Prophylactic cranial irradiation and small cell lung cancer

Accelerated aging, decreased white matter integrity, and associated neuropsychological dysfunction 25 years after pediatric lymphoid malignancies

PURPOSE

CNS-directed chemotherapy (CT) and cranial radiotherapy (CRT) for childhood acute lymphoblastic leukemia or lymphoma have various neurotoxic properties. This study aimed to assess their impact on the maturing brain 20 to 30 years after diagnosis, providing a much stronger perspective on long-term quality of life than previous studies.

PATIENTS AND METHODS

Ninety-three patients treated between 1978 and 1990 at various intensities, with and without CRT, and 49 healthy controls were assessed with magnetic resonance diffusion tensor imaging (DTI) and neuropsychological tests. Differences in fractional anisotropy (FA)-a DTI measure describing white matter (WM) microstructure-were analyzed by using whole brain voxel-based analysis.

RESULTS

CRT-treated survivors demonstrated significantly decreased FA compared with controls in frontal, parietal, and temporal WM tracts. Trends for lower FA were seen in the CT-treated survivors. Decreases in FA correlated well with neuropsychological dysfunction. In contrast to the CT group and controls, the CRT group showed a steep decline of FA with age at assessment. Younger age at cranial irradiation and higher dosage were associated with worse outcome of WM integrity.

CONCLUSION

CRT-treated survivors show decreased WM integrity reflected by significantly decreased FA and associated neuropsychological dysfunction 25 years after treatment, although effects of CT alone seem mild. Accelerated aging of the brain and increased risk of early onset dementia are suspected after CRT, but not after CT.

Long-term effects of cranial irradiation and intrathecal chemotherapy in treatment of childhood leukemia: a MEG study of power spectrum and correlated cognitive dysfunction

Background

Prophylaxis to prevent relapses in the central nervous system after childhood acute lymphoblastic leukemia (ALL) used to consist of both intrathecal chemotherapy (CT) and cranial irradiation (CRT). CRT was mostly abolished in the eighties because of its neurotoxicity, and replaced with more intensive intrathecal CT. In this study, a group of survivors treated with CRT before 1983 and another group treated without CRT thereafter are investigated 20–25 years later, giving a much stronger perspective on long-term quality of life than previous studies. The outcomes will help to better understand these groups’ current needs and will aid in anticipating late effects of prophylactic CRT that is currently applied for other diseases. This study evaluates oscillatory neuronal activity in these long-term survivors. Power spectrum deviations are hypothesized to correlate with cognitive dysfunction.

Methods

Resting state eyes-closed magnetoencephalography (MEG) recordings were obtained from 14 ALL survivors treated with CT + CRT, 18 treated with CT alone and 35 controls. Relative spectral power was calculated in the δ, θ, α1, α2, β and γ frequency bands. The Amsterdam Neuropsychological Tasks (ANT) program was used to assess cognition in the executive functions domain. MEG data and ANT scores were correlated.

Results

In the CT + CRT group, relative θ power was slightly increased (p = 0.069) and α2 power was significantly decreased (p = 0.006). The CT + CRT group performed worse on various cognitive tests. A deficiency in visuomotor accuracy, especially of the right hand, could be clearly associated with the deviating regional θ and α2 powers (0.471 < r < 0.697). A significant association between decreased regional α2 power and less attentional fluctuations was found for CT + CRT patients as well as controls (0.078 < r < 0.666). Patients treated with CT alone displayed a power spectrum similar to controls, except for a significantly increased level of left frontal α2 power (p = 0.030).

Conclusions

The tendency towards global slowing of brain oscillatory activity, together with the fact that dementia has been reported as a late effect of CRT and the neuropsychological deficiencies currently present, suggest that the irradiated brain might be aging faster and could be at risk for early‐onset dementia. The CT group showed no signs of early aging.

Small-cell carcinoma of the urinary bladder: diagnosis and management

Small-cell carcinoma of the urinary bladder (SCCUB) accounts for less than 1% of all cancers arising in the urinary bladder. Current diagnosis and management of SCCUB are often patterned after small-cell lung cancer (SCLC). However, SCCUB therapy is different from that for SCLC. For example, many patients with SCCUB undergo local resection, which is rarely performed in SCLC. As in SCLC, platinum-etoposide combination chemotherapy is employed as the main systemic treatment option for SCCUB. Chemotherapy is usually combined with other therapeutic modalities, especially in patients whose disease is limited to the locoregional area. Owing to the rarity of this malignancy, no prospective study has been performed that establishes the efficacy and duration of chemotherapy or the relative efficacy of platinum-etoposide versus other chemotherapeutic regimens. This article provides a comprehensive review of the current status of SCCUB diagnosis and management, as well as some unique insights into this rare tumor.

