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What are the main points of the guidelines for limited-period and extensive-period SCLC diagnosis and treatment radiotherapy? A detailed explanation! On April 23-24, the 2021 CSCO Guide will be held in Beijing in a combined online and offline manner.
This conference includes lung cancer, head and neck tumors, breast cancer, gynecological tumors, urinary system tumors, melanoma and sarcoma, gastrointestinal tumors, tumor nutrition therapy, hepatobiliary and pancreatic tumors, immunotoxicity and tumor-related disease management, and hematological tumors.
In 11 special sessions, well-known experts in various oncology fields in China will interpret the guidelines for various cancers in the form of lectures and reports.
At the 2021 CSCO Guidelines Conference, Professor Bi Nan from the Department of Radiotherapy, Cancer Hospital of the Chinese Academy of Medical Sciences, brought us an interpretation of the 2021 version of the CSCO Small Cell Lung Cancer (SCLC) Diagnosis and Treatment Guidelines.
Professor Bi Nan One.
Overview of radiotherapy points for limited-stage SCLC Table 1 Overview of limited-stage SCLC-radiotherapy▌ Standard treatment for T1-2N0 patients with limited-stage SCLC: surgery + adjuvant chemotherapy A 2016 retrospective study analyzed the 2003-2011 National Cancer Database (NCDB) Data of 954 SCLC patients with T1-2N0M0 undergoing surgery or surgery + adjuvant chemotherapy.
The results showed that surgery + adjuvant chemotherapy significantly prolonged the survival benefit of patients with node-negative SCLC compared with surgery alone.
A retrospective study in 2017 analyzed the data of 492 NCDB patients with T1-2N0M0 SCLC who underwent surgery + adjuvant chemotherapy or concurrent chemoradiation from 2003 to 2011.
The results showed that surgery + adjuvant chemotherapy significantly prolonged the survival benefit of lymph node-negative SCLC patients compared with concurrent radiotherapy and chemotherapy.
▌ There is controversy about T1-2N0 patients with limited-stage SCLC undergoing PCI after surgery.
Patients with stage I SCLC who receive radical surgery and systemic radiotherapy have a lower brain metastasis rate (<10%), and brain prevention radiotherapy and chemotherapy may benefit more low.▌ Postoperative N+ patients: It is recommended to add adjuvant chest radiotherapy.
According to the data of 3017 patients included in the NCDB database, the 5-year survival rate of pN1 receiving adjuvant radiotherapy increased by 5.
6%, but there was no statistically significant difference (P=0.
22).
The sample size is unbalanced and local recurrence data is lacking.
For patients with positive hilar lymph nodes, mediastinal radiotherapy is still recommended as appropriate.
The pN2 with positive mediastinal lymph nodes received postoperative chemotherapy combined with adjuvant radiotherapy significantly improved the 5-year survival rate (29.
0% vs 18.
6%, P<0.
001).
Therefore, it is recommended that pN2 be combined with simultaneous or sequential mediastinal radiotherapy on the basis of postoperative chemotherapy.
The total dose of adjuvant radiotherapy is 50Gy, and the target areas include the ipsilateral hilar, ipsilateral mediastinum, and subcarinal areas with high risk.
Stereotactic body radiotherapy (SBRT) + chemotherapy (class 2A evidence) can be recommended for those who are not suitable for surgery on T1-2N0.
▌ Standard treatment for patients exceeding T1-2 and N0: Synchronous/sequential radiotherapy and chemotherapy Synchronous radiotherapy and chemotherapy are better than sequential radiotherapy and chemotherapy.
Historical data shows that patients add radiotherapy during the first to second cycles of chemotherapy, compared to 5~ After 6 cycles, the survival period of sequential radiotherapy was significantly prolonged.
Concurrent radiotherapy is recommended to use cisplatin/etoposide, 21 to 28 days per cycle.
The optimal total dose of radiotherapy and the division plan have not yet been determined.
It is recommended that 45Gy/1.
5Gy, Bid/3 weeks or 60~70Gy, 1.
8~2.
0Gy, Qd/6~8 weeks, the radiotherapy target area is the primary tumor target area according to the post-chemotherapy Remaining tumors are delineated.
For lymph nodes that are in complete remission after induction chemotherapy, the entire drainage area where the lymph nodes are located should be irradiated.
