International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationFactors Affecting the Risk of Brain Metastasis in Small Cell Lung Cancer With Surgery: Is Prophylactic Cranial Irradiation Necessary for Stage I-III Disease?
Introduction
Small cell lung cancer (SCLC) is characterized by rapid tumor growth, early dissemination, and a poor prognosis. On the basis of the 2011 NCCN (National Comprehensive Cancer Network) guidelines, surgery is only a recommendation for clinical stage I (T1-2N0) SCLC patients. However, surgical treatment may be given to stage II/III SCLC patients under the following situations: some resectable patients with no definite histopathologic diagnosis after bronchoscopic biopsy and cytologic biopsy, patients with preoperative diagnoses of non-small cell lung cancer (NSCLC), and patients with combined small cell lung cancer because the NSCLC component is less sensitive to chemotherapy and radiation therapy. Additionally, recent studies have reported that multimodality treatment involving surgery achieved a good prognosis in SCLC patients with limited-stage disease.
Brain metastases are common in patients with SCLC. About 15%-20% of SCLC patients had detectable brain metastases at the time of initial diagnosis, and the incidence of brain metastases increased as high as 50%-65% at postmortem examination 1, 2. It has been shown 3, 4, 5, 6, 7 that prophylactic cranial irradiation (PCI) can decrease the incidence of brain metastases and even improve the survival of SCLC patients.
Is PCI necessary for all SCLC patients after surgical resection? Few results have been reported about the frequency of the incidence of brain metastases in surgically treated SCLC. This study retrospectively analyzed 126 SCLC patients with surgical resection in our hospital to assess the risk factors of brain metastases and to discuss the indications for PCI treatment for those patients.
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Patients
One hundred twenty-six patients treated in our hospital between January 1998 and December 2009 were included in this study. The selection criteria were as follows: patients had pathologically proven SCLC, had undergone surgery, had negative pretreatment results of computed tomography or magnetic resonance imaging of the head at the time of initial diagnosis, and had no history of any other cancer. None of the patients had received PCI. TNM staging was defined according to the current American
Factors predictive of overall survival
The median survival for the entire patient population was 34 months. For the whole population, the survival at 1, 3, and 5 years was 80.6%, 46.8%, and 34.9%, respectively. Univariate analysis revealed that pathology stage, surgical resection, and brain metastases were significant factors that correlated with survival rate (Table 2). The 5-year survival rates for patients with pathologic stages I, II, and III were 54.8%, 35.6%, and 14.1%, respectively (P=.001). In a comparison of patients with
Discussion
Chemoradiation therapy is recommended as standard management in patients with limited-stage SCLC. Surgery followed by chemotherapy is recommended for stage T1-2N0 disease. However, several small series 8, 9, 10, 11, 12, 13, 14 have recently reported favorable survival outcomes in limited-stage patients who underwent surgery. Badzio et al (8) compared 67 SCLC patients who underwent surgery followed by adjuvant chemotherapy with or without radiation therapy, and they reported that the 5-year rate
Conclusion
We recommend that PCI be considered in stage II-III SCLC patients after surgery, not in stage I SCLC patients after complete resection. The limitations of this study include its retrospective design and that there were no comparisons between patients with PCI and without PCI. Further prospective work is required to determine the indication for PCI in SCLC patients after surgery.
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Cited by (56)
Pathological Stage N1 Limited-Stage Small-Cell Lung Cancer Patients Can Benefit From Surgical Resection
2023, Clinical Lung CancerRadiotherapy for small cell lung cancer in current clinical practice guidelines
2022, Journal of the National Cancer CenterProphylactic Cranial Irradiation for Resectable Small-Cell Lung Cancer
2018, Clinical Lung CancerCitation Excerpt :Compared with surgery alone, patients who received adjuvant therapy had a significantly improved 5-year OS. The use of PCI, however, has not been consistent in this literature (Table 1).13-20 In this same study, the authors reported that approximately 10% of the entire cohort received radiotherapy directed to the brain (presumed by the authors to be prophylactic), of which a large percentage also received adjuvant chemotherapy.
Linlin Gong and Qi Wang contributed equally to this paper.
Conflict of interest: none.