Small Cell Lung Cancer Treatment Professional Information

Recurrent Small Cell Lung Cancer

Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. Refer to the PDQ levels of evidence summary for more information.

The prognosis for small cell lung carcinoma that has progressed despite chemotherapy is exceedingly poor regardless of stage. Expected median survival is 2 to 3 months. These patients should be considered for palliative therapy or clinical trials. Patients who are primarily resistant to chemotherapy and those who have received multiple chemotherapy regimens rarely respond to additional treatment. However, patients who have initially responded and relapsed more than 6 months following initial treatment are more likely to respond to additional chemotherapy. While no single chemotherapy regimen should be considered standard, those that have shown activity as second line treatment include oral etoposide, etoposide/cisplatin, cyclophosphamide/doxorubicin/vincristine (CAV), lomustine/methotrexate, and topotecan.^1-8 A randomized comparison of second line treatment with either CAV or topotecan reported no significant difference in response rates or survival, but palliation of symptoms was better with topotecan.⁸[Level of evidence: 1iiC]

Some patients with intrinsic endobronchial obstructing lesions or extrinsic compression due to tumor have achieved successful palliation with endobronchial laser therapy (for endobronchial lesions only) and/or brachytherapy.⁹ Expandable metal stents can be safely inserted under local anesthesia via the bronchoscope, resulting in improved symptoms and pulmonary function in patients with malignant airways obstruction.¹⁰ Patients with progressive intrathoracic tumor after failing initial chemotherapy can achieve significant tumor responses, palliation of symptoms, and short-term local control with external-beam radiation therapy. However, only the rare patient will experience long-term survival following "salvage" radiation therapy.¹¹

Patients with central nervous system recurrences can often obtain palliation of symptoms with radiation therapy and/or additional chemotherapy. The majority of patients treated with radiation therapy obtain objective responses and improvement following radiation therapy.¹² A retrospective review showed that 43% of patients treated with additional chemotherapy at the time of CNS relapse respond to second-line chemotherapy.¹³

Treatment options:

1. Palliative radiation therapy.¹¹
   
2. Salvage chemotherapy can provide some palliative benefit for patients previously sensitive to standard chemotherapy.^2,4-8
   
3. Local palliation with endobronchial laser therapy, endobronchial stents, and/or brachytherapy.^9,10
   
4. Clinical trials of phase I or phase II drugs. Refer to PDQ or to CancerNet (http://cancernet.nci.nih.gov) for information on clinical trials for patients with recurrent small cell lung cancer.

References:

1. Greco FA: Treatment options for patients with relapsed small cell lung cancer. Lung Cancer 9(Suppl 1): s85-s89, 1993.
2. Johnson DH, Greco FA, Strupp J, et al.: Prolonged administration of oral etoposide in patients with relapsed or refractory small-cell lung cancer: a phase II trial. Journal of Clinical Oncology 8(10): 1613-1617, 1990.
3. Spiro SG, Souhami RL, Geddes DM, et al.: Duration of chemotherapy in small cell lung cancer: a Cancer Research Campaign trial. British Journal of Cancer 59(4): 578-583, 1989.
4. Evans WK, Osoba D, Feld R, et al.: Etoposide (VP-16) and cisplatin: an effective treatment for relapse in small-cell lung cancer. Journal of Clinical Oncology 3(1): 65-71, 1985.
5. Sekine I, Nishiwaki Y, Kakinuma R, et al.: Late recurrence of small-cell lung cancer: treatment and outcome. Oncology 53(4): 318-321, 1996.
6. Chute JP, Kelley MJ, Venzon D, et al.: Retreatment of patients surviving cancer-free 2 or more years after initial treatment of small cell lung cancer. Chest 110(1): 165-171, 1996.
7. Ardizzoni A, Hansen H, Dombernowsky P, et al.: Topotecan, a new active drug in the second-line treatment of small-cell lung cancer: a phase II study in patients with refractory and sensitive disease. Journal of Clinical Oncology 15(5): 2090-2096, 1997.
8. Schiller J, von Pawel J, Shepherd F, et al.: Topotecan (T) versus (vs) cyclophosphamide (C), doxorubicin (A) and vincristine (V) for the treatment (tx) of patients (pts) with recurrent small cell lung cancer (SCLC): a phase III study. Proceedings of the American Society of Clinical Oncology 17: A-1755, 456a, 1998.
9. Miller JI, Phillips TW: Neodymium:YAG laser and brachytherapy in the management of inoperable bronchogenic carcinoma. Annals of Thoracic Surgery 50(2): 190-196, 1990.
10. Wilson GE, Walshaw MJ, Hind CR: Treatment of large airway obstruction in lung cancer using expandable metal stents inserted under direct vision via the fibreoptic bronchoscope. Thorax 51(3): 248-252, 1996.
11. Ochs JJ, Tester WJ, Cohen MH, et al.: "Salvage" radiation therapy for intrathoracic small cell carcinoma of the lung progressing on combination chemotherapy. Cancer Treatment Reports 67(12): 1123-1126, 1983.
12. Carmichael J, Crane JM, Bunn PA, et al.: Results of therapeutic cranial irradiation in small cell lung cancer. International Journal of Radiation Oncology, Biology, Physics 14(3): 455-459, 1988.
13. Kristensen CA, Kristjansen PE, Hansen HH: Systemic chemotherapy of brain metastases from small-cell lung cancer: a review. Journal of Clinical Oncology 10(9): 1498-1502, 1992.

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