FIRE drill.

Top Line: The current standard for anyone with small cell lung cancer (SCLC) metastatic to the brain is the addition of whole brain radiation (WBRT).

The Study: This is primarily due to extrapolation for initial successes with prophylactic cranial irradiation, largely before the rise in popularity and accessibility to stereotactic radiosurgery (SRS). In other words, if WBRT helps even those without radiographic evidence of intracranial disease, it certainly shouldn’t be withheld from those with visible brain mets. Should it…? FIRE-SCLC, short for First-line Radiosurgery for SCLC, was a single-arm, 28-center, 6-nation retrospective cohort study evaluating, well, just what it sounds like. 710 patients (98 of whom were treated on the Japanese prospective JLGK0901 trial) who received upfront SRS for any number of SCLC brain mets (13% had >10) between 1994-2018 were compared to 216 similar patients receiving upfront WBRT. On propensity score matching, receipt of WBRT was unsurprisingly associated with a significantly prolonged time to CNS failure (HR 0.35) with no difference in median overall survival, which was >6 months after SRS versus >5 months after WBRT. The authors do note, however, the standout median survival of 11 months for those treated with upfront SRS for a single brain met (n=232). Finally, overall neurological mortality (12%) and leptomeningeal progression (11%), were relatively low after SRS.

TBL: The authors conclude upfront SRS for SCLC brain mets is reasonable for “carefully-selected populations” (read: with good performance status and a single brain met). | Rusthoven, JAMA Oncol 2020