Would you offer PCI to a patient with LS-SCLC, who presented initially with paraneoplastic syndrome (encephalomyelitis), but had no neurocognitive sequelae after chemoradiation?

I am not a big fan of PCI. I think the term itself is a misnomer. PCI trials in LS-SCLC were conducted in an era when MRI brains were not performed.

Let's look at the "outdated" data that all of us, including NCCN, quote. A meta-analysis conducted by Auperin and colleagues demonstrated a 5.4% 3-year OS benefit with PCI when compared with no PCI (Aupérin et al., PMID 10441603). In this meta-analysis, they included seven trials with enrollment periods ranging from "1977-1994." Some of these trials ...

This is a difficult question and I am not sure there is a "yes" or "no" answer. This depends on whether the patient's primary disease has had good response to chemotherapy and radiation and whether the patient has any neurological complaints at all at the time of consideration of PCI or other risk factors for PCI toxicities. A concern is that even if there are no obvious sequelae from the paraneoplastic syndrome, one might worry that there are non-obvious sequelae that together with PCI result i...

SWOG S1827 (MAVERICK) trial is under way for both LS and ES SCLC patients in order to study the benefits of PCI in the modern era. Ideally, patients should be enrolled in this trial since the question of PCI is so controversial. Outside of this protocol, NRG LU005, which is a trial for chemo radiation plus minus immunotherapy, "strongly" encourages PCI for LS-SCLC. I would be curious to know if anyone has studied the effects of PCI in the context of paraneoplastic encephalomyelitis. I don't know...

This is a difficult question to answer definitively either way. While yes, PCI is still standard of care for LS-SCLC based on an OS benefit, the benefits are modest and are currently being called into question. For most patients, we still recommend it. Clearly, in the elderly or in patients with underlying cognitive deficits, we often omit it as the risks outweigh the benefits. For the patient with paraneoplastic encephalitis, we really do not have a good way to estimate the risk of cognitive to...