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Small cell lung cancer

Key sources
The following summarized guidelines for the evaluation and management of small cell lung cancer are prepared by our editorial team based on guidelines from the Cancer Care Ontario Foundation (CCO/ASCO 2023), the American Cancer Society (ACS 2023), the European Society of Medical Oncology (ESMO 2022; 2021), the American Association for Thoracic Surgery (AATS/ESTS 2022), the American College of Chest Physicians (ACCP 2021; 2013), the U.S. Preventive Services Task Force (USPSTF 2021), the Spanish Association of Medical Oncology (SEOM 2020), the American Society of Clinical Oncology (ASCO 2020), and the American Society for Radiation Oncology (ASTRO 2020).
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Guidelines

1.Screening and diagnosis

Indications for screening, low-dose computed tomography, ACS
Obtain annual screening for lung cancer with low-dose CT in asymptomatic individuals aged 50-80 years being current smokers or former smokers with a ≥ 20 pack-year smoking history, regardless of the number of years since quitting smoking.
B
Provide evidence-based smoking cessation counseling and offer interventions to current smokers before starting lung cancer screening. Engage individuals in a shared decision-making discussion about the benefits, limitations, and harms of lung cancer screening. Stop screening in individuals with comorbidities substantially limiting life expectancy.
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  • Indications for screening (other modalities)

  • Indications for screening (requirements for screening programs)

2.Classification and risk stratification

Staging
As per ESMO 2021 guidelines:
Diagnose SCLC according to the WHO criteria.
B
Stage SCLC according to the AJCC/UICC TNM 8th edition.
B

3.Diagnostic investigations

Initial evaluation
As per ESMO 2021 guidelines:
Elicit smoking history, perform a physical examination, and obtain a CBC, liver enzymes, sodium, potassium, calcium, glucose, LDH, creatinine, and lung function test (if localized disease) in the initial evaluation of patients with SCLC.
B
Assess for potential autoimmune-mediated paraneoplastic neurological symptoms and detect paraneoplastic disorders in patients eligible for immunotherapy.
B

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  • Imaging for staging

4.Diagnostic procedures

Biopsy and histopathology, primary tumor, ESMO: prefer histology over cytology for pathological diagnosis.
B

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  • Biopsy and histopathology (mediastinum)

  • Biopsy and histopathology (metastases)

  • Molecular testing

5.Medical management

General principles
Consider ensuring timely and efficient delivery of care in patients with known or suspected lung cancer.
C
Consider using a multidisciplinary team approach in patients with lung cancer requiring multimodality therapy.
C

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  • Management of bronchial intraepithelial neoplasia

  • Management of limited-stage disease (surgical resection)

  • Management of limited-stage disease (adjuvant chemoradiotherapy)

  • Management of limited-stage disease (concurrent chemoradiotherapy)

  • Management of limited-stage disease (technical considerations for radiotherapy)

  • Management of limited-stage disease (elderly patients)

  • Management of limited-stage disease (prophylactic cranial irradiation)

  • Management of extensive-stage disease (systemic therapy)

  • Management of extensive-stage disease (consolidative radiotherapy)

  • Management of extensive-stage disease (elderly patients)

  • Management of extensive-stage disease (prophylactic cranial irradiation)

  • Management of extensive-stage disease (palliative care)

  • Management of relapsed/refractory disease

  • Symptomatic management (pain control)

  • Symptomatic management (cough)

  • Symptomatic management (hemoptysis)

  • Symptomatic management (airway obstruction)

  • Symptomatic management (pleural effusion)

  • Symptomatic management (trapped lung)

  • Symptomatic management (tracheoesophageal fistulas)

  • Symptomatic management (superior vena cava syndrome)

  • Symptomatic management (neurologic symptoms)

  • Symptomatic management (spinal cord compression)

  • Symptomatic management (bone symptoms)

  • Symptomatic management (hematological toxicity)

  • Symptomatic management (psychological symptoms)

6.Nonpharmacologic interventions

Smoking cessation: as per ESMO 2021 guidelines, provide smoking cessation counseling as the occurrence of second malignancies, particularly if smoking is continued, is of concern in lung cancer survivors.
B

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  • Alternative and complementary therapies

7.Perioperative care

Preoperative cardiorespiratory assessment: obtain an assessment by a multidisciplinary team (including a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist) in patients with lung cancer planned for curative surgical resection. Obtain a full evaluation in elderly patients with lung cancer planned for curative surgical resection, regardless of age.
B
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  • Perioperative thromboprophylaxis (lobectomy/segmentectomy)

  • Perioperative thromboprophylaxis (pneumonectomy)

8.Specific circumstances

Elderly and frail patients: consider offering standard treatment with concurrent chemoradiotherapy with curative intent in treatment-naïve older patients with limited-stage SCLC and ECOG performance status 0-1.
B
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  • Patients with transformed lung cancer

  • Patients with Pancoast tumor (evaluation)

  • Patients with Pancoast tumor (neoadjuvant therapy)

  • Patients with Pancoast tumor (surgical resection)

  • Patients with Pancoast tumor (definitive and palliative therapy)

  • Patients with additional pulmonary nodules (same lobe)

  • Patients with additional pulmonary nodules (ipsilateral different lobe)

  • Patients with additional pulmonary nodules (contralateral lobe)

  • Patients with multifocal lung cancer (evaluation)

  • Patients with multifocal lung cancer (management)

  • Patients with second primary lung cancer

9.Preventative measures

Smoking cessation: as per ACCP 2021 guidelines, offer evidence-based tobacco cessation treatment in current smokers undergoing low-dose CT screening.
B

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  • Diet

  • Chemoprevention

10.Follow-up and surveillance

Surveillance after curative-intent therapy: as per ESMO 2021 guidelines, obtain CT every 2-3 months in patients with extensive-stage disease potentially qualifying for further treatments.
B
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