Lung Cancer.pdf

Treatment of Limited-Stage Small Cell Lung Cancer 201
For lesions with hilar or mediastinal nodal involvement, the subcarinal
nodes are electively irradiated with borders described in the preceding
paragraph or 3 cm below the carina electively. We do not electively irradiate
the contralateral hilar nodes or the lower mediastinal nodes. We use a
higher-energy (6 or 18 MV) linear accelerator to avoid unnecessary scatter
to the surrounding normal tissue and to give a uniform dose distribution
to the target volume. TRT is done using 3-dimensional conformal radiation
therapy treatment planning with inhomogeneity correction.
At M.D. Anderson, we give intravenous etoposide (120 mg/m 2 ) and intravenous
cisplatin (60 mg/m 2 ) for 4 cycles starting on day 1 of TRT. Each
cycle of chemotherapy lasts 21 days. TRT is given in twice-daily 1.5-Gy
fractions with a 6-hour interfraction interval 5 days per week for 3 weeks,
for a total tumor dose of 45 Gy. Sometimes we treat patients with a combination
of irinotecan and cisplatin as induction or maintenance chemotherapy
since irinotecan has been shown to be an active agent against SCLC
(Noda et al, 2002). Occasionally a combination of paclitaxel and carboplatin
is used, especially in patients with renal dysfunction.
For PCI at M.D. Anderson, we usually give 25 Gy in 10 fractions or 30
Gy in 15 fractions by linear accelerator with 6-MV photons to the whole
brain. PCI is given to patients who have a complete response to
chemotherapy and TRT and have no severe cognitive abnormality identified
on neuropsychological tests. In a study of the impact of PCI on cognitive
function, baseline and follow-up neuropsychological tests revealed
that 83% (25/30) of patients with limited-stage SCLC had evidence of
cognitive dysfunction prior to PCI, and no significant differences were
found between results on pretreatment and posttreatment cognitive function
tests (Komaki et al, 1995a).
Assessments during Treatment
During treatment, patients are assessed for esophagitis, pneumonitis, neutropenic
fever, anemia, and electrolyte imbalances. For severe esophagitis,
local analgesics, along with oral analgesics or fentanyl citrate (Duragesic)
or both, are given. Nutritional status is assessed before treatment and
weekly throughout treatment. Nutritional supplements and correction of
electrolyte imbalances is done promptly. Appropriate antibiotics are
started immediately if patients develop neutropenic fever or bacterial infection.
Granulocyte colony-stimulating factor and erythropoietin are
given as indicated, usually on Friday after TRT if patients are receiving
TRT. Occasionally, steroids are required for treatment of pneumonitis.
Limiting the volume irradiated with TRT is the most important way to
prevent pneumonitis. Concurrent doxorubicin or bleomycin with TRT is
contraindicated because of the potential for damage to normal lung, heart,
and skin.