Lung – SCLC

This category is usually limited to a very few number of patients with a T1-2 disease (T ≤ 5) and negative mediastinal staging.

Most of them in practice are usually incidental post-op findings.

After a complete resection (R0) with no evidence of residual disease and negative post-op CT Scan and brain CT/MRI, patients should receive systemic Cisplatin-based adjuvant therapy. Mediastinal RT or PCI is not usually indicated and data lacks in this setting.

In case of any residual disease (positive margins or positive post op findings), concurrent CRT if still feasible vs treat as an ES-SCLC.

Concurrent ChemoRadioTherapy (CRT) is the standard of care, followed by Durvalumab as a consolidation therapy since the ADRIATIC trial.

The chemotherapy is usually Cisplatin-based, GCSF is not recommended during CRT. RT must start with cycle 1 preferrable, or cycle 2 if there are delays or for logistical reasons. “Benefit from durvalumab was seen for patients who received either cisplatin or carboplatin. The 3-year OS rate with carboplatin was 65.3% for durvalumab (median not reached) vs 46.7% for placebo (median 33.4 months). For cisplatin, the rate was 52.1% for durvalumab (median 41.9 months) vs 48.1% for placebo (median 34.3 months).”

PCI has been considered standard since a meta-analysis from 1999, that showed an improvement in OS and intracranial relapse, but in a heterogenous population, without baseline or follow up imaging and in times when CT Scan and brain MRIs were not available. The ADRIATIC trial. was not planned to evaluate PCI, however it showed that the addition of Durvalumab benefit both subgroups with and without PCI.

PCI is associated with neurocognitive toxicity that gets worse with age (>60). And with a disease that has a high likelihood of relapse, one should weigh in the quality of life that we give to our patients in their short lifespan. PCI is strongly recommended with hippocampal avoidance and memantine, for ECOG 0, fit and < 60 (ASCO says < 70) patients who are in remission post CRT. For the others, it’s a case by case.

The ongoing S1827 / MAVERICK trial will hold the answers for all LS and ES SCLC: MRI and treat when relapse vs PCI + MRI.