Small Cell Lung Cancer Clinical Practice Guidelines (ESMO, 2021)

European Society for Medical Oncology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 29, 2021

Updated guidelines on diagnosis, treatment, and follow-up of small cell lung cancer (SCLC) were published on April 9, 2021 by the European Society for Medical Oncology (ESMO) in the Annals of Oncology.[1]


SCLC should be diagnosed according to the World Health Organization criteria.

Currently, no predictive biomarker is available and programmed death-ligand 1 (PD-L1) and tumor mutational burden (TMB) testing are not recommended in routine clinical practice.


Surgery may be considered in patients with clinical stages I and II (cT1-2N0) following a multidisciplinary board decision. Pathological mediastinal staging is required.

Adjuvant chemotherapy should be given after surgical resection of SCLC. For limited-stage (stage I-III) SCLC, the preferred regimen is cisplatin plus etoposide. Carboplatin may be substituted for cisplatin if that agent is contraindicated.

Granulocyte colony-stimulating factor (G-CSF) is an option to prevent hematologic toxicity.

Concurrent thoracic radiation therapy (RT) and adjuvant chemotherapy is recommended in patients with an R1-R2 resection or positive mediastinal lymph nodes (N2) and in patients with T1-4N0-3M0 tumors and a good performance status (PS 0-1).

Thoracic RT should be initiated as early as possible, preferably on the first or second chemotherapy cycle. Sequential chemoradiotherapy (CRT) is an option for patients with poor PS, comorbidities, and/or high disease volume.

A PD-L1 inhibitor (atezolizumab or durvalumab) can be added in patients with treatment-naive extensive-stage SCLC, a PS of 0-1, and no contraindications for immunotherapy.

Prophylactic cranial irradiation

Treatment-responsive patients with stage III SCLC and a PS of 0-1 should be offered prophylactic cranial irradiation (PCI; 25 Gy/10 fractions). PCI can be considered in patients with a PS of 2. The role of PCI is not as well defined in other circumstances.

PCI (20 Gy/5 fractions and 25 Gy/10 fractions) is justified without prior MRI staging or follow-up in patients of age <75 years and a PS of 0-2 who have responded to chemotherapy.

PCI can be omitted in patients with extensive-stage SCLC who do not have brain metastases on MRI after chemotherapy and who can be followed up with regular brain MRI.


Patients with limited-stage disease who have received potentially curative treatment should undergo  CT scans every 3-6 months for 2 years with lengthening of intervals thereafter.

Regular brain MRIs (every 3 months in the first year and then every 6 months) are advised in patients who did not undergo PCI.

For more information, please go to Small Cell Lung Cancer (SCLC). For more Clinical Practice Guidelines, please go to Guidelines.


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