Small-Cell Lung Cancer

Stephen V. Liu¹ and Glen J. Weiss²

¹University of Southern California School of Medicine, Los Angeles, CA, USA

²Cancer Treatment Centers of America, Goodyear, AZ and Translational Genomics Research Institute (TGen), Phoenix, AZ and University of Arizona College of Medicine, Phoenix, AZ, USA

Multiple Choice Questions

1. What is the leading risk factor for developing small-cell lung cancer (SCLC)?

Exposure to radon
Exposure to asbestos
Smoking cigarettes
Air pollution

Smoking cigarettes is the leading cause of SCLC, and it is not uncommon to diagnose this type of lung cancer in current smokers. Radon is a distant, second most common cause for lung cancer. Asbestos and air pollution are risk factors, but they are minimal when compared to cigarette smoking.

2. Should surgery ever be considered for a patient with limited-stage SCLC?

Yes
Yes, but only in a select group of patients
No

While many consider SCLC a systemic disease at diagnosis, there is a small subset of patients with limited disease who appear to benefit from surgery. Several retrospective analyses report 5-year survival rates approaching 50% for patients with pathologic stage I SCLC treated with resection. Of note, these data also demonstrate a significant discordance between clinical and pathologic staging. While surgical resection should be considered for patients with stage I SCLC, an exhaustive staging work-up, including positron emission tomography–computed tomography (PET–CT) and mediastinoscopy, must be completed prior to resection.

Case study 78.1

A 50-year-old woman is found to have a large lung mass on a preoperative chest X-ray. Work-up reveals a T2N1, limited-stage SCLC, and you recommend concurrent cisplatin plus etoposide with thoracic radiation.

• What radiation schedule do you recommend?

Twice daily ×30 treatments (15 days). While the ideal schedule is not known, hyperfractionation of radiation has been shown to improve survival in patients with limited-stage SCLC receiving concurrent chemotherapy. In this study, patients on the twice-daily schedule had a 5-year survival of 26%, compared to 16% for those treated once daily. There is increased toxicity, specifically a higher rate of acute esophagitis. Of note, a recent meta-analysis did not show a statistically significant difference in survival, but a trend toward better outcomes was noted. For patients able to comply with a twice-daily schedule, I would select a hyperfractionation approach. An ongoing RTOG trial is exploring a boost approach that delivers 70 Gy in 7 weeks.

Case study 78.2

A 67-year-old man with limited-stage SCLC just completed six cycles of cisplatin and etoposide. A restaging CT scan shows a partial response.

1. Would you offer this patient prophylactic cranial irradiation (PCI)?

The brain has been an important site of late relapse for patients with SCLC, and the use of PCI has been shown to decrease the risk of future brain metastases and improve overall survival. Initial studies were conducted in patients with limited-stage SCLC who had achieved a complete response. Subsequent studies demonstrated similar benefit for patients with extensive-stage SCLC who achieved any response. While there are less prospective data for patients with limited-stage SCLC who achieve a partial response, PCI is a reasonable treatment strategy that is supported by current National Comprehensive Cancer Network guidelines.

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