This document provides an overview of carcinoma of the lung, beginning with an introduction to lung cancer history and epidemiology. It then covers lung anatomy and bronchopulmonary segments. Details are given on staging, histological types, symptoms, modes of spread, and paraneoplastic syndromes of lung cancer. Small cell lung cancer is introduced, with notes on risk factors and pathological features. Management of lung cancer is also briefly mentioned.

1. CARCINOMA OF LUNG
DR SWEEKRUTI
MODERATOR- DR MAHALAKSHMI

2. FLOW OF PRESENTATION
 INTRODUCTION
 ANATOMY
 EPIDEMIOLOGY
 STAGING
 PARANEOPLASTIC SYNDROMES
 MODE OF SPREAD
 SMALL CELL LUNG CANCER- INTRODUCTION
 SYMPTOMS
 MANAGEMENT
 SUMMARY
 REFERENCES

3. INTRODUCTION
 Lung cancer has been described since as early as 1500 where a deadly disease
lasting for 25 years existed in miners of Germany which was initially described
as occupational disease.
 One of the first descriptions of lung cancer was in 1912 by Adler who went
onto describe 374 cases of primary lung cancer.
 By 1920 about 1 % of all malignancies was lung cancer.
 In 1941 Oschner and Debakey stated that increase in the pulmonary
carcinoma was attributed to increase in smoking and further evidence was
provided by Doll and Hill.

4. ANATOMY
 The lungs are situated on each side of the mediastinum, which contains
the heart, trachea, esophagus, and great vessels.
 LUNG - apex - towards the neck, 2-3 cm above clavicle
- base - over diaphragm
- surfaces : costal - along the chest wall
: mediastinal - molded to the heart and other
mediastinal
structures.
 Pleura – visceral : cover the lungs
parietal : cover the inside of the chest
 Lobes – Right lung : 3 – upper, middle, lower
Left lung : 2 – upper, lower

5.  Fissures – Right lung : horizontal/minor, oblique/major
Left lung : oblique
Oblique fissure: forward and downward from approximately the level of the fifth
thoracic vertebral body to the diaphragm, dividing the lungs into upper and
lower lobes.
Horizontal fissure: separates the right middle from the right upper lobe, fanning
out forward and laterally from the hilum.

7. BRONCHOPULMONARY SEGMENTS

8. ARTERIAL AND VENOUS DRAINAGE
 Bronchial arteries supply bronchial tree and pulmonary tissue.
 Right side -1 bronchial artery from third right posterior intercostal artery.
 Left side- 2 bronchial arteries- arising from descending thoracic aorta.
 Venous drainage- first and second divisions of bronchi is from bronchial veins.
 Right bronchial veins drains into azygous vein.
 Left bronchial vein drains into hemiazygos vein.
 The greater part is drained by pulmonary veins.

9. NODAL STATIONS (IASLC)

11. EPIDEMIOLOGY
 Lung cancer accounts for 13% of total cases of cancer and 18% of cancer
related deaths.
 Among males it is the most commonly diagnosed cancer and cause of death
whereas in females it is the fourth most commonly diagnosed cancer.
 Incidence and mortality rate for lung cancer rose from 1930s to 1990 and then
it began to drop with great gender disparity in terms of incidence since then.

12. ETIOLOGY

13. STAGING
 T STAGING
 Tx - Primary tumor cannot be assessed, or tumor proven by the presence of malignant
cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy
 T0 - No evidence of primary tumor
 Tis - Carcinoma in situ
- SCC in situ
- Adenocarcinoma in situ, Adenocarcinoma with pure lepidic pattern =< 3cm in
greatest dimension.
 T1 - Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura,
without bronchoscopic evidence of invasion more proximal than the lobar bronchus
(i.e., not in the main bronchus)

14.  T1mi- Minimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension)
with a predominantly lepidic pattern and ≤5 mm invasion in greatest
T1a - Tumor is ≤1 cm in greatest dimension
T1b - Tumor >1 cm but ≤2 cm in greatest dimension
T1c - Tumor >2 cm but ≤3 cm in greatest dimension
 T2 - Tumor >3 cm but ≤5 cm or having any of the following features: involves the main
bronchus but without involvement of the carina, irrespective of its distance from
carina ; invades the visceral pleura; or associated with atelectasis or obstructive pneumonitis
that extends to the hilar region, involving part or all of the lung
T2a - Tumor >3 cm but ≤4 cm in greatest dimension
T2b - Tumor >4 cm but ≤5 cm in greatest dimension
 T3 - Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the
following: parietal pleura, chest wall (including superior sulcus tumors), phrenic nerve,
parietal pericardium, or separate tumor nodule(s) in same lobe as the primary
 T4 -Tumor >7 cm or tumor of any size of that invades diaphragm, mediastinum, heart,
great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina;
separate tumor nodule(s) in an ipsilateral lobe different from that of the primary

