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ROLE OF RADIATION IN SMALL CELL
LUNG CANCER
Dr Bharti Devnani
Moderator:- Dr Sheh Rawat
Staging of SCLC depends on radiation portals
(Veteran’s administration lung group)
Limited Stage
Disease confined to I/L h...
Definitive (For LS)
Thoracic radiation as a part of CCRT
Adjuvant RT
Node positive cases after lobectomy
Prophylactic cran...
ROLE OF THORACIC RADIATION IN
LIMITED STAGE
EVOLUTION
Before the introduction of chemo in 1970,
RT was the mainstay of treatment
CT
More local recurrences with chemo ...
EVIDENCE FOR THORACIC RADIOTHERAPY
25-30% reduction in the local recurrence with 5-7% increase in 2 year survival
with add...
ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
...
ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
...
Takada et al.J Clin Oncol 2002; 20:3054-60.
Better outcome with CCT with a trend towards improved OS.
Concurrent RT redu...
ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
...
Benefit in 2 year survival rate with early RT(within 9 weeks or before 3rd cycle)
Factors which have significant impact on the benefit
of early RT were:-
 Type of chemotherapy
 The fractionation scheme
Concept of SER
Start of any treatment
until the end of
radiotherapy
Cancer Treat Rev 2007; 33:461-73.
 Significant 2 & 5 years improvement in survival when
RT was started within 30 days of ...
Early and concurrent chemoradiation is preferred over
late and sequential schedule.
ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
...
High chances of local recurrence with conventional
RT, attempts made to improve the outcome by:-
Hyperfractionated
Acceler...
417 patients LS-
SCLC
45 Gy at 1.5
Gy/#B.D.x3weeks
45 Gy/25# at 1.8
Gy/# x5 weeks
Grade -3
Esophagitis
(27%v/s 11%)
P<0.001
ONGOING TRIALS (HYPERFRACTIONATION &
DOSE ESCALATION)
ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
...
RT PORTALS
 PET based planning should be used. (PET at the
time of radiotherapy planning or within 4 weeks)
 GTV = Post ...
ROLE OF THORACIC RT IN
EXTENSIVE STAGE
CR at distant sites and
any response at local
site (n=210)
CT
+
RT= 54 Gy/36#
CT alone
Median survival-17 months v/s 11 mo...
PROPHYLACTIC CRANIAL
IRRADIATION
Rationale
 Frequent brain mets in SCLC
 20 %- at diagnosis
 80%- during the course of the disease
 Once symptomatic- r...
Incidence of brain metastasis decreased by 25% at 3 years (58.6% v/s
33.3%)
5.4 % survival benefit with addition of PCI
PCI IN EXTENSIVE STAGE DISEASE
14.6 % v/s
40.4%
27.1% v/s 13.3%
at 1 yr
DOSE OF PCI
Limited stage
25 Gy/10#
24 Gy/8#
30Gy/15#
Extensive stage
25 Gy/10#
Shorter fractionation scheme of 20 Gy/5# c...
ROLE OF RT IN ADJUVANT SETTING
ROLE OF RT IN PALLIATION (EXRT)
RADIATION FOR BRAIN METASTASIS
WBRT- 30Gy/10#
BONE METS & PATHOLOGICAL FRACTURE
30 Gy/10#
20Gy/5#
24Gy/6#
8 Gy single fraction
ROLE OF RADIATION IN ONCOLOGIC
EMERGENCIES IN SCLC
SPINAL CORD COMPRESSION
30Gy/10#
SUPERIOR VENA CAVA OBSTRUCTION
 Symptomatic relief in
70-90% cases with
radiotherapy alone.
 Dose- initial high dose
fra...
ROLE OF ENDOBRONCIAL
BRACHYTHERAPY - HEMOPTYSIS
TAKE HOME MESSAGE
LS-SCLC
Concurrent CCT/RT
Early(1st or 2nd cycle)
Dose-45 Gy @1.5 Gy bd or 50-60 Gy @1.8 Gy once daily
Any response to che...
