General Data

Patient C. C.
78/f
Filipino
Catholic
 Chief complaint: shoulder pain,
Left
HPI:
3 months
(+)left shoulder pain aggravated by cold
temperature
(-)limited range of motion
(-) swelling

Few hrs ptc, patient still with above symptom

prompted consult in our institution. Patient
requested admission for executive checkup,
hence admitted.
 Review of system

General: (+) Loss of appetite(+) Weight Loss

Skin: (-) Color changes (-) Lesions
Head and Neck: (-) Blurring of vision (-) Nose pain
(-) Otalgia (+) Sore Throat
Respiratory : (+) Cough productive (-) Shortness of
breath
Cardiovascular: (-) Easy fatigability (-) Palpitation (+)
Chest pain
GIT: (-) Diarrhea (-) Constipation (-) Melena
GUT : (-) Anuria (-) Polyuria (-) Oliguria (-) Hematuria
Hematologic : (-) Easy bruisability
 Past Medical History
PMH:
(+) Frozen shoulder Right
(+) 6months completed PTB treatment
2014
(+) allergic Rhinitis
(+) hypertension for 1 yr
(-) DM
(-) asthma
(-) allergy to food or drugs
 Past Surgical History
PSH:
S/P Cholecystectomy
S/P LTCS
S/P D&C
S/P Appendectomy
 Personal and social History
Non smoker
Occasional alcoholic beverage
drinker
 Family Medical History
FMH:
(+) Hypertension- father side
(+) Allergies- Both sides
(-) cancer
 Physical Examination
GENERAL: awake, comfortable and not in cardio-respiratory
distress. vital signs: BP 110/80, CR 89, RR 24, T 36.8
SKIN: Skin is brown, no visible lesions. Warm to touch with good
skin turgor.
HEENT: Normocephalic head. Hair is evenly distributed. Anicteric
sclerae, pink palpebral conjunctivae, no nasoaural discharge, no
tonsilopharyngeal congestion, no cervical lymphadenopathy,
CHEST & LUNGS: Symmetrical chest expansion, no retractions,
no lagging, decreased breath sound on Left .
HEART: Adynamic precordium, normal rate, regular rhythm, no
murmurs
ABDOMEN: flabby, normoactive bowel sounds, soft, non tender
to palpation.
GENITOURINARY: unremarkable
EXTREMITIES: Grossly normal extremities, no edema, no pallor,
no cyanosis with full & equal peripheral pulses.
 NEUROLOGICAL EXAM

CEREBRAL: awake, alert, comfortable, oriented to time, place, and person

Cerebellum: good posture and good gait, able to do rapid alternating movements,
no nystagmus

Cranial Nerves:
I: able to smell
II, III: 2 mm equal, round, reactive to light, intact consensual and direct light reflex
III, IV, VI: intact EOM
V: good masseter tone
VII: no facial asymmetry
VIII: intact hearing; patient responds upon hearing name
IX,X: able to swallow, uvula at the midline
XI: cannot shrug both shoulder
XII: tongue is in the midline, able to protrude tongue
 Diagnostic procedures
PT: Patient Activity: 94.2/Test 13.4/INR 1.04
CBC: hgb 113/ hct 34/ wbc 9.8/ neut 83/
lymp 11/ mono 1/ band 5/ plt 557
UA- unremarkable
Total protein 63, alb 37, globulin 26, A/G
ratio 1.42, LDH 191, FBS 5.23
BUN- 3.7, Crea 54, Uric acid 0.23, SGPT 7,
SGOT 27, alk phos 96, Na 137, K 4, Ica 1.18
 Cont
Feb 28, 2016
Xray both shoulders- irregular
opacities in the soft tissues superior
to the greater tubercle of the right
humerus, consider calcific tendinosis
CXR- moderate pleural effusion left.
Left hilar opacity, consider mass
lesion, suggest CT scan,
atheromatous aorta
 Cont
March 1, 2016
UTZ of hemothorax to quantify fluid-
consider massive pleural effusion,
left with approximate volume of
1,168cc, unremarkable Right lung.
 Cont
March 2, 2016
Pleural fluid GS/CS AFB - (-) negative
CXR- s/p thoracentesis, follow up CXR since
feb 28 shows decrease in Left sided pleural
effusion still with obscured left cardiac
border and left hemidiaphragm, likely due
to interval instrumentation. Irregular convex
opacity is again seen in the left hilum, this
may relate to a primary bronchogenic CA.
CT scan correlation still suggested
 March 3, 2016
Chest CT scan(plain and non ionic IV contrast) - solid
heterogeneously enhancing mass, anterior segment
of the left upper lobe, extending into the hilum as
described. Primary consideration is bronchogenic
carcinoma. Suggest histopathologic correlation.
Pneumonia, anteromedial and lateral segments of
the lower lobe. Moderate left sided pleural effusion.
Atherosclerotic aorta. Note of dilated left intrahepatic
ducts and common bile duct

