Prophylactic cranial irradiation in lung cancer

Factors associated with overall survival, progression-free survival and toxicity in patients with small cell lung cancer and thoracic irradiation in a clinical real-world setting

BACKGROUND

Small-cell lung cancer (SCLC) is a malignant tumor known for its poor prognosis. In addition to chemotherapy and immunotherapy irradiation plays a big role especially in inoperability. This study evaluated prognostic factors in patients with SCLC, receiving chemotherapy and thoracic irradiation, that may affect overall survival (OS), progression-free survival (PFS) and toxicity.

METHODS

Patients with limited disease (LD) SCLC (n = 57) and extensive disease (ED) SCLC (n = 69) who received thoracic radiotherapy were analyzed retrospectively. The prognostic factors sex, age, Karnofsky performance status (KPS), tumor-, nodal-stage and timepoint of start of irradiation in relation to the first cycle of chemotherapy were evaluated. Start of irradiation was stratified as early ([Formula: see text] 2 cycles of chemotherapy), late (3 or 4 cycles) and very late ([Formula: see text] 5 cycles). Results were analyzed by Cox univariate and multivariate as well as logistic regression analysis.

RESULTS

The median OS of LD-SCLC patients was 23.7 months in early, and 22.0 months in late start of irradiation. In very late start, median OS was not reached. PFS was 11.8, 15.2 and 47.9 months, respectively. In patients with ED-SCLC OS was 4.3 months in early, 13.0 months in late and 12.2 months in very late start of irradiation. PFS was 6.7, 13.0 and 12.2 months, respectively. Prognosis of patients with LD- or ED-SCLC receiving late or very late start of irradiation was significantly prolonged in OS and PFS compared to an early start (p < 0.05). KPS [Formula: see text] 80 shows a significant increase of OS and PFS in ED-SCLC. Female sex and smaller mean lung dose were associated with lower risk of toxicity.

CONCLUSION

Late or very late start of irradiation is a prognosis-enhancing factor in LD-SCLC and ED-SCLC for OS and PFS. KPS [Formula: see text] 80 increases prognosis of OS and PFS in ED-SCLC as well. Toxicity is less common in female sex and patients with low mean lung dose in LD-SCLC.

A novel analytical framework for risk stratification of real-world data using machine learning: A small cell lung cancer study

In recent studies, small cell lung cancer (SCLC) treatment guidelines based on Veterans' Administration Lung Study Group limited/extensive disease staging and resulted in broad and inseparable prognostic subgroups. Evidence suggests that the eight versions of tumor, node, and metastasis (TNM) staging can play an important role to address this issue. The aim of the present study was to improve the detection of prognostic subgroups from a real-word data (RWD) cohort of patients and analyze their patterns using a development pipeline with thoracic oncologists and machine learning methods. The method detected subgroups of patients informing unsupervised learning (partition around medoids) including the impact of covariates on prognosis (Cox regression and random survival forest). An analysis was carried out using patients with SCLC (n = 636) with stage IIIA-IVB according to TNM classification. The analysis yielded k = 7 compacted and well-separated clusters of patients. Performance status (Eastern Cooperative Oncology Group-Performance Status), lactate dehydrogenase, spreading of metastasis, cancer stage, and CRP were the baselines that characterized the subgroups. The selected clustering method outperformed standard clustering techniques, which were not capable of detecting meaningful subgroups. From the analysis of cluster treatment decisions, we showed the potential of future RWD applications to understand disease, develop individualized therapies, and improve healthcare decision making.

Prophylactic Cranial Irradiation in Patients With High-Risk Metastatic Non-Small Cell Lung Cancer: Quality of Life and Neurocognitive Analysis of a Randomized Phase II Study

PURPOSE

To this date, studies regarding the use of prophylactic cranial irradiation (PCI) versus standard of care (SoC) for patients with non-small cell lung cancer have shown limited benefit in survival outcomes, in addition to the potential effects on quality of life (QoL) and neurocognitive function (NCF). This randomized, phase II study evaluated the role of PCI in QoL and NCF, in a population comprised of subjects at a high risk for development of brain metastases (BM).

