Small Cell Lung Cancer

 Small Cell Lung Cancer

Chemotherapy and Radiation Therapy

 For people with small cell lung cancer, regardless of stage, chemotherapy is an essential part of treatment. Radiation treatment may be used as well depending on the stage of cancer.

In the earliest stages of non-small cell lung cancer, chemotherapy is sometimes given before surgery to reduce tumor size and eliminate early spreading. Doctors call this approach neoadjuvant chemotherapy. For patients with limited lymph node involvement, chemotherapy can also be given post-surgery to kill any remaining cancer cells. This is known as adjuvant chemotherapy and helps prevent the chance of cancer recurrence.

For people with limited-stage small cell lung cancer, combination chemotherapy plus radiation therapy given at the same time is the recommended treatment. The most commonly used initial chemotherapy regimen is etoposide (Toposar or Vepesid) plus cisplatin (Platinol), known as EP.

For later stage cancers when surgery is no longer an option, chemotherapy is often administered with simultaneous radiation therapy. Known as combined chemoradiation therapy, this option often boasts survival rates higher than either treatment given alone or one after the other. This treatment is common if the cancer has spread to the mediastinal lymph nodes, which are located outside of the lung near the trachea and esophagus.

For people with extensive-stage small cell lung cancer, chemotherapy alone using the EP regimen is the standard treatment. However, another regimen that may be used is carboplatin (Paraplatin) plus irinotecan (Camptosar)

Radiation therapy of the brain may be used before or after chemotherapy for some people whose cancer has spread to the brain.

Preventive Radiation Therapy to the Brain

In more than half of the people with small cell lung cancer, the cancer also spreads to the brain. For people whose lung cancer has responded to chemotherapy, doctors may prescribe radiation therapy to the brain to help prevent the cancerfrom spreading to the brain. This procedure is known as prophylactic cranial irradiation (PCI). This can benefit patient with both limited-stage and extensive-stage small cell lung cancers.

Three-dimensional conformal radiation therapy delivers radiation beams tailored to the size, shape, and location of the cancer. Using a linear accelerator, the oncologist aims radiation beams at the cancer from different directions. Treatment is typically done twice a day, five days a week, over the course of three weeks. Breaking the total dose of radiation into smaller doses, called fractions, provides enough therapy to manage the tumor, while reducing the risk of side effects.

NYU Langone physicians use several different approaches for external beam radiation therapy, which is delivered using a machine called a linear accelerator. This machine can be moved around you during treatment sessions, helping oncologists to target the entire tumor. These approaches have different degrees of targeting, and our doctors can talk to you about the best treatment option for you.

Lung Cancer Staging

TX Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (for example, not in the main bronchus)1

T1a Tumor 2 cm or less in greatest dimension

T1b Tumor more than 2 cm but 3 cm or less in greatest dimension

T2 Tumor more than 3 cm but 7 cm or less or tumor with any of the following features (T2 tumors with these features are classified T2a if 5 cm or less): involves main bronchus, 2 cm or more distal to the carina; invades visceral pleura (PL1 or PL2); associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

T2a Tumor more than 3 cm but 5 cm or less in greatest dimension

T2b Tumor more than 5 cm but 7 cm or less in greatest dimension

T3 Tumor more than 7 cm or one that directly invades any of the following: parietal pleural (PL3), chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus less than 2 cm distal to the carina1 but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe

T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different ipsilateral lobe

Distant Metastasis (M)

M0 No distant metastasis

M1 Distant metastasis

M1a Separate tumor nodule(s) in a contralateral lobe, tumor with pleural nodules or

malignant pleural (or pericardial) effusion2

M1b Distant metastasis (in extrathoracic organs)

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastases

N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)

N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)

 

			N0	N1	N2	N3
			No regional lymph node metastasis	Metastasis in ipsilateral pulmonary or hilar lymph nodes	Metastasis in ipsilateral mediastinal/subcarinal lymph nodes	Metastasis in contralateral mediastinal/hilar or lymph supraclavicular nodes
T1	Tumor < 3 cma
	T1a	Tumor ≤ 2 cma	IA-T1aN0	IIA-T1aN1	IIIA-T1aN2	IIIB-T1aN3
	T1b	Tumor > 2 cm but ≤ 3 cma	IA-T1bN0	IIA-T1bN1	IIIA-T1bN2	IIIB-T1bN3
T2	Tumor > 3 cm but ≤ 7 cma or tumor with#. Invading visceral pleura, bronchus ≥ 2 cm from carina, atelectasis extending to hilum, but not involving the entire lung
	T2a	Tumor > 3 cm but ≤ 5 cma	IB-T2aN0	IIA-T2aN1	IIIA-T2aN2	IIIB-T2aN3
	T2b	Tumor > 5 cm but ≤ 7 cma	IIA-T2bN0	IIB-T2bN1	IIIA-T2bN2	IIIB-T2bN3
T3	Tumor > 7 cma; OR invading chest wall diaphragm, phrenic nerve, mediastinal pleura, pericardium; OR tumor < 2 cm distal to the carina, OR atelectasis of entire lung; OR separate tumor nodule(s) in same lobe
	T3>7	Tumor > 7 cma	IIB-T3>7N0	IIIA-T3>7N1	IIIA-T3>7N2	IIIB-T3>7N3
	T3Inv	Invading chest wall diaphragm, phrenic nerve, mediastinal pleura, pericardium	IIB-T3InvN0	IIIA-T3InvN1	IIIA-T3InvN2	IIIB-T3InvN3
	T3Centr	Tumor < 2 cm distal to the carina	IIB-T3CentrN0	IIIA-T3CentrN1	IIIA-T3CentrN2	IIIB-T3CentrN3
	T3Satell	Separate tumor nodule(s) in same lobe	IIB-T3SatellN0	IIIA-T3SatellN1	IIIA-T3SatellN2	IIIB-T3SatellN3
T4	Tumor invading heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, spine; OR tumor nodules(s) in a different ipsilateral lobe
	T4Inv	Tumor invading heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, spine	IIIA-T4InvN0	IIIA-T4InvN1	IIIB-T4InvN2	IIIB-T4InvN3
	T4Ipsi Nod	Tumor nodules(s) in a different ipsilateral lobe	IIIA-T4Ipsi NodN0	IIIA-T4Ipsi NodN1	IIIB-T4Ipsi NodN2	IIIB-T4Ipsi NodN3