Pleural fluid cytology- positive for malignant cells.

 Course in the ward:
Upon admission,
laboratory work ups were requested;
CBC, BUN, Crea, SGPT, SGOT, Alk phos,
Uric acid, Na, K, Ica, PT, PTT, BT, CXR,
bilateral shoulder Xray, 12 L ECG,
Urinalysis.
diclofenac 75mg iv q 12
omeprazole 40mg OD.
 On the first hospital day, patient is
conscious coherent, not in cardiorespiratory
distress.
(+) cough occasional
(+) shoulder pain
(+) loss of appetite
Patient was started with peroxicam 20mg
once a day SL prn for pain.
Patient was referred and subsequently seen
by a pulmonologist for co management.
 On the second hospital day,
patient is conscious, coherent, not in
cardiorespiratory distress.
(+) Thoracentesis
(+)550 cc of fluids.
repeat cxr was requested
 On the third hospital day, patient is
conscious, coherent, not in cardio
respiratory distress.
(+)CT scan with non ionic IV contrast
Therapeutic management was
started with cefipime 1g TIV q12 and
Fluimucil 600mg BID.
 On the fourth hospital day, patient
has no new subjective complaint.
Patient was referred and
subsequently seen by a TCVS with
the following considerations;
mediastinal mass thymoma VS
lymphoma, although bronchogenic
CA cant totally be ruled out. If mass
is thymoma then there is a role for
surgical resection.
 On the fifth hospital day, patient has
no new subjective complaint.
Patient was referred to oncologist but
the patient decided to HAMA and was
subsequently discharged.
Lung Cancer
 Lung cancers are generally divided into two
main categories:
small cell lung cancer(SCLC)
and nonsmall cell lung cancer (NSCLC).
NSCLC accounts for approximately 85% of all
lung cancers.
Histologically, NSCLC is divided further into
adenocarcinoma, squamous cell
carcinoma (SCC), and large cell
carcinoma.
 Lung cancer was a rare entity in the early
1900s but has since become far more
prevalent.
The prevalence of lung cancer is second only to
that ofprostate cancer in men and
breast cancerin women.
By the end of the 1900s, lung cancer had
become the leading cause of preventable death
in the United States, and recently, it surpassed
heart diseaseas the leading cause of smoking-
related mortality.
 Lung cancer is the leading cause of
cancer-related mortality in both men
and women not only in the United
States but also throughout the world.
In 2015, the disease is expected to
cause more than 158,000 deaths in
the United Statesmore than
colorectal, breast, and prostate
cancers combined.
 Most lung carcinomas are diagnosed at an
advanced stage, conferring a poor prognosis.
The need to diagnose lung cancer at an early
and potentially curable stage is thus obvious.
In addition, most patients who develop lung
cancer have been smokers and have
smoking-related damage to the heart and
lungs, making aggressive surgical or
multimodality therapies less viable options.
 Lung cancer is often insidious,
producing no symptoms until the
disease is well advanced.
In approximately 7-10% of cases,
lung cancers are diagnosed
incidentally in asymptomatic patients,
when a chest radiograph performed
for other reasons reveals the disease.
 Because of the importance of stage
on the therapeutic decision-making
process, all patients with NSCLC
must be staged adequately.
A complete staging workup for
NSCLC should be carried out to
evaluate the extent of disease.
 Treatment primarily involves surgery,
chemotherapy, or radiation therapy.
Because most lung cancers cannot
be cured with currently available
therapeutic modalities, the
appropriate application of skilled
palliative care is an important part of
the treatment of patients with
NSCLC.
Non-small Cell Lung Cancer
Non-small cell lung cancer (NSCLC)
accounts for approximately 85% of
all lung cancers. Histologically,
NSCLC is divided into
Adenocarcinoma
squamous cell carcinoma (SCC)
large cell carcinoma.
 Adenocarcinoma
Adenocarcinoma, arising from the bronchial
mucosal glands.
most common NSCLC cancer in the United
States, representing 35-40% of all lung cancers.
most commonly in persons who do not
smoke.
It usually occurs in a peripheral location within
the lung.
Bronchoalveolar carcinoma is a distinct subtype
of adenocarcinoma with a classic manifestation as
an interstitial lung disease on chest radiograph.
