Aggressive Palliation in Extensive Stage Small Cell Lung Cancer, Practice Guidelines versus Clinical Practice: A Case Report and Review of the Literature

Small cell lung cancer (SCLC) constitutes approximately 16% of all primary lung cancers, with more than 35,000 new cases per year. Two-thirds of patients present with extensive stage disease (ES-SCLC) due to a tendency to metastasize early. Outcomes remain poor, with a median survival of approximately 10 months and a two-year overall survival of <10%. Current recommendations call for combination chemotherapy alone in patients without localized symptoms. Thoracic radiation therapy following a good clinical response is controversial. We report on a patient with ES-SCLC that had an excellent response to chemotherapy and underwent whole brain radiotherapy for a known brain metastasis and consolidative radiotherapy to the thorax. His latest follow-up demonstrates only a stable residual pulmonary nodule and no evidence of active metastatic disease. ES-SCLC is a relatively common presentation with a variable burden of metastatic disease. In the absence of randomized trials demonstrating the efficacy of thoracic radiation therapy, the community radiation oncologist is placed in a difficult position when addressing these patients, particularly those with otherwise good performance status and a good response to initial systemic chemotherapy. More research in this area is sorely needed to help guide treatment recommendations. 1. Introduction Small cell lung cancer (SCLC) constitutes approximately 16% of all primary lung cancers, accounting for more than 35,000 cases per year [1]. Two-thirds of patients present with extensive stage disease (ES-SCLC) due to a tendency to metastasize early to distant sites, including the brain, bones, liver, and adrenals [2]. Outcome in ES-SCLC remains poor, with a median survival of approximately 10 months and a two-year overall survival of <10% [3]. Management has evolved over the past 30 years but has done little to improve clinical outcome. Current practice guidelines in ES-SCLC recommend combination chemotherapy alone [2, 4] in patients without localized symptoms (such as superior vena cava syndrome, lobar obstruction, or painful bone metastases) or chemotherapy with or without whole brain radiation therapy in the case of brain metastases. Delivering thoracic radiation therapy following a good clinical response to systemic chemotherapy is controversial. Herein, we report a case of a patient diagnosed with ES-SCLC in a community hospital with extensive pulmonary disease, mediastinal involvement, an adrenal metastasis, and a single brain metastasis. 2. Case Report The patient was a 67-year-old African-American gentleman who