Progress in the therapy of small cell lung cancer

Small cell lung cancer (SCLC) accounts for approximately 14% of all cases of lung cancer. Combination chemotherapy is the most effective treatment modality for SCLC and recently, several new active drugs have emerged. Combinations of platinum agents with CPT-11 or gemcitabine have been successfully compared in phase III trials against the cisplatin/etoposide standard. Modest improvements in the outcome of patients with SCLC have been noted over the last two decades. Thoracic irradiation given concurrently with chemotherapy improves survival compared with sequential chemotherapy and radiation, but this approach is associated with more toxicity. Moreover, the optimal doses and fractionation of thoracic irradiation remain to be determined. Three-dimensional treatment planning is under investigation. Prophylactic cranial irradiation (PCI) has established a role in the management of patients who have achieved a complete response to the initial therapy. Novel molecular targeted therapies are among the strategies currently being investigated in SCLC.

Limited-disease small-cell lung cancer

Substantial improvements in treatment outcome for limited-disease small-cell lung cancer (LD SCLC) have been achieved in the last two decades owing to the introduction of chemotherapy (CHT) consisting of cisplatin and etoposide (PE), and the understanding that thoracic radiation therapy (TRT) is an essential component in improving treatment outcome. In addition, a recent metaanalysis confirmed the importance of prophylactic cranial irradiation (PCI) in general treatment plans for patients who show a complete response to treatment. However, numerous questions remain unanswered regarding this disease. While TRT/PE/PCI is considered to be the standard treatment in the majority of centers worldwide, the emergence of new and effective drugs (e.g., topoisomerase I inhibitors and paclitaxel) for the treatment of LD SCLC will likely affect therapy strategies in the near future. Important issues regarding optimal doses and fractionation regimens, as well as the timing of TRT, remain to be resolved. While most centers currently use b.i.d. fractionation as a result of the Intergroup findings, high-dose standard TRT may also be beneficial. TRT volumes are also considered an important issue, since they likely relate to the incidence of both local failure and toxicity. Finally, the optimization of PCI (total dose, fractionation regimen, and timing) is already under way. The value of surgery is limited to peripheral tumors and poorly responding cancer, and to confirm histology or improve local control and survival.

Twice-daily prophylactic cranial irradiation for patients with limited disease small-cell lung cancer with complete response to chemotherapy and consolidative radiotherapy: report of a single institutional phase II trial

Prophylactic cranial irradiation (PCI) has been demonstrated to significantly reduce the incidence of brain relapse from limited disease small-cell lung cancer (LD SCLC), but concerns about neurologic toxicity remain. The purpose of this report was to update a phase II institutional trial that explored the impact of twice-daily PCI on neurologic toxicity as well as outcome for this group of patients. All eligible subjects had documented complete response to induction chemotherapy and consolidative chest irradiation. The whole brain was treated with twice-daily fractions of 1.5 Gy with megavoltage irradiation to an approximate total dose of 30.0-36.0 Gy. Although not devised as a randomized study, approximately half of the eligible patients declined the protocol enrollment of their own volition and were retrospectively evaluated as a "historical" control group regarding the incidence of brain metastases. Fifteen patients accepted twice-daily PCI, with 12 deferring treatment. Median follow-up was 20 months. Disease-free survival at 2 years was 54% with twice-daily PCI versus 0% without any PCI (p = 0.013). Overall survival at 2 years was 62% with twice-daily PCI versus 23% without PCI (p = 0.032). No statistically significant neurologic deterioration was detected in the PCI group posttreatment. Thus, twice-daily PCI should be considered for patients with LD SCLC who achieve a complete response to chemoirradiation. A multi-institutional randomized trial would be necessary before making definitive recommendations.

Asymptomatic brain metastases (BM) in small cell lung cancer (SCLC): MR-imaging is useful at initial diagnosis

PURPOSE

In this study we evaluated the usefulness of MR-imaging in the detection of asymptomatic brain metastases (BM) at the initial diagnosis in patients with small cell lung cancer (SCLC) and studied the follow-up of these patients.