Thank U
 Santa air hostess se-aapki shakal meri biwi se milti
hai
 Air hostess ne zordar thappad santa k muh pe
mara
 Santa- Ka...
Very Touchy story:
"Husband forgot to wish her on his Wife's birthday.
He came home late at night from the office .....
Hi...
Role of radiation in small cell lung cancer
Role of radiation in small cell lung cancer
Role of radiation in small cell lung cancer
Role of radiation in small cell lung cancer
Role of radiation in small cell lung cancer
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Role of radiation in small cell lung cancer

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Role of radiation in small cell lung cancer

  1. 1. ROLE OF RADIATION IN SMALL CELL LUNG CANCER Dr Bharti Devnani Moderator:- Dr Sheh Rawat
  2. 2. Staging of SCLC depends on radiation portals (Veteran’s administration lung group) Limited Stage Disease confined to I/L hemithorax which could be safely encompassed with in a tolerable RT field. T1, T2, nonmetastatic  Contralateral mediastinal and I/L SCF Extensive stage Beyond I/L hemithorax T3,T4 and metastatic disease
  3. 3. Definitive (For LS) Thoracic radiation as a part of CCRT Adjuvant RT Node positive cases after lobectomy Prophylactic cranial irradiation Palliative EXRT Thoracic Brain mets Bone mets Oncologic emergencies SVCO Spinal cord compression Palliative brachytherapy Endobronchial brachytherapy: Hemoptysis
  4. 4. ROLE OF THORACIC RADIATION IN LIMITED STAGE
  5. 5. EVOLUTION Before the introduction of chemo in 1970, RT was the mainstay of treatment CT More local recurrences with chemo alone CT+RT-Standarad of care
  6. 6. EVIDENCE FOR THORACIC RADIOTHERAPY 25-30% reduction in the local recurrence with 5-7% increase in 2 year survival with addition of radiotherapy Pignon et al NEJM 1992 327;1618-24
  7. 7. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Portals (before chemotherapy v/s shrinking field)  Dose and fractionation schedules (conventional v/s hyperfractionation)
  8. 8. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Portals (before chemotherapy v/s shrinking field)  Dose and fractionation schedules (conventional v/s hyperfractionation)
  9. 9. Takada et al.J Clin Oncol 2002; 20:3054-60. Better outcome with CCT with a trend towards improved OS. Concurrent RT reduces the risk of tumor repopulation and development of resistant clones. Radiosensitizing effect
  10. 10. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Portals (before chemotherapy v/s shrinking field)  Dose and fractionation schedules (conventional v/s hyperfractionation)
  11. 11. Benefit in 2 year survival rate with early RT(within 9 weeks or before 3rd cycle)
  12. 12. Factors which have significant impact on the benefit of early RT were:-  Type of chemotherapy  The fractionation scheme
  13. 13. Concept of SER Start of any treatment until the end of radiotherapy
  14. 14. Cancer Treat Rev 2007; 33:461-73.  Significant 2 & 5 years improvement in survival when RT was started within 30 days of platinum based chemo (2-year survival: HR: 0.73, 5-year survival: HR: 0.65).  This was even more pronounced when the overall treatment time of chest radiotherapy was less than 30 days.
  15. 15. Early and concurrent chemoradiation is preferred over late and sequential schedule.