 Squamous cell carcinoma
SCC accounts for 25-30% of all lung cancers.
SCC is found in the central parts of the lung.
The classic manifestation is a cavitary lesion
in a proximal bronchus.
This type is characterized histologically by the
presence of keratin pearls and can be
detected with cytologic studies because it has
a tendency to exfoliate.
It is the type most often associated with
hypercalcemia.
Nonsmall cell lung cancer. A cavitating right lower lobe
squamous cell carcinoma.
 Large-cell carcinoma
Large-cell carcinoma accounts for 10-15%
of lung cancers
typically manifesting as a large
peripheral mass on chest radiograph.
Histologically, this type has sheets of
highly atypical cells with focal
necrosis, with no evidence of
keratinization (as is typical of SCC) or
gland formation (as is typical of
adenocarcinomas).
 Small cell lung cancer
(SCLC)
Small cell lung cancer (SCLC), previously known
as oat cell carcinoma
SCLC is an aggressive subtype of lung cancer.
Without treatment, in a few weeks it could be
fatal.
It is important to determine if the cancer is
limited or at an extensive stage.
Limited-stage cancer is treated with
chemotherapy and radiation.
Extensive-stage cancer is treated with
chemotherapy alone.
 SCLC is a neuroendocrine carcinoma
that exhibits aggressive behavior, rapid
growth, early spread to distant sites.
exquisite sensitivity to chemotherapy
and radiation, and frequent association
with distinctparaneoplastic syndromes
including hypercalcemia, Eaton-lambert
syndrome, syndrome of inappropriate
diuretic hormone, and many others.
 Etiology
Causes of lung cancer include the following:
Smoking (78% in men, 90% in women)
Asbestos exposure
Radon exposure
Halogen ether exposure
Chronic interstitial pneumonitis
Inorganic arsenic exposure
Radioisotope exposure, ionizing radiation
Atmospheric pollution
Chromium, nickel exposure
Vinyl chloride exposure
Signs and symptoms
Diagnostic procedures
 Routine Laboratory Studies
A complete blood cell count (CBC) with differential, serum
electrolyte levels, renal function studies, and liver function
tests (LFTs) are all part of the routine staging workup, and in
some cases,
these studies may reveal the sites of metastasis (eg, elevated
serum calcium and/or alkaline phosphatase [ALP] levels with
bone metastasis).
These tests are also important to assess organ function before
starting therapy.
Serum lactate dehydrogenase (LDH) and sodium levels also
provide prognostic information.
Increased uric acid levels and impaired renal function may
indicate the possibility of rapid tumor lysis syndrome with
therapy.
 Chest Radiography
A chest radiograph is usually the first test ordered in
patients in whom a lung malignancy is suggested.
Clues from the chest radiograph may suggest the diagnosis of
lung cancer, but may not be helpful in identifying a histologic
subtype.
If the tumor is clearly visible and measurable, chest
radiography can sometimes be used to monitor response to
therapy.
Chest radiographs may show the following:
Pulmonary nodule, mass, or infiltrate
Mediastinal widening
Atelectasis
Hilar enlargement
Pleural effusion
Nonsmall cell lung cancer. Bronchoscopy. A
large central lesion was diagnosed as nonsmall
cell carcinoma.
 Bronchoscopy and FNA
Small cell lung cancer (SCLC) is usually centrally
located and can be approached easily with a
bronchoscope.
The advantage of endoscopy is direct visualization
of the tumor, allowing for direct biopsy as well as
cytologic examination of bronchial washings.
For tumors that cannot be diagnosed with
transbronchial biopsy, transthoracic percutaneous
fine-needle aspiration (FNA) carried out under
computed tomography (CT) scan guidance is a
reasonable alternative.
 Sputum Cytology
Sputum cytology is a noninvasive test and, if
positive, can provide an accurate diagnosis of central
lung cancers.
Centrally located endobronchial tumors may exfoliate
malignant cells into sputum. (This location and
tendency to exfoliate are most common in squamous
cell carcinomas [SCCs].)
Therefore, sputum cytology can be a quick and
inexpensive diagnostic test if results are positive.
The false-positive rate for sputum cytology is 1%, but
the false-negative rate is as high as 40%.

