Prophylactic Cranial Irradiation (PCI) vs Active MRI Surveillance for Small-Cell Lung Cancer: The Case for Equipoise.

5 years ago

Prophylactic Cranial Irradiation (PCI) vs Active MRI Surveillance for Small-Cell Lung Cancer: The Case for Equipoise.

Rusthoven CG, Kavanagh BD

Prophylactic cranial irradiation (PCI) for small-cell lung cancer (SCLC) offers a consistent reduction in the incidence of brain metastases (BM), at the cost of measurable toxicity to neurocognitive function and quality of life in the setting of characteristic pathologic changes to the brain. The sequelae of PCI have historically been justified by the perception of an overall survival (OS) advantage specific to SCLC. This rationale has now been challenged by a randomized trial in extensive-stage SCLC demonstrating equivalent progression-free survival and a trend toward improved OS with PCI omission in the context of modern MRI staging, surveillance, and salvage therapy. In this article, we critically examine the randomized trials of PCI in extensive-stage SCLC and discuss their implications on the historic data supporting PCI for limited-stage SCLC from the pre-MRI era. Further, we review the toxicities of moderate doses of radiation to the entire brain that underlie the growing interest in active MRI surveillance and PCI omission. Finally, the evidence supporting prospective investigation of radiosurgery for limited BM in SCLC is reviewed. Overall, our aim is to provide an evidence-based assessment of the debate over PCI vs active MRI surveillance and to highlight the need for contemporary trials evaluating optimal CNS management in SCLC.

Publisher URL: https://www.ncbi.nlm.nih.gov/pubmed/28882584

DOI: PubMed:28882584