In patients with SCLC (proven or suspected), a staging evaluation is recommended consisting of a medical history and physical examination, complete blood count and comprehensive chemistry panel with renal and hepatic function tests, CT of the chest and abdomen with intravenous contrast or CT scan of the chest extending through the liver and adrenal glands, MRI or CT of the brain, and bone scan. If PET is obtained, then bone scan may be omitted. Complete blood count should include differential.

In patients with clinically limited stage SCLC, PET imaging is suggested. Remark: If PET is obtained, then bone scan may be omitted. PET scan use is also applicable to extensive stage SCLC.

In patients with SCLC, it is recommended that both the Veterans' Administration system (limited stage vs extensive stage) and the American Joint Committee on Cancer/International Union Against Cancer seventh edition system (TNM) should be used to classify the tumor stage.

In patients with clinical stage I SCLC, who are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head MRI/CT and PET or abdominal CT plus bone scan) are recommended.

In patients with clinical stage I SCLC, after a thorough evaluation for distant metastases and invasive mediastinal stage evaluation, surgical resection is suggested over nonsurgical treatment.

In patients with stage I SCLC who have undergone curative-intent surgical resection, platinum-based adjuvant chemotherapy is recommended.

In patients with limited stage SCLC, early chemoradiotherapy, with accelerated hyperfractionated radiation therapy (twice-daily treatment) concurrently with platinum-based chemotherapy, is recommended. Comparison of accelerated hyperfractionated radiotherapy with an extended course of daily radiation therapy at standard fractionation is currently being investigated.

In patients with limited stage or extensive stage SCLC who achieve a complete or partial response to initial therapy, prophylactic cranial irradiation is recommended. Remark: The regimen of 25 Gy in 10 daily fractions has the greatest supporting data for safety and efficacy. The panel notes that a recent Japanese study failed to demonstrate survival advantage with prophylactic cranial irradiation in patients with extensive stage SCLC. On publication of the mature data from this study, the recommendation for prophylactic cranial irradiation in extensive stage SCLC might be subject to revision.

In patients with extensive stage SCLC who have completed chemotherapy and achieved a complete response outside the chest and complete or partial response in the chest, a course of consolidative thoracic radiotherapy is suggested. Further evaluation of this question is required before a treatment recommendation can be made.

In patients with either limited stage or extensive stage SCLC, four to six cycles of platinum-based chemotherapy with either cisplatin or carboplatin plus either etoposide or irinotecan are recommended over other chemotherapy regimens. Clinical trials in the United States and Europe have not demonstrated a benefit for the irinotecan regimen over that based on etoposide. In limited stage disease, four cycles is preferred.

In patients with relapsed or refractory SCLC, the administration of second-line, single-agent chemotherapy is recommended. Remark: Reinitiation of the previously administered first-line chemotherapy regimen is recommended in patients who experience relapse 6 months from completion of initial chemotherapy. Enrollment onto a clinical trial is encouraged. Single-agent topotecan has U.S. Food and Drug Administration approval in this context.

In elderly patients with limited stage SCLC and good performance status (Eastern Cooperative Oncology Group 0 to 2), treatment with platinum-based chemotherapy plus thoracic radiotherapy is suggested, with close attention to management of treatment-related toxicity.

In elderly patients with extensive stage SCLC and good performance status (Eastern Cooperative Oncology Group 0 to 2), treatment with carboplatin-based chemotherapy is suggested.

In elderly patients with SCLC and poor performance status, treatment with chemotherapy is suggested if the poor performance is due to SCLC.