1. Atienza-Arellano to Benavidez

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

3. 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

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

5. Physical Examination  General Appearance  fairly nourished  fairly developed with normal vital signs  no abnormal physical exam findings in the rest of the systems

6. 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

7. Diagnostics  Abdominal CT scan  normal liver and adrenal glands  Whole body bone scan  (-) metastasis  Brain CT scan  (-) mass lesions

8. 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?

9. Clinical Staging  The clinical staging of Small Cell Lung Cancers (SCLC) is based on localization and extent of involvement of regional lymph nodes.

10. 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

11. 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

12. 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

13. 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

14. 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

15. Question # 2: Present a plan of management for this patient.

16. Management Sequence CounselingStaging Intervention Options Follow-Up Chemo therapy SurgeryProphylactic Cranial Irradiation Chemoradio therapy Radio therapy Palliative and Supportive Care

17. 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.

18. 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.

19. Intervention Options  Chemotherapy  Radiation therapy  Chemoradiotherapy  Prophylactic cranial irradiation  Surgery

20. 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

21. 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.

22. 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.

23. 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

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

25. 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

26. 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

27. 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.

28. 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?

29. 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.

30. 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.

31. 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

32. 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

33. 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.

34. 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.

35. Management: SCLC vs NSCLC SCLCNSCLC Cisplatin/Carboplatin Doxorubicin (Adriamycin)VP16 (Etoposide) Taxanes CyclophosphamideGemcitabine VincristineIfosfamide TaxanesGefitinib TopotecanEriotinib Bevacizumab

36. Question # 4: How would you explain the prognosis of this case to the patient and his family

37. 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)

38. 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 UntreatedWith Chemo Long-Term (>3 years) Limited-stage12 weeks18 months30-40% Extensive-stageMedian survival: 9 months<5% survive 2 years

39. 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…

40. 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

41. 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