Small Cell Carcinoma of Lung

Management of Small Cell Carcinoma of Lung ,[object Object],[object Object],[object Object],[object Object]

Introduction ,[object Object],[object Object],[object Object],[object Object]

Classification: WHO 1999 Source: Brambilla et al The new World Health Organization classification of lung tumours Eur Respir J 2001; 18:1059-1068 “ SCLC presents a proliferation of small cells ( <4 lymphocytes in diameter ) with unique and strict morphological features....” Primary epithelial lung cancers Small Cell (Oat Cell Type) Non Small Cell type ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Relevant Anatomy ,[object Object],[object Object]

Nodal Anatomy Data from Autopsy Series Kunz et al 1985

Epidemiology ,[object Object],[object Object],[object Object],[object Object]

Cell of Origin ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Carcinoid Atypical Carcinoid SCLC

Etiology ,[object Object],[object Object],[object Object],[object Object],Data from Annual Report to the Nation on the Status of Cancer, 1973-1996, With a Special Section on Lung Cancer and Tobacco Smoking Wingo et al JNCI Journal of the National Cancer Institute 1999 91(8):675-690;

Clinical Features: Thoracic Disease Local Symptoms Cough Dyspnea Chest Pain Mediastinal Involvement Hoarseness Retrosternal Chest pain Vocal Cord Palsy Horner's Syndrome Superior Vena Caval Syndrome Hemoptysis Post obstructive Wheezing

Hemaotogenous Metastasis ,[object Object],[object Object]

Clinical Features: Extrathoracic ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical Features: Extrathoracic ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Paraneoplastic Syndromes Cancer Cachexia Endocrinological Syndromes Neurological Syndromes Musculoskeletal Syndromes Dermatological Syndromes Hematological and Vascular ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Tit-bits on some syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neurological Syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neurological Syndromes.. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],MG LEMS

Neurological Syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Investigative Workup ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Evolution of pathological classification

Gross Pathology ,[object Object],[object Object],[object Object],[object Object]

Microscopic pathology ,[object Object],[object Object],[object Object],[object Object],[object Object]

Combined SCLC ,[object Object],[object Object],[object Object],[object Object]

Chest X rays Pleural Effusion Phrenic Nerve palsy Mass Collapse

Radiology Miller WE: Roentgenographic manifestations of lung cancer. In Strauss MJ (ed): Lung Cancer: Clinical Diagnosis and Treatments, 2nd ed. New York, Grune and Stratton, 1983.

CT scan Mass Pleural Effusion Node Necrosis Mediastinal Shift

Staging ,[object Object],[object Object],[object Object],[object Object]

VALSG Definition ,[object Object],[object Object],[object Object],[object Object],[object Object]

Controversies in Staging ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prognostic Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Treatment Outline SCLC Stage Localized Disease Extensive Disease Radiation Therapy (Curative intent ?) + Systemic Combination Chemotherapy Systemic Combination Chemotherapy + Palliative Radiation + Palliative Care and Support

Radiation Sensitivity Source: Radiation Biology of Lung Cancer; Sullivan et al JCB supp24

Radiation Biology ,[object Object],[object Object],[object Object],[object Object]

Role of Radiation therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dose Time Fractionation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Planning RT for Localized SCLC ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Palliative Radiotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Manual Marking ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Guidelines for RT planning ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Portal arrangements Upper Lobe Middle Lobe Lower lobe

Results of Thoracic RT ,[object Object],[object Object],[object Object],[object Object],[object Object]

Changing Paradigms of R x Paradigm 1 : Surgery as Standard Treatment Paradigm 2 : Thoracic radiation better than Surgery Paradigm 3 : Thoracic Irradiation with adjuvant Chemotherapy Paradigm 4 : Combination chemotherapy with adjuvant Radiotherapy Paradigm 5 : Integrated Chemotherapy and Radiation therapy

RT results 2 yr survival 2 yr local control

Is TRT needed? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Is TRT needed ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Is TRT needed ,[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Addition Thoracic Radiation is definitely indicated in Limited Stage SCLC both to improve LC and OS

?? Controversies ?? ,[object Object],[object Object],[object Object],[object Object]

Deciding the treatment volume ,[object Object],[object Object],[object Object],[object Object],[object Object]

Intrathoracic Volume Incorporation ,[object Object],[object Object],[object Object],Conclusion : Failure to include opposite mediastinal and hilar nodes in the treatment volume can lead to significant intrathoracic failures Data from While J et al Impact of Radiation therapy quality control in LC in SCLC

Post CCT or Pre CCT volume? 21/5/1977 6/7/1977 26/8/1977 11/10/1977 26/10/1977

Pre CCT vs Post CCT volume ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : It is safe to irradiate only the post CCT volume.

Portal Design ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Customized portal designing is unlikely to add to control

Dose and Fractionation of Radiation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dose of Radiotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Altered Fractionation Conclusion : Altered fractionation with split course is not effective

Continuous AF schemes Conclusion : Sadly Continuous AF is too toxic for routine use !!!

Sequencing with CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CRT protocols ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Concurrent vs Sequential CCT ,[object Object],[object Object],[object Object],[object Object],[object Object]

Why not Concurrent CRT? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Alternating Chemoradiation ,[object Object],[object Object],[object Object],[object Object],Conclusion : Alternate CRT is inferior to sequential CRT

Early vs Late Thoracic RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Timing of RT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Timing of RT Conclusion : Early Start of RT does lead to a better outcome

Role of PCI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Benefit from PCI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Meta-analysis ,[object Object],[object Object],[object Object],[object Object]

Toxicity of PCI ,[object Object],[object Object],[object Object],[object Object]

Practice Guidelines ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Chemotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Cisplatin based CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Alternative CCT regimens ,[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Single agent Topotecan fails to improve results over those obtained by PE regimen in SCLC when used as 1 st line approach

Combination CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Toxicity of CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

More intensive CCT ,[object Object],[object Object],[object Object],[object Object]

Alternative Strategies ,[object Object],[object Object],[object Object]

Dose intensification Conclusion : Dose intensification by 25 – 50% over the standard doses fails to improve the survival but increases toxicity significantly

Weekly Chemotherapy Conclusion : Dose intensification by giving weekly CCT fails to improve the survival but increases toxicity significantly

Alternating CCT ,[object Object],[object Object],[object Object],[object Object],[object Object],Conclusion : Alternating non cross resistant CCT regimens failed to improve results as compared to standard regimens

Chemotherapy for recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Management of SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Radiotherapy in SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Radiotherapy in SVCO ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Investigational Agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Other agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Follow up Goals ,[object Object],[object Object],[object Object]

Follow Up Protocol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Follow up: Other Issues ,[object Object],[object Object],[object Object],[object Object]

Conclusions ,[object Object],[object Object],[object Object],[object Object]

Small Cell Carcinoma of Lung

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Small Cell Carcinoma of Lung