Top Line: You shouldn’t proceed into 2022 without brushing up on the 2021 ESMO guidelines for the management of small cell lung cancer (SCLC).
The Guidelines: First up is work-up. A brain MRI is recommended for everyone and so is a PET whenever employing definitive radiation with coverage of gross disease only. Interestingly, despite recent advances in systemic therapy recs, there is currently no role for assessing PD-L1 status. When it comes to treatment recommendations for limited stage (LS)-SCLC, not much has changed in the past two decades. Meaning 45 Gy delivered in 30 twice daily fractions over 3 weeks with concurrent cisplatin and etoposide remains the tried and true standard. Radiation ideally starts with the first cycle of chemo but can be delayed until the second or third if needed to meet necessary dose constraints—in which case you should still include the pre-chemo nodal volume but can reduce to the post-chemo primary lung tumor volume. Prophylactic cranial irradiation of 25 Gy in 10 daily fractions should continue to be discussed with patients with good response to chemoradiation for LS-SCLC, but close surveillance is reasonable for anyone with LS- or extensive stage (ES)-SCLC willing to comply with regular brain MRIs (every 3 months for the first year, then every 6 months). What has changed in the past couple of years is the addition of atezolizumab or durvlaumab to first-line cis/etoposide for ES-SCLC. In patients who achieve a response to this, consolidative chest radiation of 30 Gy in 10 daily fractions should be discussed, as should PCI as above. In addition, lurbinectedin is a newer targeted agent approved for second-line therapy.
TBL: Contemporary ESMO standard of care for SCLC includes definitive radiation to PET-avid disease only, the option for frequent MRI surveillance in lieu of PCI, the addition of atezo or durva to first-line chemo for ES-SCLC. | Dingemans, Ann Oncol 2021