PATIENTS AND METHODS

One-hundred and twenty-five patients with SCLC were investigated with MR-imaging.

RESULTS

In 112 patients with normal neurological findings, MR-imaging of the brain demonstrated BM in 17 patients (15%). Six of these 17 patients were therefore upgraded to extensive disease (ED). Two of these 17 patients died during chemotherapy because of progressive disease and 3 patients became neurologic symptomatic with progressive disease on MR-imaging of the brain. After completion of chemotherapy a repeated MR-imaging of the brain in the remaining 12 patients showed 1 complete remission, 4 partial remission and 7 progressive disease of the BM.

CONCLUSION

This study showed that at presentation an unexpectedly high percentage of SCLC patients had asymptomatic BM on MR-imaging. We propose that MR-imaging of the brain should be included in the staging of SCLC patients as well for staging, prognosis and therapy.

Efficacy and safety of prophylactic cranial irradiation in patients with small cell lung cancer

BACKGROUND

Prophylactic cranial irradiation (PCI) as part of the treatment regimen for patients with limited stage small cell lung cancer (SCLC) remains controversial. The present study was performed to analyze the efficacy and safety of PCI in patients with limited stage SCLC who achieved complete remission.

PATIENTS AND METHODS

Between 1983 and 1993, thirty-nine patients with limited stage SCLC who had shown complete remission after chemotherapy were enrolled prospectively into the non-randomized study. Eighteen of them received PCI (PCI+), while 21 did not (PCI-). Pretreatment CT or MRI of the brain was performed in all patients. Patients were prospectively evaluated by a neurologist at regular intervals.

RESULTS

Three PCI+ patients and seven PCI- patients developed brain metastases. The frequencies of brain metastases were not significantly different between the groups (Fisher's exact test, p = 0.207), but brain metastases in PCI+ patients tended to occur later (log rank, p = 0.008). Overall survival was significantly longer in PCI+ patients (log rank, p < 0.001). Early toxicity consisted of headache, nausea, fatigue, concentration problems and alopecia. These symptoms and signs were mild and usually reversible within a few months. Late toxicity was studied in patients whose survival exceeded two years. Seven PCI+ patients survived for more than two years, while no PCI- patients survived for more than two years. Memory problems were seen in six of the seven patients. These problems were non-disabling and, once established, remained stable for months to years. The most prominent radiologic abnormalities were cortical atrophy and leukoencephalopathy, found in four of the five patients who underwent radiologic follow-up examination.

CONCLUSIONS

This non-randomized study suggests that PCI may be effective by decreasing the frequency of brain metastases and by increasing the brain metastasis-free survival and overall survival, with a minor risk of clinical and radiologic neurotoxicity.

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.

Sequelae in long-term survivors of small cell lung cancer

PURPOSE

Central nervous system (CNS) effects of chemotherapy and prophylactic cranial irradiation (PCI) are studied in long-term small cell lung cancer (SCLC) survivors. The exact significance and pathogenesis of the neurotoxicity is still unknown, as studies on this subject lack sufficient patient numbers and are performed in an extremely varied manner.

METHODS AND MATERIALS

Fifty-nine survivors (> 2 years from diagnosis) were examined neurologically and neuropsychologically, and underwent a cranial computer tomography (CT) scan or magnetic resonance (MR). Eight patients were excluded from further analysis for various reasons (not SCLC-related CNS disease, n = 6; no chemotherapy nor PCI treatment, n = 2). The remaining 51 patients were divided into three groups; group 1 = chemotherapy alone (n = 21), group 2 = sequential PCI (n = 19), and group 3 = concurrent or sandwiched PCI (n = 11). Groups were neuropsychologically compared in matched controls.

RESULTS

Performance status did not differ significantly between various treatment groups; all patients remained ambulatory and capable of self-care. Mental impairment (n = 20), motor abnormalities (n = 9), and visual complaints (n = 1), were found in five patients in group 1 (24%), eight patients in group 2 (42%), and eight patients in group 3 (73%). Analysis of brain atrophy revealed no significant results; however, white matter abnormalities were found more frequently in group 3. Neuropsychologically no significant group differences existed, although interference sensitivity and difficulties with divided attention tended to occur more frequently in patients treated with PCI. Mean neuropsychometric results of treatment groups were significantly worse than those of matched controls.

