The AJCC TNM staging system is used to select patients with stage T1 to 2N0 who are suitable for surgery.
The TNM staging system should be used first in clinical studies because it can more accurately assess prognosis and guide treatment.
1. T1 to 2N0 limited stage SCLC
Surgery + adjuvant chemotherapy (EP regimen or EC regimen, 4-6 cycles) is recommended for T1-2N0 limited stage SCLC without mediastinal lymph node metastasis after systematic staging. If the presence of mediastinal lymph node metastasis is not clear by systematic staging, mediastinoscopy, ultrasound endoscopy or pathology may be performed to exclude potential mediastinal lymph node metastasis. Postoperative prophylactic brain irradiation is recommended.
2. Limited stage SCLC beyond T1 to 2N0
Prophylactic brain irradiation is recommended for patients who have achieved disease control (complete or partial remission) with the combination of chemotherapy and radiotherapy.
(1) ECOG PS score 0-2: Prefer synchronous chemotherapy and radiotherapy; if patients cannot tolerate synchronous radiotherapy and chemotherapy, sequential chemotherapy and radiotherapy are also feasible options.
(2) ECOG PS 3~4 scores caused by SCLC: Various factors should be fully considered and treatment regimen should be carefully selected, single agent chemotherapy or reduced combination chemotherapy regimen can be considered. If the ECOG PS score can reach below 2 after treatment, sequential radiotherapy can be considered. If the ECOG PS score still cannot be restored to below 2, chest radiotherapy can be used according to the specific situation.
(3) Non-tumor ECOG PS score of 3-4: In principle, the best supportive therapy should be given.
3. Extensive stage SCLC
Patients with ECOG PS 0~2 and ECOG PS 3~4 caused by SCLC should be treated with chemotherapy-based combination therapy. First-line treatment is recommended for EC regimen combined with or without atelelizumab, 4-6 cycles of chemotherapy with EP regimen, IP regimen or IC regimen, and best supportive therapy for patients with ECOG PS 3-4 not caused by tumor.
(1) Patients without local symptoms and brain metastases: Patients who achieve complete/partial remission with first-line chemotherapy are eligible for chest radiotherapy. Patients with no brain metastases on review after effective initial therapy may be considered for prophylactic brain irradiation.
(2) Patients with local symptoms: local treatment for symptomatic conditions should be given electively on the basis of first-line chemotherapy, for example, patients with superior vena cava syndrome or obstructive pulmonary atelectasis or spinal cord compression may be given local radiotherapy electively; patients with bone metastases may be given local orthopedic fixation for sites at high risk of fracture, if necessary, in addition to elective local palliative external irradiation. Patients with no brain metastases on review after effective initial treatment should also be given prophylactic brain irradiation.
(3) Patients with brain metastases: In addition to first-line systemic chemotherapy, whole-brain radiotherapy is recommended. Thoracic radiotherapy is feasible for patients who achieve complete remission or partial remission with initial treatment. If the tumor size is small (diameter <4cm), or intracranial oligometastases, or metastases recurring after whole brain radiotherapy, the location of the tumor foci is deep, and the patient's general condition is poor and cannot tolerate conventional radiotherapy or surgery, stereotactic radiotherapy can be chosen.
(4) Follow-up treatment for patients with relapsed/resistant progressive SCLC: patients with relapse or progression within 6 months after first-line chemotherapy can choose topotecan, irinotecan, gemcitabine, vincristine, vincristine, and other drugs.
For those who relapse or progress within 6 months after first-line chemotherapy, they can choose topotecan, irinotecan, gemcitabine, vincristine, temozolomide or paclitaxel; for those who relapse or progress after 6 months, they can choose the initial treatment regimen. Third-line regimens: choose anlotinib or participate in clinical trials.