Atienza-Arellano to Benavidez

HistoryHistory

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

History 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

HistoryHistory

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

Physical ExaminationPhysical Examination

General Appearance fairly nourished fairly developed with normal vital

signs no abnormal physical exam findings

in the rest of the systems

DiagnosticsDiagnostics

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

DiagnosticsDiagnostics

Abdominal CT scan normal liver and adrenal glands

Whole body bone scan (-) metastasis

Brain CT scan (-) mass lesions

Question # 1:Question # 1:How would you stage this patient?How would you stage this patient?

Are there any differences between Are there any differences between the staging of small cell and non-small the staging of small cell and non-small

cell carcinoma? Why is this so?cell carcinoma? Why is this so?

Clinical StagingClinical 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 SCLCClinical 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 SCLCClinical 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 SCLCClinical 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 SCLCClinical 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 SCLCClinical 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:Question # 2:Present a plan of management for this Present a plan of management for this

patient.patient.

Management SequenceManagement Sequence

Counseling

StagingIntervention Options Follow-

Up

Chemo therap

y

Surgery

Prophylactic Cranial Irradiation

Chemoradio therapy

Radio therap

y

Palliative and Supportive Care

CounselingCounseling

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.

StagingStaging

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 OptionsIntervention Options

Chemotherapy Radiation therapy Chemoradiotherapy Prophylactic cranial irradiation Surgery

ChemotherapyChemotherapy

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 therapyRadiation 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.

ChemoradiotherapyChemoradiotherapy

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 Prophylactic cranial irradiationirradiation

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

SurgerySurgery

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

SCLC

Palliative care and Palliative care and supportive caresupportive 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 Palliative care and supportive caresupportive 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 upFollow 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:Question # 3:Are there any differences in the Are there any differences in the

management of small cell and non-management of small cell and non-small cell lung cancer? If so, what are small cell lung cancer? If so, what are

these differences and what are the these differences and what are the reasons behind them?reasons behind them?

Management: SCLC vs. Management: SCLC vs. NSCLCNSCLC 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. Management: SCLC vs. NSCLCNSCLC 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. Management: SCLC vs. NSCLCNSCLC NSCLC (Non-Small Cell Lung Cancer)

Surgery is used as first line treatment. Types of Surgery:1. Lobectomy – helps preserve pulmonary

function2. 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. Management: SCLC vs. NSCLCNSCLC 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 Management: SCLC vs NSCLCNSCLC 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 Management: SCLC vs NSCLCNSCLC 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 Management: SCLC vs NSCLCNSCLC

SCLC NSCLCCisplatin/Carboplatin Cisplatin/Carboplatin

Doxorubicin (Adriamycin)

VP16 (Etoposide)

VP16 (Etoposide) Taxanes

Cyclophosphamide Gemcitabine

Vincristine Ifosfamide

Taxanes Gefitinib

Topotecan Eriotinib

Bevacizumab

Question # 4:Question # 4:How would you explain the How would you explain the

prognosis of this case to the prognosis of this case to the patient and his familypatient and his family

PrognosisPrognosis

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)

PrognosisPrognosis

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

With Chemo

Long-Term(>3 years)

Limited-stage 12 weeks

18 months 30-40%

Extensive-stage

Median survival: 9 months

<5% survive 2

years

PrognosisPrognosis

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…  

PrognosisPrognosis

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

PrognosisPrognosis

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