CONCLUSIONS

Although more intensively treated patients showed more neurologic impairment and patients in group 3 had more white matter abnormalities, there was no statistic evidence for additional neurotoxicity of PCI. Marked neuropsychometric differences between patients and matched controls may indicate that cognitive impairment is partly disease related, probably due to emotional distress and deteriorated physical condition.

Thoracic and cranial radiotherapy for limited-stage small cell lung cancer

Chemotherapy remains the mainstay of treatment for small cell lung cancer (SCLC). For patients with limited-stage disease, the addition of thoracic radiotherapy confers a moderate improvement in local control and a modest survival benefit, but these improvements come at the cost of increased toxic reactions. The optimal method for integrating chemotherapy and thoracic radiotherapy is unresolved. Concurrent and alternating strategies are appealing because they allow uninterrupted delivery of chemotherapy, but they have not been proven to be superior to conventional sequential approaches. Based on limited data, delivery of thoracic radiation early in the treatment course may be preferable to delivery later in the course. There is evidence of a radiation dose-response effect for SCLC, and, in standard regimens, thoracic radiation doses in the range of 50 to 60 Gy are recommended. The use of limited radiation fields (to postchemotherapy tumor volumes) appears reasonable. Results for alternative thoracic radiation fractionation schedules such as accelerated hyperfractionation are promising and worthy of further investigation. The role of prophylactic cranial irradiation (PCI) is controversial and should be individualized. It should be considered for the favorable subgroup of patients with limited-stage disease who achieve a complete response to chemotherapy and thoracic radiotherapy. If given, we recommend a total dose of 30 to 36 Gy in 2-Gy fractions; PCI should not be delivered concomitantly with chemotherapy.

Follow-up of cognitive functioning in patients with small cell lung cancer

PURPOSE

Study of the course of possible treatment-related cognitive impairment in patients with small cell lung cancer.

METHODS AND MATERIALS

Thirty-two consecutive patients with small cell lung cancer underwent successive neurologic and neuropsychologic examinations until 5 months after prophylactic cranial irradiation, and in their pretherapeutic condition were compared to matched controls. Patients with brain metastases were excluded from this study.

RESULTS

Neurologic examination revealed central nervous system (CNS) abnormalities only in the 14 patients with brain metastases. In the remaining patients, neuropsychologic tests showed clear differences between the pretherapeutic performance of patients and that of matched controls (p < 0.001), but no significant deterioration either during or after therapy (0.1 < p < 0.8).

CONCLUSION

The difference between the pretherapeutic performance of patients and that of matched controls may indicate disease-related cognitive impairment. Within the observation period, no adverse effects of the used therapy were found. Our observations underline the importance of a pretherapeutic assessment in neurotoxicity research.

Single fraction prophylactic cranial irradiation for small cell carcinoma of the lung

The effectiveness of a single 8-Gy fraction prophylactic cranial irradiation regime was assessed in 106 patients with small-cell carcinoma of the lung. All patients had limited stage disease and received combination chemotherapy consisting of either cisplatin or carboplatin with ifosfamide, etoposide, and vincristine (VICE). Cranial irradiation was administered 48 h after the first cycle of chemotherapy and was well tolerated. Actual 2-year survival was 35% and cranial relapse occurred in 22% of those patients who achieved complete remission. This compares favourably with a cranial relapse rate of 45% incomplete remitters previously reported with the same chemotherapy regime after a minimum follow-up of 2 years where PCI was not used. Formal psychometric testing was performed retrospectively on a series of 25 long-term survivors of whom 14 were taken from this reported series. Whilst 75% of patients were impaired on at least one test with 68% performing badly in the most complex task, this was not associated with clinically detectable neurological damage and the patients did not complain of memory or concentration difficulties. In conclusion, single fraction PCI, when used with platinum based combination chemotherapy, appears to be equally effective but may be less neurotoxic than the more standard fractionated regimes.

Dose-response relationship for radiation therapy of subclinical disease

PURPOSE

To determine the dose-response relationship for elective treatment of subclinical metastatic deposits and validate a model for metastatic tumor cell burden.

METHODS AND MATERIALS

The incidence of overt metastases in electively irradiated potential sites of spread from carcinomas of the head and neck, breast, cervix, ovary, lung, and testis, and from melanomas and osteosarcomas, was compared with the incidence in patients not receiving elective irradiation. The reduction in incidence of metastases was analyzed as a function of radiation dose.

