Felip, E.

Pavlidis, N.

Stahel, R. A.

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ESMO Minimum Clinical Recommendations for diagnosis,treatment and follow-up of small-cell lung cancer (SCLC)Incidence. The crude incidence of lung cancer in the European Unionis 52.5/100 000 per year, the mortality 48.7/100 000 peryear. Among men the rates are 82.5 and 77.0/100 000 peryear, among women 23.9 and 22.3/100 000 per year,respectively. SCLC accounts for 20% of all cases. About90% of lung cancer mortality among men (and 80% amongwomen) is attributable to smoking.Diagnosis. Pathological diagnosis should be made according to theWorld Health Organisation classification from a broncho-scopic, Tru-cut or surgical biopsy or fine needle aspiration.Staging and risk assessment. Patients are usually staged according to a simple two-stagesystem developed by the Veteran’s Administration LungCancer Study Group as limited disease (LD) or extensivedisease (ED):Limited disease. The definition is based on the possibility of encompassingall detectable tumor within a “tolerable” radiotherapy port.Patients with limited disease have tumor deposits restrictedto one hemithorax with regional lymph node metastasisincluding ipsilateral hilar, ipsilateral supraclavicular, med-iastinal and contralateral hilar nodes.Extensive disease. It represents any tumor beyond the bounds defined aboveincluding ipsilateral lung metastases and malignant pleuraleffusion.. In addition to a complete history and physical examination,staging procedures should at least include the following:chest X-ray, complete blood count, liver and renal functiontests, LDH, sodium, and a CT scan of chest and upperabdomen.. Additional tests to define limited disease in patients withsymptoms or abnormal physical examination suggestingmetastasis are: a bone scintigraphy, a CT scan or MRI ofthe brain, and a bone marrow biopsy. Once any one of thesetests is positive, extensive disease has been confirmed andthere is no need to proceed with the rest of the tests [V, D].TreatmentTreatment of limited disease. Standard regimens, also for patients diagnosed at surgery,are either based on etoposide-platinum or cyclophospha-mide-doxorubicin and should be given for 4–6 cycles [I, A].Maintenance chemotherapy does not result in any sub-stantial improvement in survival [II, A].. Etoposide-cisplatin is widely regarded as state-of-the-artchemotherapy for limited disease, particularly because thisregimen can be combined with concurrent irradiation with-out unacceptable toxicity [II, A].. Chest radiotherapy increases local control and survival andshould be given to all patients with limited disease. Severalstudies suggest to start thoracic radiotherapy early duringchemotherapy [II–III, A].. Prophylactic cranial irradiation is indicated in patients witha complete remission from limited disease because itreduces the lifetime risk of cerebral metastases andimproves survival [II, B].Treatment of extensive disease. Chemotherapy with the same regimens as for limited dis-ease and given for 4–6 cycles also improves survival forpatients with extensive disease and is usually the mosteffective way to ameliorate clinical symptoms [II, A].Second-line chemotherapy. Patients relapsed from a response to first-line chemotherapyshould be considered for second-line chemotherapy [III, B].Response evaluation. Response evaluation is recommended at least at the end oftreatment by repetition of the initial radiographic tests [V, D].Follow-up. There is no evidence that follow-up of asymptomaticpatients is needed. Specific examinations as clinicallyindicated.NoteLevels of Evidence [I–V] and Grades of Recommendation[A–D] as used by the American Society of Clinical Oncologyare given in square brackets. Statements without grading wereAnnals of Oncology 16 (Supplement 1): i30–i31, 2005doi:10.1093/annonc/mdi829q 2005 European Society for Medical Oncologyconsidered justified standard clinical practice by the expertsand the ESMO faculty.Literature1. Sundstrom S, Bremnes RM, Kaasas S et al. Cisplatin and etoposideregimen is superior to cyclophosphanide, epirubicin, and vincristineregimen in small cell lung cancer: results form a randomized phaseIII trial with 5 years’ follow-up. J Clin Oncol 2002; 20: 4665–4672.2. Pignon JP, Arriagada R, Ihde DC et al. A meta-analysis of thoracicradiotherapy for small cell lung cancer. N Engl J Med 1992; 327:1618–1624.3. McCracken JD, Janaki LM, Crowley JJ et al. Concurrent chemother-apy/radiotherapy for limited small-cell lung carcinoma: A SouthwestOncology Group Study. J Clin Oncol 1990; 8: 892–898.4. Auperin A, Arriagada R, Pignon JP et al. Prophylactic cranialirradiation for patients with small-cell lung cancer in completeremission. Prophylactic Cranial Irradiation Overview CollaborativeGroup. N Engl J Med 1999; 341: 476–484.Coordinating authors for the ESMO Guidelines Task Force: E. Felip1,N. Pavlidis2 & R. A. Stahel31Invited author, Hospital Universitario Vall D’Hebron, Barcelona, Spain;2Assigned task force member, University of Ioannina, Dept. MedicalOncology, 45110 Ioannina, Greece; 3Assigned task force member, Div. ofOncology, University Hospital, Ra¨mistr. 100, CH-8091 Zu¨rich,SwitzerlandApproved by the ESMO Guidelines Task Force: February 2002, lastupdate December 2004.Correspondence to:ESMO Guidelines Task ForceESMO Head OfficeVia La Santa 7CH-6962 LuganoSwitzerlandi31

ESMO Minimum Clinical Recommendations for diagnosis, treatment and follow-up of small-cell lung cancer (SCLC)

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