How do you manage multiple brain metastases from small cell lung cancer?

In general, I think WBRT is a reasonable treatment for small-cell lung cancer (SCLC) brain metastases. That being said, our institution has considered SRS for select patients depending on a variety of factors as the treatment paradigm for this is evolving. There have been some studies addressing SRS for SCLC brain metastases - the FIRE-SCLC study (Rusthoven et al., PMID 32701125) was a multicenter cohort study that reported first line SRS and first line WBRT in SCLC patients with brain metastase...

In our precedent study to FIRE-SCLC that looked at SRS salvage following WBRT and SRS alone (Cifarelli et al., PMID 31599324), we reported a median number of mets treated as 2 with an IQR:[1-5].

"On univariate analysis, the only factor significantly associated with distant brain control was number of lesions treated with SRS (1-yr distant brain control 65% for SRS to ≤2 lesions vs 36% for GKRS to >2 lesions, P = .001). However, on multivariate analysis, this effect was not confirmed."

One factor ...

We manage small cell lung cancer based primarily on the overall health of the patient, KPS, and volume of brain disease compared to volume of disease in the body. If they present with a large systemic burden urgently (i.e., liver disease, compressive lesions in the chest), we actively pursue urgent chemotherapy and short-interval observation given the high response rate in the brain. If there is a minimally symptomatic or symptomatic lesion in the brain or higher volume disease, we typically off...

Distant failure for SRS vs WBRT for some defined number of brain mets in SCLC may not be the sole appropriate goal. Endpoints should include duration of functional independence, harm from re-treatment with SRS salvage for the SRS and WBRT arm (not common), harm from WBRT including worsening fatigue, and factors such as the extent and control of extracranial disease at the time of treatment should be taken into account as it relates to re-seeding vs. distant failure of cells already in the brain,...

I think it is more about total volume (30 cc seems reasonable), rather than total number. But frankly SRS for SCLC is not new, multiple papers on it over the years, just now NRG-CC009 to add to and strengthen the existing data suggesting that SRS is a good first choice for patients. Many in the field have been doing SRS for small cell for years, if not a couple of decades, knowing that a pivot to WBRT in the future is always possible if the pace of future progression outweighs a continued SRS ap...

NRG-CC009 has changed the management for patients diagnosed with SCLC by establishing SRS as an appropriate option, similar to patients diagnosed with NSCLC. It's important to note that while the amended trial enrollment did not have an upper limit of brain mets, the median number of brain metastases treated on trial with SRS was 2. This low intracranial burden is inherently a favorable population for SRS. Thus, while SRS would be first-line for most patients with limited brain mets, patient sel...

Personal and institution experience.