The staging, diagnosis and treatment of small cell lung cancer, the three major modules are clear!

*For medical professionals for reading reference

Come and collect!

Small cell lung carcinoma (SCLC) accounts for about 15%of lung cancer. Not only is the cells small, but also the shape is like oatmeal grains, so it is also called oatocytoma. SCLC is a low -differentiated nerve endocrine tumor, which has endocrine function, and SCLC has a high degree of malignancy, and it also proliferates quickly and moves early. Therefore, 2/3 patients have metastasis of the brain, liver, bone, and adrenal glands when they are diagnosed, just like "oatmeal".

How should SCLC diagnose?

2021 Edition of the China Clinical Oncology Society (CSCO) SCLC diagnosis and treatment guide pointed out [1]: In the early stage of lung cancer screening plan, high -risk population should receive low -dose spiral CT screening. Class Ⅰ recommendations for tumor diagnosis are chest enhancement CTs, and the image staging must be enhanced MR I.

Methods to obtain tissue or cytology include: fibrous bronchial mirrors, ultrasonic bronchial mirrors (EBUS), pelvic pelvic puncture, lymph nodes or superficial mass biopsy, and slurry effusion cytology. In terms of pathological diagnosis, morphological diagnosis is important. In order to clarify whether the tumor is SCLC, the immune group (IHC) test must be performed.

How should SCLC be staged?

The treatment of any cancer needs to consider the progress of the patient's condition. Some patients are mild, and some patients are severe. Although they are also a cancer, the choice of treatment plan is very different.

For the SCLC installment, the National Comprehensive Cancer Network (NCCN) working group combines the method of combining the AJCC TNM staging system and the Veteran Management Bureau (VA) SCLC solution [2]. SCLC uses the same TNM system as other cancer species before the joint use of VA stages (limited period and extensive period).

TNM staging system represents Tumor (tumor), node (lymph nodes), and metastasis: T describes the size of the tumor; n describes whether there are cancer cells in the lymph nodes; M describes whether the cancer has spread to different parts of the body.

China's clinical stages of SCLC are also roughly the same, mainly divided into limited period and extensive period. SCLC regularly SCLC refers to the lesion of the thoracic cavity, interval, front diagonal muscle and clavicle upper lymph nodes, but there must be no obvious upper cavity venous compression, vocal cord paralysis, and thoracic effusion. ; Wide -term SCLC refers to the lesion that exceeds the limited time, including malignant thoracic effusion and pericardial effusion, and blood row transfer [1].

How should SCLC be treated?

Although SCLC is highly sensitive to radiotherapy and radiotherapy, most of the patients will eventually transfer and spread. Almost all SCLC patients have a tendency to spread their body during diagnosis. Therefore, combined with chemotherapy plus chest radiotherapy is the main treatment method of the disease, and surgical resection is only implemented among very few patients.

Patients in T1-2 in SCLC during the limited period include surgical patients and patients who are not suitable for surgery. Patients undergoing surgery, if the pathological prompt N0 is prompted after surgery, chemotherapy should be applied. Patients of N1 also need to consider hypertrophy of lymph nodes. Patients in N2 receive auxiliary chemotherapy+hypertrophy radiotherapy. T-2, N0 patients, if the PS score is 0-2 points, you can consider chemotherapy synchronization or sequential radiotherapy; if the PS score is poor (not SCLC), it is not suitable for radiotherapy or chemotherapy schemes. Best support treatment should be used. Essence

The prognosis of this type of tumor is extremely poor. Systemic chemotherapy can extend the survival period and improve the symptoms. However, due to the usually relief period of drug resistance, the comprehensive treatment is the key to reducing the cure. It has been more than 30 years for relying on Polycin and platinum drugs as a wide range of SCLC first -line standard treatment schemes [3]. In recent years, the development of Immune Checkpoint Inchibitor (ICI) has improved the survival of SCLC patients.

