SMALL CELL LUNG CARCINOMA Sthenjiswa Mhlongo Consultant: Prof A - - PowerPoint PPT Presentation

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SMALL CELL LUNG CARCINOMA Sthenjiswa Mhlongo Consultant: Prof A - - PowerPoint PPT Presentation

Feb 17, 2024 571 likes •806 views

SMALL CELL LUNG CARCINOMA Sthenjiswa Mhlongo Consultant: Prof A Sherriff 16/02/2019 University of Free State T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za DISCLOSURE None T: +27(0)51 401 9111 | info@ufs.ac.za |

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

SMALL CELL LUNG CARCINOMA

Sthenjiswa Mhlongo Consultant: Prof A Sherriff University of Free State

16/02/2019

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

DISCLOSURE

  • None
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

CASE

  • 50 year old male
  • Referred from Cardiothoracic Surgery
  • 3 months history of persistent cough
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

HISTORY

  • Main complaint: persistent cough for 3 months. Associated haemoptysis,

voice hoarseness and occasional left chest pain. Weight loss.

  • Co-morbidities: HIV Negative. No known co-morbid diseases
  • Employed as truck driver
  • Social: strong smoking history - 30 pack year, social drinker
  • Family history: none of note
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

EXAMINATION

  • ECOG 1
  • Hoarseness
  • No palpable nodes
  • Respiratory rate 19breath/min
  • Chest: not in respiratory distress. Decrease air entry on left lung field. Fine

diffuse crepitations.

  • CVS: normal heart sounds
  • Abdomen: soft. No organomegaly
  • No neurological fallout
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

WORK UP

  • Lung biopsy: Small cell carcinoma. IHC was (+) for CK 7,

TTF-1, synaptophysin & chromogranin.

  • Initial CXR: left upper lobe lung mass adjacent to superior

left hilum. Left upper lobe consolidative chages + pleural

  • thickening. Right lung fibrotic changes.
  • Bloods:

– Full blood count with differential counts – Urea, electrolytes & creatinine – Sodium 133 – LDH 200U/L – Albumin 33

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

PLAIN CHEST X-RAY

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

  • Staging CT: Superior mediastinal mass 106 x 104mm, direct

infiltration of left parasternal chest wall between the 2nd & 3rd rib ends anteriorly. Left brachiocephalic artery encasement. 12mm bronchopulmonary LN. 11mm pretracheal LN. Small left sided pleural effusion. Bilateral lung fibrosis. No metastatic disease

  • Cytology pleural effusion: no malignant cells.
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CT IMAGING

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BONE SCINTIGRAPHY

Bone scintigraphy: increased uptake on left lateral aspect of manubrium and medial aspect of left 1st rib. Direct sternum infiltration. No skeletal metastasis.

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PROGNOSTIC FEATURES

  • Stage at presentation
  • Performance Status
  • Sex
  • weight loss > 5% over 6

months

  • Biochemical variables:

– Low sodium – ALP > 1,5x ULN – LDH > ULN

  • Presence of

paraneoplastic syndromes (controversial)

  • Continuation of smoking
  • Poor nutritional status

Our patient’s poor prognostic features:

  • Male
  • Weight loss >5%
  • LDH > upper limit of

normal

  • Sodium < normal
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

SUMMARY

  • 50 year old male SCLC limited stage
  • ECOG PS 1
  • No comorbidities
  • Manchester scoring 2
  • Poor prognostic features:

– Male – Weight loss >5% – LDH > upper limit of normal – Sodium < normal

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HIGHLY RESPONSIVE BUT ALSO HIGH RELAPSE RATES WITHIN 2 YEARS!! DESPITE OPTIMAL TREATMENT

  • Survival :

– Limited stage: med OS 14-24months. 5yr OS 20% – Extensive stage: med OS 6-11 months. 5yr OS 2% – Shorter survival in untreated disease.

  • NB: para neoplastic

syndromes at presentation may also influence patient clinical condition +

  • management. Presence of

paraneoplastic syndromes in generally unfavourable.

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

ROLE OF RADIATION

  • Role of thoracic radiotherapy is well established for LS – SCLC with marked

improvement in OS

  • Early initiation of concurrent chemo radiation improves OS outcomes
  • Optimal timing of radiation with 1st or 2nd cycle of chemotherapy
  • Dose fractionation:

– Hyper fraction vs standard fractionation – LC better with BD fractionation BUT OS very similar – Adverse effects esp. oesophagitis more frequent in BD fractionation

  • 3D conformal vs IMRT
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DISCUSSION POINTS

  • Treatment options:

– Optimum Dose Fractionation with concurrent chemotherapy:

  • 60- 70Gy/2Gy?
  • 45Gy/1,5Gy BD?