  16. 16. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Dose and fractionation schedules (conventional v/s hyperfractionation)  Portals (before chemotherapy v/s shrinking field)
  17. 17. High chances of local recurrence with conventional RT, attempts made to improve the outcome by:- Hyperfractionated Accelerated radiotherapy Dose escalation
  18. 18. 417 patients LS- SCLC 45 Gy at 1.5 Gy/#B.D.x3weeks 45 Gy/25# at 1.8 Gy/# x5 weeks Grade -3 Esophagitis (27%v/s 11%) P<0.001
  19. 19. ONGOING TRIALS (HYPERFRACTIONATION & DOSE ESCALATION)
  20. 20. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Dose and fractionation schedules (conventional v/s hyperfractionation)  Portals (before chemotherapy v/s shrinking field)
  21. 21. RT PORTALS  PET based planning should be used. (PET at the time of radiotherapy planning or within 4 weeks)  GTV = Post induction chemotherapy volume  Omission of elective nodal irradition.  Low rates of local recurrence(11% with only CT based planning, 3 % with PET based planning)  Decreases the esophageal toxicity significantly.
  22. 22. ROLE OF THORACIC RT IN EXTENSIVE STAGE
  23. 23. CR at distant sites and any response at local site (n=210) CT + RT= 54 Gy/36# CT alone Median survival-17 months v/s 11 months Survival rate at 3 years-22% v/s 13% Survival rate at 5 years-9% v/s 4%
  24. 24. PROPHYLACTIC CRANIAL IRRADIATION
  25. 25. Rationale  Frequent brain mets in SCLC  20 %- at diagnosis  80%- during the course of the disease  Once symptomatic- results have been poor.
  26. 26. Incidence of brain metastasis decreased by 25% at 3 years (58.6% v/s 33.3%) 5.4 % survival benefit with addition of PCI
  27. 27. PCI IN EXTENSIVE STAGE DISEASE 14.6 % v/s 40.4% 27.1% v/s 13.3% at 1 yr
  28. 28. DOSE OF PCI Limited stage 25 Gy/10# 24 Gy/8# 30Gy/15# Extensive stage 25 Gy/10# Shorter fractionation scheme of 20 Gy/5# can be used. Dose>30 Gy should be avoided due to high risk of neurotoxicity
  29. 29. ROLE OF RT IN ADJUVANT SETTING
  30. 30. ROLE OF RT IN PALLIATION (EXRT)
  31. 31. RADIATION FOR BRAIN METASTASIS WBRT- 30Gy/10#
  32. 32. BONE METS & PATHOLOGICAL FRACTURE 30 Gy/10# 20Gy/5# 24Gy/6# 8 Gy single fraction
  33. 33. ROLE OF RADIATION IN ONCOLOGIC EMERGENCIES IN SCLC
  34. 34. SPINAL CORD COMPRESSION 30Gy/10#
  35. 35. SUPERIOR VENA CAVA OBSTRUCTION  Symptomatic relief in 70-90% cases with radiotherapy alone.  Dose- initial high dose fractionation of 3- 4 Gy followed by 1.8 Gy fractionation
  36. 36. ROLE OF ENDOBRONCIAL BRACHYTHERAPY - HEMOPTYSIS
  37. 37. TAKE HOME MESSAGE
  38. 38. LS-SCLC Concurrent CCT/RT Early(1st or 2nd cycle) Dose-45 Gy @1.5 Gy bd or 50-60 Gy @1.8 Gy once daily Any response to chemo-PCI to a dose of 25 Gy/10# ES-SCLC Any response to chemo- PCI-25 Gy/10# or shorter 20 Gy/5# can be used. Possible value of local RT are the subject of ongoing investigation. Palliation
  39. 39. Thank U
  40. 40.  Santa air hostess se-aapki shakal meri biwi se milti hai  Air hostess ne zordar thappad santa k muh pe mara  Santa- Kamal hai, Aadat bhi milti hai
  41. 41. Very Touchy story: "Husband forgot to wish her on his Wife's birthday. He came home late at night from the office ..... His wife shouted: How would u feel if u dont see me for next few days? He couldnt believe his luck. He replied at once.'' Wowww.....That would be great..!'' Monday passed & he didn't see her. Tuesday he didnt see her . . & wednesday passed too . . On Thursday the swelling was better & he could see her from the corner of his left eye...

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