Topics:
Lung Cancer • Radiation Oncology • Palliation • Neuro-Oncology • Thoracic Malignancies • Stereotactic Radiosurgery • Medical Oncology • Brain Metastases • Small cell lung cancer
Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the completion of concurrent chemoradiation to the chest (or not at all, if the patient is elderly or refuses it). On the one hand, it's a pragmatic approach to avoid delaying chemotherapy, but on the other hand, we know whole brain RT improves survival in limited and extensive stage disease (and maybe for the patients with brain metastasis who were included in these studies but not thought to have brain mets because of the imaging done at the time).
Answer from: Radiation Oncologist at Academic Institution
This excellent question was posed in 2014 and it may be worth re-visiting today in 2020, as interest in the potential role of first-line SRS (without prior WBRT or PCI) has increased for carefully selected patients with small cell lung cancer (SCLC) brain metastases.One important development in the ...
Comments
Radiation Oncologist at Christus St Vincent
Now in 2023, have you become more bullish or less ...
Now in 2023, have you become more bullish or less ...
Radiation Oncologist at Vanderbilt-Ingram Cancer Center
Not to speak for Dr. @Rusthoven, but given the FIR...
Not to speak for Dr. @Rusthoven, but given the FIR...
Answer from: Radiation Oncologist at Community Practice
This is an excellent, and very clinically relevant question, for which I am going to offer a contrarian viewpoint. First of all, as with all patients, we have to define the intent of therapy. If they have small cell lung cancer (SCLC) with a brain metastasis or metastases, all treatments henceforth...
Answer from: Radiation Oncologist at Community Practice
Patients presenting with a solitary, or "limited", visible brain metastasis have extensive disease regardless of performance status or identifiable disease elsewhere. Standard practice is whole brain. The dose and fraction scheme are arguable. The need to start systemic therapy is obvious but usua...
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Radiation Oncologist at Thomas Jefferson University Hospital
Well said, @Andrew T. Turrisi. I subscribe to all ...
Well said, @Andrew T. Turrisi. I subscribe to all ...
Answer from: Radiation Oncologist at Community Practice
At our institution, we have historically used WBRT to manage patients with SCLC and brain metastasis (even if only a single brain metastasis was present on MRI) if they have never received PCI. This practice pattern was largely derived from the exclusion of patients with SCLC from all RCTs testing l...
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Radiation Oncologist at Ohio State University James Cancer Center
This is a great trial! Can't wait to see the resul...
This is a great trial! Can't wait to see the resul...
Answer from: Radiation Oncologist at Community Practice
It is odd that for both limited and extensive stage we do PCI and for visible cancer in the brain we talk about SRS alone first to expedite chemotherapy. For palliative stage IV disease, delaying chemo by few weeks would not affect survival. If a patient has impending chest symptoms outside the brai...
Answer from: Radiation Oncologist at Academic Institution
There is decent data suggesting the response rate in the brain with chemotherapy is the same as it is in the thorax and I feel completely comfortable treating asymptomatic brain metastases with chemotherapy as long as more frequent imaging of the brain is employed. As for symptomatic patients, I bel...
Answer from: Radiation Oncologist at Community Practice
I've spoken with Rodney Wegner who has published observational series using gamma knife and cyberknife in SCLC, and he tells me that he *is not* an advocate of initial SRS in SCLC. He said: "Is someone misquoting my paper again?" Even in an expedient situation, some urgency to start systemic therapy...
Answer from: Radiation Oncologist at Academic Institution
Regarding updates in 2023, as a follow up to FIRE-SCLC (Rusthoven et al., PMID 32496550), our group recently published the CROSS-FIRE study in JNCI (Rusthoven et al., PMID 37142267), which compared first-line SRS outcomes in SCLC to those in NSCLC.
The international study analyzed two cohorts, incl...
Answer from: Radiation Oncologist at Academic Institution
"Limited" brain metastases from small cell may be an oxymoron. There is very limited data on SRS in the upfront setting. There are a few publications on up front SRS for small cell. At the end is my text from one of my texts on the matter.This is not to say that I have not done SRS upfront for limit...
Answer from: Radiation Oncologist at Academic Institution
For us, the standard practice for significant mets is SRS upfront followed by chemo and then WBRT outback. Since our time to SRS is less than 48 hrs, this keeps therapy on track.
Answer from: Radiation Oncologist at Community Practice
In this series, 14 patients had GK upfront. http://www.redjournal.org/article/S0360-3016(12)01725-7/abstract. The results for the upfront srs mirror our own for a similarly small number of patients. There is also a series from Pittsburgh -Wegner et all published in The Red Journal in 2012.
We will also delay whole brain radiation in newly ...
Until you stop the chemotherapy and they all come ...