15. N AND M STAGING
 N0 No regional lymph node involvement
 N1 Involvement of ipsilateral intrapulmonary, or peribronchial, hilar lymph nodes (STATION
10 -14)
 N2 Involvement of mediastinal or subcarinal lymph nodes (STATION 2-9)
 N3 Involvement of contralateral mediastinal or hilar lymph nodes. Involvement of ipsilateral
or contralateral scalene or supraclavicular nodes (STATION 1)
 M0 No distant metastasis
 M1 Distant metastasis present
M1a Separate tumor nodule(s) in a contralateral lobe; tumor with pleural or
pericardial nodule(s) or malignant pleural or pericardial effusion. Microscopically confirmed.
M1b Single extrathoracic metastasis. Microscopically confirmed.
M1c Multiple extrathoracic metastases in one or several organs. Microscopically
confirmed.

18. GROUP STAGING

19. CHANGES

20. HISTOLOGICAL TYPES
Histological Type Percentage involved characteristics
Non small cell lung
cancer
Adenocarcinoma(lepcidic
, acinar, papillary,
micropapillary, colloid ,
mucinous)
Squamous cell carcinoma
80
40
25
Peripheral
Central and more with
smoking
Large cell carcinoma
Small cell cancer
10
15
Peripheral
Central, massive
lymphadenopathy and
with paraneoplastic
sydromes
Other types (such as
carcinoid)
5 varies

21. Pathological staging
 In accordance with IASLC recommendations adopted by the AJCC, when pathologic staging of
lymph nodes is pursued sampling of the following lymph nodes are taken:
For Right sided lung cancer (upper & middle lobe) :
1. Para tracheal (stations 2R and 4R)
2. Subcarinal (station 7),
3. hilar (station 10R)
4. interlobar lymph nodes (station 11R)
 Stations 2 ,4 ,7 ,10 , 11
For Left sided lung cancer (upper lobe) :
1. aortopulmonary window (station 5)
2. ascending aorta (station 6)
3. subcarinal (station 7)
4. hilar (station 10L)
5. interlobar (station 11L)
 Stations 5 ,6 ,7 ,10 , 11

22. SYMPTOMS
 INTRATHORACIC SPREAD
 Intrathoracic effects of lung cancer – cough (most common),
dyspnea, hemoptysis and chest pain.
 The central etiology for many symptoms is owing to a growing
tumor involving the airway. Cough occurs most frequently in
patients with squamous cell and small cell carcinomas
because of their tendency to involve central airways.
 Dyspnea may also be due to the development of atelectasis,
postobstructive pneumonia, or a pleural or pericardial
effusion.

23.  Chest pain may be attributed to direct extension to the mediastinum, parietal
pleura, or chest wall.
 Pleuritic pain may also be the result of obstructive pneumonitis or a pulmonary
embolus related to a hypercoagulable state ( trousseau sign of
malignancy/migratory thrombophlebitis).
 Involvement of the recurrent laryngeal nerve along its course under the arch of
the aorta can result in hoarseness.
 Irritation of the phrenic nerve may initially produce hiccups, and progressive
damage can produce unilateral paralysis of the diaphragm with shortness of
breath.

24.  Obstruction of the superior vena cava (SVC) from primary tumor or
mediastinal lymphadenopathy causes symptoms that commonly include a
sensation of fullness in the head and dyspnea.
 Physical findings include jugular venous distension and occasionally swelling
of the face and arms.
 SVCO– more common in SCLC

26.  73 year old male presented with difficulty in breathing and cough.
 He was evaluated and diagnosed with carcinoma of lung with superior vena
caval obstruction.
 Was planned and treated with EBRT- 30Gy/10Fr to the mediastinal mass.

