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Small cell lung cancer
Small Cell Lung Cancer SCLC
Othman Saleh
Grand Valley State University
Small cell lung cancer
1a. Presenting signs and symptoms of patient (history and physical)
A 57 year- old white male was diagnosed with a small cell carcinoma of the lung. Patient
presented earlier in the fall of 2014 and at that time the doctor found abnormality with his
imaging. He mentioned that he discontinued tobacco use approximately 2- ½ years ago after
approximately an 80-pack-year history and reports social use of ethanol. In addition, he reports
that his parent had skin cancer.
2a. Epidemiology
Lung cancer is a form of cancer that originates in the lungs. Like any other cancers, it
results from an abnormality in the cell. An article titled, Lung Cancer: Epidemiology, Etiology,
and Prevention, stated that “lung cancer is the leading cause of cancer death in the United States
and around the world. Almost as many Americans die of lung cancer every year than die of
prostate, breast, and colon cancer combined.” As mentioned lung cancer claims more lives each
year than other cancers combined, that’s how deadly and serious lung cancer is. There are three
main types of lung cancer; non-small cell, small cell, and carcinoid.
1. Non-Small Cell Lung Cancer
According to American Cancer Society, “About 85% to 90% of lung cancers are nonsmall cell lung cancer (NSCLC).” There are 3 leading subtypes of NSCLC. The cells in these
subtypes vary in mass, form, and chemical make-up. American Cancer Society declared about
25% to 30% of all lung cancers are squamous cell carcinomas, 40% of lung cancers are
adenocarcinomas, and 10% to 15% of lung cancers are large cell carcinoma.
Small cell lung cancer
2. Small Cell Lung Cancer
About 10% to 15% of all lung cancers are small cell lung cancer (American Cancer
Society 2015).
3. Lung Carcinoid Tumor
Carcinoid tumors of the lung account for fewer than 5% of lung tumors (American
Cancer Society 2015).
Overall, including both small cell and non-small cell, The American Cancer Society’s estimates
for lung cancer in the United States for 2015 are:
◾ “About 221,200 new cases of lung cancer (115,610 in men and 105,590 among women)
◾ And estimated 158,040 deaths from lung cancer (86,380 in men and 71,660 among women),
accounting for about 27% of all cancer deaths.”
1c. Etiology (study the causes of a disease) risk factors
The book, Lung Cancer discussed many causes and risk factors related to lung cancer. It
discussed some cancer- causing substances such as tobacco smoke, asbestos, radon, family
history and so forth. According to Lung Cancer, lung cancer is caused by a mutation in your
DNA. The authors discussed how the body is built to fight, protect, and repair itself from any
damage; however with constant exposure to carcinogens, the body becomes weak to fight off
damages done to the body. In addition, Healthline explains in more details how carcinogens can
affect the body and cause diseases like cancer to develop. Healthline states, “Lung cancer is
caused by a mutation in your DNA. When cells reproduce, they divide and replicate, forming
Small cell lung cancer
identical cells, so that your body is constantly renewing itself. Inhaling harmful, cancer-causing
substances (carcinogens) like cigarette smoke, asbestos, and radon, damages the cells that line
your lungs. At first your body may be able to repair itself. With repeated exposure your cells
become increasingly damaged. Over time, the cells begin to act abnormally and grow
uncontrollably. This is how cancer can develop.” Our immune systems constantly fight off
diseases but too much of everything is always bad. Being exposed to carcinogens is commonly
negative but we always get exposed to carcinogens somehow by environmental factors such as
pollution, radiation, and asbestos. But in some situations like smoking tobacco is where people
expose themselves to additional carcinogens, and that’s where it becomes too much.
Tobacco smoke
Smoking is the main cause for lung cancer. American Cancer society mentioned that lung
cancer is more familiar now compared to other types of cancer than in the early 20th century
because cigarette became freely available and more people began smoking. According to
American Cancer Society, “At least 80% of all lung cancer deaths are thought to result from
smoking, and this number is probably even higher for small cell lung cancer. It is very rare for
someone who has never smoked to have small cell lung cancer.” Basically they’re mentioning
how significant smoking relates to lung cancer. It’s mentioned that it’s almost unheard of for
