Andrew T. Turrisi III, MD

Almost 40% of patients with newly diagnosed small-cell lung cancer (SCLC) have disease confined to the ipsilateral hemithorax and within a single radiation port, ie, limited-stage disease. The median survival for this group of patients after treatment is approximately 15 months, with one in every four patients surviving 2 years. Current optimal treatment consists of chemotherapy with platinum/etoposide, given concurrently with thoracic radiation. Surgery may represent an option for very early-stage disease, but its added value is uncertain. Prophylactic cranial irradiation (PCI) is used for patients with limited-stage SCLC who have achieved a complete response following initial therapy, as it decreases the risk of brain metastases and provides an overall survival benefit. Newer targeted agents are currently being evaluated in this disease and hold the promise of improving current outcomes seen in patients with early-stage disease.

Elderly patients with stage I-III non-small-cell lung cancer (NSCLC) constitute a peculiar patient population and need specific therapeutic approaches. Limited resections are an attractive alternative for elderly patients with resectable NSCLC because of the potential reduction in postoperative complications. Curative radiation therapy is an acceptable alternative for elderly patients who are unfit for or refuse surgery. Hypofractionated stereotactic body radiation therapy is of particular interest for this population because of its favorable tolerance.

In a campaign mounted against theuse of prophylactic cranial irradiation(PCI) in small-cell lung cancer(SCLC), the battle cry of the anti-PCI crowd 10 to 15 years ago was“Fry now, pay later.” The problemwas that some patients survived andseemed to suffer from the treatment.In those days, the high frequency ofbrain metastasis was underestimated.It was commonly thought that withoutPCI, 20% of patients failed at sitesin the brain, and with PCI, only 5%failed.

Patients with limited-stage small-cell carcinoma of the lung are treated with combined-modality therapy with the intent to cure. Standard therapy consists of platinum-based combination chemotherapy, thoracic irradiation, and

Many readers may find the article by Ost on photodynamic therapy (PDT) for lung cancer to be their introduction to this novel modality. If, for no other reason than this, the article is valuable. For those who address cancer as a systemic problem, first and foremost, the article may offer little to whet the appetite. On the other hand, the review may tempt the intellectual palates of those of us who focus our efforts on solving the sour problems of local cancers, their control, and the cost of aggressive therapies.

Although the need to combine thoracic radiotherapy with systemic chemotherapy in the curative treatment of limited small-cell lung cancer is now widely acknowledged, there is substantial disagreement on how best to do this. This paper reviews radiotherapeutic factors but also highlights the important interactions that occur with some classes of chemotherapeutics. Studies examining variables like dose and volume are clearly in order. Concurrent therapy given early has been adopted throughout most of the world, except Europe. The reasons for this are explored. Multiple studies are now showing excellent results with fewer total cycles of chemotherapy. Integrationof newer drugs is another challenge for clinical investigators at the close of this century. [ONCOLOGY 12(Suppl 2):15-18, 1998]

It is now established that the treatment of choice for limited small-cell lung cancer (SCLC) in the United States, Canada, and Japan is thoracic radiotherapy (TRT)