27.  EXTRATHORACIC SPREAD
 Contralateral lung, liver, bone, adrenals, and brain are the most
frequent sites of distant disease.
 Asymptomatic liver metastases may be detected at presentation
by liver enzyme abnormalities or on staging workup imaging.
 Bone metastasis-
1. ALP Increased
2. S.calcium increased
3. Osteolytic lesion > osteoblastic one, although a mixed picture is
common. (note: NSCLC- osteolytic, SCLC- osteoblastic)
4. most common site- vertebral bodies
 Adrenal metastasis- asymptomatic & benign.
PET can distinguish b/w adenoma and malignant

28.  Brain metastasis:
1. symptoms include headache, vomiting, visual field loss, hemiparesis, cranial
nerve deficit, and seizures.
2. In NSCLC, Adenocarcinoma- MC
SCC- least common
3. In patients with SCLC, metastasis to brain is present in approximately 20% to 30%
of patients at presentation.

29. PARANEOPLASTIC SYNDROMES
 A paraneoplastic syndrome is a disease or symptom that is the consequence of
cancer cells in the body but is not attributable to the local presence of tumor.
These phenomena are thought to be mediated by humoral factors secreted by
tumor cells or by an immune response against the tumor.
 Associated syndromes – Cushing’s syndrome
 SIADH
 Hypercalcemia
 Lambert-Eaton syndrome
 HPOA

30. Cushing’s Syndrome
 Ectopic production of adrenocorticotropic hormone (ACTH).
 Patients typically presents with:
1. muscle weakness/wasting
2. hyperpigmentation
3. weight loss
3. Hypertension
4. hirsutism
5. Osteoporosis
6. Hypokalemic alkalosis
7. hyperglycemia.
8. Acanthosis nigricans over axilla, neck.
 Cushing syndrome is relatively common in patients with SCLC and with carcinoid tumors of the lung.
 SCLC patients with Cushing syndrome appear to have a worse prognosis than those without Cushing
syndrome.

31. Syndrome of inappropriate antidiuretic
hormone.
 The syndrome of inappropriate antidiuretic hormone (SIADH)
secretion is frequently caused by SCLC and results in hyponatremia.
 Approximately 10% of patients who have SCLC exhibit SIADH, and
SCLC accounts for approximately 75% of all SIADH.
 Symptoms include:
1. headache
2. muscle cramps,
3. Anorexia
4. decreased urine output.
5. If left untreated, cerebral edema can develop, leading to mental
status changes, coma, seizures, and respiratory arrest.
 Besides treating the underlying cancer, demeclocycline is the agent
of choice.

32. Hypercalcemia
 Hypercalcemia in patients with lung cancer may be
attributable to the secretion of a parathyroid hormone–
related protein (PTHrP), calcitriol, or other cytokines,
including osteoclast-activating factors
 squamous cell carcinoma >adenocarcinoma >SCLC
 Symptoms of hypercalcemia include:
1. anorexia,
2. nausea/vomiting
3. Constipation
4. Lethargy
5. Polyuria, polydipsia,
6. dehydration.
 Renal failure, confusion, and coma are late manifestations.

33. Lambert-Eaton Myasthenia Syndrome
(LEMS)
 Lambert-Eaton myasthenic syndrome (LEMS) is an
autoimmune disorder characterized by muscle weakness of
the limbs that improves with repeated testing, in contrast
to myasthenia gravis, which worsens with repetition.
 Proximal muscles are predominantly affected, and patients
complain of difficulty climbing stairs and rising from a
sitting position.
 SCLC accounts for approximately 60% of all LEMS.
 The neurologic symptoms of LEMS precede the diagnosis of
SCLC in >80% of cases, often by months or years.

34. Hypertrophic Osteoarthropathy
 Is defined by clubbing and periosteal proliferation of the tubular bones.
 HPO is further characterized by a symmetrical, painful arthropathy that
usually involves the ankles, knees, wrists, and elbows.
 People with hypertrophic osteoarthropathy may have bone scans showing
parallel lines of activity along the cortex of the shafts and ends of tibiae,
femurs and radii; especially around the knees, ankles and wrists.
 MC in Adenocarcinoma.