If there is clear mediastinal lymph node metastasis, even if no enlarged lymph nodes are found in the ipsilateral hilum, the target area should include the ipsilateral hilum .
▌ Limited-period brain preventive radiotherapy for patients with CR/PR achieved by radiotherapy and chemotherapy is recommended for preventive brain irradiation (PCI); patients with SD after radiotherapy and chemotherapy, and controversial stage I SCLC undergoing radical surgery and systemic chemotherapy For patients, PCI is recommended as appropriate; PCI is not recommended for elderly patients over 70 years old, with a PS score >2, and patients with neurocognitive impairment.
two.
Overview of the main points of radiotherapy for extensive-stage SCLC Table 2 Overview of radiotherapy for extensive-stage SCLC The treatment of extensive-stage SCLC (ES-SCLC) has undergone earth-shaking changes in the immunotherapy era.
The role of radiotherapy in the immunotherapy era is currently lacking a large sample of phase III randomized controls Clinical evidence, all evidence-based medicine evidence still comes from the era of radiotherapy and chemotherapy.
▌ How should radiotherapy be used for ES-SCLC patients without local symptoms and no brain metastases? Patients with CR/PR in the early stage of ES-SCLC treatment may consider the phase III randomized controlled clinical trial CREST study of chest radiotherapy, which included 498 ES-SCLC patients from 42 centers in Europe, with a baseline PS score of 0 to 2, and PR/CR after chemotherapy , No brain metastasis, no history of chest radiotherapy.
Patients receiving thoracic radiotherapy (30Gy/10F) significantly improved OS (11.
8mo vs 7.
5mo, P<0.
001) and PFS (4mo vs 3mo, P=0.
001) compared with the control group.
The CSCO guidelines recommend that among ES-SCLC patients who are sensitive to first-line chemotherapy, the efficacy is determined to be CR/PR, and the general state is good, the addition of chest radiotherapy can benefit, especially for those with residual chest lesions and small distant metastatic lesions .
It is recommended that at least 3D-CRT be used for radiotherapy technology, and more advanced technologies are recommended, including (but not limited to) 4D-CT and/or PET-CT simulated positioning, IMRT/VMAT, IGRT, and respiratory movement management strategies.
Early ES-SCLC treatment of CR/PR patients should carefully consider PCI.
In 2007, the EORTC study suggested that PCI can increase the survival rate and reduce the probability of later brain metastasis.
However, recently, a randomized controlled study in Japan suggested that in the case of brain MRI to exclude intracranial metastases, PCI can reduce the probability of intracranial metastases (48%vs69%, P<0.
0001), but it does not bring about survival.
Benefits Therefore, after ES-SCLC chemotherapy and chest radiotherapy, the survival benefits of PCI for patients who achieve PR/CR are still controversial and should be determined carefully.
If PCI is not performed, the frequency of brain magnetic examination is once every three months in the first year; once every six months in the second year.
The intracranial progress of SCLC patients is very fast.
If no testing is performed, the opportunity for salvage treatment may have been missed when obvious symptoms appear.
▌ For ES-SCLC patients with local symptoms, radiotherapy is mainly used for palliative reduction of ES-SCLC patients with local symptoms.
Radiotherapy is mainly used for palliative reduction, and it is better to cooperate with chemotherapy, immunotherapy and other systemic treatments.
Palliative radiotherapy for ES-SCLC metastases is often used for tumor metastasis to the brain, spinal cord, mediastinal lymph nodes, and bones.
According to the patient's clinical symptoms and the efficacy of chemotherapy, immediate or limited delivery is given.
▌ The efficacy of PCI in patients with brain metastases needs further exploration.
According to the data of the IMpower133 study, it can be seen that the use of PCI in patients with brain metastases is safe and well tolerated, but the efficacy needs to be further explored.
For patients with asymptomatic brain metastases, systemic chemotherapy should be given first, and elective whole-brain radiotherapy (WBRT) (30Gy/10F) should be given.
For patients with symptomatic brain metastases, WBRT should be given as soon as possible, if the patient’s expected survival time is longer For more than 4 months, stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) can be selected for local consolidation treatment of residual lesions, or whole brain simultaneous increased intensity-modulated radiotherapy (SIB-IMRT).
For patients with brain metastases after PCI, SRS/SRT is the first choice.
If conditions do not permit, repetitive WBRT can be considered.
