Management of SCLC with BMs is limited, and relies essentially on radiotherapy over the decades. WBRT is the standard treatment for them. Tyler P. Robin et al. (Robin, Jones, Amini et al. 2018) suggested radiosurgery alone is associated with favorable outcomes for SCLC patients afflicted with isolated BMs.
According to the results of IMPOWER133 and CASPIAN, atezolizumab and durvalumab, two kinds of PD-L1 monoclonal antibody, both had showed anti-tumor activity for ES-SCLC patients. QZ et al.(Zhou, Zhao, Wang et al. 2020) reported a case who achieved complete remission of local lesions after receiving durvalumab monotherapy as a third-line treatment. PD-L1 inhibitors seemed to be a new choice for SCLC patients. Tumor cells downregulate the immune response and promote immune tolerance by expressing PD-L1 and binding PD-1 expressed on the T cells. Immune checkpoint inhibitor (ICI) can block the interaction(Keir, Butte, Freeman et al. 2008), stimulate the normal activity of immune cells to achieve the anti-tumor effect. In theory, both PD-1 inhibitor and PD-L1 inhibitor have anti-tumor activities. Nevertheless, there was no convincing evidence which have proved that SCLCs obtain OS or PFS benefit from PD-l inhibition(Gadgeel, Pennell, Fidler et al. 2018, Owonikoko, Park, Govindan et al. 2021, Rudin, Rudin, Navarro et al. 2020, Spigel, Vicente, Ciuleanu et al. 2021). Fortunately, a meta-analysis(Yu, Chen, Cai et al. 2021) showed that SCLC patients had OS benefit from PD-1 inhibitors plus chemotherapy compared to chemotherapy. In this study, about 24 patients in group B applied PD-L1 monoclonal antibody during treatment, 36 people received PD-1 monoclonal antibody, and the other 4 individuals accepted two kinds of drugs successively. Further analysis of our study did not figure out which kind of drug benefit more. We found that compared to SCLC patients with BMs who only received CRT, the OS and IPFS were significantly improved among patients who received CRT plus immunotherapy no less than 4 cycles. The result was similar with the study of Schapira E. et al. (Schapira, Hubbeling, Yeap et al. 2018), who found the concurrent treatment of PD-1 inhibitors and radiotherapy improved the OS (median OS 17.6months) and locoregional disease control of NSCLC patients with BMs. Besides, a phase two study of tislelizumab in combination with platinum-based for ES-SCLC also showed a promising result. It demonstrated that the median PFS of SCLC patients was 6.9 months and the median OS was 15.6 months(Wang, Zhao, Ma et al. 2020). Furthermore, a case report using pembrolizumab alone in SCLC third-line treatment achieved a complete response(Zhang, Zhu and Lv 2020).
As proved, radiotherapy could modulate the immunogenicity of tumor cells. Sadly, it rarely generated durable therapeutic responses. Repeated radiation treatments always lead to serious side effects. Prolong the therapeutic responses seems to be a good way to improve the therapeutic effect. Dovedi et al.(Dovedi, Adlard, Lipowska-Bhalla et al. 2014) observed enhanced therapeutic efficacy from combination treatment of radiotherapy and immunotherapy. And they found increased expression of PD-L1 caused by low doses of local fractionated-dose radiotherapy delivered as 10 Gy in 5 fractions, which cohered with the result of Dovedi et al.(Sharabi, Nirschl, Kochel et al. 2015). Furthermore, lots of studies showed that radiation could enhance the adaptive immune system. Anurag Gupta(Gupta, Probst, Vuong et al. 2012) indicated that irradiation could activate tumor-associated dendritic cells, which resulted in the improvement of the antigen presentation to T cells. Eric A. Reits et al.(Reits, Hodge, Herberts et al. 2006) demonstrated that irradiation could upregulate the expression of MHC class Ⅰmolecules to reinforce the detection by the immune system. Simon J. The enhanced activity of immune system caused by radiotherapy may have helped the improvement.
It’s a pity that we did not observe significantly improvement of IORR and IDCR in group B. Prerna Guleria(Guleria, Kumar, Malik et al. 2020) indicated that PD-L1 expression on SCLC was extremely low, with a ratio of only about 3%. Ryul Kim et al. (Kim, Keam, Kim et al. 2019) suggested the levels of PD-1 + TILs were significantly decreased in BMs compared with primary lung lesion. In this study, only 6 patients detected the level of PD-L1 expression, one of them was 30%, the other 5 were lower than 3%. Maybe this can explain the result. And perhaps it is the reason why the survival benefit was not obvious among SCLC patients compared with NSCLC patients.
Our data indicated that both immunotherapy and ECM were related to the OS of SCLC patients with BMs. We found that many patients passed away from uncontrolled extracranial diseases rather than BMs, which was confirmed by Riihimaki M et al. (Riihimaki, Hemminki, Fallah et al. 2014).They suggested that SCLC patients were more likely to die of liver metastases or bone metastases rather than brain metastases. In their study, the 1-year survival rate was only 19% among patients with liver metastases while it was around 41% among patients with brain metastases. Denise et al. (Bernhardt, Konig, Aufderstrasse et al. 2018) suggested that ECM status significantly impact the OS of SCLCs with BMs, controlled or stable disease of ECM had longer median OS than those progressively or not controlled. The IMPOWER133(Goldman, Dvorkin, Chen et al. 2021) suggested that SCLC patients with liver metastases had OS benefit from treatment of PD-L1 inhibitor plus chemotherapy. Thus, we hypothesized that the additional immunotherapy would contribute to the management of the extracranial diseases, in turn the prolonged OS of Group B.
Given that SCLC patients with BMs have survival benefit from chemotherapy plus immunotherapy and radiotherapy for BMs. The timing of immunotherapy applied is not clear. The result of KEYNOTE-189(Gadgeel, Rodriguez-Abreu, Speranza et al. 2020) indicated that applying pembrolizumab in first-line rather than second-line treatment brought longer PFS for NSCLC patients. However, PD-1 monoclonal antibody did not show anti-tumor efficacy neither used in first-line(Rudin, Rudin, Navarro et al. 2020) nor second-line(Spigel, Vicente, Ciuleanu et al. 2021) treatment. Moreover, some patients in Group B used ICIs across the lines, which suggests the role of continuous using of ICIs in prolonging the OS of SCLC patients.
We acknowledge the limitations of our retrospective analysis. This is a single-institution analysis. Few patients with poor ECOG status were enrolled in our study, which might result in overestimate the efficacy of immunotherapy. Patients in group B applied different kinds of immune inhibitors, which might influence the outcome. Furthermore, treatment-related brain necrosis, memory deterioration and cognitive disorder were not analyzed in this study.
Further prospective clinical studies of the treatment for extensive-stage SCLC patients should be performed.