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Management of Small Cell Carcinoma of Lung ,[object Object],[object Object],[object Object],[object Object]
Introduction ,[object Object],[object Object],[object Object],[object Object]
Classification: WHO 1999 Source: Brambilla et al The new World Health Organization classification of lung tumours Eur Respir J 2001; 18:1059-1068 “ SCLC presents a proliferation of small cells ( <4 lymphocytes in diameter ) with unique and strict morphological features....”  Primary epithelial lung cancers Small Cell (Oat Cell Type) Non Small Cell type ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Relevant Anatomy ,[object Object],[object Object]
Nodal Anatomy Data from Autopsy Series Kunz et al 1985
Nodal Drainage
Epidemiology ,[object Object],[object Object],[object Object],[object Object]
Cell of Origin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Carcinoid Atypical Carcinoid SCLC
Etiology ,[object Object],[object Object],[object Object],[object Object],Data from Annual Report to the Nation on the Status of Cancer, 1973-1996, With a Special Section on Lung Cancer and Tobacco Smoking Wingo et al JNCI Journal of the National Cancer Institute 1999 91(8):675-690;
Clinical Features: Thoracic Disease Local Symptoms Cough Dyspnea Chest Pain Mediastinal Involvement Hoarseness Retrosternal Chest pain Vocal Cord Palsy Horner's Syndrome Superior Vena Caval Syndrome Hemoptysis Post obstructive Wheezing
Hemaotogenous Metastasis ,[object Object],[object Object]
Clinical Features: Extrathoracic  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Features: Extrathoracic  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Paraneoplastic Syndromes Cancer Cachexia Endocrinological Syndromes Neurological Syndromes Musculoskeletal Syndromes Dermatological Syndromes Hematological and Vascular ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Tit-bits on some syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Neurological Syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Neurological Syndromes.. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],MG LEMS
Neurological Syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Investigative Workup ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Evolution of pathological classification
Gross Pathology ,[object Object],[object Object],[object Object],[object Object]
Microscopic pathology ,[object Object],[object Object],[object Object],[object Object],[object Object]
Combined SCLC ,[object Object],[object Object],[object Object],[object Object]
Chest X rays Pleural Effusion Phrenic Nerve palsy Mass Collapse
Radiology Miller WE: Roentgenographic manifestations of lung cancer. In Strauss MJ (ed): Lung Cancer: Clinical Diagnosis and Treatments, 2nd ed. New York, Grune and Stratton, 1983.
CT scan Mass Pleural Effusion Node Necrosis Mediastinal Shift
Staging ,[object Object],[object Object],[object Object],[object Object]
VALSG Definition ,[object Object],[object Object],[object Object],[object Object],[object Object]
VALSG vs ISALC : LD
Controversies in Staging ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prognostic Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of SCLC
Treatment Outline SCLC Stage Localized Disease Extensive Disease Radiation Therapy (Curative intent ?) + Systemic Combination Chemotherapy Systemic Combination Chemotherapy + Palliative Radiation  +  Palliative Care and Support
Radiation Sensitivity Source: Radiation Biology of Lung Cancer; Sullivan et al JCB supp24
Radiation Biology ,[object Object],[object Object],[object Object],[object Object]
Role of Radiation therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Dose Time Fractionation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Planning RT for Localized SCLC ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Palliative Radiotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Manual Marking ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Guidelines for RT planning ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Portal arrangements Upper Lobe Middle Lobe Lower lobe
Critical organs and doses
Results of Thoracic RT ,[object Object],[object Object],[object Object],[object Object],[object Object]
Results
Effect of palliative RT
Changing Paradigms of R x  Paradigm 1 : Surgery as Standard Treatment Paradigm 2 : Thoracic radiation better than Surgery Paradigm 3 : Thoracic Irradiation with adjuvant Chemotherapy  Paradigm 4 : Combination chemotherapy with adjuvant Radiotherapy  Paradigm 5 : Integrated Chemotherapy and Radiation therapy
RT results 2 yr survival 2 yr local control
Is TRT needed? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Is TRT needed ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Is TRT needed ,[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Addition Thoracic Radiation is definitely indicated in Limited Stage SCLC both to improve LC and OS
?? Controversies ?? ,[object Object],[object Object],[object Object],[object Object]
Ideal Volume
Deciding the treatment volume ,[object Object],[object Object],[object Object],[object Object],[object Object]
Intrathoracic Volume Incorporation ,[object Object],[object Object],[object Object],Conclusion : Failure to include opposite mediastinal and hilar nodes in the treatment volume can lead to significant  intrathoracic failures Data from While J et al Impact of Radiation therapy quality control in LC in SCLC
Post CCT or Pre CCT volume? 21/5/1977 6/7/1977 26/8/1977 11/10/1977 26/10/1977
Pre CCT vs Post CCT volume ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : It is safe to irradiate only the post CCT volume.
Portal Design ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Customized portal designing is unlikely to add to control
Time, Dose & Fractionation
Dose and Fractionation of Radiation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Dose of Radiotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Altered Fractionation  Conclusion : Altered fractionation with split  course is not effective
Continuous AF schemes Conclusion : Sadly Continuous AF is too toxic for routine use !!!
Sequencing with CCT
Sequencing with CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CRT protocols ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Concurrent vs Sequential CCT ,[object Object],[object Object],[object Object],[object Object],[object Object]
Why not Concurrent CRT? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Alternating Chemoradiation ,[object Object],[object Object],[object Object],[object Object],Conclusion : Alternate CRT is inferior to sequential CRT
Early vs Late Thoracic RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Timing of RT
Timing of RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Timing of RT Conclusion : Early Start of RT does lead to a better outcome
Role of PCI
Role of PCI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Benefit from PCI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Meta-analysis ,[object Object],[object Object],[object Object],[object Object]
Toxicity of PCI ,[object Object],[object Object],[object Object],[object Object]
Practice Guidelines ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Chemotherapy
Chemotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Single Agent Chemotherapy
Standard CCT regimens
Cisplatin based CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Alternative CCT regimens ,[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Single agent Topotecan fails to improve  results over those obtained by PE regimen in SCLC when used as 1 st  line approach
Alternative Chemotherapy
Combination CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Toxicity of CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
More intensive CCT ,[object Object],[object Object],[object Object],[object Object]
Alternative Strategies ,[object Object],[object Object],[object Object]
Dose intensification Conclusion : Dose intensification by 25 – 50% over the standard doses fails to improve the survival but increases toxicity significantly
Weekly Chemotherapy Conclusion : Dose intensification by giving weekly CCT fails to improve the survival but increases toxicity significantly
Alternating CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Alternating non cross resistant CCT regimens failed to improve results as compared to standard regimens
Chemotherapy for recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
SVCO in SCLC
SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Radiotherapy in SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Response to RT
Radiotherapy in SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Investigational Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Follow up Goals ,[object Object],[object Object],[object Object]
Follow up Goals ,[object Object],[object Object],[object Object]
Follow Up Protocol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Follow up: Other Issues ,[object Object],[object Object],[object Object],[object Object]
Conclusions ,[object Object],[object Object],[object Object],[object Object]
Thank You

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