35. SPREAD
 SPREAD : 3 WAYS – DIRECT EXTENSION
LYMPAHTICS ( REGIONAL)
HEMATOGENOUS ( DISTANT)
 METASTATIC SITES- lymph nodes, liver, adrenals, Bones, Brain, kidney,
pancreas, lung, pleura.
 Adrenals- 50%
 Liver-30 to 50%
 Brain – 20%
 Bone- 20%

36. SMALL CELL LUNG CANCER

37. SCLC-INTRO
 Small cell lung cancer contributes to 15% of total lung cancer.
 SCLC is a rapidly progressing disease with high recurrence rates and poor
outcomes
 The incidence of SCLC as reported by SEER database has declined from 17% to
13% in the past 30 years.
 Tobacco exposure causes SCLC in over 97% of the cases.
 The incidence of SCLC peaked in men during 1980s and since has been
trending down but now the gender gap has narrowed down and currently half
of the patients diagnosed with SCLC are women.
 5 year survival has increased from 4.9% to 6.4%and median survival has
remained stable over the years at 7 months.

38.  Risk factors-
 tobacco exposure – 80 to 90%
 Indoor radon exposure
 Occupational and environmental carcinogens:
arsenic
 - polycyclic hydrocarbons
 -asbestos

39. PATHOLOGY
 Light microscopy- dense sheets of small cells, scant
cytoplasm, fine granular nuclear chromatin, absent nucleoli
and frequent mitoses- small round blue cell tumor.
 Necrosis is present
 Nuclear molding is characteristic
 High proliferation rate- mitotic count of 60-80 per 2mm2 and
ki 67 index of 80-100%.
 Component of NSCLC including adenocarcinoma, squamous
cell,large cell, spindle cell or giant cell carcinoma is present –
combined SCLC- 28% of cases.

40.  IMMUNOHISTOCHEMISTRY-
 Neuroendocrine markers- chromogranin, synaptophysin, CD-56
 However upto 10% of SCLC may be negative.
 New markers- INSM1 still under evaluation.
 TTF-1 positive in 70 - 80% of cases of SCLC.

41. SYMPTOMS
 Fatigue most common
 Decreased physical activity
 Cough
 Dyspnea
 Decreased appetite and weight loss.
 SVCO- 10 % of SCLC cases.
 Most patients present with metastases- most common are bone metastases- lytic
lesions > brain mets> hepatic and adrenal mets.

42.  Paraneoplastic syndromes are more commonly associated –
 SIADH-75% but symptomatic only in 5% of the cases.(good response to
chemotherapy)
 Increased levels of ACTH in 50% of cases but only 5% have cushings syndrome and if
presented with same, then they have limited survival.
 Hypercalcemia is rare.
 Neurological PNS (poor response to antineoplastic therapy)
 - Subacute peripheral sensory neuropathy
 - LEMS
 -cerebellar degeneration
 - retinopathy

43. STAGING
 LIMITED- disease confined to the hemithorax and regional nodes and can
be encompassed in a tolerable radiation field.
 No malignant pleural effusion
 1/3 rd patients present with this stage.
 Median survival of 23 months
 EXTENSIVE- disease that has metastasized and cannot be encompassed in a
tolerable radiation port.
 Have malignant pleural effusion.
 Median survival of 8-9 months.

44. PREDICTIVE AND PROGNOSTIC FACTORS.
 Females have better response and survival
 Paraneoplastic cushing syndrome has poor outcome
 Continued use of tobacco during treatment is a poor predictive factor.
 Increased LDH level in 33-57% and is a negative prognostic factor.
 Circulating tumor cell enumeration is tried as a factor.
 Metastatic sites and number also is a prognostic factor.

45. MOLECULAR CHARACTERIZATION
 Characterized by mutations in TP53 and RB1 in all cases.
 Gene amplification of MYC , MYCN and MYCL1and recurrent gene fusion of MYCL1
and may be drivers of oncogenesis.
 Inactivating mutations of NOTCH family genes in 25%.
 Inactivation of PTEN
 Amplification of SOX-2 in 27% of cases.
 Increased levels of c-KIT, BCL-2 and BIM and BAX.
 Also elevated were PARP enzyme, chk-2 and serine/threonine kinase ATM
proteins.
 Tumor specific methylation noted in NEUROD1, HAND1, REST and BCL-2
 BET proteins are expressed in SCLC.

46. INVESTIGATIONS
 IASLC recommends 3 step procedures –
 Step 1- history and examination
 plain radiographs of chest
 blood tests – CBC/ LDH/ Calcium/ LFT
 Step 2- CECT of chest and upper abdomen
-PET CT scan
- bone scan
- Brain CT /MRI
- bronchoscopy
Step 3- Invasive procedure such as – surgical exploration of mediastinum, pleural space and
pericardium.

