In regards to Chu et al.: Patterns of brain metastasis immediately before prophylactic cranial irradiation (PCI): implic
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LETTER TO THE EDITOR
In regards to Chu et al.: Patterns of brain metastasis immediately before prophylactic cranial irradiation (PCI): implications for PCI optimization in limited‑stage small cell lung cancer Lukas Käsmann1,2,3* , Chukwuka Eze1,2, Julian Taugner1,2 and Farkhad Manapov1,2,3
Abstract We read the article entitled “Patterns of brain metastasis immediately before prophylactic cranial irradiation (PCI): implications for PCI optimization in limited-stage small cell lung cancer” with great interest. In that study, the author reported about the importance of PCI timing in limited stage small cell lung cancer (LS-SCLC) in the era of MRI surveillance. In addition, the authors raise the issue of neurotoxicity of PCI. In this letter, we aimed to clarify the value of PCI in LS-SCLC and present ongoing trials regarding PCI and MRI surveillance in SCLC. As a result, we see the need for the development of a prediction tool to estimate the risk of intracranial relapse in LS-SCLC after chemoradiotherapy in order to support shared decision making through improved guidance. Historically, brain as a metastatic site has a special importance in limited stage small cell lung cancer (LS-SCLC) [1, 2]. Earlier studies reported more than 50% cumulative risk of symptomatic brain metastases (BM) 2 years after initial diagnosis. Poor median survival after development of intracranial relapse was also documented. Prophylactic cranial irradiation (PCI) was shown to significantly reduce the incidence of symptomatic BM, especially, in the first 2 years after treatment. Based on the clinical practise guideline of ASTRO in 2020, PCI is strongly recommended for LS-SCLC (stage II or III) after response to chemoradiation [3]. Importantly, patients with higher risk of neurocognitive decline after PCI should be critically considered and treatment should be based on shared decision-making. *Correspondence: [email protected] 1 Department of Radiation Oncology, University Hospital LMU Munich, Munich, Germany Full list of author information is available at the end of the article
Conversely, the pivotal meta-analysis by Aupérin et al. could not demonstrate an effect of PCI on other metastases and local or regional recurrences [4]. Additionally, data on the occurrence of extracranial progression were only available for 67% of the cohort. Hence, no clear conclusion concerning application of PCI and extracranial disease control could be made [4]. Implementation of MRI surveillance has changed the significance of PCI in LS-SCLC. In 2008, the first retrospective study reported on the importance of a second contrast-enhanced cranial MRI immediately before the start of PCI for detection of occult intracranial relapse in LS-SCLC patients after chemoradiotherapy (CRT) [5]. In the same year, Seute et al. [6] described that implementation of cranial MRI at initial diagnosis of SCLC leads to a significant increase in the estimated prevalence of BM. Another important finding of the study was the prognostic role of a single intracranial metas
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