Elsevier

Lung Cancer

Volume 69, Issue 2, August 2010, Pages 133-140
Lung Cancer

Review
Radiotherapy in small-cell lung cancer: Where should it go?

https://doi.org/10.1016/j.lungcan.2010.04.019Get rights and content

Abstract

Small-cell lung carcinomas (SCLC) represent less than 20% of all lung cancers. As it is an aggressive tumour, on account of its high and early risk of dissemination, only a third of patients have limited-stage disease at diagnosis. For these patients, the current state-of-the-art treatment involves cisplatin–etoposide chemotherapy combined with chest radiotherapy. Because of the high risk of brain metastases, prophylactic cranial irradiation (PCI) is indicated in good responders and should be part of the standard management of these patients on the basis of a PCI meta-analysis showing a 5% increase in survival at 3 years. The 5-year survival rate reaches 25% in the best series. This progress is subsequent to a better combination of polychemotherapy and both thoracic and cerebral irradiation. In extensive disease, radiotherapy has also a place in the management of SCLC: PCI reduces the risk of brain metastases and significantly improves overall survival, so that cisplatin (or carboplatin)–etoposide followed by PCI in responding patients has become the standard treatment. Many issues are subject for further clinical research concerning timing, volume and schedule of thoracic radiotherapy to be used in combination with chemotherapy regimen. Progress in thoracic radiotherapy can only be achieved by including patients in prospective studies.

Introduction

Small-cell lung cancer (SCLC) represents about 12–20% of lung cancers. The histopathological differentiation between small cell and non-small cell (NSCLC) is very important as treatment strategies vary according to the pathological type. As SCLC has a high propensity for early metastatic dissemination, chemotherapy is the cornerstone treatment, but SCLC is also very sensitive to radiotherapy. Patients often have an initial bulky mediastinal presentation and have a high risk of metastatic spreading because of an elevated doubling-time [1]. Because of its unique behaviour, it has a separate staging system from NSCLC. After staging procedure, SCLC is classified as limited or extensive disease according to the Veterans Administration Lung Cancer Study Group Classification [2]. Limited disease is defined as confined to a hemithorax and the regional lymphatic nodes (mediastinum, homolateral and contralateral hilar regions, homolateral supraclavicular fossa), thus theoretically accessible to radiotherapy. Limited disease represents about a third of patients. Even if this classification has been used for many years, the International Association for the Study of Lung Cancer (IASLC) has recently published recommendations in order to use the new TNM classification also in SCLC [3]. The 7th TNM classification seems more accurate to identify patient subgroups and its use could be useful in the future.

Section snippets

Radiotherapy and chemotherapy combination

Thoracic radiotherapy (TR) was the main treatment for limited disease SCLC before the introduction of chemotherapy in the 70s. With the increasing use of chemotherapy, with response rates varying between 70% and 90%, the role of TR progressively diminished. Nevertheless, when chemotherapy was used alone, clinicians observed a high rate of local recurrence, of about 50%, which could be divided by 2 or 3 when radiotherapy was combined to chemotherapy. Several randomized trials were then performed

Thoracic radiotherapy

Even if chemotherapy is the backbone of SCLC treatment especially in extensive disease, TR has been evaluated as a consolidative therapy after chemotherapy. As thoracic control may be problematic, Jeremic et al. [67] decided to undertake a randomized study to evaluate whether thoracic radiotherapy as consolidation treatment could improve the poor results observed in SCLC extensive disease. Only patients who had an extra-thoracic complete response to 3 cycles of chemotherapy were randomized;

Conclusion

In the past ten years, progress in small-cell lung cancer comes mainly from a better integration of chemotherapy with both thoracic radiotherapy and prophylactic cranial irradiation. However there are many issues still unanswered in terms of optimal thoracic dose, optimal fractionation, optimal drug combination that need to be addressed within randomized studies. The interval between the “start of any treatment until the end of radiotherapy” (SER) which should be as short as possible, and

Conflicts of interest

None declared.

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