1. ROLE OF RADIATION IN SMALL CELL
LUNG CANCER
Dr Bharti Devnani
Moderator:- Dr Sheh Rawat

2. Staging of SCLC depends on radiation portals
(Veteran’s administration lung group)
Limited Stage
Disease confined to I/L hemithorax which could be
safely encompassed with in a tolerable RT field.
T1, T2, nonmetastatic
 Contralateral mediastinal and I/L SCF
Extensive stage
Beyond I/L hemithorax
T3,T4 and metastatic disease

3. Definitive (For LS)
Thoracic radiation as a part of CCRT
Adjuvant RT
Node positive cases after lobectomy
Prophylactic cranial irradiation
Palliative EXRT
Thoracic
Brain mets
Bone mets
Oncologic emergencies
SVCO
Spinal cord compression
Palliative brachytherapy
Endobronchial brachytherapy: Hemoptysis

4. ROLE OF THORACIC RADIATION IN
LIMITED STAGE

5. EVOLUTION
Before the introduction of chemo in 1970,
RT was the mainstay of treatment
CT
More local recurrences with chemo alone
CT+RT-Standarad of care

6. EVIDENCE FOR THORACIC RADIOTHERAPY
25-30% reduction in the local recurrence with 5-7% increase in 2 year survival
with addition of radiotherapy
Pignon et al NEJM 1992 327;1618-24

7. ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
 Portals
(before chemotherapy v/s shrinking field)
 Dose and fractionation schedules
(conventional v/s hyperfractionation)

8. ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
 Portals
(before chemotherapy v/s shrinking field)
 Dose and fractionation schedules
(conventional v/s hyperfractionation)

9. Takada et al.J Clin Oncol 2002; 20:3054-60.
Better outcome with CCT with a trend towards improved OS.
Concurrent RT reduces the risk of tumor repopulation and
development of resistant clones.
Radiosensitizing effect

10. ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
 Portals
(before chemotherapy v/s shrinking field)
 Dose and fractionation schedules
(conventional v/s hyperfractionation)

11. Benefit in 2 year survival rate with early RT(within 9 weeks or before 3rd cycle)

12. Factors which have significant impact on the benefit
of early RT were:-
 Type of chemotherapy
 The fractionation scheme

13. Concept of SER
Start of any treatment
until the end of
radiotherapy

14. Cancer Treat Rev 2007; 33:461-73.
 Significant 2 & 5 years improvement in survival when
RT was started within 30 days of platinum based chemo
(2-year survival: HR: 0.73, 5-year survival: HR: 0.65).
 This was even more pronounced when the overall
treatment time of chest radiotherapy was less than 30
days.

15. Early and concurrent chemoradiation is preferred over
late and sequential schedule.

16. ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
 Dose and fractionation schedules
(conventional v/s hyperfractionation)
 Portals
(before chemotherapy v/s shrinking field)

17. High chances of local recurrence with conventional
RT, attempts made to improve the outcome by:-
Hyperfractionated
Accelerated
radiotherapy
Dose escalation

18. 417 patients LS-
SCLC
45 Gy at 1.5
Gy/#B.D.x3weeks
45 Gy/25# at 1.8
Gy/# x5 weeks
Grade -3
Esophagitis
(27%v/s 11%)
P<0.001

19. ONGOING TRIALS (HYPERFRACTIONATION &
DOSE ESCALATION)

20. ISSUES IN THORACIC RT OF SCLC
 Sequencing with chemotherapy
(concurrent v/s sequential)
 Timing of RT
(Early v/s late)
 Dose and fractionation schedules
(conventional v/s hyperfractionation)
 Portals
(before chemotherapy v/s shrinking field)

21. RT PORTALS
 PET based planning should be used. (PET at the
time of radiotherapy planning or within 4 weeks)
 GTV = Post induction chemotherapy volume
 Omission of elective nodal irradition.
 Low rates of local recurrence(11% with only CT
based planning, 3 % with PET based planning)
 Decreases the esophageal toxicity significantly.

22. ROLE OF THORACIC RT IN
EXTENSIVE STAGE

23. CR at distant sites and
any response at local
site (n=210)
CT
+
RT= 54 Gy/36#
CT alone
Median survival-17 months v/s 11 months
Survival rate at 3 years-22% v/s 13%
Survival rate at 5 years-9% v/s 4%

25. PROPHYLACTIC CRANIAL
IRRADIATION

26. Rationale
 Frequent brain mets in SCLC
 20 %- at diagnosis
 80%- during the course of the disease
 Once symptomatic- results have been poor.

27. Incidence of brain metastasis decreased by 25% at 3 years (58.6% v/s
33.3%)
5.4 % survival benefit with addition of PCI

28. PCI IN EXTENSIVE STAGE DISEASE
14.6 % v/s
40.4%
27.1% v/s 13.3%
at 1 yr

29. DOSE OF PCI
Limited stage
25 Gy/10#
24 Gy/8#
30Gy/15#
Extensive stage
25 Gy/10#
Shorter fractionation scheme of 20 Gy/5# can be
used.
Dose>30 Gy should be avoided due to high risk of
neurotoxicity

30. ROLE OF RT IN ADJUVANT SETTING

32. ROLE OF RT IN PALLIATION (EXRT)

33. RADIATION FOR BRAIN METASTASIS
WBRT- 30Gy/10#

34. BONE METS & PATHOLOGICAL FRACTURE
30 Gy/10#
20Gy/5#
24Gy/6#
8 Gy single fraction

35. ROLE OF RADIATION IN ONCOLOGIC
EMERGENCIES IN SCLC

36. SPINAL CORD COMPRESSION
30Gy/10#

37. SUPERIOR VENA CAVA OBSTRUCTION
 Symptomatic relief in
70-90% cases with
radiotherapy alone.
 Dose- initial high dose
fractionation of 3- 4 Gy
followed by 1.8 Gy
fractionation

38. ROLE OF ENDOBRONCIAL
BRACHYTHERAPY - HEMOPTYSIS

41. TAKE HOME MESSAGE

42. LS-SCLC
Concurrent CCT/RT
Early(1st or 2nd cycle)
Dose-45 Gy @1.5 Gy bd or 50-60 Gy @1.8 Gy once daily
Any response to chemo-PCI to a dose of 25 Gy/10#
ES-SCLC
Any response to chemo- PCI-25 Gy/10# or shorter 20 Gy/5#
can be used.
Possible value of local RT are the subject of ongoing
investigation.
Palliation

43. Thank U

45.  Santa air hostess se-aapki shakal meri biwi se milti
hai
 Air hostess ne zordar thappad santa k muh pe
mara
 Santa- Kamal hai, Aadat bhi milti hai

46. Very Touchy story:
"Husband forgot to wish her on his Wife's birthday.
He came home late at night from the office .....
His wife shouted: How would u feel if u dont see me
for next few days?
He couldnt believe his luck. He replied at once.''
Wowww.....That would be great..!''
Monday passed & he didn't see her.
Tuesday he didnt see her
.
.
& wednesday passed too
.
.
On Thursday the swelling was better & he could
see her from the corner of his left eye...