Small cell carcinoma of the lung

The patient with limited small cell carcinoma of the lung at diagnosis is a candidate for potentially curative treatment, with a probability of long-term, disease-free survival approximating that of an adult with acute myelogenous leukemia. The 'best' treatment has not yet evolved, and many research protocols presently in progress will shed light on this question. Because microscopic dissemination of disease is present in the majority of patients, chemotherapy must be an important component of their management. Cyclophosphamide-based combinations, especially those involving vincristine with or without Adriamycin, methotrexate, or VP-16, currently appear to be the most effective. The role of radiation therapy to the primary tumor, once considered 'standard,' is now being questioned. But increased dose, better treatment planning, advances in technique,⁶¹ and/or particle (e.g., neutron) therapy may lead to an increase in efficacy of this modality. In those programs that involve combined radiation and chemotherapy, both theory and experimence suggest that agents with marked overlapping toxicity (e.g., Adriamycin and methotrexate) should not be administered simultaneously with full-dose radiation. The use of chemotherapy, followed by radiation, followed by chemotherapy in a 'sandwich' fashion, is better tolerated than a concomitant approach. However, it may also be less effective. Local therapy to the brain by irradiation will be necessary to prevent relapse in this 'sanctuary' site as long as systemic chemotherapy remains ineffective. In extensive small cell disease, elective whole-brain radiation should be carried out also, at least in those patients who show a partial or complete response after 2-4 courses of combination chemotherapy. The experience with relapse in nonbrain CNS sites indicates that these will require some form of local 'prophylactic' treatment in such patients, either intrathecal chemotherapy or neuraxis irradiation. The only hope of prolonged disease-free survival for patients with extensive disease at presentation lies in achieving a complete response with systemic chemotherapy. Present trends are toward very intensive regimens, often alternating and complex, to achieve that goal. This means more treatment-related morbidity and the need for excellent supportive care if mortality is to be avoided. Many, if not all, patients will require treatment on an inpatient basis, and at least one in five will probably require additional hospitalization for the management of complications. For all these reasons, the best treatment for most patients will be entry on a research protocol and management by a skilled multidisciplinary team.