47.  CHEST XRAY-
 Posteroanterior and lateral CXR is the first imaging done.
 Information to be used- tumor size
 lobar and segmental location of the tumor
 presence of atelectasis and its extent.
 presence of separate tumor nodules.
 evidence of lymphangitis carcinomatosis.
 relation of the primary tumor to the chest wall
 to see the nodal /intrathoracic and extrathoracic spread.
 SENSITIVITY- 78.3%
 SPECIFICITY- 97%

48.  Contrast CT of chest -
 It should confirm and refine the information obtained from CXR.
 Location of enlarged mediastinal lymph nodes
 It can establish- tumor size and extension
 - presence of separate tumor nodules
 - presence of atelectasis
 - obstructive pneumonia
 - invasion of adjacent structures.
 CT abdomen also done to visualize liver and adrenals.
 Sensitivity- 0.55
 Specificity- 0.81

49.  PET CT- indicated for patients with no signs of metastatic spread on CT.
 Evaluating metastatic spread.
 Sensitivity- 0.88
 Specificity-0.8
 It should provide – presence of normal or abnormal uptake in primary tumour and
quantification with SUV.
 Presence of normal or abnormal uptake in hilar and mediastinal nodes
 Uptake in other parts of the lung or body.
 For assessment of metabolic tumour response after treatment.
 Fibreoptic bronchoscopy – diagnostic in terms of biopsy, brushings, washings and
endobronchial or transbronchial needle aspiration.
 Sensitivity- 0.88 and 0.78 for central and peripheral tumors.
 Staging procedure- shows endobronchial involvement.
 Transthoracic needle aspiration or biopsy- peripheral tumors that remain
undiagnosed- sensitivity- 0.9, specificity- 0.97

50.  Thoracocentesis and cytopathological study for pleural fluid.- explores pleural
cavity, lung surface and mediastinum.
 VATS- also helps in diagnosis and staging and resection of peripheral nodules.
 EBUS-FNA and EBUS-FNA done when- positive mediastinal nodes on CT or PET.
 Suspicion of N1 disease, central tumors >3cm, adenocarcinoma with high PET
uptake.
 Pericardiocentesis/liver and adrenal biopsies/ endoscopies.

51. TREATMENT
Limited
• Concurrent cisplatin and etoposide
(4cycles every 3 weeks) with early RT
during cycle 1 or 2 45 Gy/1.5 Gy
b.i.d. or 60-70 Gy 2Gy/fr
• If CR or near-CR, prophylactic cranial
RT(25 Gy in 10 fx
• If pN0, chemotherapy alone. If pN+,
concurrent chemoradiation
Extensive
• Combination platinum-based
chemotherapy ± palliative RT to
symptomatic sites
• For patients with PR or CR to
chemotherapy, prophylactic
cranial RT (25 Gy in 10 fx)
• consider consolidative thoracic
RT (ex. 30 Gy in 10 fx
(Slotman Lancet 2015))

52. Limited disease
 Standard of care – stage I- resection followed by chemotherapy with 4
cycles of etoposide and cisplatin/carboplatin followed by PCI.
 Combined mortality- 14% reduction in death rate and 5.4%
improvement in 3 year survival than who received chemo alone.
 CTRT- Concurrent cisplatin and etoposide (4cycles every 3 weeks)
with early RT during cycle 1 or 2 45 Gy/1.5 Gy b.i.d. or 60-70 Gy
2Gy/fr
 If complete or near complete remission then prophylactic cranial
irradiation – 25Gy/10Fr

53. Role of surgery
 Favourable survival in stage 1 after resection and adjuvant chemotherapy.
 Reduces the risk of local recurrence after chemoradiation.
 Recent data shows that it may play a role in node negative disease after full
staging and mediastinal evaluation, PET CT and MRI.
 Lobectomy without radiation was associated with 50% of OS.
 After surgery primary mode of failure- distant dissemination.
 JCOG9101 in 2005 : Phase II study of stage I-IIIA SCLC underwent complete
surgical resection followed by adjuvant chemotherapy (EC X 4 cycles)- 3year
OS- 61%.

