Lekic M et al. / Small-cell lung cancer and brain metastases 55 Introduction Small cell lung cancer (SCLC) is a life-threatening disease, typically caused by cigarette smoking. It is almost exclusively seen in current or former smok- ers. SCLC represents approximately 13-18% of all lung cancers with a varying incidence in different countries.1 The incidence of SCLC is in decrease and the ratio of incidence between SCLC/NSCLC is decreasing as well. Without treatment, this can- cer has the most aggressive clinical course of all lung cancer types, with survival rates between 2 to 4 months. A recommendation to use TNM International Union Against Cancer (UICC) staging system for all SCLC cases was regularly accepted.2-4 However, a simple two-stage system developed by the Veteran’s Administration Lung Cancer Study Group as limited (stage) disease (LD) or extensive (stage) disease (ED) was more frequently used in clinical practice.5 Patients with limited disease have the involvement restricted to one hemithorax that can be encompassed within a tolerable radia- tion field. Extensive disease is defined as disease beyond one hemithorax and may include malig- nant pleural or pericardial effusion or haematog- enous metastases. At the time of diagnosis approximately 70% of patients have ED. Patients with extensive-stage SCLC are considered incurable, and have median survival time of approximately 9–10 months from diagnosis with the current standard treatment.5 Patients with limited SCLC have a median survival of approximately 18 months and can be cured. By using multimodality therapy, including concur- rent chemotherapy and radiotherapy, long-term disease-free survival rates can be achieved in ap- proximately 20-25% of patients.6 Although SCLC is regarded as highly sensitive to both chemotherapy and radiotherapy, fast development of resistance is a major problem. Only a modest improvement in survival has been achieved during the last 20 years, and prognosis remains poor with 5-year survival rates of around 10% and 2% in LD and ED, respec- tively.7 At the time of the initial diagnosis, approx. 20% of the patients with SCLC have detectable brain metastases, and the incidence of such metastases increases considerably during the course of dis- ease, approaching 80% at 2 years. The standard treatment of clinically evident brain metastases is whole brain radiotherapy (WBRT), usually in com- bination with corticosteroids and the solitary me- tastasis might be additional irradiated with stere- otactic radiotherapy or Gamma Knife.8-10 The re- sponse rate to brain irradiation is around 50%, but survival rates are relatively short. In a majority of observations published until now brain metastases were found to be an independent prognostic factor for short survival. However, few individual trials have not found brain metastases to affect survival adversely.11,12,13 In one of these trials the survival rates of the patients with extensive disease with or without brain metastases at the time of diagnosis was done. In this particular study extensive-stage patients with brain metastases and additional sites of metastatic disease had shorter survival com- pared to those with brain metastases alone (5 vs. 11 months).11 There are few studies showing compa- rable survival rates in patients with only brain me- tastases to the survival rates achieved in patients with LD.12,13 The objective of this retrospective study was to evaluate the median survival of SCLC patients with or without brain metastases at the time of di- agnosis treated in a routine clinical practice before the introduction of PCI as a standard treatment procedure. Patients and methods Patients with SCLC diagnosed and treated at the University Clinic Golnik between 2002 to 2007, with performance status ≤2 and eligible for stand- ard treatment of chemotherapy +/- radiotherapy were included in retrospective study. Baseline evaluations included medical history and a radio- logical examination. In all patients chest X-ray, CT scans of the chest, abdomen and brain were per- formed.3 Additional exams, like bone scintigraphy, were performed only if symptoms were present. Pathological confirmation of SCLC was mandato- ry.14 Patients were treated according to the guide- lines valid at that time. All patients with radiologi- cally confirmed brain metastases, with or without neurological symptoms, received whole brain ir- radiation (WBRT). The radiotherapy was applied at the Institute of Oncology Ljubljana, Slovenia, and patients were followed-up regularly at the University Clinic Golnik. Statistical analysis and ethical consideration The endpoint in this study was overall survival (OS) which was calculated from the date of diagno- sis to the date of death from any cause, or the date Radiol Oncol 2012; 46(1): 54-59.