someone to develop small cell lung cancer if he or she never smoked. This basically tells me that
smoking is almost 100% obvious to be the cause of small cell lung cancer.
Secondhand smoke:
Small cell lung cancer
If a person doesn’t smoke, being exposed to secondhand, breathing in the smoke of
others smoke at home, work, or in restaurants and bars can put him or her at a great risk of
developing lung cancer. Secondhand smoke is believed to takeaway more than 7,000 lives from
lung cancer each year (Healthline 2015)
Environmental factors
 Radon
Centers for Disease Control and Prevention, CDC, states, “According to the U.S. Environmental
Protection Agency (EPA), radon causes about 20,000 cases of lung cancer each year, making it
the second leading cause of lung cancer. Nearly one out of every 15 homes in the U.S. is thought
to have high radon levels. Radon comes from rocks and dirt and can get surrounded in houses
and buildings. Most houses in United States have a basement and most of radon gas can be
present there. It’s dangerous, because as mentioned it’s the second leading cause of lung cancer
and it cannot be identified with the five senses. For safety purpose and lung cancer prevention,
it’s better to test the place of shelter in case there is a high level of radon.
 Other Substances
CDC listed substances found at some workplaces that place the staffs at higher risk of
developing lung cancer. These substances include asbestos, arsenic, diesel exhaust, and some
forms of silica and chromium. It was mentioned that combing both, smoking and being exposed
to such substances, puts a person in a greater risk of developing lung cancer. American Cancer
Society stated, “Workplace exposure to asbestos fibers is an important risk factor for lung
cancer. Studies have found that people who work with asbestos (in some mines, mills, textile
plants, places where insulation is used, shipyards, etc.) are several times more likely to die of
lung cancer. In workers exposed to asbestos who also smoke, the lung cancer risk is much
Small cell lung cancer
greater than even adding the risks from these exposures separately.” So again, somehow we will
be exposed to some substances due to the environment we live in. however, creating a greater
risk goes back to the person and being aware to avoid additional carcinogens.
Family History
The authors of the book, Lung Cancer, mentioned that if a person has a family member who has
or has had lung cancer puts him or her at a higher risk of developing the disease. Also, if a
person has had cancer, he or she is in higher risk of developing it again.
Age
American Cancer Society stated, “Lung cancer mainly occurs in older people. About 2
out of 3 people diagnosed with lung cancer are 65 or older; fewer than 2% of all cases are found
in people younger than 45. The average age at the time of diagnosis is about 70.” In my
understanding, age contribute to the development of lung cancer if it can be understood because
aging process is complex. A person can be old but in perfect mental and physical shape.
However, if a person is old and became weaker; that’s when aging becomes significant as a risk
of developing cancer because a person body might not function fully as strong as once was.
1d. Compare patient to typical
The patient is 57 years of age which placed him at a higher risk of developing lung
cancer. As mentioned earlier under the age section, fewer than 2% of all cases are found in
people younger than 45 but more common for people over the age of 45 to develop lung cancer.
However, the known age is 65 where people get diagnosed of lung cancer. Moreover, the patient
used to smoke approximately an 80-pack-year history, which placed him at a greater risk since
Small cell lung cancer
smoking is number one risk factor of developing lung cancer. In addition to smoking, he
probably exposed to environmental factors such as radon, air pollution, asbestos, arsenic, and
diesel exhaust, which created a greater risk. The patient mentioned that his parent had skin
cancer, which can connect to genetics and placed him at a higher risk of developing cancer.
2. Complete patient work-up information (chronological in table form)
Based on what was found in patient chart.
Date
Procedure
Lab Tests
October 10, 2014
Imaging
October 21, 2014
Biopsy
Right hilar and
peritracheal
mass
Specimen 1:
imprint
cytology
Specimen 2:
Fine needle
aspiration
cytology
October 22, 2014
MRI
Brian
November 25, 2014
Multiple
scientigraphic
images
Evaluate for
metastases
Lab Results
Diagnosis
Abnormal
imaging
1-2 right lower lobe
