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case_images: (A) Thoracic CT at initial diagnosis in February 2019, showing a mass of about 7.5 cm x 3.9 cm in the right central lung and the right hilar, enlarged mediastinal lymph nodes. (B) Hematoxylin and Eosin staining and IHC staining of the Biopsy Specimen, indicating positivity for Ki-67, CD56, and Syn. IHC, immunohistochemistry; Syn, synaptophysin.
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case_images: Thoracic contrast-enhanced CT (Figure 1A) showed a mass of approximately 7.5 cm x 3.9 cm in the center of the right lung with corresponding bronchial obstruction and obstructive inflammation encircling the vessels of the right lung, highly suggestive of bronchogenic carcinoma. Fiberoptic bronchoscopy biopsy showed middle right lung branch small cell lung cancer (Figure 1B). Chest CT showed a marked reduction of the pulmonary lesion (Supplementary Figure 1A). However, bone ECT showed additional metastasis in the fourth thoracic vertebra (T4) (Supplementary Figure 1B).
case_images: (A) Individualized thoracic irradiation utilizing intensity-modulated radiation therapy technique. (B) Whole brain irradiation (WBI) with a sequential boost to lesions, while protecting the key functional areas of the hippocampus using TOMO technique (30Gy/10F for the whole brain and the synchronous dose of 45Gy/15F for the focus). (C) Re-irradiation of the right occipital lobe brain metastasis with stereotactic radiotherapy (SRT) by EDGE accelerator (27Gy/3F).
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case_images: On examination, the lesions in the pulmonary and mediastinal lymph nodes were markedly reduced and had almost disappeared (Supplementary Figure 2A). T4 vertebral body and 50Gy/25F thoracic involving field radiotherapy using 6MV-X-ray IMRT (Figure 2A). The organs at risk were within limits, well below the dose limit (for example, lung V5 = 52.0%, lung V20 = 22.0%, lung V30 = 11.7%, and lung Dmean = 11.5Gy) (Figure 2A). However, one month after the radiation therapy, the patient developed Grade II radiation pneumonitis according to the toxicity criteria for common adverse events (Version 4.0) (Supplementary Figure 2B). Two months after the chest radiotherapy, on re-examination, we found stable pulmonary and regional lymph node lesions, but the brain MRI (September 17, 2019) showed new enhanced nodules in the right occipital lobe (1.1 cm x 0.8 cm x 0.9 cm) and right frontal lobe (0.5 cm maximum diameter) suggesting brain metastatic lesions (Figure 2B). Whole brain irradiation (WBI) was performed using the TOMO radiotherapy technique along with a sequential boost to lesions, while protecting the key functional areas of the hippocampus (whole brain dose: 30Gy/10F, and the local dose for tumor lesions: 45Gy/15F) (Figure 2B). After whole-brain radiotherapy, the patient showed complete recovery from radiation pneumonia (Supplementary Figure 2C), and immunotherapy was restarted. From September 9 to September 11, 2020, we administered EDGE accelerator stereotactic radiotherapy (SRT) with 6 mV X-rays at a total dose of 27Gy/3F for the patient's right occipital brain metastasis (Figure 2C).
case_images: (A) The gradual increase of the right occipital lobe brain metastasis after SRT treatment in MRI. (B) Postoperative pathology of the enlarged brain lesion in the right occipital lobe, which was later confirmed as radiation necrosis. (C) Flow chart of the whole treatment.
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case_images: However, after 4 months of treatment with SRT, the aforementioned lesion began to gradually increase (Figure 3A). On June 2, 2021, the patient underwent partial surgery for this brain lesion, which was finally confirmed as radiation necrosis (Figure 3B). Anlotinib for maintenance with fine tolerance. At the last follow-up visit on 10 February 2023, overall survival (OS) from the time of first diagnosis of SCLC to present was 48 months and OS from the time of confirmation of brain metastases to present was 41 months (Figure 3C). To date, excellent tumor control had been achieved (Supplementary Figure 3) and the patient had a high quality of life.