemia were also infrequent. Fifteen patients were hospitalized for treatment of fever associated with leukopenia. Concurrent treatment with chemotherapy and radiation therapy was also tolerable, but was more toxic; 6 of 15 patients (40%) developed esophagitis (Grade 3 in 5 patients, Grade 4 in 1 patient), and 45% of all episodes of Grade 3/4 leukopenia occurred during concurrent therapy. Other nonhematologic toxicity was uncommon. Twenty-nine of 38 patients (76%) achieved a partial or complete response to treatment (limited stage, 14 of 15 patients, 93%; extensive stage, 15 of 23 patients, 65%). The complete response rate was 26% (limited stage disease, 40% versus extensive stage disease, 17%). Median actuarial overall survival was 7 months for patients with extensive stage disease, and 17 months for patients with limited stage disease. Prophylactic whole brain irradiation was not used, and seven patients developed brain metastases as their initial site of relapse.

CONCLUSIONS

The combination of paclitaxel, administered by 1-hour infusion, carboplatin and extended schedule etoposide is feasible and well tolerated in the doses administered in this Phase II trail. This regimen was highly active with treatment results comparable to other standard regimens. Increased doses of both paclitaxel and carboplatin could probably be tolerated and are currently being evaluated. Precise definition of the role of paclitaxel in the treatment of small cell lung carcinoma awaits the results of randomized studies.

Neurologic disorders in 203 consecutive patients with small cell lung cancer. Results of a longitudinal study

BACKGROUND

Neurologic complications of small cell lung cancer (SCLC) are manifold. The incidence and course of the various metastatic and nonmetastatic neurologic disorders were studied prospectively in a cohort of SCLC patients.

METHODS

The 203 patients underwent neurologic examinations on a regular basis, prior to therapy, during and after treatment, from 1983 through 1994. Routine computer tomography or magnetic resonance imaging of the brain was performed before therapy and after 2 years' survival. Other auxiliary diagnostic tests were performed as required.

RESULTS

The majority of the 174 neurologic disorders, diagnosed in 132 patients, were associated with metastases. A total of 79 patients developed brain metastases. The cumulative risk of brain metastases reached 47% for limited and 69% for extensive disease patients at 2 years from diagnosis. Survival following the diagnosis of brain metastases was significantly longer for patients with brain metastases at the initial diagnosis of SCLC than for patients with delayed brain metastases (P < 0.01, long rank test). The most frequent paraneoplastic syndrome with neurologic symptoms was that of inappropriate secretion of antidiuretic hormone (SIADH), which was diagnosed in 11 patients. Antibody-mediated paraneoplastic neurologic syndromes were diagnosed in five patients. Chemotherapy for SCLC caused SIADH to subside in most patients. In contrast, the antibody-mediated syndromes did not respond to SCLC therapy. Adverse effects of treatment included peripheral neuropathy, encephalopathy, radiation plexopathy, and steroid myopathy. However, unlike the other complications, peripheral neuropathy was reversible.

CONCLUSIONS

This clinical investigation confirmed the frequency of central nervous system metastatic involvement as well as the diversity of the neurologic complications in SCLC. The high frequency of brain metastases justifies a reappraisal of prophylactic cranial irradiation in this patient group.