endobronchial imprint
cytology and FNA station
7
No areas of photopenia
are identified. Bilateral
renal excretion is seen
with a small amount of
radiotracer activity with
the bladed
Positive small
cell carcinoma
Lung carcinoma,
light headedness,
vertigo,
weakness
Nothing to
suggest
metastatic
disease.
Degenerative
changes of the
appendicular and
axial skeleton.
Small cell lung cancer
December 30, 2014
Imaging
Comparison
January 21, 2015
consultation
Treatment
options
February 3, 2015
simulation
treatment
No significant
change
Radiation
therapy
Linear
accelerator
3a. Anatomy and physiology discussion
The lungs are a pair of spongy air-filled organs located on either side of the thorax. The main
purpose of the lungs is to exchange gases between the air we breathe and blood. Carbon dioxide
is removed from the bloodstream and oxygen enters the bloodstream. The right lung consists of
three lobes; the superior, middle, and inferior lobes. The horizontal fissure separates the superior
and the middle lobes, while the right oblique fissure divides the middle and inferior lobes. The
left lung consists of two lobes; superior and inferior lobes separated by the left oblique fissure.
The trachea inhale air into the lungs through the bronchi. The bronchi then divide into smaller
branches known as bronchioles, and finally reach a bunch of small air sacs called alveoli; where
the oxygen from the air is absorbed into lung. Carbon dioxide is a waste product leaves from the
blood to the alveoli, where it can be exhaled. The lungs are protected by a thin tissue called the
pleura, it serves as a lubricant allowing the lungs to expand and contract with each breath
(WebMD 2015). Refer to the anatomy & lymphatic section for graphical detail.
Muscles and Bones
The diaphragm is the strong wall of muscle that separates the chest cavity from the abdominal
cavity. The ribs are bones supporting and protecting the chest cavity. They move to help the
lungs expand and contract (American lung Association 2015).
Small cell lung cancer
3b. Regional lymphatic drainage
The lymphatic system is significant in lung cancer because it is one of the major routes of
regional spread. Left and right lower lobe as well as the right middle lobe lymphatics drain to the
posterior mediastinum and subcarinal lymph nodes. Right upper lobe lymphatics drain toward
the superior mediastinum, whereas the left upper lob lymphatics typically course lateral to the
aorta and subclavian artery in the anterior mediastinum along the left main bronchus to the
superior mediastinum. Ultimately, all of these lymphatic channels drain into the right lymphatic
or left thoracic ducts, which empty into the subclavian veins. Basically, most of the lymphatic
drainage ultimately reaches the right superior mediastinum and right supraclavicular regions
(LWWOncology 2015). Refer to the anatomy & lymphatic section for graphical detail.
3c. Anatomy & lymphatic graphics
The Lungs (Human Anatomy): Picture, Function, Definition, Conditions. (n.d.). Retrieved April
8, 2015, from http://www.webmd.com/lung/picture-of-the-lungs
Small cell lung cancer
Lungs. (n.d.). Retrieved April 8, 2015, from http://medicalterms.info/anatomy/Lungs/
GUWS Medical. (2015, April 1). Retrieved April 8, 2015, from
http://www.guwsmedical.info/heart-failure/nerves-of-the-thoracic-wall.html
Small cell lung cancer
4a. Pathology
Small cell lung cancer, also known as oat cell carcinoma, differs from non-small cell lung
cancers due to their clinical and biologic characteristics. It’s known as an aggressive type of lung
cancer. It is a neuroendocrine carcinoma that shows destructive behavior, fast growth, and early
spread to regional sites. Small cell lung carcinoma (SCLC) arises in peribronchial sites and
penetrates the bronchial submucosa (Medscape 2015).
There two types of small cell cancer lung cancer; small cell carcinoma (oat cell cancer) and
combined small cell carcinoma. Symptoms of SCLC may include blood sputum, chest pain,
coughing, loss of appetite, shortness of breath, weight loss, fever, and swallowing difficulty.
However, most of SCLC gets discovered usually after it has already spread to other parts of the
body. Bone scan, chest x-ray, complete blood count, CT scan, MRI, and liver function tests are
examinations that detect or diagnose lung cancer. Moreover, biopsy can be done to identify if the
disease is present (Midline Plus 2015).
4b. staging
Staging system is a typical way to figure out how large a cancer is and if it has spread. There are
two staging systems that are used to describe the stage of SCLC.
Limited and extensive stage