Therefore, in the China Clinical Oncology Society (CSCO) Guide, patients with no local symptoms and brain metastases are treated according to the PS score: PS score 0-2 and tumor PS scores are poor, and chemotherapy+immunotherapy can be given in front line ( For example, Dagotabi Mipida+chemotherapy, Adi Zhuzab+chemotherapy); if the PS scoring caused by tumors is not poor, the best support treatment is recommended. If the patient has local symptoms, radiotherapy and systemic chemotherapy is given. Patients accompanied by brain metastases, if there is no symptoms, receive systemic treatment first, and then give whole brain radiotherapy; patients with symptoms of brain metastases give priority to whole brain radiotherapy, and symptoms are stable.

The recommendation of front -line therapy is based on two studies, which are Impower133 and Caspian research. IMPOWER133 Study [2] is a random, double -blind, multi -centered phase III clinical study, which is included in 403 patients with a wide range of SCLC patients. The platinum (EP) scheme is induced, and then sequentially follows the treatment of Antidizumab; another set of EP+placebo therapy, sequential placebo maintenance treatment. The main endpoint of the study is the total survival period (OS) and no progressive survival (PFS). The final research results show that the median OS of the Adidizab and the placebo group is 12.3 months VS10.3 months (P = 0.007); = 0.02). The toxicity of Ayidzumab combined with the drug group is controllable. The results of Caspian's research showed that the data as of March 27, 2021, the median follow -up time was 39.4 months, and the maturity was 86%. Compared with the EP group, the Durai Umimab+EP group continues to show OS significant improvement: HR is 0.71 (95%C Ⅰ 0.60-0.86; P = 0.0003), Durai Umimab+EP group and EP group The median OS is 12.9 months VS 10.5 months; the 2 -year OS rate is 22.9% VS 13.9%; the 3 -year OS rate is 17.6% vs 5.8%, showing the "long tail effect" of immunotherapy, and the EP group and the EP group Compared with, the long -term OS benefits have obvious advantages [3].

Not only that, Caspian studied a total of 123 patients with an unprepared ES-SCLC patient in 28 research centers in China. The results show that the Chinese queue has a consistent benefit trend with global data. The median OS is 14.4 months. Become the only PD-L1 inhibitor that has benefited from the Chinese SCLC population [4].

In the second -tier treatment, if the recurrence time is ≤6 months, the topology can be considered for the use of topology or participating in clinical trials; the recurrence time is more than 6 months, and the original solution can be selected. In the three-line and above treatment, if patients with a PS score of 0-2 can consider using Arotinib.

For patients with composite SCLC, the treatment plan refers to pure SCLC regardless of patients with limited or extensive patients. If it contains adenocarcinoma ingredients, genetic testing can be considered; those with driving gene mutations can consider targeted therapy.

The treatment of transformation SCLC is very different from the primary SCLC. In terms of the overall treatment strategy of transforming SCLC, layered treatment can be layered according to the progress of the disease: patients with rapid progress in system adopting standard SCLC chemotherapy schemes; patients with local slow progress, adopt standard SCLC chemotherapy schemes or continue the original EGFR-TKI+local treatment ; Patients with slow progress in the system refer to the original treatment plan based on chemotherapy.

Expert Reviews

Professor Kuangshu Gen of Xiushui County People's Hospital: Follow the guide and standardize treatment to create greater benefits for patients with SCLC

Professor Kuangshugen pointed out that SCLC should be accurately staged before formulating the treatment decision -making, and a systemic system is required. SCLC's staging has always followed the second phase of the United States Veterans Cancer Association (VALG), which is mainly based on the important position of radiotherapy in SCLC treatment. The AJCC TNM staging system is suitable for selecting patients with T1-2n0s suitable for surgery. Clinical research should first use the TNM staging system, as it can more accurately evaluate prognosis and guidance treatment. I think the SCLC installment should be combined with the AJCC TNM staging method with the second phase of VALG. In terms of surgery, the SCLC of the Ⅰ-ⅠA stage may benefit from surgery, and the role of surgery is controversial.