54. Role of chemotherapy
 Induction chemotherapy is given to reduce the bulk of the disease prior to
thoracic radiation.
 EP(etoposide and cisplatin/carboplatin) regimen was first explored in 1980s
following CAV regimen which has reported response rate of 55% and has lower
side effects even when given with radiation treatment.
 ETOPOSIDE- 100mg/m2 on day 1 and 3 with cisplatin 100mg/m2 or carboplatin
300mg/m2 on day 1.
 Carboplatin with etoposide is considered as first line of treatment for patients
with ES disease and who cannot tolerate cisplatin
 Einhorn et al reported that 2 cycles of consolidation after CAV regimen with 6
cycles produced longer survival than CAV only.

55. ROLE OF RT
 JCOG trial
 Sample size -231
 evaluated concurrent versus sequential chemotherapy and thoracic RT in LS –
SCLC.
 All patients received 45Gy in 1.5Gy (twice daily) and 4 cycles of cisplatin and
etoposide every 4weeks concurrent with radiotherapy or every 3 weeks
sequentially before RT.
 Patients treated concurrently had longer median survival as compared to
patients treated sequentially – 27 months over 20 months.

56.  Fried et al did a meta-analysis that included more than 1500 patients from 7
randomised trials evaluating the timing of RT when given concurrently with
multiagent chemotherapy.
 The use of early thoracic RT with cycles 1 or 2 of chemotherapy was
associated with better 2 year OS as compared to delayed or sequential
chemotherapy and radiation.
 Pignon et al in 1992 was a meta-analysis of 13 trials and sample size of 2140
patients.
 Chemo with or without thoracic radiation
 RT improved OS by 5.4% vs chemo alone.

58.  OS was higher with twice daily arm at 26% at 5 years,
 Local recurrence with twice daily was 36%
 Significant increase in grade 3 esophagitis with no difference in late
toxicity with twice daily arm.
 Dose escalation – described by RTOG 0239 and Choi et al.
 RTOG showed step wise escalation from 50.4 to 64.8 Gy and the
maximum tolerated dose was 61.2 Gy. 2 year OS- 37% and LR Control-
80%.

59.  CONVERT TRIAL- Concurrent once daily versus twice daily radiotherapy. Trial
in 2016
 Sample- 547
 Comparing 45Gy twice daily to 66Gy once daily.
 2 year OS was not significantly different
 Grade 3 esophagitis- 19% in both arms
 Concluded that once daily was an alternative to twice daily radiation
treatment.

60.  VOLUMES PRESCRIBED-
 GTV- Gross primary and nodal disease.
 CTV- GTV +0.5 -1 cm + pre chemo involved nodal disease
 PTV- according to the institution protocol (5mm)
 DOSE prescribed- 45 Gy in 1.5 Gy (twice daily ) or 60-70 Gy at 1-8 to 2.0 Gy
 Followed by PCI.

61. Extensive disease
 Treatment options-
 combination platinum based chemotherapy
 with or without palliative RT to symptomatic sites.
 Partial and complete response to chemotherapy- PCI given
- Consolidative thoracic RT (30Gy/ 10 fr)
 Brain metastases - WBRT (30-37.5Gy in 10-15 Fr)
 Median survival – 12 months
 5year OS- <5-10%

62. ROLE OF RT
 Role of thoracic irradiation was described by multiple trial
 CREST TRIAL- To show the benefit of thoracic irradiation in extensive stage
disease,
 Sample- 498
 Received chemotherapy and had complete response received thoracic RT-
30Gy in 10 fractions and PCI Versus PCI alone.
 OS-2 year of 13% v/s 3%

63.  CREST Trial-
 Sample size- 498 patients
 Randomised to thoracic RT (30Gy in 10 Fr) to no thoracic RT with PCI in all
patients.
 Recurrence in intervention arm was 44% as compared to 80% with no thoracic
RT.
 2 year OS with test arm was 13% versus 3%
 Greater survival benefit with thoracic RT.

64.  Chemotherapy-
 JCOG compared cisplatin and irinotecan with EP regimenas initial treatment
in ES SCLC.
 Sample size- 230
 Median and 2 year survival rate was better with cisplatin and irinotecan and
diarrhea was common with irinotecan and myelosuppression was more
common with EP group.
 ECOG 7593 and several meta-analysis was done to prove the efficacy of
maintenance therapy but they translated to only 2 weeks of benefit and
increased toxicity.