 Although small cell lung cancer

(SCLC) usually presents as a large,
central tumor, tumor cells frequently
involve the submucosal layer of the
bronchus with little or no exophytic
endobronchial extension.
Therefore, sputum cytology is not as
useful for diagnosing SCLC as it is for
the diagnosis of squamous cell
carcinoma.
 Needle Thoracentesis
(Ultrasound Guided)
Needle thoracentesis is both diagnostic and
therapeutic in patients presenting with
respiratory distress.
Thoracentesis has a sensitivity of only 80%
with a specificity greater than 90%.
In patients suspected of having lung cancer
who have an accessible pleural effusion, if the
pleural fluid cytology finding is negative (after
at least 2 thoracenteses), thoracoscopy is
recommended as the next step to aid in
diagnosis.
 Computed Tomography
A chest CT scan is the standard for staging.
The findings of CT scans of the chest and clinical
presentation usually allow a presumptive
differentiation between NSCLC and small cell
lung cancer (SCLC).
Massive lymphadenopathy and direct
mediastinal invasion are commonly associated
with small cell carcinoma.
A mass in or adjacent to the hilum is a particular
characteristic of SCLC and is seen in about 78%
of cases.
Lung cancer, small cell. Contrast-enhanced CT scan of the chest
shows a large left lung and a hilar mass, with invasion of the left
 Magnetic Resonance Imaging
MRI is most useful when evaluating a
patient in whom spinal cord compression
is suggested.
In addition, brain MRI has a greater
sensitivity than CT scan for detection of
central nervous system (CNS) metastasis.
MRI may be used when findings of
superior sulcus and brachial plexus
tumors are equivocal on CT scans.
 Bone Scintigraphy
The skeletal system is common
site of metastases for lung
cancers.
If patients report bone pain or if their
serum calcium and/or alkaline
phosphatase levels are elevated, a
bone scan should be obtained to
search for bone metastases
Lung cancer, small cell. Whole-body nuclear medicine bone scanning
with anterior and posterior images reveal multiple abnormal areas of
increased radiotracer activity in the pelvis, spine, ribs, and left
scapula. These findings are consistent with bony metastatic disease.
The bones are commonly affected in patients with small-cell lung
 Positron Emission Tomography
PET scanning using fluoro-182-deoxyglucose (FDG) has
proven to be an excellent modality for evaluating solitary
pulmonary nodules and has been approved by the US
Food and Drug Administration (FDA) for this indication.
The average sensitivity and specificity of FDG-PET
scanning for detecting a malignancy was reported to be
0.97 and 0.78, respectively.
Studies also suggest that PET scanning is useful for
searching for systemic spread if other diagnostic
modalities cannot clarify an abnormality that may change
the treatment of the patients condition.
However, false-positive and false-negative results occur.
Lung cancer, small cell.
Coronal positron emission
tomogram shows
abnormal areas of
increased metabolic
activity in the left hilar
and left adrenal regions
consistent with a hilar
tumor with left adrenal
metastasis.
Thoracoscopy and Mediastinoscopy