– 3 D Conformal vs IMRT – Optimal timing of PCI

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

OUR MANAGEMENT

  • Concurrent chemo radiation
  • 54Gy in 2Gy fractions with concurrent Cisplatin and Etoposide
  • Restaging CT after completing adjuvant chemotherapy

– Lung mass 56 x 61mm (106 x 104mm) – No measurable LN

  • Condition deteriorated to ECOG 2 , was still smoking heavily!
  • Not for PCI
  • For follow up
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

Thank You Ngiyabonga

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

  • Staging: AJCC Staging Vs Veteran Administration Lung Study Group staging

system

  • Highly responsive BUT also high relapse rates within 2 years!! Despite

treatment

  • Clinical presentation
  • NB: para neoplastic syndromes
  • Work Up: include brain >30% patients present with brain mets at diagnosis
  • Common sites mets: Brain 30% > adrenal 20-30% > liver 25% > lung > bone
  • Survival :

– Limited stage: med OS 14-24months. 5yr OS 20% – Extensive stage: med OS 6-11 months. 5yr OS 2%

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

CHEMO RADIATION

  • Benefit of adding XRT: Pigno meta-analysis – 13 trial, 2140pt. XRT 45-50Gy/20-

25#. Chemo CAV/MTX/VP16. 5% improvement in OS

  • Concurr vs Sequential (Japanese Clin Onc Group 9104):

– n=231 – XRT 45Gy/1,5Gy BD + Cispl 80mg/m2 day 1 + Etop 100mg/m2 d1-3 – Concurr 4wkly chemo x 4 cycles begins XRT on day 2 of 1sst cycle chemo – med OS 27 months. 2yr OS 54% – Sequential q3w before start xrt x 4 cycles – med OS 20mnths. 2yr OS 35%

  • Early vs Late CCRT:

– (1) NCIC study 1993. 308 pt randomized. XRT 45Gy in 15 #

  • Early Start XRT at #2 chemo( wk. 3): PFS 15,4 – med os 21,2 – 5yr OS

26%

  • Late start XRT at #6 chemo (wk. 15): PFS 11,8 – med OS 16 – 5yr OS

11% – (2) Jeremic Trial 1997. 107 pt. 54Gy in 1,5Gy BD. 4 x Carb+Etop & 4x Cisp+Etop. Carb with Xrt

  • Early RT wk. 1-4: med survival 34 months – 5yr OS 30%
  • Late RT wk. 6-9: med survival 26mnths – 5yr OS 15%
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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

  • Dose #

– InterGrp 0096. 406pt . Randomized C-RT + PCI 25Gy

  • 45Gy/1,8Gy # OD + conc chemo in wk. 1. total chemo 4 x Cispl/Etop

q3w LC 36% 5yr OS 18%

  • 45Gy /1,5Gy# BD + conc chemo in wk. 1. total chemo 4 x Cispl/Etop

q3w LC 52% 5yr OS 26%. However gr 3 oesophagitis more frequent (27 vs 11%)

  • CRITISM!!! 45Gy OD not bio equivalent to 45gy BD

– COVERT: hyper# + dose escalation for OS!! 4 x chemo Cispl/Etop. RT begins d22. DLY RT non inferior to BD RT!!

  • 45Gy/30# BD 2yr OS 56%
  • 66Gy/33 #OD 2yr OS 51%

– CALGB30610/RTOG 0538 – PENDING

  • (A) 45Gy/30# BD + conc Cispl/Etop x4
  • (B) 70Gy/35# OD + conc Cispl/Etop x 4
  • (C) 61,2Gy/34#. 1,8Gy OD for 16 days then CONCOMITANT BOOST

1,8Gy BD x 9days

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T: +27(0)51 401 9111 | info@ufs.ac.za | www.ufs.ac.za

  • IMRT: no significant diff LC or OS compared to 3D RT. Consider

if v20> 30% or FEV1 <1. Less oesophagitis + PEG placement with IMRT

  • Post Chemo Volumes. Include pre chemo involved nodes. BUT

NOT elective nodal xrt.

  • Auperin Meta-analysis of PCI (NEJM 1999)

– PCI for LC SCLC if CR after chemo – Improved OS at 3 years by 5% – Incidence of brain mets decrease from 58 – 33% at 3years