Lung Cancer Staging IA-T1aN0

Lung Cancer Staging IA-T1aN0

Primary tumor is ≤2 cm in greatest dimension; No regional lymph node metastasis; No distant metastasis

Lung Cancer Staging IIA-T1aN1

Lung Cancer Staging IIA-T1aN1

Primary tumor is ≤2 cm in greatest dimension; Metastasis in ipsilateral pulmonary or hilar lymph nodes; No distant metastasis

Treatments For Lung Cancer Stage 3

Treatments For Lung Cancer Stage 3

4D Computed Tomography and Gating

 

A problem for most external radiation systems is that lung tumors often move when you breathe—interfering imaging tests and forcing radiation oncologists to expand the treatment area so no cancer is missed. While holding your breath can help, many lung patients can’t do so for very long and the effort doesn’t guarantee accuracy.

Because the lung is a constantly moving organ, our team uses four-dimensional computed tomography (4D CT) scans to help guide treatment. This advanced scanning technique helps determine the tumor’s movement within the body, so that radiation can be adjusted to target the cancer and not surrounding normal tissues.

We use our sophisticated 4D computerized tomography (CT) scanner before lung cancer treatment, to take images of the tumor throughout your breathing cycle. Sometimes, it turns out the tumor doesn’t move much. But in many cases, our team uses the scans to determine the best point in your breathing cycle (gating) to deliver treatment, providing more refined therapy and sparing healthy lung tissue.

To achieve this goal, you will receive a four-dimensional CT (4D CT) that allows the physician to track your tumor’s motion and draw an area that captures this trajectory. This same CT will be used to calculate the radiation doses for planning. We also will be applying gentle pressure below your sternum bone to encourage you to take shallower breaths during the CT scan and treatment, reducing lung tumor motion. With more limited lung motion from our compression technique and acquiring 4D CT information, we can reduce normal lung tissues' radiation exposure compared to older techniques due to a much high level of certainty that the tumor is now in the field of radiation.

Stereotactic Ablative Body Radiotherapy (SABR)

SABR, also referred to as Stereotactic Body Radiation therapy (SBRT), is a technologically innovative form of radiation treatment that enables delivery of high doses of radiation to the tumor over a shorter number of treatments. In published studies, this has been shown to confer a primary tumor control rate exceeding 80 percent. At time of its initial development, SABR was restricted to frail and elderly patients who were not medically fit to tolerate surgery.

Stereotactic ablative radiotherapy (SABR) is a new type of radiotherapy. It’s also known as stereotactic body radiotherapy (SBRT). You may have heard of Cyberknife®, which is a type of SABR. SABR is not available for pancreatic cancer on the NHS, but it may be available as part of a clinical trial.

Currently, SABR is being offered to our patients in two scenarios: (1) to those patients whose medical conditions preclude them from surgery after evaluation by a thoracic surgeon and (2) those patients who refuse surgery. Research studies are currently being done to examine SABR for patients who are also healthy surgical candidates, and these results will be available over the coming years.

SABR delivers a higher dose of radiotherapy at each treatment. Because the dose is higher, you will usually only need three to five treatments over one to two weeks. However, each treatment session will take longer than other types of radiotherapy. It is important that this treatment is carried out very accurately. This is to reduce the risk of damage to healthy tissues from the high dose of radiation.

At City of Hope, we use a form of radiation delivery known as intensity modulated radiation therapy (IMRT) for SABR treatment. IMRT allows for the radiation beam to be blocked in specific areas during the therapy session, minimizing exposure to normal tissues.

Some research has suggested that SABR may be effective in helping to control pancreatic cancer. But there is no evidence to show that it is more effective than other types of radiotherapy. It may be more convenient because you will need fewer treatments. But there is a risk of damage to the stomach or bowel from the high dose of radiation, which could cause side effects. We need more research into SABR for pancreatic cancer.