Most of patients with SCLC have a wide range of diagnosis, and the opportunities for surgery are quite slim. Therefore, the status of systemic treatment is irreplaceable. In the clinical diagnosis and treatment, most of them follow the guideline specifications to formulate a treatment plan for patients with SCLC. The domestic and foreign guidelines include chemotherapy combined immunotherapy in the ES-SCLC first-line therapy. Detozumab, both of which are PD-L1 inhibitors. On February 13, 2020, the China National Drug Administration (NMPA) approved the Adidarzumab combined chemotherapy for the first-line treatment ES-SCLC; on July 14, 2021, the first-line treatment of ES treatment of ES -SCLC's new indications are approved in China. Based on my country's huge population base, this will undoubtedly benefit many patients with ES-SCLC who are trapped in trouble.

Professor of Pingyu County People's Hospital Professor: Accurately selects SCLC beneficiaries, immune+chemotherapy prospects are expected

Professor Dai Guohua pointed out that although immunochemical combined chemotherapy has brought certain benefits to patients with SCLC, there are still many ways to go in accurate screening beneficiaries. Tumor Mutation Burden (TMB) may predict the efficacy of immune examination point inhibitors, and the use of NGS multi -genome combinations to estimate TMB is a clinical method. When the tissue specimen is insufficient, the use of NGS to detect circulating hematoma cell DNA (CTDNA) for TMB estimation is one of the potential technical means. At present, there is no approved targeting drug or guidance of the SCLC. [5-6]. Circulating Tumor Cells (CTCS) refers to cells with tumor characteristics in the circulating blood. CTCS, as a "liquid biopsy specimen" representing the primary tumor, can monitor the condition of SCLC patients in real time, dynamic, and nonsense. The detection rate of CTCS in the SCLC crowd is 67%-86%. Detection of CTCS helps to correctly judge the clinical stage of the disease in order to choose the appropriate treatment plan, guide individual chemotherapy of SCLC patients, monitor tumor recurrence and metastasis, and judge the treatment efficacy efficacy And predicting prognosis survival, it is also a means to analyze the resistance molecular mechanism and solve the heterogeneity of tumor [7].

At the annual conference of the European Cancer Internal Science (ESMO) annual meeting in 2021, the latest research data released by Caspian showed that the two -year OS ratio of Diaguli Mipida combined chemotherapy reached 22.9%, which means that nearly 1/4 ES ES -SCLC patients can achieve survival for more than 2 years. The 3 -year OS rate also reached 17.6%, which was increased by 3 times. It was also well reflected in my clinical work. Some SCLC patients accepted the exciting results after the treatment of PD-L1 inhibitors represented by Pad-L1 in control. I also hope that Daguyu's SCLC indication can be included in medical insurance as soon as possible, and it can also be widely used in grass -roots hospitals to benefit more SCLC patients.

references:

[1] CSCO small cell lung cancer diagnosis and treatment guide 2021.

[2] liu SV, et al. J clin oncol. 2021 Feb 20; 39 (6): 619-630

[3]Jonathan W Goldman， Mikhail Dvorkin， Yuanbin Chen， et al. Durvalumab，with or without tremelimumab，plus platinum–etoposide versus platinum–etoposide alone in first-line treatment of extensive-stage small-cell lung cancer(CASPIAN)： Updated Results from a Randomised, Controlled, Open-Label, Phase 3 trial.the Lancet Oncology.2020.

[4]PazAres1 L， Chen Y， Reinmuth N， et al.Durvalumab ± tremelimumab + platinum-etoposide in firstline extensive-stage SCLC (ES-SCLC)：3-year overall survival update from the phase Ⅲ CASPIAN study. 2021 ESMO. Lba61.

[5] Samstein RM, Lee Ch, Shoushtari An, et al. Tumor Mutational Load Predicts Survival Immunotherapy Across Multiple Cancer Types [J]. Nat Genet, 2019, 51 (2): 202-206.

2012, 18 (4): 1138-1145. [7] cheng y, liu XQ, FAN Y, et al. Circulating tumor Cell Count/Change for Outcome Prediction in Patients with Extensive Small-Cell LUNCER [J].Future Oncol, 2016, 12 (6): 789-799.

Approval number: CN-96219 Expired Date: 2023-6-19

*The interview /writing of this article is supported by Astrikang for reference for medical and health professionals

*This article is only used to provide scientific information to medical people, and does not represent the viewpoint of this platform

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