Limited stage- cancer is only in the chest and can be treated with radiation therapy.
Lymph nodes superior to the clavicle can be affected in limited stage. About 1 out of 3
people with SCLC has limited stage when cancer is first found.
Small cell lung cancer

Extensive stage- cancer has spread outside the chest. About 2 out of 3 people have
extensive disease when their cancer is diagnosed.

SCLC is staged this way for treatment purposes (American Cancer Society 2015).
The TNM staging system
TNM is recognized system used to describe the growth and spread of lung cancer. TNM system
describes 3 keys of information; T describes the size of the tumor, N describes the spread to
regional lymph nodes, and M describes whether the cancer has metastasized to other organs.
Numbers or letters are added after T, N, and M to offer more detailed information.
T categories for lung cancer
TX: The main tumor can’t be assessed.
T0: There is no evidence of a primary tumor.
Tis: Cancer is found only in the top layers of cells lining the air passages. It has not grown into
deeper lung tissues. This is also known as carcinoma in situ.
T1: The tumor is not greater than 3 centimeters, and has not extended to the pleura and does not
affect the main branches of the bronchi.
T2: The tumor has 1 or more of the following features:




It is greater than 3 cm across but not more than 7 cm.
It involves a main bronchus, but is not closer than 2 cm to the carina
It has grown into the pleura.
The tumor partially clogs the airways, but this has not caused the entire lung to collapse
or develop pneumonia.
T3: The tumor has 1 or more of the following features:



It is larger than 7 cm across.
It has grown into the chest wall, diaphragm, the mediastinal pleura, or parietal
pericardium.
It invades a main bronchus and is closer than 2 cm (to the carina, but it does not involve
the carina itself.
Small cell lung cancer


It has grown into the airways enough to cause an entire lung to collapse or to cause
pneumonia in the entire lung.
Two or more separate tumor nodules are present in the same lobe of a lung
T4: The cancer has 1 or more of the following features:


A tumor of any size has grown into the mediastinum, the heart, the aorta, trachea, the
esophagus, the backbone, or the carina.
Two or more separate tumor nodules are present in different lobes of the same lung.
N categories for lung cancer
NX: Nearby lymph nodes cannot be assessed.
N0: There is no spread to nearby lymph nodes.
N1: The cancer has spread to lymph nodes within the lung and/or around the area.
N2: The cancer has spread to lymph nodes around the carina or mediastinum.
N3: The cancer has spread to lymph nodes near the collarbone on either side, and/or spread to
hilar or mediastinal lymph nodes on the side opposite the primary tumor.
M categories for lung cancer
M0: No spread to distant organs or areas.
M1a: Any of the following:



The cancer has spread to the other lung
Cancer cells are found in the fluid around the lung
Cancer cells are found in the fluid around the heart
M1b: The cancer has spread to distant lymph nodes or to other organs such as the liver, bones, or
brain
Stage grouping for lung cancer
Stage 1
T1,M0,N0
Stage 2
T1,N1,M0
Stage 3
T1-3, N2,M0
Stage 4
Any T, any N,M1
- (American Cancer Society 2015)
T2,N0,M0
T3,N0,M0
T3,N1,M0
Any T,N3,M0
T4,N2,M0
Small cell lung cancer
4c. Grading
Grade refers to the appearance of the individual cancer cells under the microscope.
Cancer grading helps to find patient’s prognosis and survival outlook. Tumor grading is
determined by taking cancerous tissues through biopsy and microscopically tests for cell
characteristics and aggressiveness. The test tissues can be graded as high or low depending on
their status. High grading tells us that the cancer is aggressive, poor differentiated, grow faster,
and spread faster. Low grading means that cancer is well differentiated, less aggressive, and
likely to spread. The book titled as Cancer Staging Handbook from the American Joint
Committee on Cancer (AJCC) discussed specifically tumor grading for SCLC.
Grade
Gx : Grade cannot be assessed
G1 : Well differentiated
G2 : Moderately differentiated
G3 : Poor differentiated
G4 : Undifferentiated
4d. Patients pathology, stage and grade
Pathology samples were obtained through biopsy and were sent to the lab. The lab results
indicated that the patient is diagnosed of a small cell carcinoma of the lung. Primary tumor was
present in the right lower lobe with a mass measuring 7.6 x4.5 cm. In addition, it has spread to
the right upper lobe nodular lesion, measuring 1.4 x 1.3 cm. There was no evidence of
Small cell lung cancer
metastasis. However, there was a large mass present with in the mediastinum and right suprahilar
region. According to the staging and the patient’s chart, the patient’s disease is limited.
According to the TNM staging, his tumor can be classified a T3 (It is larger than 7cm), N3 (The
cancer has spread to lymph nodes to hilar or mediastinal lymph nodes), and M0 (no spread to
other organs). By grouping T3, N3, M0; the patient’s cancer falls under stage 3.
5a. Radiation Therapy (RT) treatment plan and Rx for patient
Following simulation and using image fusion treatment planning, a six-field intensity modulated
radiation therapy was developed. The patient was treated to the right lung mediastinum using 6
MV photons. Patient chart discussed a total of 6,000 cGy to be delivered in 30 fractions of 200
cGy per fraction.
5b. RT treatment information and patient set-up
The patient setup up was supine, head first, with the aid of an alpha-cradle and a sponge
underneath his knees in order to reproduce the same setup for every treatment and provide an
accurate and precise treatment.
5c. RT treatment type and how it was delivered
Beam
AP
RPO Chest
RPO
RPO Chest RAO Chest
RAO Chest
Chest
Gantry
0.0
200
230
260
300
330
0.0
0.0
0.0
0.0
0.0
0.0
angles
Collimator
angles
Small cell lung cancer
Couch
0.0
0.0
0.0
0
0
0
Wedges
None
None
None
None
None
None
Block
MLC
MLC
MLC
MLC
MLC
MLC
Bolus
None
None
None
None
None
None
Planned
89.2 cm
87.1 cm
82.1 cm
79.7 cm
85.5 cm
87.2 cm
52.3 MU
48.5 MU
66.1 MU
64.7 MU
50.2 MU
58.2 MU
6 MV
6 MV
6 MV
6 MV
6 MV
6 MV
Photons
Photons
Photons
Photons
Photons
Photons
angles
SSD
Monitor
Units
Energy
5d. RT complication and side effect and how they were treated
According to the chart, the patient was having some fatigue and having some early dysphagia,
which are common side effects of radiation therapy. It was recommended for him to drink a lot
of fluid.
6a. Adjuvant therapies (traditional), complications and side effect and how they are treated
Treatment options are based on the stage of the cancer and overall health of the patient.
As mentioned earlier, small cell lung cancer are typically staged as either limited or extensive.
Unfortunately, SCLC spread by the time it is diagnosed, so surgery might not be a good option
for treatment. Chemotherapy and radiation therapy the other main options for lung cancer.
Moreover, if the patient is a smoker, it’s better for him or her to quit before treatment. American
Small cell lung cancer
Cancer society states, “Studies have shown that patients who stop smoking after a diagnosis of
lung cancer tend to have better outcomes than those who don’t.” Chemo therapy is the use of
cancer killing drugs taking by mouth or injected into the body. The side effects of chemotherapy
are hair loss, fatigue, constipation, anemia, loss of appetite, and bleeding problems. Radiation
therapy is a method of delivering how dose of radiation to a specific volume while sparing other
critical organs, this can be done by internal or external. Side effects of radiation therapy may
include dysphagia, difficulty breathing, fatigue, skin irritation, and weight loss. Treatment
options for each stage are as follow:
Limited Stage SCLC
Most of patients with limited stage SCLC are treated with both chemo and radiation. Surgery is
not a preferred option when the tumor is too large or it has spread to regional lymph nodes and
other parts in the chest. Chemo drugs such as etoposide plus either cisplatin or carboplatin are
used. Combining chemo and radiation is called concurrent chemoradiation. This gives them a
better outcome and prognosis (American cancer society 2015).
Extensive stage SCLC
Patients with limited extensive SCLC and are in good overall health to undergo chemo, it can
often treat symptoms helps patient live longer. The most commonly used combination is
etoposide plus either cisplatin or carboplatin. Most patients will benefit from it when the tumor
shrinks. Unfortunately, the cancer will reoccur at some point in their life; this happens to almost
all patients with extensive stage SCLC (American cancer society 2015).
6b. what other therapies (6a) and complications did patient have?
Small cell lung cancer
According to the patient chart, he went through radiation therapy and chemotherapy.
7. Critical structures and dose tolerances
Radiation beam pass through the following structures when treating lung cancer. The table
information below was taking from a book titled, Principle and Practice of Radiation Therapy by
Washington and Leaver.
Structures
Side Effects
TD 5/5 (cGy)
Spinal cord
Neurologic complications,
5000
fibrosis, and occlusion of
capillaries.
Normal lung
Pneumonitis, fibrosis
2000
Heart
Pericarditis
4300
Esophagus
Acute esophagitis
5000
Bone marrow
Suppression
2500
Skin
Necrosis, ulcerate on
5500
Liver
Liver diseases
3500
Bone
Necrosis
6500
Small cell lung cancer
8. Routes of spread
A book by the tittle, Decision Making in Radiation Oncology, declared the three most common
routes of spread in lung cancer; local extension, regional spread to the lymphatics, and distant
metastasis. The authors explained more detailed as follow:
Local extension

