Utility of Prophylactic Cranial Irradiation for Extensive-Stage Small-Cell Lung Cancer in the MRI Screening Era

Keller, Andrew; Ghanta, Siddharth; Rodríguez‐López, Joshua L.; Patel, Ankur; Beriwal, Sushil

doi:10.1016/j.cllc.2021.03.009

Cited by 9 publications

(4 citation statements)

References 26 publications

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“…It is evident that RT to the brain not only activates the systemic immune state but also reduces the risk of brain metastasis. PCI is associated with a decrease in brain metastases in ES-SCLC, without a demonstrable impact on OS [40]. However, it should be noted that this reduction is primarily observed when RT is administered sequentially after chemotherapy.…”

Section: Pci Is For Es-sclc During Rst-line Immunotherapymentioning

confidence: 93%

Immune activation effects at different irradiated sites and optimal timing of radioimmunotherapy in patients with extensive-stage small cell lung cancer: a real-world analysis

Wang

Chen

et al. 2023

Preprint

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Background In view of the limited data on radiotherapy (RT) combined with immunotherapy in patients with extensive-stage small cell lung cancer (ES-SCLC), this study aimed to identify the immune activation effect on different sites and the survival outcomes of radioimmunotherapy at different treatment stages. Methods Forty-five patients diagnosed with ES-SCLC were included in this retrospective analysis. We collected the overall survival (OS) of the patients,, recorded the blood cell counts before, during, and after RT, and derived blood index ratios such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII). The datasets were analyzed using the Spearman rank correlation test, Kruskal-Wallis rank sum test, logistic regression, and survival analysis. Results Among the selected blood indices, the delta-NLR/PLR/Sll correlated with different irradiated organs, and the mean ranks of these three indices were the lowest in the brain-irradiated group during immunotherapy. Additionally, adjunct first-line immunotherapy with RT demonstrated a significant improvement compared to second- or third-line therapy and subsequent therapies. Conclusion Our findings suggest that compared to other organs, the strongest immune activation effect occurs with brain RT, and ES-SCLC patients who received radioimmunotherapy (RIT) earlier achieved higher OS rates.

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Section: Pci Is For Es-sclc During Rst-line Immunotherapymentioning

confidence: 93%

Immune activation effects at different irradiated sites and optimal timing of radioimmunotherapy in patients with extensive-stage small cell lung cancer: a real-world analysis

Wang

Chen

et al. 2023

Preprint

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“…Notably, 83% of the patients in the control group who developed brain metastases received remedial brain radiotherapy compared to 60% in the EORTC trial. Keller et al 51 showed that MRI screening after chemotherapy is important because almost 16% of patients who are chemotherapy-responsive were detected unsuspected brain metastases. PCI reduced brain metastases with no significant effect on OS in the MRI screening era.…”

Section: Progress Of Pci and Srsmentioning

confidence: 99%

Progress in radiotherapy for small‐cell lung cancer

Yang,

Zhao

2023

Precision Radiation Oncology

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Small‐cell lung cancer (SCLC) is a highly aggressive neuroendocrine tumor that is prone to spread extensively. Compared to non‐small‐cell lung cancer (NSCLC), SCLC treatment progresses slowly. Although SCLC is highly sensitive to chemotherapy during the initial treatment, most patients still experience resistance and recurrence after receiving chemotherapy. A meta‐analysis demonstrated that thoracic radiotherapy (TRT) improves overall survival in SCLC. The results of the CALGB and CONVERT trials provide evidence for the efficacy of once‐daily high‐dose TRT. TRT at 60 Gy administered twice daily significantly improved survival without increasing toxicity. The long‐standing debate over the optimal timing of radiotherapy has not been fully resolved. SBRT has excellent local control rates and is a safe and effective treatment option for patients with stage I or II SCLC. Prophylactic cranial irradiation (PCI) is used to reduce treatment‐related neurotoxicity to the extent that there has been a recent discussion on whether magnetic resonance imaging (MRI) monitoring can replace PCI. Radiotherapy combined with immunotherapy significantly improves the survival rate of patients with NSCLC; however, its clinical effectiveness has not been systematically explored in patients with SCLC. Therefore, we summarize the evolving therapeutic strategies, (TRT for limited stage‐SCLC and consolidative TRT for extensive stage‐SCLC) and improved radiotherapy techniques (role of SBRT in stage I or II node‐negative SCLC, progress of PCI, and stereotactic radiosurgery), and discuss the possibilities and prospects of radiotherapy combined with immunotherapy for SCLC.