RESULTS

The dose-response curve for control of subclinical metastases is linear and shallow, and extrapolates to a dose intercept not demonstrably different from zero. A small threshold may reflect growth of residual micrometastases between treatment for the primary and elective irradiation. The shallow linear dose response reflects interpatient heterogeneity in metastatic tumor cell burden, ranging from 1 to M cells, where M is the upper limit of clinical undetectability. While a dose of 50 Gy in 2 Gy fractions is necessary to achieve an overall 90% reduction in the incidence of metastases, the metastatic cell burden in a proportion of patients can be eliminated by low doses. Thus, worthwhile rates of control can still be achieved when "tolerance" dictates lower than optimal doses, evidenced by the linearity and lack of significant threshold in the dose-response curve. This is an important difference from treatment of gross disease. The biological effectiveness of elective treatment is measured directly by the percent reduction in failure rate. Although it depends upon the log cell kill, it relates only to that proportion of patients harboring subclinical disease, and, therefore, is not well described by the increase in the cure rate for the total patient population. The linear dose-response relationship for reduction in failure rate is independent of the "natural" (untreated) incidence of subclinical metastasis, and, therefore, of site, histology, growth rate, stage, or other characteristics of the tumor. Conversely, the clinical effectiveness of elective treatment is measured by increase in tumor control rate and depends upon the "natural" incidence of metastasis: the higher it is, the greater the absolute increase in cure rate from a constant biological effect (log cell kill).

CONCLUSIONS

(a) High control rates for subclinical metastases require doses of about 50 Gy in 2 Gy fractions, but worthwhile benefits can be achieved by lower doses if necessitated by reduced tolerance; (b) elective treatment of subclinical metastases should be instituted close to the time of treatment of the primary; (c) the biological effectiveness of elective radiation (or chemotherapy) should be measured by the percentage decrease in metastasis, not by improvements in the rate of control; and (d) demonstration of success in clinical trials of adjuvant therapy is more likely the higher the incidence of metastases in untreated controls.

Randomized comparison of etoposide-cisplatin vs. etoposide-carboplatin and irradiation in small-cell lung cancer. A Hellenic Co-operative Oncology Group study

PURPOSE

To compare the efficacy and toxicity of etoposide and cisplatin (EP) with etoposide and carboplatin (EC) in combination with irradiation in small-cell lung cancer (SCLC).

METHODS

Previously untreated patients (pts) with SCLC and measurable or evaluable disease were randomized to receive either cisplatin 50 mg/m2 on days 1-2 or carboplatin 300 mg/m2 on day 1, both combined with etoposide 300 mg/m2 on days 1-3 every 21 days for 6 treatment cycles. The vast majority of responding limited disease (LD) pts and complete responders (CR) with extensive disease (ED), also received thoracic irradiation (TI) and prophylactic cranial irradiation (PCI) concurrently with the third cycle.

RESULTS

Of the 147 patients registered, 143 were eligible; median performance status (PS, WHO) was 1, and tumour stage was LD in 41 pts of each treatment group. The mean delay between cycles was 8 days in the EP group and 9 in the EC group increasing in both arms with the number of treatment courses. The drug dose administered per unit time as a proportion of the protocol dose was 74% and 80% for the two groups respectively. Leukopenia, neutropenic infections, nausea, vomiting, neurotoxicity and hyperergic reactions were more frequent and/or severe in the EP group. The CR rates were 57% and 58% for EP and EC respectively. Median survival for all pts was 12.5 and 11.8 months, respectively.

CONCLUSION

Both treatments proved to be effective, with no differences in response and survival between the two treatment arms. The EC regimen was associated with significantly less toxicity.

Complications associated with the treatment of small cell lung cancer

Major modalities of treatment in small cell lung cancer include chemotherapy, radiation therapy and surgery and all of these cause both early and late toxicities. Common toxicities, both early and late, are described in all of the modalities of treatment. Emphasis on new approaches such as the use of colony-stimulating factors to reduce myelosuppression, new antiemetics to make cisplatin and anthracyclines much more tolerable, the use of cardiotoxic anthracyclines such as Epirubicin and emphasis on the incidence of second malignancies in this population, some of which will likely decrease due to decreased use of procarbazine and nitrosoureas along with fewer courses of chemotherapy.

Should current management of small cell lung cancer include prophylactic cranial irradiation?

