Management of brain metastasis with magnetic resonance imaging and stereotactic irradiation attenuated benefits of prophylactic cranial irradiation in patients with limited-stage small cell lung cancer

Abstract

BackgroundMagnetic resonance imaging (MRI) enables a more sensitive detection of brain metastasis and stereotactic irradiation (SRI) efficiently controls brain metastasis. In limited-stage small cell lung cancer (LS-SCLC), prophylactic cranial irradiation (PCI) in patients with good responses to initial treatment is recommended based on the survival benefit shown in previous clinical trials. However, none of these trials evaluated PCI effects using the management of brain metastasis with MRI or SRI. This study aimed to determine the effects of MRI and SRI on the benefits of PCI in patients with LS-SCLC.MethodsThe clinical records of pathologically proven SCLC from January 2006 to June 2013 in facilities equipped with or had access to SRI in Japan were retrospectively reviewed. Patients with LS-SCLC and complete or good partial responses after initial treatment were included in the study and analyzed by the Kaplan-Meier method.ResultsOf 418 patients with SCLC, 124 met criteria and were divided into patients receiving PCI (PCI group; n = 29) and those without PCI (non-PCI groups; n = 95). At baseline, ratios of patients with stage III were significantly advantageous for the non-PCI group, although younger age and high ratios of complete response and MRI confirmed absence of brain metastasis were advantageous for the PCI group. Neither median survival times (25 vs. 34 months; p = 0.256) nor cumulative incidence of brain metastasis during 2 years (45.5 vs. 30.8 %; p = 0.313) significantly differed between the two groups. Moreover, these factors did not significantly differ among patients with stage III disease (25 vs. 26 months; p = 0.680, 42.3 vs. 52.3 %; p = 0.458, respectively).ConclusionPCI may be less beneficial in patients with LS-SCLC if the management with MRI and SRI is available.

Treatment Response and Prophylactic Cranial Irradiation Are Prognostic Factors in a Real-life Limited-disease Small-cell Lung Cancer Patient Cohort Comprehensively Staged With Cranial Magnetic Resonance Imaging

“…52 Furthermore, Ozawa et al deemed that PCI might be less effective in LS-SCLC provided extended management with cranial MRI and SRS were readily accessible. 53 PCI has thus been the topic of recurring discussion as experts have serially debated its pros and cons in particular in relation to potential neurologic sequelae. Historically, prior to the publication by Aupérin et al, Cmelak and colleagues published a large survey with a total of 1231 responders, 13 including 628 (51%) radiation oncologists, 587 (48%) medical oncologists.…”

“…Ozawa and colleagues postulated that PCI may be less effective in LS-SCLC provided extended management with brain MRI and SRS was readily accessible. 53 As previously extensively discussed, the landmark meta-analyses of PCI included trials in the pre-MRI era. Thus, critics have argued that its modest survival benefit might dissipate in the presence of comprehensive brain imaging as some have suggested that the improved survival outcome conferred by PCI may be attributed to treatment response of subclinical BM to cranial irradiation and not per se "PCI".…”

Prophylactic cranial irradiation (PCI) or magnetic resonance imaging (MRI) monitoring in limited small cell lung cancer: is it a question?

“…There are several reports but always with a very limited number of patients. In the series of Ozawa et al, patients had MRI just before PCI: 29 patients received PCI and 95 not (28). At 2 years the incidence of brain metastases was respectively 45.5% and 30.8% in the group with and without PCI; without any difference in survival.…”

Treatment of limited disease small cell lung cancer: the multidisciplinary team

“…Patients have to be prepared for hair loss, potentially with the help of psycho-oncologists, to minimise the impact on quality of life. When PCI is not implemented, close follow-up with cranial MRI should be performed if therapeutic radiotherapy would be an option [97].…”