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“…In a recent RCT conducted in Japan, Takahashi et al [5] compared PCI and MRI surveillance and mandated brain MRI evaluation before enrolment and after 3, 6, 9, 12, 18, 24 months of follow-up; this approach ensured the exclusion of radiologically detectable brain metastasis and timely detection of brain metastasis development; moreover, this Japanese trial revealed that in ES-SCLC patients with MRI-confirmed brain metastasis free status, PCI did not prolong overall survival (hazard ratio: 1.27; P = 0.094), despite that it reduced the risk of brain metastasis development from 59.0 to 32.9% at 1-year follow up; notably, 83% patients in the control group who developed brain metastasis received salvage radiotherapy to the brain, whereas in the EORTC trial, only 59% patients in the control group who developed symptomatic brain metastasis underwent brain radiotherapy [5]. A recent study reported a 15.7% brain metastasis rate in baseline brain metastasis free ES-SCLC patients who responded to initial chemotherapy and who were re-evaluated with brain MRI before PCI [6 ▪ ]. These results suggested that the prompt identification of brain metastasis by brain MRI may have increased the chance of patients to receive salvage radiation and subsequently improved survival, and the strategy of omitting PCI in the context of active MRI surveillance and prompt salvage radiation to detected brain metastases is feasible in ES-SCLC.…”

Section: Prophylactic Cranial Irradiation In Extensive-stage Small Ce...mentioning

confidence: 99%

Prophylactic cranial irradiation in small cell lung cancer: an update

Chu

Zhu

2022

Current Opinion in Oncology

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Purpose of reviewThe current review presents recent updates in the seminal literature of research on prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC).Recent findingsBrain MRI restaging before the administration of PCI reveals a substantial proportion of brain metastasis in baseline brain metastasis free extensive-stage SCLC (ES-SCLC) and limited-stage SCLC (LS-SCLC). Posthoc analyses from the CASPIAN and IMpower133 trials revealed decreases in brain metastasis rates in ES-SCLC treated with chemoimmunotherapy relative to the brain metastasis rates in ES-SCLC treated with chemotherapy alone. A recent meta-analysis of literature published after the landmark 1999 Auperin meta-analysis confirmed the survival benefit of PCI in LS-SCLC patients. A recent study employing PET before and after PCI demonstrated that hippocampal avoidance -PCI (HA-PCI) preserved the metabolic activity of the hippocampi compared with regular PCI. Two phase III trials evaluating neurocognitive functions after HA-PCI versus PCI have yielded conflicting results. Ongoing clinical trials (MAVERICK, PRIMALung, NRG CC003, NCT04535739, NCT04829708 and NCT03514849) regarding PCI versus MRI surveillance and HA-PCI versus PCI were also discussed.SummaryCurrently, the indications for PCI in SCLC are under question in the modern MRI era. Result from prospective phase III, MRI staged and MRI monitored RCTs are expected to elucidate the role of PCI in LS-SCLC and ES-SCLC. Preliminary results indicated that adding immunotherapy to chemotherapy may reduce brain metastasis rate in SCLC. Further data to this aspect are warranted to determine the role of PCI in the immuno-chemotherapy era. The future direction for PCI should be the comprehensive integration of personalized patient selection, HA-PCI utilization and potential employment of other neurocognitive preservation strategies.

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Utility of Prophylactic Cranial Irradiation for Extensive-Stage Small-Cell Lung Cancer in the MRI Screening Era

Cited by 9 publications

References 26 publications

Immune activation effects at different irradiated sites and optimal timing of radioimmunotherapy in patients with extensive-stage small cell lung cancer: a real-world analysis

Immune activation effects at different irradiated sites and optimal timing of radioimmunotherapy in patients with extensive-stage small cell lung cancer: a real-world analysis

Progress in radiotherapy for small‐cell lung cancer

Prophylactic cranial irradiation in small cell lung cancer: an update

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