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Atienza-Arellano to Benavidez. History RR, 54 year old male who is referred for further management.
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Transcript of Atienza-Arellano to Benavidez. History RR, 54 year old male who is referred for further management.
LUNG MALIGNANCIESCASE # 3: SMALL CELL LUNG CANCER
Atienza-Arellano to Benavidez
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
StagingIntervention Options Follow-Up
Chemo therap
y
Surgery
Prophylactic Cranial Irradiation
Chemoradio therapy
Radio therap
y
Palliative and Supportive Care
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 Therapy1. 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 NSCLCCisplatin/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 ratesUntreat
edWith
ChemoLong-Term(>3 years)
Limited-stage 12 weeks
18 months 30-40%
Extensive-stage
Median survival: 9 months
<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 non-responsive 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