METHODS AND MATERIALS

Eligible patients had histologically confirmed non-small cell lung cancer without baseline BM, harboring epidermal growth factor receptor mutations, anaplastic lymphoma kinase rearrangements, or elevated carcinoembryonic antigen (CEA) at diagnosis. Participants were assigned to receive SoC or SoC plus PCI (25 Gy in 10 fractions). Primary endpoint was BM at 24 months (BM-24), for which the study was powered. Secondary endpoints included QoL assessed using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and the Lung Cancer module (LC13) and NCF assessed using the Mini Mental State Examination (MMSE). Patients were followed every 3 months for a year for QoL and NCF.

RESULTS

From May 2012 to December 2017, 84 patients were enrolled in the study, 41 were allocated to PCI while 43 received SoC. Efficacy outcomes are discussed in a separate article. The global health-QoL scores were similar at 3, 6, 9, and 12 months after randomization between both study arms, with no significant differences when comparing by groups. At 1-year postrandomization, median global health QoL scores were 83 (p25-p75: 75-83) and 83 (p25-p75: 75-83) in the control and experimental arms, respectively. There were no significant changes in terms of the mean differences between subjects in either study arm when analyzing the change between baseline and 12-month scores (16.4 ± 19.9 vs 12.9 ± 14.7; P = .385). Seventeen patients were alive at database lockdown in February 2020, without significant differences in median MMSE (30 [p25-75: 29-30] vs 30 [p25-75: 28-30]) or QLQ-C30 scores (75.0 [p25-75: 50-87.2] vs 67.0 [p25-75: 50.0-100.0]).

CONCLUSIONS

Among a selected high-risk population for developing BM, PCI did not significantly decrease QoL or neurocognitive function as assessed using the MMSE. Future studies are warranted to assess this observation, using more varied and sensitive tools available to date.

Analysis of Factors Affecting Brain Metastasis in Limited-Stage Small-Cell Lung Cancer Treated With Definitive Thoracic Irradiation

Background

Small-cell lung cancer (SCLC) is the most lethal cancer. With the development of chemotherapy and radiotherapy, brain metastasis (BM) emerged as one most predominant treatment failure. However, the factors affecting BM have not been identified completely. The purpose of this study was to investigate the risk factors involved in the development of BM in patients with limited-stage small-cell lung cancer (LS-SCLC) following definitive thoracic radiotherapy (TRT) and to provide a reference for the planning of a clinical treatment strategy.

Methods

The clinical data of patients with LS-SCLC treated with neoadjuvant chemotherapy (NAC) followed by TRT were collected and retrospectively reviewed. The factors affecting BM, BM-free survival (BMFS) and overall survival (OS) rates were analyzed statistically.

Results

A total of 152 patients with LS-SCLC fulfilled the inclusion criteria were reviewed. Following TRT, 31 (20.4%) patients achieved CR, 90 (59.2%) patients reached PR, 31 (20.4%) patients maintained SD, and no patients developed PD. The OS at 1, 3, and 5 years was 80.6, 34.2, and 19.4%, respectively. Multivariate analyses indicated that the greatest dimension of primary tumor (Dmax-T) and short-term response to TRT were risk factors affecting BM. The clinical N stage (cN), greatest dimension of metastatic nodes (Dmax-N), short-term response to TRT, and adjuvant chemotherapy (AC) were identified as independent factors correlated with OS.

Conclusions

Poor short-term response to TRT and huger Dmax-T were risk factors for BM. AC following TRT improved patient survival, but not decreased BM. However, due to the limitations associated with the retrospective design of the present study, further prospective clinical trials are required to confirm these conclusions.

Treatment and toxic effects of prophylactic cranial irradiation in stage II-III non-small cell lung cancer: A meta-analysis

OBJECTIVE

To determine the role of prophylactic cranial irradiation (PCI) in non-small cell lung cancer (NSCLC) patients using meta-analysis.

METHODS

PubMed, Embase, the Cochrane Database of Systematic Review and the China National Knowledge Infrastructure databases were systematically searched for studies published between 1 January 1980 and 31 March 2019. Search terms included "non-small cell lung cancer," "prophylactic cranial irradiation" and "clinical trials." The research data extracted from above studies was analyzed by Review Manager 5.3 and Stata12.0 software. The outcomes included development of brain metastases (BMs), overall survival (OS), disease-free survival (DFS), BMs for different diagnoses, toxicity, quality of life (QoL).