What are the main points of the guidelines for limited-period and extensive-period SCLC diagnosis and treatment radiotherapy? A detailed explanation! On April 23-24, the 2021 CSCO Guide will be held in Beijing in a combined online and offline manner.
This conference includes lung cancer, head and neck tumors, breast cancer, gynecological tumors, urinary system tumors, melanoma and sarcoma, gastrointestinal tumors, tumor nutrition therapy, hepatobiliary and pancreatic tumors, immunotoxicity and tumor-related disease management, and hematological tumors.
In 11 special sessions, well-known experts in various oncology fields in China will interpret the guidelines for various cancers in the form of lectures and reports.
At the 2021 CSCO Guidelines Conference, Professor Bi Nan from the Department of Radiotherapy, Cancer Hospital of the Chinese Academy of Medical Sciences, brought us an interpretation of the 2021 version of the CSCO Small Cell Lung Cancer (SCLC) Diagnosis and Treatment Guidelines.
Professor Bi Nan One.
Overview of radiotherapy points for limited-stage SCLC Table 1 Overview of limited-stage SCLC-radiotherapy▌ Standard treatment for T1-2N0 patients with limited-stage SCLC: surgery + adjuvant chemotherapy A 2016 retrospective study analyzed the 2003-2011 National Cancer Database (NCDB) Data of 954 SCLC patients with T1-2N0M0 undergoing surgery or surgery + adjuvant chemotherapy.
The results showed that surgery + adjuvant chemotherapy significantly prolonged the survival benefit of patients with node-negative SCLC compared with surgery alone.
A retrospective study in 2017 analyzed the data of 492 NCDB patients with T1-2N0M0 SCLC who underwent surgery + adjuvant chemotherapy or concurrent chemoradiation from 2003 to 2011.
The results showed that surgery + adjuvant chemotherapy significantly prolonged the survival benefit of lymph node-negative SCLC patients compared with concurrent radiotherapy and chemotherapy.
▌ There is controversy about T1-2N0 patients with limited-stage SCLC undergoing PCI after surgery.
Patients with stage I SCLC who receive radical surgery and systemic radiotherapy have a lower brain metastasis rate (<10%), and brain prevention radiotherapy and chemotherapy may benefit more low.▌ Postoperative N+ patients: It is recommended to add adjuvant chest radiotherapy.
According to the data of 3017 patients included in the NCDB database, the 5-year survival rate of pN1 receiving adjuvant radiotherapy increased by 5.
6%, but there was no statistically significant difference (P=0.
22).
The sample size is unbalanced and local recurrence data is lacking.
For patients with positive hilar lymph nodes, mediastinal radiotherapy is still recommended as appropriate.
The pN2 with positive mediastinal lymph nodes received postoperative chemotherapy combined with adjuvant radiotherapy significantly improved the 5-year survival rate (29.
0% vs 18.
6%, P<0.
001).
Therefore, it is recommended that pN2 be combined with simultaneous or sequential mediastinal radiotherapy on the basis of postoperative chemotherapy.
The total dose of adjuvant radiotherapy is 50Gy, and the target areas include the ipsilateral hilar, ipsilateral mediastinum, and subcarinal areas with high risk.
Stereotactic body radiotherapy (SBRT) + chemotherapy (class 2A evidence) can be recommended for those who are not suitable for surgery on T1-2N0.
▌ Standard treatment for patients exceeding T1-2 and N0: Synchronous/sequential radiotherapy and chemotherapy Synchronous radiotherapy and chemotherapy are better than sequential radiotherapy and chemotherapy.
Historical data shows that patients add radiotherapy during the first to second cycles of chemotherapy, compared to 5~ After 6 cycles, the survival period of sequential radiotherapy was significantly prolonged.
Concurrent radiotherapy is recommended to use cisplatin/etoposide, 21 to 28 days per cycle.
The optimal total dose of radiotherapy and the division plan have not yet been determined.
It is recommended that 45Gy/1.
5Gy, Bid/3 weeks or 60~70Gy, 1.
8~2.
0Gy, Qd/6~8 weeks, the radiotherapy target area is the primary tumor target area according to the post-chemotherapy Remaining tumors are delineated.
For lymph nodes that are in complete remission after induction chemotherapy, the entire drainage area where the lymph nodes are located should be irradiated.
