Small Cell Lung Cancer Case Presentations UCSF/UCD Thoracic Oncology Conference

Transcription

1 Small Cell Lung Cancer Case Presentations UCSF/UCD Thoracic Oncology Conference Matthew Gubens, MD Heather Wakelee, MD Extensive Stage SCLC Stanford University School of Medicine November 21, yo Caucasian man presents with productive cough, progressive SOB, hoarseness, profound fatigue PMH: COPD and pulmonary fibrosis since 2002, HTN NKDA Medications: Amlodipine, atenolol, furosemide, albuterol/ ipratropium inhaler Social History: Retired factory worker. 50 pack year smoking history, quit 2002 Physical examination Pale, thin man, in NAD but winded after walking across examination room ECOG PS 2 VS: O2 sat 95% at rest RA, other VSS Decreased BS inferior ½ of L lung field Labs CBC and BMP WNL 1

2 Do you routinely get a PET scan to complete staging of small cell lung cancer? 1. Yes 2. No 85% CT C/A/P: extensive bulky mediastinal and L hilar LAD, encasement of L mainstem bronchus, nodular pleural thickening, moderate pleural effusion Brain MRI: negative Biopsy: small cell lung cancer Yes 15% No After completion of staging, which chemotherapy regimen would you start for this patient? 1. Cisplatin+ etoposide 2. Cisplatin + topotecan 3. Cisplatin + irinotecan 4. Carboplatin + etoposide 5. Carboplatin + irinotecan 6. Carboplatin + pemetrexed 8 1 5% 5% If this patient was of Japanese ancestry which chemotherapy regimen would you choose? 1. Cisplatin+ etoposide 2. Cisplatin + topotecan 3. Cisplatin + irinotecan 4. Carboplatin + etoposide 5. Carboplatin + irinotecan 6. Carboplatin + pemetrexed 33% 61% 6% Cisplatin+ eto... Cisplatin + to... Cisplatin + ir... Cisplatin+ eto... Cisplatin + to... Cisplatin + ir... 2

3 The patient receives 4 cycles of carboplatin / etoposide and achieves a near complete response in the chest masses and lymphadenopathy After 4 cycles of chemotherapy with the patient achieving a CR, what would you recommend next? 1. Observation with serial imaging 2. Prophylactic cranial irradiation (PCI) 3. Chest radiation to original tumor site and original lymph nodes 21% 4. PCI and chest radiation to original tumor site and original lymph nodes 5. 2 more cycles of the same chemotherapy Observation wi... Prophylactic c... 37% Chest radiatio... 5% 21% PCI and chest... 16% 2 more cycles... If the patient recurs after 4 months and assuming no open trials, what treatment would you offer? There is a clinical trial with amrubicin (A) open at another local facility. Before going there, the patient would like to hear your input. You tell him that: Irinotecan 31% 1. Irinotecan 2. Platinum + irinotecan 3. Topotecan 4. CAV: cyclophosphamide, adriamycin, vincristine 5. Repeat his previous chemo regimen 6. Best supportive care 7. Other Platinum + iri... 25% 25% Topotecan CAV: cyclophos... 19% Repeat his pre... Best supportiv... Other 1. A is effective only in platinum sensitive patients 2. A is equally effective in platinum sensitive and resistant patients 3. A appears to be more effective than topotecan in platinum relapsed/refractory patients 4. A is better than topotecan in Asian studies but no evidence exists in North American studies 8% A is effective... A is equally e... 17% 17% A appears to b... 58% A is better th... 3

4 Limited Stage SCLC 64 yo Caucasian man presents with URI symptoms, since resolved, for which his primary care physician ordered a CXR that showed a 3cm L lung mass PMH: HTN, dyslipidemia NKDA Medicines: Hydrochlorothiazide, enalapril, simvistatin SH: Veteran, works in car dealership. 45PY smoking history, still smoking 1 PPD. Physical exam Slightly thin appearing man in NAD ECOG PS 0 VSS, including O2 sat 98% on RA Clear chest exam Laboratory studies CBC, BMP, LFTs all WNL CT C/A/P: confirms the 3cm left lung lesion seen in CXR, without mainstem bronchus involvement, no LAD Brain MRI: negative Biopsy: small cell lung cancer 4

5 What would you do next? After a negative PET scan, you send the patient for mediastinoscopy, and no positive nodes are found. What would you do next? 1. Complete staging with a PET scan 2. Perform a mediastinoscopy 3. Both a PET and a mediastinoscopy 47% 53% 1. Start chemotherapy with cisplatin + etoposide 2. Send the patient for resection, then prophylactic cranial irradiation (PCI) 3. Send the patient for resection, then give cisplatin + etoposide if nodes are negative 4. Start definitive chemotherapy/radiation with 8% plans for PCI 15% 77% Complete stagi... Perform a medi... Both a PET and... Start chemothe... Send the patie... Send the patie... Start definiti... If nodes are positive on mediastinoscopy, what would you do next? 1. Start definitive chemotherapy with cisplatin + etoposide 2. Start concurrent chemoradiation with cisplatin + etoposide 3. Start neoadjuvant chemotherapy with cisplatin + etoposide, then send the 6% patient for resection Start definiti... Start concurre... 71% 24% Start neoadjuv... If nodes are positive on PET, but his ECOG PS was 3 due to his SCLC, what would you do next? 39% 39% 1. Start chemotherapy 2. Start concurrent chemoradiation 3. Best supportive care Start chemothe... Start concurre... 22% Best supportiv... 5

6 After completion of concurrent chemoradiation when would you ever consider NOT giving PCI 1. Patient > 70 years old 2. Progressive disease 3. Either 1 or 2 67% 27% 7% Patient > 70 y... Progressive di... Either 1 or 2 6