Utility of Prophylactic Cranial Irradiation for Limited Stage Small Cell Lung Cancer in the Modern Era with Magnetic Resonance Imaging Surveillance

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

doi:10.1016/j.clon.2021.03.018

Cited by 13 publications

(11 citation statements)

References 24 publications

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“… 5 Since Takahashi et al 6 published their study on the negative effect of PCI on extensive‐stage SCLC, an increasing number of studies have questioned the role of PCI in LS‐SCLC. 7 , 8 , 9 , 10 …”

Section: Introductionmentioning

confidence: 99%

Prophylactic cranial irradiation for limited‐stage small‐cell lung cancer in the magnetic resonance imaging era

et al. 2022

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Background We investigated the role of prophylactic cranial irradiation (PCI) in limited‐stage small‐cell lung cancer (LS‐SCLC) according to tumor response in the magnetic resonance imaging (MRI) era. Methods We retrospectively evaluated patients with LS‐SCLC without brain metastases (BMs) on MRI who achieved either complete response (CR) or partial response (PR) after initial chemoradiotherapy at our center from 2006 to 2017. Results This study comprised 116 patients (median age, 58 years; men, 92; women, 24). After initial chemoradiotherapy, 53 patients achieved CR, while 63 patients achieved PR. Eighty‐three patients received PCI. Patients who received PCI had better overall survival (OS, 5‐year: 52.5% vs. 35.1%; p = 0.012) and progression‐free survival (PFS, 5‐year: 45.0% vs. 28.2%; p = 0.001) and a lower incidence of BMs (5‐year: 18.3% vs. 39.4%; p = 0.010). In the subgroup analysis, PCI improved OS (5‐year: 67.8% vs. 46.7%, p = 0.005) and PFS (5‐year: 65.2% vs. 35.0%, p = 0.021) and decreased BM risk (5‐year: 12.1% vs. 52.4%, p = 0.002) for patients with CR. However, PCI had no benefit (5‐year OS: 40.5% vs. 35.6%, p = 0.763; 5‐year BMs: 24.6% vs. 31.9%, p = 0.561) for patients with PR. Conclusions Tumor response remained an important factor for selecting patients for PCI in the MRI era. PCI should be recommended for patients with LS‐SCLC who achieve CR after initial thoracic chemoradiotherapy.

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Section: Introductionmentioning

confidence: 99%

Prophylactic cranial irradiation for limited‐stage small‐cell lung cancer in the magnetic resonance imaging era

et al. 2022

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“…Conversely, in a recent analysis of 297 patients with LS-SCLC, PCI was not independently associated with substantial improvement in OS (HR 0.844, 95% CI 0.604–1.180, p = 0.32) [ 18 ]. S. Ghanta et al demonstrated that PCI significantly prolonged neurological survival (HR 0.23, 95% CI 0.08–0.65; p = 0.01) and brain metastasis-free survival (HR 0.25, 95% CI 0.12–0.51; p < 0.01) but had no role in improving OS (HR 0.74, 95% CI 0.49–1.11; p < 0.01) [ 19 ]. We included 1068 patients with LS-SCLC, including 324 in each cohort who were matched for further comparisons.…”

Section: Discussionmentioning

confidence: 99%

“…The conflicting survival outcomes in the EORTC trial and Japanese trial of ES-SCLC challenged the contemporary rationality to recommend PCI for LS-SCLC, which was mainly based on pre-MRI data [7,8]. Several small retrospective studies have explored the role of PCI for LS-SCLC in the contemporary era [18][19][20][21][22]. Nevertheless, the findings varied.…”

Section: Discussionmentioning

confidence: 99%

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Prophylactic cranial irradiation (PCI) versus active surveillance in patients with limited-stage small cell lung cancer: a retrospective, multicentre study

et al. 2022

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Background The recommendation of PCI for limited-stage small cell lung cancer (LS-SCLC) is primarily based on evidence from the pre-magnetic resonance imaging (MRI) era. However, as MRI accuracy improves and stereotactic radiosurgery advances, the role of PCI for LS-SCLC has become uncertain. This study aims to compare the contemporary survival outcomes of patients with LS-SCLC treated with PCI versus active surveillance. Methods We conducted a retrospective cohort study in which 1068 patients with LS-SCLC who achieved a good response to first-line chemoradiotherapy were consecutively enrolled from 5 tertiary medical centres between June 2009 and June 2019. Of these patients, 440 received PCI, while 628 received surveillance without PCI. Propensity score matching with a 1:1 ratio was performed to balance the baseline characteristics of the two cohorts. The endpoints were overall survival (OS) and the incidence of brain metastasis (BM). Results In total, 648 patients were matched. The baseline characteristics were generally well balanced. At a median follow-up of 64.5 months (range 2–190), patients who underwent PCI had a significantly lower risk for BM than those who underwent surveillance. The 3-year cumulative incidence rate of BM was 28.2% (95% CI 22.5–33.8%) in the PCI cohort and 38.5% (32.6–44.5%) in the surveillance cohort (Gray’s p = 0.002). However, the lower incidence of BM in the PCI cohort did not translate into a significant extension of OS. The median OS was 35.8 months (95% CI 27.6–44.0 months) in the PCI cohort versus 32 months (26.4–37.6 months) in the surveillance cohort (HR 0.90, 95% CI 0.74–1.10, p = 0.29). Multivariable analysis showed that disease stage, chemoradiotherapy sequence, and response to chemoradiotherapy were independent prognostic factors for BM or OS. Conclusions Overall, PCI reduces the risk for BM but does not substantially prolong OS compared with active surveillance. A phase 3, prospective clinical trial (NCT04829708) we initiated is currently underway, which is expected to corroborate our results.

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“…In a recent meta-analysis of 28 studies published after the landmark 1999 meta-analysis via Auperin et al [2,16 ▪ ], the PCI group showed significant advantage in terms of overall survival over the no-PCI control (adjusted hazard ratio: 0.62); this trend remained in the MRI-staged (adjusted hazard ratio: 0.62) and CRT-treated subgroups (adjusted hazard ratio: 0.58) [16 ▪ ]. Some retrospective studies have not found a significant benefit to overall survival in LS-SCLC staged with brain MRI; the PCI groups still showed an improved brain metastasis rate and brain metastasis caused death rates [17,18]. One retrospective study by Pezzi et al [19 ▪ ] revealed neither significantly reduced brain metastasis rate nor improved overall survival.…”

Section: Prophylactic Cranial Irradiation In Limited-stage Small Cell...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 Limited Stage Small Cell Lung Cancer in the Modern Era with Magnetic Resonance Imaging Surveillance

Cited by 13 publications

References 24 publications

Prophylactic cranial irradiation for limited‐stage small‐cell lung cancer in the magnetic resonance imaging era

Prophylactic cranial irradiation for limited‐stage small‐cell lung cancer in the magnetic resonance imaging era

Prophylactic cranial irradiation (PCI) versus active surveillance in patients with limited-stage small cell lung cancer: a retrospective, multicentre study

Prophylactic cranial irradiation in small cell lung cancer: an update

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