The literature on the use of prophylactic cranial irradiation (PCI) in the management of small cell lung cancer (SCLC) is reviewed, focusing on the ten randomized trials published until 1991. Eight out of ten randomized trials have shown some reduction in the frequency of CNS relapse in patients who have had PCI, whereas none have shown any survival benefit associated with PCI. Current data indicate that survival is exclusively dependent on an effect of PCI in only a very limited subgroup of patients (10% of complete responders). It is generally agreed that PCI is not justified in patients who are not in CR, but even in this situation it is unknown whether PCI is necessary. The current therapeutic potentials seem to leave comparable fractions of patients without sufficient palliation of their symptomatic brain metastases regardless of whether or not PCI is given. Data from sufficiently large randomized trials have to be matured and analyzed, before the role of PCI in SCLC can be defined.

Consolidative thoracic radiotherapy and prophylactic cranial irradiation in limited disease small cell lung cancer

Between 1983 and 1990, 128 patients with limited disease small cell lung cancer (SCLC) received consolidative thoracic irradiation after reaching a complete (CR) or partial response (PR) to combination chemotherapy. Patients in CR (n = 85) received 35-36 Gy in 12-14 fractions and patients in PR (n = 43) 24-30 Gy in 3-6 fractions. Until 1989, prophylactic cranial irradiation (PCI) was given to patients in CR. There was no significant difference in survival between the CR and PR group. However, patients with residual tumor detected by radiology or bronchoscopy or cyto-/histology had significantly longer survival than those with residual tumor demonstrated by more than one of the above methods of investigation. Overall, local progression was observed in 22% and distant dissemination in 63% of patients. The rate of brain metastases was significantly lower in patients treated with methotrexate and nitrosurea containing schedules and PCI, compared to those who were treated with other schedules (irrespective of PCI).

Comparative study of prophylactic cranial irradiation in patients with small cell lung cancer achieving a complete response: a long-term follow-up result

Between 1981 and 1986, a total of 46 patients with small cell lung cancer (SCLC) achieving a complete response by chemotherapy with or without chest irradiation were randomized either to receive prophylactic cranial irradiation (PCI) or not. With a median follow-up time of 8.5 years for both groups, only five of 23 patients (22%) in the PCI group developed brain relapse, while 12 out of 23 (52%) in the no PCI group did so (P < 0.05). The frequency of patients developing a sole brain relapse during their whole clinical course was 4% for the PCI group and 17% for the no PCI group, however, the difference was not statistically significant. Patient survival was better for the PCI group (median survival time of 21 months, and 5-year survival rate of 22%) as compared with the no PCI group (median survival time of 15 months, and 5-year survival rate of 13%), showing a marginal significance (P = 0.097). Late neurologic toxicity was infrequent; only one developed a mild deterioration among seven long-term disease-free survivors in the PCI group. These results appear to warrant further clinical trials to clarify the utility of PCI in patients with SCLC achieving a complete response.

Prospective evaluation of the effect on initial brain metastases from small cell lung cancer of platinum-etoposide based induction chemotherapy followed by an alternating multidrug regimen

BACKGROUND

During the 1980s reports describing the effect of systemic chemotherapy on brain metastases from chemosensitive tumours emerged, including a few retrospective reports on small cell lung cancer (SCLC) patients.

DESIGN

Previously untreated SCLC patients with no other malignancy, but in some cases with mixed histological subtype, who had symptomatic brain metastases verified by contrast enhanced CT-scan, were treated with a multidrug combination chemotherapy regimen and no cranial irradiation. Radiotherapy was optional at cranial relapse or progression at the discretion of the physician in charge. The intracranial effect was evaluated by 4-weekly CT-scan and neurological examination, according to a standardized scoring system.

END POINTS

Intracranial response, duration of response, neurological score, terminal CNS status, and survival.

RESULTS

21 patients were included, corresponding to 8.6% of consecutive SCLC patients at our institution. 8 patients died before follow-up leaving 13 evaluable for response. In the former group, all patients had WHO performance status of 3-4 compared to 6/13 in the latter group. Of the 13 evaluable patients, 1 had early progression in the CNS and 1 had no change. 11 had CT-scan verified response, with a median duration of 135 days. Most patients, including all complete responders, had improvement in their neurological score. 6 out of 11 responders died without active CNS disease. The crude median survival was 111 days, whereas the median survival (early deaths excluded) was 197 days.

CONCLUSION

Systemic combination chemotherapy was effective for palliation of initial brain involvement in the majority of patients in a small consecutive series. The role of consolidating cranial irradiation in responders should be assessed by a randomized trial.

