Download LUNG MALIGNANCIES CASE # 3: RR

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
 Smoker : consumes 3 packs per day for more
than 30 years
History
 Review of Systems
 (+) weight loss of 30 lbs in 2 months
 (+) anorexia
 (-) headache
 (-) back pain
 (-) abdominal pain
 (-) bowel changes
Physical Examination
 General Appearance
 fairly nourished
 fairly developed with normal vital signs
 no abnormal physical exam findings in the rest
of the systems
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
 Fiberoptic bronchoscopy
 (+) large fungating mass
 location : area of the right mainstem bronchus
 biopsy - consistent with small cell lung cancer
Diagnostics
 Abdominal CT scan
 normal liver and adrenal glands
 Whole body bone scan
 (-) metastasis
 Brain CT scan
 (-) mass lesions
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?
Clinical Staging
 The clinical staging of Small Cell Lung
Cancers (SCLC) is based on localization and
extent of involvement of regional lymph
nodes.
Clinical Staging of SCLC
1. Limited-stage Disease (30% of all SCLC)
 confined to one hemithorax and regional
lymph nodes (mediastinal, contralateral hilar,
ipsilateral supraclavicular)
 may include contralateral supraclavicular
lymph nodes, recurrent laryngeal nerve
involvement, and obstruction of superior
vena cava
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
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
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
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
Question # 2:
Present a plan of management for this patient.
Management Sequence
Counseling
Intervention
Options
Staging
Chemo
therapy
Radio
therapy
Chemoradio
therapy
Follow-Up
Prophylactic
Cranial
Irradiation
Palliative and Supportive Care
Surgery
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.
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.
Intervention Options
 Chemotherapy
 Radiation therapy
 Chemoradiotherapy
 Prophylactic cranial irradiation
 Surgery
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
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.
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.
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
Surgery
 Considered if cancer is only small and
localized to one tumor nodule; rarely used for
SCLC
 Lobectomy – preferred operation for SCLC
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
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
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.
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?
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.
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.
Management: SCLC vs. NSCLC
 NSCLC (Non-Small Cell Lung Cancer)
 Surgery is used as first line treatment.
 Types of Surgery:
1. Lobectomy – helps preserve pulmonary function
2. Wedge resection/segmentectomy - Sublobar
resections are used for patients with poor
pulmonary reserve
3. Video-assisted thoracoscopic surgery (VATS) minimally invasive surgical modality being used
for both diagnostic and therapeutic lung cancer
surgery
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
Management: SCLC vs NSCLC
 NSCLC (Non-Small Cell Lung Cancer
 Types of Radiation Therapy
1. 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)
2. Stereotactic body radiotherapy (SBRT) - precise
targeting of high-dose radiation to the tumor
3. Radiofrequency ablation (RFA) - radiofrequency
waves passing through a probe increase the
temperature within tumor tissue that results in
destruction of the tumor.
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.
Management: SCLC vs NSCLC
SCLC
NSCLC
Cisplatin/Carboplatin
Cisplatin/Carboplatin
Doxorubicin (Adriamycin)
VP16 (Etoposide)
VP16 (Etoposide)
Taxanes
Cyclophosphamide
Gemcitabine
Vincristine
Ifosfamide
Taxanes
Gefitinib
Topotecan
Eriotinib
Bevacizumab
Question # 4:
How would you explain the prognosis of this case to
the patient and his family
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)
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
Untreated
Limited-stage
Extensive-stage
With Chemo
12 weeks
18 months
Median survival: 9 months
Long-Term
(>3 years)
30-40%
<5% survive 2
years
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…
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 nonresponsive to treatment survive only 2-3 months –
chemorefractory disease
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