65. PCI
 Brain mets in 18% of SCLC patients.
 Cumulative incidence of 50% over 2 years.
 Brain is the most common site and earliest mets.
 With prophylactic cranial irradiation, risk of brain mets reduces from 59% to 33% at 3 years
with survival benefit of 21%.
 Considered for – LS or ES patient with complete or near complete response to induction
therapy.
 May not be necessary in stage I SCLC
 Standard dose- 25Gy in 10fractions (Intergroup Trial) for LS and 20Gy in 5 fractions for ES.
 Given 4-6 weeks after chemotherapy .
 Hippocampi sparing RT- to reduce RT induced neurotoxicity.
 Toxicity – neurological and intellectual damage

66.  INDICATIONS: GIVEN IN
 Patients with LS stage and with radiological complete remission
 Documented absence of brain mets.
 Good performance status.
 DISADV : long term neurological toxicity difficult to evaluate.
 As demonstrated by Johnson et and and Laukkanen et al neurological deficits
and memory loss was present in long term survivors of SCLC and who had
received PCI.

67.  Trials for PCI
 AUPERIN and EORTC trial- done to define the dose for PCI in 720 patients.
 Patients with limited stage disease with complete response to CTRT
received 25 Gy in 10 fractions , 36 Gy in 18 fractions versus 24 Gy given
twice daily.
 Cumulative incidence of brain mets – 29% in std dose and 23% for higher
dose.
 poor OS with high dose arm
 Establish 2.5 Gy X 10 Fr as preferred regimen.

68. FOLLOW UP
 LIMITED STAGE- they are recommended surveillance body imaging, blood work
and examination every 3 months for 2 years and 6 months for third year
followed by annual testing.
 EXTENSIVE STAGE- after therapy they should be monitored every 2 months for
first year , 3-4 months for year 2 and year 3 , then 6 months for year 4 and 5
then annually.

69. AGENTS UNDER TRIAL
 Temsirolimus and everolimus (m TOR inhibitors) have been tried in recurrent
setting but with no clear benefit.
 Navitoclax and vistusertib are being tried in recurrent SCLC.
 Bevacizumab with EP in untreated ES disease has shown improved progression
free survival but no OS benefit.
 Sunitinib as maintenance therapy in ES disease has shown benefit in terms of
PFS and overall survival.
 Cediranib is being tried in relapsed setting and has shown promising PFS.

70.  CHECK MATE 451 TRIAL - CheckMate 451, a double-blind phase III trial,
evaluated nivolumab plus ipilimumab and nivolumab monotherapy as
maintenance therapy following first-line chemotherapy for ED-SCLC.
 Maintenance therapy with nivolumab plus ipilimumab did not prolong OS for
patients with ED-SCLC who did not progress on first-line chemotherapy.
 Rovalpituzumab Tesirine an antibody drug conjugate against DLL3 is tried in
relapsed setting and achieved good disease control in DLL3 positive patients.

71. CASE SCENARIO
 Mr S, 57 year old male was evaluated for complaints of cough with sputum for 6
months duration.
 CT Thorax – subtotal collapse of upper lobe of left lung
 - multiple enlarged left hilar mediastinal nodes.
 - left pleural effusion.
 FDG PET CT- metabolically active heterogeneously enhancing mass in left hilar
region causing cut off of left upper lobe and segmental bronchus and encasing left
left main bronchus of pulmonary artery.
 Size- 7.4 x 5.4 x 8.9 cm
 Active prevascular, aorto-pulmonary, subaortic, subcarinal and left hilar, left lower
and upper paratracheal nodes and left supraclavicular lymph nodes.
 MRI BRAIN -NAD

72. PRE CHEMO
POST CHEMO

73.  STAGE- Limited Stage- T4N3M0 – STAGE IIIB
 TREATMENT GIVEN AND PLANNED – weekly cisplatin and etoposide given 4
cycles.
 Planned radiation treatment – thoracic radiation treatment- dose
 Followed by PCI- 25Gy/10Fr

74. Summary

76. References
 Perez and Brady 7th edition- principles and practice of radiation oncology.
 AJCC Cancer staging manual 8TH edition.
 Devita, Hellman and Rosenberg’s – principles and practice of oncology- 11th
edition.
 Rehman I, Kerndt CC, Rehman A. Anatomy, Thorax, Heart Left
Anterior Descending (LAD) Artery. [Updated 2021 Jul 26].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482375/
 Glatzer M, Schmid S, Radovic M, et al. The role of radiation therapy in the
management of small cell lung cancer. Breathe 2017; 13: e87–e94.

77. THANK YOU