What is the optimal dose and fractionation schedule of prophylactic cranial irradiation in patients with extensive stage SCLC?

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What is the optimal dose and fractionation schedule of prophylactic cranial irradiation in patients with extensive stage SCLC?

The Prophylactic Cranial Irradiation Overview Collaborative Group meta-analysis of individual patient data from seven trials included mostly patients with limited stage SCLC although a minority had extensive stage SCLC.[1] This analysis confirmed a reduction in the incidence of brain metastases with increasing doses of prophylactic cranial irradiation (PCI), but no effect on survival.

A randomised EORTC trial of PCI in patients with extensive stage SCLC utilised a range of PCI doses and fractionation schemes, the commonest of which were 20Gy/5Fr, 30Gy/10Fr, 30Gy/12Fr and 25gy/10Fr.[2] Sixty two percent of patients received 20Gy/5Fr. However, allocation to radiotherapy dose/fractionation schedule was not randomised.

As such, the optimal radiotherapy dose and fractionation schedule for extensive stage SCLC has not yet been defined.

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Evidence summary and recommendations

Evidence summary Level References
Prophylactic cranial radiotherapy schedules ranging from 20Gy in 5 fractions to 30Gy in 12 fractions reduce the incidence of brain metastases and improve survival in extensive stage SCLC patients who achieve a response to initial therapy.

Last reviewed November 2015

II [2]
Over this dose range, higher radiotherapy doses confer no survival advantage over lower ones

Last reviewed November 2015

I [1]
Evidence-based recommendationQuestion mark transparent.png Grade
For patients with extensive stage small cell lung cancer who achieve a response to initial therapy, a range of prophylactic cranial irradiation dose schedules from 20Gy in 5 fractions to 30Gy in 10 fractions is reasonable.

Last reviewed November 2015

B


Practice pointQuestion mark transparent.png

There is insufficient evidence to recommend a particular prophylactic cranial irradiation dose or fractionation schedule over any other. However, since extensive stage small cell lung cancer has a median survival of less than a year, a short fractionation schedule (20Gy in 5 fractions) is recommended for most patients.
Last reviewed November 2015

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References

  1. 1.0 1.1 Prophylactic Cranial Irradiation Overview Collaborative Group. Cranial irradiation for preventing brain metastases of small cell lung cancer in patients in complete remission (review). Cochrane Database Syst Rev 2009 Jan Abstract available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002805/pdf.
  2. 2.0 2.1 Slotman B, Faivre-Finn C, Kramer G, Rankin E, Snee M, Hatton M, et al. Prophylactic cranial irradiation in extensive small-cell lung cancer. N Engl J Med 2007 Aug 16;357(7):664-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17699816.

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Appendices

Further resources

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