RESULTS

Fifteen trials (nine RCTs and six non-RCTs) involving 2418 NSCLC patients met the inclusion criteria. There was a significant reduction in the risk of developing BM in patients who received PCI compared with those who did not (95% CI, 0.20-0.37; P < 0.00001). PCI significantly reduced the BM of squamous cell carcinoma (P = 0.02), but not for adenocarcinoma (P = 0.07) and other pathological types (P = 0.29). There was a significant increase in DFS for the PCI compared to the non-PCI group (P = 0.006); however, OS did not significantly differ (P = 0.15). In addition, fatigue significantly increased in the PCI group (P = 0.0002). Cognitive disturbance showed no significant difference between PCI and non-PCI groups (P = 0.06).

CONCLUSION

This study showed that, compared with non-PCI, PCI significantly decreased the incidence of NSCLC BM and improved the DFS of patients, and reduced the BM rate from squamous cell carcinoma. However, it showed no effect on OS and the BM rate of adenocarcinoma and other pathological types of tumors. There were limited data concerning PCI-related toxicity and QoL.

Prophylactic cranial irradiation in small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of prophylactic cranial irradiation (PCI) in treating patients with small cell lung cancer (SCLC) has not been clear, and recent randomized studies have demonstrated conflicting results from previously published findings. The purpose of this study was to reevaluate the efficacy of PCI in patients with SCLC and to assess factors associated with its efficacy.

METHODS

We conducted a quantitative meta-analysis to explore the efficacy of PCI in patients with SCLC. A literature search was performed using EMBASE, MEDLINE, Cochrane and ClinicalTrials.gov databases. We pooled the data and compared overall survival (OS) and brain metastasis (BM) between patients treated with PCI (PCI group) and patients without PCI treatment (observation group).

RESULTS

Of the 1074 studies identified in our analysis, we selected seven studies including 2114 patients for the current meta-analysis. Our results showed that the PCI group showed decreased BM (HR = 0.45, 95% CI: 0.38-0.55, P < 0.001) and prolonged OS (HR = 0.81, 95% CI: 0.67-0.99, P < 0.001). However, in terms of OS, the pooled analysis showed a high heterogeneity (I² = 74.1%, P = 0.001). In subgroup analyses of OS, we found that the heterogeneity mainly came from patients with brain imaging after initial chemoradiotherapy (HR = 0.94, 95% CI: 0.74-1.18, P = 0.59).

CONCLUSIONS

The results of this study showed that PCI has a significant effect on decreasing BM but little benefit in prolonging OS when brain imaging was introduced to confirm lack of BM after initial chemoradiotherapy and before irradiation.

Prophylactic cranial irradiation for patients with lung cancer

The incidence of brain metastases in patients with lung cancer has increased as a result of improved local and systemic control and better diagnosis from advances in brain imaging. Because brain metastases are responsible for life-threatening symptoms and serious impairment of quality of life, resulting in shortened survival, prophylactic cranial irradiation has been proposed in both small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) to try to improve incidence of brain metastasis, survival, and eventually quality of life. Findings from randomised controlled trials and a meta-analysis have shown that prophylactic cranial irradiation not only reduces the incidence of brain metastases in patients with SCLC and with non-metastatic NSCLC, but also improves overall survival in patients with SCLC who respond to first-line treatment. Although prophylactic cranial irradiation is potentially associated with neurocognitive decline, this risk needs to be balanced against the potential benefit in terms of brain metastases incidence and survival. Several strategies to reduce neurotoxicity are being investigated.

Patient preferences regarding prophylactic cranial irradiation: A discrete choice experiment

INTRODUCTION

In patients with non-small cell lung cancer (NSCLC) treated with chemoradiotherapy (CRT), prophylactic cranial irradiation (PCI) is not standard practice. This study determined patient preferences for PCI with respect to survival benefit, reduction in brain metastases (BM) and acceptable toxicity.

METHODS

A Discrete Choice Experiment was completed pre- and post-treatment. Patients made 15 hypothetical choices between two alternative PCI treatments described by four attributes: amount of life gained, chance of BM, ability to care for oneself, and loss of memory. Participants also chose between PCI and no PCI.

RESULTS

54 and 46 surveys were completed pre- and post-treatment. The most important attributes pre-treatment were: a survival benefit >6months, of 3-6months, avoiding severe problems with memory and self-care, avoiding quite a bit of difficulty with memory and maximally reducing BM recurrence. Post-treatment, BM reduction became more important. 90% of patients would accept PCI for a survival benefit >6months, with a maximal reduction in BM even if severe memory/self-care problems occurred. With a 10% reduction in BM and mild problems with memory and self-care 70% of patients pre- (90% post-treatment) would accept PCI for a survival benefit of 1-3months, and 52% pre- (78% post-treatment) for no survival benefit.