Small-cell lung cancer: an overview of issues in therapy

As one of the few chemo- and radiosensitive neoplasms among the common epithelial solid tumors of adults, small-cell lung cancer has long tantalized clinical investigators. Although for the last 15-20 years therapy has yielded high remission rates, including substantial complete remission rates, results have not improved very much over nearly two decades of intensive therapeutic research, and long-term disease-free survival remains an elusive goal for the large majority of patients. At this point the number of promising untested hypotheses in therapy is quite small, and major advances will probably have to await either the serendipitous discovery of much more active drugs than we now possess, or else the purposeful development of new approaches based on insights into the nature of the transformed state and the biology of SCLC itself.

Carboplatin as second line treatment for recurrent or progressive brain metastases from small cell lung cancer

Patients with brain metastases from small cell lung cancer (SCLC) have a poor prognosis. Although most patients die from metastatic disease outside the central nervous system, this disabling metastatic site often needs treatment to mitigate the signs and symptoms of intracranial disease. The effect of carboplatin (400 mg/m2 every 4 weeks) as second line treatment for recurrent or progressive brain metastases was studied in 20 SCLC patients. 19 patients could be evaluated: 16 by contrast enhanced brain computer tomography (CT) scan (2 patients had complete response, 6 partial response, 4 stable disease and 4 progressive disease) and 3 patients clinically, who had progressive disease. The objective response rate in the brain was 40% (95% CI:22-61%). The median response duration was 8 weeks (range 2-29). The median survival was 15 weeks (range 1-44). Previous cranial irradiation appeared to be beneficial for survival. There was only mild haematological and gastrointestinal toxicity. Carboplatin has activity against brain metastases and gives palliation in responding patients.

Late toxicities and complications in three-year survivors of small cell lung cancer

123 patients with small cell lung cancer (SCLC) presented to the National Cancer Center Hospital (Tokyo) between 1978 and 1986. 22 of 71 patients with limited stage disease (LD) and none of 52 patients with extensive disease (ED) survived for 3 years. 15 of the 22 three year survivors had significant late complications. All patients received chemotherapy and either thoracic irradiation, resection or both. No prophylactic cranial irradiation was given. 4 patients developed cardiac failure, 2 with a dilated cardiomyopathy, despite the fact that no patient received over 420 mg/m2 of doxorubicin. 12 patients of the 17 who received thoracic irradiation developed radiation pneumonitis and 3 required hospitalisation for severe haemoptysis (2) or cavity formation (1). 1 patient who received nimustine developed a fatal myelodysplastic syndrome and 2 additional patients developed second primary tumours in the oesophagus (1) and stomach (1). Mild peripheral neuropathy (WHO grade 1) was persistent in 3 patients and asymptomatic azotemia (WHO grade 1) in 7. Despite advances in the treatment of SCLC there are very few asymptomatic long-term survivors.

The value of computed tomographic (CT) scan surveillance in the detection and management of brain metastases in patients with small cell lung cancer

One hundred and twenty-seven consecutive patients presenting with small cell lung cancer were entered into a whole-brain CT scan surveillance study, starting at presentation and repeating at 3-monthly intervals for 2 years as an alternative to prophylactic cranial irradiation (PCI). The aim of the study was to detect CNS metastases at an early asymptomatic stage in the hope that prompt CNS radiotherapy could achieve long-term control; at the same time unnecessary PCI with its potential long-term morbidity could be avoided. CNS metastases were found in 56 patients (44%) including 16 (13%) at diagnosis and 40 at a median of 4 months (range 1-27 months) after completing chemotherapy. No patient developed CNS disease while on chemotherapy. Thirty-six patients were asymptomatic at diagnosis (group A) but 20 developed clinical CNS relapse between scans (group B) (interval relapse). Despite prompt radiotherapy 56% of patients in group A and 60% of patients in group B died with active CNS disease. Likewise, there was no survival difference between patients in group A, group B or those who never developed CNS disease. Regular 3-month CT scan surveillance is therefore not an effective substitute for PCI.

Resolution of small cell lung cancer intracranial metastases with standard dose chemotherapy

Brain metastases are a well recognized problem in patients with small cell lung cancer (SCLC). Most patients are treated with whole brain cranial irradiation therapy which frequently improves symptoms. In this report we present data on two patients who achieved radiologically confirmed complete resolution of brain metastases treated with standard dose chemotherapy for SCLC.