Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Small cell lung cancer

2,840 views

Published on

Brief Description of Epidemiology, Pathophysiology, Staging and Management of Small Cell Lung Cancer

Published in: Health & Medicine
  • Be the first to comment

Small cell lung cancer

  1. 1. Small Cell Lung Cancer Dr. Yogesh Belagali MD Medical Advisor- Oncotherapeutics
  2. 2. Index • Introduction • Epidemiology • Pathophysiology • Staging System • Management of Limited Stage Disease – Chemotherapy – Radiotherapy • Management of Extensive Stage Disease – Chemotherapy – Radiotherapy • Summary
  3. 3. Introduction • Most common cancer worldwide – Estimated 1,600,000 new cases – 1,380,000 deaths/year • The term lung cancer, or bronchogenic carcinoma, refers to malignancies that originate in the airways or pulmonary parenchyma.
  4. 4. Indian Scenario:2012 http://globocan.iarc.fr/Pages/fact_sheets_population.aspx Cancer Incidence Mortality 5-year prevalence Number (%) ASR (W ) Number (%) ASR (W ) Number (%) Prop. Lung 70275 6.9 6.9 63759 9.3 6.3 32464 1.8 3.7 Incidence: •Male: 11/1,00,000 (most common) •Female: 3.1/1,00,000 ( 4th )
  5. 5. Histology
  6. 6. NSCLC vs SCLC NSCLC SCLC Incidence 80% 16% Origin Epithelial cells of the lung Nerve producing cells of the lung (bronchi) Classification  Squamous cell  Large cell  Adenocarcinoma  Limited stage  Extensive stage Metastatic potential Less than SCLC Rapid metastatic potential Treatment  Surgery  Chemotherapy  Radiotherapy  Chemotherapy  Radiotherapy 5 year survival  Stage I : 57 – 67%  Stage II : 39 – 55%  Stage III : 5 – 25%  Stage IV : < 1%  Limited 20%  Extensive < 1%
  7. 7. 5 Year Survival Rates – By Stage • Non-Small Cell Lung Cancer • IA 58-73% • IB 43-58% • IIA 36-46% • IIB 25-36% • IIIA 19-24% • IIIB 7-9% • IV 2-13% • Small Cell Lung Cancer • Limited 18-38% • Extensive 1%
  8. 8. Patho physiology • Small cells with scant cytoplasm • Ill- defined cell borders • Finely granular nuclear chromatin • Absent or inconspicuous nucleoli • Extensive Necrosis • High mitotic count
  9. 9. Staging system • To determine whether thoracic radiation should be incorporated in conjunction with chemotherapy for localized disease • Two types of classification – The tumour-node-metastases (TNM) classification – The VA Lung Study Group (VALSG) limited disease- extensive stage (LD-ED) system. • Most Commonly used
  10. 10. • Limited stage disease (LD) – Confined to the ipsilateral hemithorax – All known disease can be encompassed within a single radiation port • Extensive stage disease (ED) – Disease in the contralateral hemithorax and distant metastases Staging system
  11. 11. Management of Limited Stage Disease
  12. 12. Limited Stage Disease • Chemoradiotherapy is indicated as the initial treatment. • Four cycles of chemotherapy is the mainstay of treatment for patients with SCLC • In addition to chemotherapy, there is a significant role for radiation therapy (RT)
  13. 13. Chemotherapy • Current Standard Regimen – Cisplatin 80 mg/m2 IV on day 1 – Etoposide 1000 mg/m2 IV on day 1,2 & 3 • • 21 day Cycle for Four Cycles
  14. 14. Other Chemotherapy Regimens • Irinotectan + Cisplatin • Paclitaxel + Etoposide + Carboplatin • Carboplatin+ Etoposide + Vincristine for 6 cycles
  15. 15. • The timing of radiotherapy is best when it is used concurrently with chemotherapy early after the beginning of treatment • 5-year survival rate of about 20% has been reported for LD cases. • Recommended dose: 45Gy twice daily 1.5Gy fractions over 3 weeks (accelerated hyperfractionation) Thoracic Radiotherapy
  16. 16. Thoracic radiotherapy • Delivery at the second cycle of chemotherapy • For patients with either a PS or very bulky disease, delay the initiation of RT until the third cycle of chemotherapy
  17. 17. Role of PET in LD • PET may have a role in designing radiation treatment volumes • PET- based involved nodal radiation results in a low rate of isolated nodal failures (3%), with a low percentage of acute esophagitis