If there is clear mediastinal lymph node metastasis, even if no enlarged lymph nodes are found in the ipsilateral hilum, the target area should include the ipsilateral hilum .
▌ Limited-period brain preventive radiotherapy for patients with CR/PR achieved by radiotherapy and chemotherapy is recommended for preventive brain irradiation (PCI); patients with SD after radiotherapy and chemotherapy, and controversial stage I SCLC undergoing radical surgery and systemic chemotherapy For patients, PCI is recommended as appropriate; PCI is not recommended for elderly patients over 70 years old, with a PS score >2, and patients with neurocognitive impairment.
two.
Overview of the main points of radiotherapy for extensive-stage SCLC Table 2 Overview of radiotherapy for extensive-stage SCLC The treatment of extensive-stage SCLC (ES-SCLC) has undergone earth-shaking changes in the immunotherapy era.
The role of radiotherapy in the immunotherapy era is currently lacking a large sample of phase III randomized controls Clinical evidence, all evidence-based medicine evidence still comes from the era of radiotherapy and chemotherapy.
▌ How should radiotherapy be used for ES-SCLC patients without local symptoms and no brain metastases? Patients with CR/PR in the early stage of ES-SCLC treatment may consider the phase III randomized controlled clinical trial CREST study of chest radiotherapy, which included 498 ES-SCLC patients from 42 centers in Europe, with a baseline PS score of 0 to 2, and PR/CR after chemotherapy , No brain metastasis, no history of chest radiotherapy.
Patients receiving thoracic radiotherapy (30Gy/10F) significantly improved OS (11.
8mo vs 7.
5mo, P<0.
001) and PFS (4mo vs 3mo, P=0.
001) compared with the control group.
The CSCO guidelines recommend that among ES-SCLC patients who are sensitive to first-line chemotherapy, the efficacy is determined to be CR/PR, and the general state is good, the addition of chest radiotherapy can benefit, especially for those with residual chest lesions and small distant metastatic lesions .
It is recommended that at least 3D-CRT be used for radiotherapy technology, and more advanced technologies are recommended, including (but not limited to) 4D-CT and/or PET-CT simulated positioning, IMRT/VMAT, IGRT, and respiratory movement management strategies.
Early ES-SCLC treatment of CR/PR patients should carefully consider PCI.
In 2007, the EORTC study suggested that PCI can increase the survival rate and reduce the probability of later brain metastasis.
However, recently, a randomized controlled study in Japan suggested that in the case of brain MRI to exclude intracranial metastases, PCI can reduce the probability of intracranial metastases (48%vs69%, P<0.
0001), but it does not bring about survival.
Benefits Therefore, after ES-SCLC chemotherapy and chest radiotherapy, the survival benefits of PCI for patients who achieve PR/CR are still controversial and should be determined carefully.
If PCI is not performed, the frequency of brain magnetic examination is once every three months in the first year; once every six months in the second year.
The intracranial progress of SCLC patients is very fast.
If no testing is performed, the opportunity for salvage treatment may have been missed when obvious symptoms appear.
▌ For ES-SCLC patients with local symptoms, radiotherapy is mainly used for palliative reduction of ES-SCLC patients with local symptoms.
Radiotherapy is mainly used for palliative reduction, and it is better to cooperate with chemotherapy, immunotherapy and other systemic treatments.
Palliative radiotherapy for ES-SCLC metastases is often used for tumor metastasis to the brain, spinal cord, mediastinal lymph nodes, and bones.
According to the patient's clinical symptoms and the efficacy of chemotherapy, immediate or limited delivery is given.
▌ The efficacy of PCI in patients with brain metastases needs further exploration.
According to the data of the IMpower133 study, it can be seen that the use of PCI in patients with brain metastases is safe and well tolerated, but the efficacy needs to be further explored.
For patients with asymptomatic brain metastases, systemic chemotherapy should be given first, and elective whole-brain radiotherapy (WBRT) (30Gy/10F) should be given.
For patients with symptomatic brain metastases, WBRT should be given as soon as possible, if the patient’s expected survival time is longer For more than 4 months, stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) can be selected for local consolidation treatment of residual lesions, or whole brain simultaneous increased intensity-modulated radiotherapy (SIB-IMRT).
For patients with brain metastases after PCI, SRS/SRT is the first choice.
If conditions do not permit, repetitive WBRT can be considered.