Thoracoscopy is usually reserved for tumors that

remain undiagnosed after bronchoscopy or CT-
guided biopsy.
Thoracoscopy is also an important tool in the
management of malignant pleural effusions.
Mediastinoscopy may be used to obtain tissue
from cancer that has infiltrated into the
mediastinum.
It is usually performed to evaluate the status of
enlarged mediastinal lymph nodes (seen on CT
scan) before attempting definitive surgical resection
of lung cancer.
 Video-assisted thoracoscopy (VATS) is a newer modality
that may be used to sample small peripheral tumors
(less than 2 cm in diameter), pleural tumors, or pleural
effusions for diagnostic or staging purposes.It is safe
and can provide a definitive diagnosis with a high
degree of accuracy and minimal risk to the patient.
The reported sensitivity rate ranges between 0.80 and
0.99, the specificity rate ranges between 0.93 and 1,
and the negative predictive value ranges between 0.93
and 0.96.Survival with assisted VATS is comparable to
complete VATS and can be cost-effective.
 Histologic Findings
Small cell lung cancer (SCLC) is typically
centrally located, arising in peribronchial
locations.
These tumors are thought to develop from
neuroendocrine Kulchitsky cells and are
composed of sheets of small, round to
spindled cells with dark nuclei, scant
cytoplasm, and fine, granular (salt and
pepper) nuclear chromatin with
indistinct nucleoli.
High-power photomicrograph of small cell carcinoma on the left
side of the image with normal ciliated respiratory epithelium on
the right side of the image.
 TNM Classification for Non-Small Cell Lung Cancer
Primary tumor (T)
Primary tumor cannot be assessed, or the tumor is proven by the presence of malignant
TX
cells in sputum or bronchial washing but is not visualized by imaging or bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, no
bronchoscopic evidence of invasion more proximal than the lobar bronchus (not in the
T1
main bronchus); superficial spreading of tumor in the central airways (confined to the
bronchial wall )
T1a Tumor 2 cm in the greatest dimension
T1b Tumor > 2 cm but 3 cm in the greatest dimension
Tumor > 3 cm but 7 cm or tumor with any of the following:Invades visceral pleura
Involves the main bronchus 2 cm distal to the carina
T2
Associated with atelectasis/obstructive pneumonitis extending to hilar region but not
involving the entire lung
T2a Tumor > 3 cm but 5 cm in the greatest dimension
T2b Tumor > 5 cm but 7 cm in the greatest dimension
Tumor > 7 cm or one that directly invades any of the following:

Chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal
pleura, or parietal pericardium;
T3 Or tumor in the main bronchus < 2 cm distal to the carina but without involvement of the
carina

Or associated atelectasis/obstructive pneumonitis of the entire lung or separate tumor

nodule(s) in the same lobe
Tumor of any size that invades any of the following: mediastinum, heart, great vessels,
T4 trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; or separate
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional node metastasis

Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and

N1
intrapulmonary nodes, including involvement by direct extension

N2 Metastasis in the ipsilateral mediastinal and/or subcarinal lymph node(s)

Metastasis in the contralateral mediastinal, contralateral hilar, ipsilateral or

N3
contralateral scalene, or supraclavicular lymph nodes

Distant metastasis (M)

MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

Separate tumor nodule(s) in a contralateral lobe; tumor with pleural nodules or

M1a
malignant pleural (or pericardial) effusion

M1b Distant metastasis

Stage T N M
T1a N0 M0
Ia
T1b N0 M0
Ib T2a N0 M0
T1a N1 M0
T1b N1 M0
IIa
T2a N1 M0
T2b N0 M0
T2b N1 M0
IIb
T3 N0 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
IIIa
T3 N1 M0
T4 N0 M0
T4 N1 M0
T4 N2 M0
T1 N3 M0
IIIb T2 N3 M0
T3 N3 M0
T4 N3 M0
IV T Any N Any M1a or 1b
 TNM Classification for Small Cell Lung Cancer
Primary tumor (T)
Primary tumor cannot be assessed, or tumor is proven by the presence of malignant cells in
TX
sputum or bronchial washings but not visualized by imaging or bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, no bronchoscopic
T1 evidence of invasion, more proximal than the lobar bronchus (ie, not in the main bronchus);
or superficial spreading of tumor in the central airways (confined to the bronchial wall)
T1a Tumor 2 cm in greatest dimension
T1b Tumor > 2 cm but 3 cm in greatest dimension
Tumor with any of the following features of size or extent:Tumor > 3 cm but 7 cm
Invades visceral pleura (PL1 or PL2)
T2 Involves the main bronchus 2 cm distal to the carina
Associated with atelectasis/obstructive pneumonitis extending to hilar region but not
involving the entire lung
T2a Tumor > 3 cm but 5 cm in greatest dimension
T2b Tumor > 5 cm but 7 cm in greatest dimension
Tumor > 7 cm, or one that directly invades any of the following:
Chest wall (including superior sulcus tumors), parietal pleural (PL3), diaphragm, phrenic
nerve, mediastinal pleura, or parietal pericardium;
T3
Or, tumor in the main bronchus < 2 cm distal to the carina but without involvement of the
carina; or associated atelectasis/obstructive pneumonitis of the entire lung; or separate
tumor nodule(s) in the same lobe
Tumor of any size that invades any of the following: heart, mediastinum, great vessels,
T4 trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; or separate tumor
nodule(s) in a different ipsilateral lobe
Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis
Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph
N1 nodes and intrapulmonary nodes, including involvement by direct
extension

N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)

Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral

N3
or contralateral scalene, or supraclavicular lymph node(s)

Distant metastasis (M)

M0 No distant metastasis
M1 Distant metastasis
Separate tumor nodule(s) in a contralateral lobe tumor with pleural
M1a
nodules or malignant pleural (or pericardial) effusion
M1b Distant metastasis
Stage T N M
Limited disease
0 Tis N0 M0
T1a N0 M0
Ia
T1b N0 M0
Ib T2a N0 M0
T1a N1 M0
T1b N1 M0
IIa
T2a N1 M0
T2b N0 M0
T2b N1 M0
IIb
T3 N0 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
IIIa
T3 N2 M0
T4 N0 M0
T4 N1 M0
T4 N2 M0
T1 N3 M0
IIIb T2 N3 M0
T3 N3 M0
T4 N3 M0
Extensive disease IV T Any N Any M1a or 1b
Notes:Limited disease: Confined to the ipsilateral hemithorax, which can be safely encompassed within a
tolerable radiation field (T any, N any, M0; except T3-T4 due to multiple lung nodules that do not fit in a
tolerable radiation field)
Extensive disease: Beyond ipsilateral hemithorax, which may include malignant pleural or pericardial
effusion or hematogenous metastases (T any, N any, M1a/b; T3-T4 due to multiple lung nodules that do
not fit in a tolerable radiation field)
 Management
Treatment primarily involves
surgery, chemotherapy, or
radiation therapy.
Because most lung cancers cannot
be cured with currently available
therapeutic modalities, the
appropriate application of skilled
palliative care is an important part of
the treatment of patients with
NSCLC.
 Management
Surgery is the treatment of choice for
patients with nonsmall cell lung
cancer (NSCLC) stages I through IIIA.
In addition, patients with resected
lung cancer have a high risk of
relapse and are treated with adjuvant
chemotherapy.
 Patients with stage IIIB and IV NSCLC
are usually offered chemotherapy
with the option of surgery.
Radiation is a reasonable option for
treatment in patients who are not
candidates for surgery; the role of
adjuvant radiation therapy after
resection of the primary tumor
remains controversial.
Management
 Limited-Stage SCLC - Standard
Management
Standard management of patients with limited-
stage small cell lung cancer (SCLC) involves
combination chemotherapy and concurrent
thoracic radiotherapy.
Therefore, it is necessary to refer patients to a
radiation oncologist, as well as a medical
oncologist.
For combination chemotherapy, the American
College of Chest Physicians (ACCP)
recommends four cycles of a platinum
agent and etoposide
 Radiotherapy
Patients with limited-stage SCLC typically
receive concurrent chemotherapy and thoracic
radiotherapy, which should begin as early as
possible, preferably within 30 days of the
start of chemotherapy.
For patients who are eligible for early
concurrent chemoradiotherapy, the American
College of Chest Physicians (ACCP)
recommends concurrent accelerated
hyperfractionated radiotherapy (twice-daily
treatment) with platinum-based chemotherapy
Prophylactic cranial irradiation