  18. 18. Prophylactic cranial irradiation (PCI) • Used for the purpose of controlling microscopic brain metastases in the treatment of SCLC • Rate of brain metastasis is significantly reduced by PCI
  19. 19. PCI- Clinical Facts • 2-year rate of brain metastasis decreases from 67% in the control group to 40% in PCI group (p<10 -13 ) • 2-year cumulative rate of brain metastasis as an isolated first site of relapse decreased from 45% to 19% (p<10 -6 ) • 2-year rate of OS increased from 21.5% to 29% in the control group (P=0.14). Arriagada R, Le Chevalier T, Borie F, et al. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. J Natl Cancer Inst. 1995;87(3):183-190.
  20. 20. • Meta-analysis on 987 patients with SCLC – PCI was associated with an absolute decrease of 25.3% in the cumulative incidence of brain metastasis at 3 years – An absolute increase in OS of 5.4% at 3 years • PCI has become standard practice for patients with SCLC who have complete remission after chemo radiotherapy of the primary thoracic tumor PCI- Clinical Facts Auperin A, Arriagada R, Pignon JP, et al. Prophylactic cranial irradiation for patients with small-cell lung cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J Med. 1999;341(7):476-484.
  21. 21. Recommended dose for PCI • The standard dose of PCI should be 25 Gy in 10 fractions within 2 weeks • A dose of 30 Gy over 3 weeks may be an acceptable alternative
  22. 22. Extensive Stage Disease • Systemic chemotherapy- Primary Modality • Prophylactic cranial irradiation - in patients who have responded to systemic chemotherapy • Thoracic radiation – increas3 the percentage of long-term survivors.
  23. 23. Management of Extensive Stage Disease
  24. 24. • Median survival for patients with ES-SCLC is about 8 to 13 months • Less than 5 percent of those with ES-SCLC survive beyond two years
  25. 25. Chemotherapeutic Regimens used in ED • Platinum plus etoposide – Cisplatin plus etoposide (PE) – Carboplatin plus etoposide (CE) • Cisplatin plus irinotecan – Cisplatin (60 mg/m2 on day 1) plus irinotecan (60 mg/m2 on days 1, 8, and 15) every four weeks – Significantly higher response rate compared with the etoposide-based regimen (84 versus 68 %), longer median survival (12.8 versus 9.4 months)
  26. 26. • Carboplatin plus irinotecan • Topotecan plus cisplatin • Epirubicin plus cisplatin • Paclitaxel + Cisplatin + Etoposide Chemotherapeutic Regimens used in ED
  27. 27. • Four Drug Regimen – Etoposide (100 mg/m2 on days 1 to 3) plus – Cisplatin (100 mg/m2 on day 2) – Cyclophosphamide (400 mg/m2 on days 1 to 3) – Epirubicin (40 mg/m2 on day 1) • Administered every four weeks for six courses • Significant increases in response rate (76 versus 61%) and survival (median 10.5 versus 9.3 months and one-year 40 versus 29 %) Chemotherapeutic Regimens used in ED
  28. 28. Thoracic Radiotherapy for ES- SCLC • Role of TRT in ES-SCLC is unclear • It is typically not considered part of the standard of care • Some preliminary evidence suggests that adding TRT to chemotherapy improves the survival of patients with ES-SCLC • PCI is recommended
  29. 29. Summary of SCLC Management • T1N0, pathologic stage T1-T2N0 limited- stage disease – lobectomy and nodal dissection or nodal sampling, followed by – Chemotherapy, followed by – PCI
  30. 30. • Nodal positive LS-SCLC (cT-1-4pN1- 3M0) – Concurrent TRT. – PCI should be recommended for patients with good treatment response – TRT should start concurrently during the 1st or 2nd cycle of chemotherapy – 45 Gy given in BID 1.5 Gy fractions is the preferred regimen Summary of SCLC Management
  31. 31. • ES-SCLC – TRT may be recommended in patients after 4-6 cycles of chemotherapy, – Particularly when PCI is planned, and local thoracic disease is remarkable, or causing local symptoms – 30-54 Gy in 2-3 Gy daily is the preferred regimen. Summary of SCLC Management

×