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LUNG MALIGNANCIES CASE # 3: Small CELL LUNG CANCER

Atienza-Arellano to Benavidez. LUNG MALIGNANCIES CASE # 3: Small CELL LUNG CANCER. History. RR, 54 year old male who is referred for further management. History. History of Present Illness 1 week PTC progressive weight loss chronic cough Pertinent Social History

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LUNG MALIGNANCIES CASE # 3: Small CELL LUNG CANCER

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  1. Atienza-Arellano to Benavidez LUNG MALIGNANCIESCASE # 3: Small CELL LUNG CANCER

  2. History • RR, 54 year old male who is referred for further management.

  3. History • History of Present Illness • 1 week PTC • progressive weight loss • chronic cough • Pertinent Social History • Smoker : consumes 3 packs per day for more than 30 years

  4. History • Review of Systems • (+) weight loss of 30 lbs in 2 months • (+) anorexia • (-) headache • (-) back pain • (-) abdominal pain • (-) bowel changes

  5. Physical Examination • General Appearance • fairly nourished • fairly developed with normal vital signs • no abnormal physical exam findings in the rest of the systems

  6. Diagnostics • Chest x-ray • widened mediastinum • Chest CT scan with contrast • (+) mass associated with enlarged peribronchial and hilar nodes (both sides) • location : mediastinum • size : 4x5 cm • Fiberopticbronchoscopy • (+) large fungating mass • location : area of the right mainstem bronchus • biopsy - consistent with small cell lung cancer

  7. Diagnostics • Abdominal CT scan • normal liver and adrenal glands • Whole body bone scan • (-) metastasis • Brain CT scan • (-) mass lesions

  8. Question # 1:How would you stage this patient?Are there any differences between the staging of small cell and non-small cell carcinoma? Why is this so?

  9. Clinical Staging • The clinical staging of Small Cell Lung Cancers (SCLC) is based on localization and extent of involvement of regional lymph nodes.

  10. Clinical Staging of SCLC 1. Limited-stage Disease (30% of all SCLC) • confined to one hemithorax and regional lymph nodes (mediastinal, contralateralhilar, ipsilateralsupraclavicular) • may include contralateralsupraclavicular lymph nodes, recurrent laryngeal nerve involvement, and obstruction of superior vena cava

  11. Clinical Staging of SCLC 2. Extensive-stage Disease • cancer exceeding the boundaries which define limited-stage disease • cardiac tamponade, malignant pleural effusion, and bilateral pulmonary parenchymal involvement generally qualify disease as extensive-stage

  12. Clinical Staging of SCLC • Staging between small cell carcinoma and non-small cell carcinoma are different because their management approaches differ from each other. • SCLC STAGING UPDATE: staging for lung cancers have recently been revised and to date only one staging is used for all cancers • TNM International Staging System for Lung Cancer

  13. Clinical Staging of SCLC • Using the simple two-stage system • Px has Limited-stage SCLC • Mass is confined in the right hemithorax as well as contralateral peribronchial and hilar nodes

  14. Clinical Staging of SCLC • Using the TNM International Staging System for Lung Cancer • Px has Stage IIIB Cancer (T2 N3 M0) • T2: tumor size >3cm, involves right main bronchus • N3: metastasis to contralateral mediastinal and contralateral hilar nodes • M0: no distant metastasis

  15. Question # 2:Present a plan of management for this patient.

  16. Management Sequence Intervention Options Counseling Staging Follow-Up Chemo therapy Radio therapy Chemoradio therapy Prophylactic Cranial Irradiation Surgery Palliative and Supportive Care

  17. Counseling • Includes talking to Mr. RR and his family, explaining his condition, the natural history of the disease, prognosis and his options. • It is important to stress smoking cessation and avoidance of exposure to secondhand smoke, radon, asbestos, metals and other risk factors.

  18. Staging • This is the process of finding out how far the cancer has spread. Treatment and the outlook for recovery depend on the stage of cancer.

  19. Intervention Options • Chemotherapy • Radiation therapy • Chemoradiotherapy • Prophylactic cranial irradiation • Surgery

  20. Chemotherapy • Main treatment for SCLC • Patients with limited stage disease have high response rates (60-80%) and a 10-30% complete response rate • It significantly prolongs survival and there is a quick tumor regression providing rapid palliation of tumor-related symptoms

  21. Radiation therapy • It is most often given at the same time as chemotherapy in limited stage disease to treat the tumor and lymph nodes in the chest. • After chemotherapy, radiation therapy is sometimes used to kill any small deposits of cancer that may remain.

  22. Chemoradiotherapy • Chemotherapy given concurrently with thoracic radiation is more effective than sequential chemoradiation, but is associated with significantly more esophagitis and hematologic toxicity • Patients undergoing chemoradiotherapy should be carefully selected based on good performance status and pulmonary reserve.