CONCLUSION

Improvement in survival is the most important attribute of PCI with patients willing to accept significant toxicity for maximum survival and less toxicity for less survival benefit. BM reduction became more important after treatment. The majority of patients would accept PCI for no survival benefit and a reduction in BM.

Human embryonic stem cell-derived oligodendrocyte progenitors remyelinate the brain and rescue behavioral deficits following radiation

Radiation therapy to the brain is a powerful tool in the management of many cancers, but it is associated with significant and irreversible long-term side effects, including cognitive decline and impairment of motor coordination. Depletion of oligodendrocyte progenitors and demyelination are major pathological features that are particularly pronounced in younger individuals and severely limit therapeutic options. Here we tested whether human ESC-derived oligodendrocytes can functionally remyelinate the irradiated brain using a rat model. We demonstrate the efficient derivation and prospective isolation of human oligodendrocyte progenitors, which, upon transplantation, migrate throughout the major white matter tracts resulting in both structural and functional repair. Behavioral testing showed complete recovery of cognitive function while additional recovery from motor deficits required concomitant transplantation into the cerebellum. The ability to repair radiation-induced damage to the brain could dramatically improve the outlook for cancer survivors and enable more effective use of radiation therapies, especially in children.

Prophylactic cranial irradiation in small cell lung cancer: a single institution experience

BACKGROUND

Prophylactic cranial irradiation (PCI) is used to prevent the development of brain metastases in small cell lung carcinoma. PCI confers an overall survival (OS) benefit in both limited and extensive stage disease.

AIMS

We analyze the incidence of symptomatic brain metastases, progression-free survival (PFS) and OS in a cohort of patients who received PCI, in a 5-year period.

METHODS

A retrospective review of all patients who had received PCI between 2006 and 2011 at the Whitfield Clinic was completed. Patient- and disease-related characteristics, the number of patients who developed brain metastases, PFS and OS data were collected.

RESULTS

24 patients were identified. 14 (58.3 %) patients were male, 10 (41.7 %) were female, with a mean age of 62.5 years (range 31-78). All patients were smokers. 12 (50 %) patients had limited stage small cell lung cancer (SCLC), 12 (50 %) had extensive stage disease. 2 (8.2 %) patients developed brain metastases post PCI (p = 0.478.) The median PFS for limited stage SCLC was 13 months (range 3-20) and 10 months (range 5-18) for extensive stage SCLC. Median OS was 15 months (range 4-29) in limited stage SCLC, and 11 months (range 5-29) in extensive stage SCLC.

CONCLUSIONS

Our study demonstrated a low incidence of symptomatic brain metastases and favourable median PFS and OS in the patients that received PCI, when compared to published phase III data.

Prognostic factors and survival of patients with small cell lung cancer in a northeastern Chinese population

BACKGROUND

This study presents the characteristics and treatment of small cell lung cancer (SCLC) and an analysis of the factors that impact survival in northeastern Chinese populations, among both smokers and non-smokers.

METHODS

A retrospective review was performed using 485 Chinese patients diagnosed with pathologically confirmed SCLC diagnoses between January 2001 and December 2007. Data on patient characteristics, treatment patterns, and outcome information was collected systematically. Univariate analysis and the Cox multivariate regression model were used to evaluate prognostic factors.

RESULTS

Median survival time was 16 months in all patients, 31 months in limited stage (LS) patients, and 10 months in extensive-stage (ES) patients. Never-smoking patients (P= 0.0368) with good performance status (PS) (P= 0.0044) or with normal lactate dehydrogenase (LDH) levels (P < 0.0001), demonstrated superior survival rates. Multivariate analysis identified that cycles of chemotherapy, PS, LDH levels, recurrence or progression, and clinical stage were each independent prognostic factors applicable to all patients. In LS-SCLC, cycles of chemotherapy were the only prognostic indicator; however, cycles of chemotherapy, LDH levels, and recurrence or progression, were all significant factors in ES-SCLC.

CONCLUSION

Cycles of chemotherapy, PS, LDH levels, recurrence or progression, and clinical stage were proved to be independent prognostic factors for SCLC with variant value based on the SCLC tumor stage.