The ACCP and the 2013 National

Comprehensive Cancer Network
(NCCN) guidelines recommend PCI in
patients with limited-stage disease
who have achieved a complete
remission or in those with stage I
disease who have undergone
resection.
 Arriagada et al performed a meta-analysis of
randomized trials of PCI in limited-stage SCLC
and showed a 5% overall survival
advantage in patients who received PCI.
Although such an analysis has inherent
limitations, PCI is currently offered to patients
with limited-stage SCLC who have achieved a
complete or partial response after having
completed initial chemoradiotherapy.
 Extensive-Stage SCLC - Standard
Management
Patients with extensive-stage small cell lung cancer (SCLC)
are treated with combination chemotherapy alone.
The administration of carboplatin or cisplatin plus
etoposide remains the standard of care in North America
for extensive SCLC.
The American College of Chest Physicians (ACCP), the
National Comprehensive Cancer Network (NCCN), and the
European Society for Medical Oncology (ESMO) guidelines
recommend that patients with extensive-stage
disease receive 4-6 cycles (but not >6 cycles) of
cisplatin- or carboplatin-based combination
chemotherapy (eg, cisplatin plus etoposide or irinotecan)
 Radiotherapy
In general, radiotherapy is used only to palliate
symptoms, if required (eg, for painful bone
metastases) in extensive-stage SCLC.
Response rates are excellent, but patients
invariably relapse.
The ACCP indicates that consolidative thoracic
radiotherapy to the chest is a treatment option
for patients who achieve a complete response
(CR) outside the chest and complete or partial
(PR) response in the chest.
Prophylactic cranial irradiation

As with limited-stage disease, offer

prophylactic cranial irradiation (PCI) to all
responding patients with extensive stage
SCLC; this treatment should be
considered standard therapy for this
stage of the disease in these patients.
Brain metastases at the time of initial
diagnosis in extensive SCLC are present in
about 18% of patients and increase to
about 80% at 2 years.
 Prognosis
Lung cancer is highly lethal. In Europe, the 5-year
overall survival rate is 11%.The highest recorded 5-
year patient survival rates are observed in the United
States. US data collected from 2004-2010 indicate
that the 5-year relative survival rate for lung cancer
was 16.8%, reflecting a steady but slow improvement
from 12.5% in 1975.However, the 5-year relative
survival rate varies markedly, depending on how
advanced the disease is at diagnosis, as follows:
49% for local disease
16% for regional disease
2% for distant stage disease
 Estimated 5-year survival rates for
specific stages of disease are as follows:
Stage IA - 75%
Stage IB - 55%
Stage IIA - 50%
Stage IIB - 40%
Stage IIIA - 10-35%
Stage IIIB - Less than 5%
Stage IV - Less than 5%