  23. Prophylactic cranial irradiation • Decreases the development of brain metastasis and results in a small survival benefit of approx. 5% in patients with complete response to chemotherapy • Deficits in cognitive ability following PCI are uncommon and often difficult to sort from the effects of chemo and normal aging

  24. Surgery • Considered if cancer is only small and localized to one tumor nodule; rarely used for SCLC • Lobectomy – preferred operation for SCLC

  25. Palliative care and supportive care • Given after chemotherapy sessions and throughout treatment • Help the patient feel better and add to patient’s comfort • May include meditation to reduce stress, acupuncture to relieve pain, peppermint tea to relieve nausea, aromatherapy, massage therapy, yoga • Pain medication, symptomatic therapy (for difficulty of breathing, etc.) when needed

  26. Palliative care and supportive care • Give antiemetics • Monitor blood counts and blood chemistries • Monitor for signs of infections • Manage neutropenia, thrombocytopenia and anemia if detected and manage emerging infections

  27. Follow up • Frequent check-ups and CT-scans to check for the effectiveness of management and to check for possible metastasis • Other therapies such as counseling and pain management, palliative care and symptomatic therapy are necessary because small cell lung cancer is often not completely cured.

  28. Question # 3:Are there any differences in the management of small cell and non-small cell lung cancer? If so, what are these differences and what are the reasons behind them?

  29. Management: SCLC vs. NSCLC • SCLC (Small Cell Lung Cancer) • Chemotherapy is used as first line treatment, with radiotherapy given sequentially. • SCLC is known to be highly sensitive to chemotherapy and radiation. • SCLC that’s confined to ipsilateral regional lymph nodes and to just one hemithorax (limited disease), a combination therapy of radiation and chemotherapy result in an 85-90% response rate, a median survival of 12-18 months and a cure in 5-15% of patients.

  30. Management: SCLC vs. NSCLC • SCLC (Small Cell Lung Cancer) • SCLC that has a more extensive stage, the median survival is 8-9 months and cures are rare. • Palliative and supportive care is required in all stages. Weight loss is an important factor indicating poor prognosis in patients with small cell lung cancer. A dietary consultation should be obtained for patients with persistent weight loss. • SCLC is usually detected at the advanced stage.

  31. Management: SCLC vs. NSCLC • NSCLC (Non-Small Cell Lung Cancer) • Surgery is used as first line treatment. • Types of Surgery: • Lobectomy – helps preserve pulmonary function • Wedge resection/segmentectomy - Sublobar resections are used for patients with poor pulmonary reserve • Video-assisted thoracoscopic surgery (VATS) - minimally invasive surgical modality being used for both diagnostic and therapeutic lung cancer surgery

  32. Management: SCLC vs. NSCLC • NSCLC (Non-Small Cell Lung Cancer) • Radiation therapy alone as local therapy, in patients who are not surgical candidates, has been associated with 5-year cancer specific survival rates of 13-39% in early-stage non-small cell lung cancer

  33. Management: SCLC vs NSCLC • NSCLC (Non-Small Cell Lung Cancer • Types of Radiation Therapy • Continuous hyperfractionated accelerated radiotherapy (CHART) – making use of hyperfractionation schedules (ex. 1.5 Gy 3 times a day for 12 days, as opposed to conventional radiation therapy at 60 Gy in 30 daily fractions) • Stereotactic body radiotherapy (SBRT) - precise targeting of high-dose radiation to the tumor • Radiofrequency ablation (RFA) - radiofrequency waves passing through a probe increase the temperature within tumor tissue that results in destruction of the tumor.

  34. Management: SCLC vs NSCLC • Combined chemoradiation therapy has been shown to improve the overall survival of patients with advance NSCLC and is actually the more conventional treatment for unrese • Palliative and supportive care is given more in the advanced stages of the disease. • NSCLC is usually detected at the early stage.

  35. Management: SCLC vs NSCLC

  36. Question # 4:How would you explain the prognosis of this case to the patient and his family

  37. Prognosis • Small cell lung cancer (SCLC) is the most aggressive of lung tumors • Rapid growth and metastasis • Certain factors affect prognosis and treatment options, including the stage of the cancer and the patient’s general health • Usually already spread at presentation and hence largely incurable via surgery • According to Harrison’s, the patient no longer meets the criteria for surgical resectability (stage I or II disease with no mediastinal node metastasis by histologic diagnosis)

  38. Prognosis • SCLC is a chemotherapy-sensitive disease • Response rates • Limited-stage: 60-80% (10-30% complete response) • Extensive-stage: 50% (almost always partial) • Survival rates

  39. Prognosis • SCLC is a chemotherapy-sensitive disease • Combined modality therapy has been shown to increase survival in patients with limited-stage disease • Nevertheless, current treatments do not cure most of the cancers • The stage of the patient’s cancer raises the chances for remission, however…

  40. Prognosis • Though initially responsive, most patients with SCLC experience relapse • Prognosis for relapse is poor • Patients who relapse >3 months after initial chemotherapy survive for 4-5 months – chemosensitive disease • Those who relapse within 3 months or are non-responsive to treatment survive only 2-3 months – chemorefractory disease

  41. Prognosis • Smoking cessation is strongly advised • Not only for the patient but also for those around him • Relative risk for developing lung cancer increases thirteenfold by active smoking and 1.5-fold by long-term passive smoking

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