Cranial magnetic resonance imaging in the staging of HER2-positive Breast Cancer Patients

AIM

The aim of the current study was to evaluate whether early detection of brain metastases (BMs) could improve survival outcomes in human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients.

MATERIAL AND METHODS

HER2-positive breast cancer patients without BMs who had no neurological symptoms within 12 months from diagnosis or relapse time of the disease were included in the study. The patients were distributed into 2 groups: Group 1 comprised patients without metastases; group 2 comprised patients with metastases. The symptomatic historic control group with BMs was defined retrospectively for survival comparisons.

RESULTS

55 (57.3%) and 41 (42.7%) patients were in groups 1 and 2, respectively. 11 of the 96 patients (11.5%) had occult BMs, and 9 of them were in group 2 whereas only 2 patients were in group 1 (22% vs. 3.6%, respectively; p = 0.008). While the median survival times from the first metastasis (28.7 vs. 22.5 months, respectively; p = 0.561) and BM (6.8 vs. 6.1 months, respectively; p = 0.511) were similar, cerebral death was numerically different (16.7% vs. 46.3%; p = 0.221) between asymptomatic (n = 9) and symptomatic patients (n = 53).

CONCLUSIONS

BMs were detected very rarely in asymptomatic, non-metastatic HER2-positive breast cancer patients compared with asymptomatic, metastatic patients. Furthermore, although early detection of BMs decreases the cerebral death rate, it does not prolong the survival rate in metastatic patients.

Biology of brain metastases and novel targeted therapies: time to translate the research

Brain metastases (BM) occur in 20% to 40% of patients with cancer and result in significant morbidity and poor survival. The main therapeutic options include surgery, whole brain radiotherapy, stereotactic radiosurgery and chemotherapy. Although significant progress has been made in diagnostic and therapeutic methods, the prognosis in these patients remains poor. Furthermore, the poor penetrability of chemotherapy agents through the blood brain barrier (BBB) continues to pose a challenge in the management of this disease. Preclinical evidence suggests that new targeted treatments can improve local tumor control but our clinical experience with these agents remains limited. In addition, several clinical studies with these novel agents have produced disappointing results. This review will examine the knowledge of targeted therapies in BM. The preclinical and clinical evidence of their use in BM induced by breast cancer, non-small cell lung cancer and melanoma will be presented. In addition, we will discuss the role of antiangiogenic and radiosensitising agents in the treatment of BM and the current strategies available to increase BBB permeability. A better understanding of the mechanism of action of these agents will help us to identify the best targets for testing in future clinical studies.

Therapeutic approaches for HER2-positive brain metastases: circumventing the blood-brain barrier

We aim to summarize data from studies of trastuzumab in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) and brain metastasis and to describe novel methods being developed to circumvent the blood-brain barrier (BBB). A literature search was conducted to obtain data on the clinical efficacy of trastuzumab and lapatinib in patients with HER2-positive MBC and brain metastasis, as well as the transport of therapeutic molecules across the BBB. Trastuzumab-based therapy is the standard of care for patients with HER2-positive MBC. Post hoc and retrospective analyses show that trastuzumab significantly prolongs overall survival when given after the diagnosis of central nervous system (CNS) metastasis; this is probably attributable to its control of extracranial disease, although trastuzumab may have a direct effect on CNS disease in patients with local or general perturbation of the BBB. In patients without a compromised BBB, trastuzumab is thought to have limited access to the brain, because of its relatively large molecular size. Several approaches are being developed to enhance the delivery of therapeutic agents to the brain. These include physical or pharmacologic disruption of the BBB, direct intracerebral drug delivery, drug manipulation, and coupling drugs to transport vectors. Available data suggest that trastuzumab extends survival in patients with HER2-positive MBC and brain metastasis. Novel methods for delivery of therapeutic agents into the brain could be used in the future to enhance access to the CNS by trastuzumab, thereby improving its efficacy in this setting.

