Small-Cell Lung Cancer Clinical Practice Guidelines (2020)

Sociedad Española de Oncologia Medica (Spanish Society for Medical Oncology)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 28, 2020

The guideline on treatment of small cell lung cancer (SCLC) was released on February 10, 2020 by the Sociedad Española de Oncologia Medica (Spanish Society for Medical Oncology).[1]

Initial Evaluation and Staging

Initial assessment must include the following:

  • Medical and smoking histories

  • Physical examination

  • Complete blood count

  • Biochemistry studies – Liver enzymes, sodium, potassium, calcium, glucose, lactate dehydrogenase levels, and kidney function tests

  • Pulmonary function tests, in patients who will be receiving thoracic radiation

Full staging includes the following:

  • Computed tomography (CT) scan, with intravenous contrast, of the chest/abdomen

  • Brain imaging with magnetic resonance imaging (MRI) (preferred) or CT scan with intravenous contrast

  • If limited-stage SLSC (LS-SCLC) is suspected, a 2-fluor-2-deoxy-D-glucose positron-emission tomography (FDG-PET)/CT scan could be performed to assess for distant metastases

Limited-Stage SCLC - Stage I–IIA (T1–T2, N0, M0)

Mediastinal staging is necessary and should be performed either by surgery (mediastinoscopy, mediastinotomy or video-assisted thoracoscopy) or by endobronchial or esophageal ultrasound-guided biopsy.

Lobectomy should be the preferred surgical procedure with a systematic lymph-node dissection.

Adjuvant systemic therapy should always be considered.

For patients with contraindications to surgery or who refuse surgery, stereotactic body radiation therapy (SBRT) may be a useful treatment.

After SBRT, systemic adjuvant chemotherapy with 4 cycles of cisplatin–etoposide is recommended.

Adjuvant radiotherapy, administered sequentially or concomitantly with chemotherapy, is recommended when N1 or N2 disease has been diagnosed after surgery.

Use of prophylactic cranial irradiation (PCI) is not recommended in patients with surgically resected early-stage SCLC (T1–2, N0, M0).

Limited-Stage SCLC - Stage IIB–IIIC (T3–4, N0, M0; T 1–4, N1–3, M0)

The standard treatment in these patients is concurrent chemotherapy and thoracic radiotherapy (CTRT).

Chemotherapy should be administered up to a maximum of 4–6 cycles.

Cisplatin plus etoposide is the recommended chemotherapy regimen to combine with thoracic radiotherapy. Carboplatin should be reserved for patients in whom cisplatin is contraindicated.

Use of prophylactic myeloid growth factor to avoid myelosuppression is not recommended in this setting.

Radiotherapy should be started as early as with the first or second course of chemotherapy.

The radiotherapy target field should be defined according to the PET/CT scan performed prior to treatment initiation and should include the involved node regions, as well as the primary tumor.

PCI (25 Gy) should be administered after CTRT in patients without progression.

Extensive-Stage SCLC (ES-SCLC)

The combination of chemotherapy and immunotherapy is currently considered the standard first-line treatment for ES-SCLC. Chemotherapy alone is an effective option in patients with contraindication for immunotherapy.

Cisplatin plus etoposide has been the standard chemotherapy regimen for patients with ES-SCLC, but carboplatin–etoposide could be an alternative regimen in patients with contraindications to cisplatin.

Alternative chemotherapy regimens are cisplatin–irinotecan, carboplatin–irinotecan, cisplatin, and epirubicin.

Immunotherapy options are atezolizumab or durvalumab.

The optimal duration of chemotherapy for patients with ES-SCLC is not well defined; in general, 4–6 cycles are recommended.

PCI may be considered in patients with good performance status who respond to treatment for ES-SCLC. Preferred schedule is 25 Gy in 10 daily fractions. PCI is not recommended for patients at high risk of neurological sequelae and should be used with caution in elderly patients.

Follow-up with brain MRI is recommended for all patients regardless of the administration of PCI.

Consolidative thoracic radiotherapy should be considered in selected patients with ES-SCLC who have completed chemotherapy and achieved a complete or near-complete response, especially those with good extrathoracic response.

Treatment of Brain Metastases

In patients with symptomatic brain metastases, whole-brain radiotherapy (WBRT) should be administered before systemic therapy.

In patients with asymptomatic brain metastasis, systemic therapy should be administered first, with assessment by cranial MRI or CT with contrast; WBRT may be administered after completion of systemic therapy or if brain metastases progress during systemic therapy.

The preferred schedule for WBRT is 30 Gy in 10 daily fractions.

In patients with cranial progression after PCI, consider repeat WBRT or, preferably, stereotactic radiosurgery if feasible.

Consider adding memantine during and after radiotherapy (PCI or WBRT).

Relapsed SCLC

All patients with relapsed SCLC should be assessed for clinical trials.

When relapse occurs more than 3 months after first-line therapy, it is considered chemo-sensitive, and reinduction of the original regimen with platinum-etoposide is recommended.

Relapse that occurs 3 months or less after first-line therapy must be considered chemo-resistant or refractory. Options are single-agent therapy with IV or oral topotecan or combination therapy with cyclophosphamide–doxorubicin–vincristine.

Follow-up

For LS-SCLC, a CT scan is recommended every 3 months in the first year, every 6 months in years 2–5, and then annually.

For ES-SCLC, a CT scan is recommended every 2 months in the first year, every 3 months in years 2 and 3, every 6 months in years 4–5, and then annually.

For more information, see Small Cell Lung Cancer. For more Clinical Practice Guidelines, please go to Guidelines.

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