“Direct involvement of pleural surfaces, chest wall, ribs, and mediastinal structures
causing hemoptysis.

Involvement of vertebral body, brachial plexus, stellate ganglion, subclavian caculature
and superior vena cava.
Regional lymph node metastasis

Lymph node drainage includes the hilar and interlobar nodes, followed by mediastinal
lymph nodes.

Mediastinal nodal routes of spread differ between upper and lower lobe tumors.
Distant metastasis

Most common sites of distant metastasis are contralateral lung, brain, bone, adrenals, and
liver” (p.265).
Small cell lung cancer
9a. Prognosis and survival
Small cell lung cancer prognosis and survival can vary significantly between patients. Patient’s
age, stage, and overall health status play major role for treatment options and prognosis. The
table information below was taking from a book titled, Principle and Practice of Radiation
Therapy by Washington and Leaver.
9b. Patients prognosis and survival
After grouping the TNM staging system; T3, N3, and M0, patient fall under the stage 3.
Unfortunately, small cell lung cancer is aggressive and deadly. The patient has 8% chance of a 5
year survival.
Small cell lung cancer
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http://www.lung.org/your-lungs/how-lungs-work/
Small cell lung cancer
What are the key statistics about lung cancer? (2014, September 12). Retrieved April 8, 2015,
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http://www.cancer.org/cancer/lungcancer-smallcell/detailedguide/small-cell-lung-cancerstaging
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