Samson David J, Seidenfeld Jerome, Simon George R, Turrisi Andrew T, Bonnell Claudia, Ziegler Kathleen M, Aronson Naomi
Technology Evaluation Center, Blue Cross Blue Shield Association, 1310 G St, NW, Washington, DC 20005, USA.
Chest. 2007 Sep;132(3 Suppl):314S-323S. doi: 10.1378/chest.07-1384.
This systematic review addressed the following key questions on managing small cell lung cancer (SCLC): the sequence, timing, and dosing characteristics of primary thoracic radiotherapy (TRTx) for limited-stage disease; primary TRTx for extensive-stage disease; effect of prophylactic cranial irradiation (PCI); positron emission tomography (PET) for staging; treatment of mixed histology tumors; surgery; and second-line and subsequent-line treatment for relapsed/progressive disease.
The review methods were defined prospectively in a written protocol. We primarily sought randomized controlled trials that compared the interventions of interest.
Robust evidence was lacking for all questions except PCI, for which a patient-level metaanalysis showed that PCI improves survival of SCLC patients who achieved complete response after primary therapy from 15.3 to 20.7% (p = 0.01). The case for concurrent over sequential radiation delivery rests largely on a single multicenter trial. Support for early concurrent therapy comes from one multicenter trial, but two other multicenter trials found no advantage. Metaanalysis did not find significant reductions in 2-year and 3-year mortality rates for early TRTx. Favorable results from a single-center trial on TRTx for extensive stage disease need replication in a multicenter setting. Relevant comparative studies were nonexistent for management of mixed histology disease and surgery for early limited SCLC. PET may be more sensitive in detecting extracranial disease than conventional staging modalities, but studies were of poor quality.
PCI improves survival among those with a complete remission to primary therapy. A research agenda is needed to optimize the effectiveness of TRTx and its components.
本系统评价探讨了小细胞肺癌（SCLC）管理中的以下关键问题：局限期疾病的原发性胸部放疗（TRTx）的顺序、时机和剂量特征；广泛期疾病的原发性TRTx；预防性脑照射（PCI）的效果；正电子发射断层扫描（PET）用于分期；混合组织学肿瘤的治疗；手术；以及复发/进展性疾病的二线及后续治疗。
在一份书面方案中前瞻性地定义了评价方法。我们主要检索比较感兴趣干预措施的随机对照试验。
除PCI外，所有问题均缺乏有力证据，对于PCI，一项患者水平的荟萃分析表明，PCI可将原发性治疗后达到完全缓解的SCLC患者的生存率从15.3%提高到20.7%（p = 0.01）。同步放疗优于序贯放疗的依据主要来自一项多中心试验。早期同步治疗的依据来自一项多中心试验，但另外两项多中心试验未发现优势。荟萃分析未发现早期TRTx可显著降低2年和3年死亡率。一项关于广泛期疾病TRTx的单中心试验的良好结果需要在多中心环境中重复验证。对于混合组织学疾病的管理和早期局限期SCLC的手术，不存在相关的比较研究。PET在检测颅外疾病方面可能比传统分期方法更敏感，但研究质量较差。
PCI可提高原发性治疗完全缓解患者的生存率。需要制定一项研究议程，以优化TRTx及其组成部分的有效性。