Redox balance- and radiation-mediated alteration in hippocampal neurogenesis

Changes in the intracellular and extracellular redox balance have been correlated with cell fate decisions in terms of proliferation versus differentiation, entering versus existing cell cycle and survival versus cell death. Adult hippocampal neurogenesis has been correlated with neuronal plasticity of learning and memory; however, the process is exquisitely sensitive to changes in redox balance. Cranial irradiation is an effective modality in treating brain tumours but often leads to deficits in hippocampus-related learning and memory, which is most likely due to sustained elevation of oxygen free radical production and suppression of hippocampal neurogenesis. The subcellular redox environment affecting hippocampal neurogenesis is largely unknown. Using mutant mice deficient in each one of the three superoxide dismutase (SOD, EC 1.15.1.1) isoforms, we have begun to determine the consequences of SOD deficiency in hippocampal neurogenesis and the related functions of learning and memory under normal condition and following cranial irradiation.

Management of brain metastasis: past lessons, modern management, and future considerations

Brain metastasis is a major challenge for patients, physicians, and the broader health care system, with approximately 170,000 new cases per year. After a diagnosis of brain metastasis, patients have a poor prognosis, but modern management has made significant advances in the past two decades to improve palliative efficacy and patient survival through a multidisciplinary approach. A number of factors must be taken into consideration in the treatment approach, including the number of intracranial lesions, the control of extracranial disease, and the patient's overall health, while weighing the benefits of treatment against the toxicities, both acute and chronic. With quality of life as an emphasis, emerging concepts for modern management of brain metastasis have sought to minimize long-term toxicities. The economic impact of such strategies for patients and the health care system has been demonstrated in some studies, but has not been a consistent area of focus. Each of these strategies, as well as novel therapeutics, has embraced the concept of personalized treatment. This review will discuss the current knowledge of modern multidisciplinary management of brain metastasis and look forward to emerging concepts.

Outcome of small cell lung cancer (SCLC) patients with brain metastases in a routine clinical setting

BACKGROUND

Small cell lung cancer (SCLC) represents approximately 13 to 18% of all lung cancers. It is the most aggressive among lung cancers, mostly presented at an advanced stage, with median survival rates of 10 to12 months in patients treated with standard chemotherapy and radiotherapy. In approximately 15-20% of patients brain metastases are present already at the time of primary diagnosis; however, it is unclear how much it influences the outcome of disease according the other metastatic localisation. The objective of this analysis was to evaluate the median survival of SCLC patients treated by specific therapy (chemotherapy and/or radiotherapy) with regard to the presence or absence of brain metastases at the time of diagnosis.

PATIENTS AND METHODS

All SCLC patients have been treated in a routine clinical practice and followed up at the University Clinic Golnik in Slovenia. In the retrospective study the medical files from 2002 to 2007 were review. All patients with cytological or histological confirmed disease and eligible for specific oncological treatment were included in the study. They have been treated according to the guidelines valid at the time. Chemotherapy and regular followed-up were carried out at the University Clinic Golnik and radiotherapy at the Institute of Oncology Ljubljana.

RESULTS

We found 251 patients eligible for the study. The median age of them was 65 years, majority were male (67%), smokers or ex-smokers (98%), with performance status 0 to 1 (83%). At the time of diagnosis no metastases were found in 64 patients (25.5%) and metastases outside the brain were presented in 153 (61.0%). Brain metastases, confirmed by a CT scan, were present in 34 patients (13.5%), most of them had also metastases at other localisations. All patients received chemotherapy and all patients with confirmed brain metastases received whole brain irradiation (WBRT). The radiotherapy with radical dose at primary tumour was delivered to 27 patients with limited disease and they got 4-6 cycles of chemotherapy. Median overall survival (OS) of 34 patients with brain metastases was 9 months (95% CI 6-12) while OS of 153 patients with metastases in other locations was 11 months (95% CI 10-12); the difference did not reach the level of significance (p = 0.62). As expected, the OS of patients without metastases at the time of primary diagnosis turned out to be significantly better compared to the survival of patients with either brain or other location metastases at the primary diagnosis (15 months vs 9 and 11 months, respectively, p < 0.001).

CONCLUSIONS

In our investigated population, the prognosis of patients with extensive SCLS with brain metastases at the primary diagnosis treated with chemotherapy and WBRT was not significantly worse compared to the prognosis of patients with extensive SCLC and metastases outside the brain. In extensive SCLC brain metastases were not a negative prognostic factor per se if the patients were able to be treated appropriately. However, the survival rates of extensive SCLC with or without brain metastases remained poor and novel treatment approaches are needed. The major strength of this study is that it has been done on a population of patients treated in a routine clinical setting.