GROUP 8
PARIK
RABASTO
PATEL, D
PATEL, J
RAGHUWANSHI
REGIS
MOLETA
MORENO
NAROMAL
CASE 8
CASE 8
HISTORY
A chain smoking 48 year old insurance company executive was referred to an
endocrinologist with complaints of increasing facial hair, a florid complexion, weight
gain, depression, and a productive cough. Levels of free cortisol in his urine were
very greatly increased. X-rays of his skull indicated that the pituitary fossa was of
normal size. However, a chest x-ray demonstrated a large mass in the right lung
and was send to Chest Clinic. Bronchoscopy revealed focal areas of thickening in
the right upper and middle lobe bronchi, and compression of the middle lobe
bronchus. Several biopsies were obtained and a specimen of bronchial washing was
sent for cytological examination. The tumor cells were relatively small, tightly
clustered and had inconspicuous nucleoli. Electron microscopic examination
revealed that some of the tumor cells contained a few small dense core granules in
the cytoplasm. Immunohistochemical stains indicated that the cells stained positive
for ACTH and calcitonin.
Bone scans and biopsies were obtained. The patient was treated with
combination chemotherapy. Within eight weeks, the large chest mass was no
longer evident on x-ray and his original symptoms had almost completely
disappeared. Urine cortisol levels returned to normal levels. However, after three
months he returned, complaining of severe headaches. A lumbar punchure was
performed and cells similar to those identified in the bronchial wash specimen
were present. Despite further chemotherapy, his condition progressively declined
and he died six weeks later. At autopsy multiple body sites were involved with
tumor. Microscopic examination of the metastases revealed tumor containing
multiple forms of differentiation including small cell, squamous cell and
adenocarcinoma elements.
HISTORY
• 48 years old, male, chain smoker, insurance company executive
• complaints of increasing facial hair, a florid complexion, weight gain,
depression, and a productive cough.
• Increased free cortisol in urine
• Pituitary fossa of normal size
• A large mass in the right lung
• Focal areas of thickening in the right upper and middle lobe bronchi, and
compression of the middle lobe bronchus
• Relatively small, tightly clustered tumor cells and had inconspicuous nucleoli.
• Few small dense core granules in the cytoplasm of some tumor cells
• Cells stained positive for ACTH and calcitonin
• Treated with combination chemotherapy
• Within eight weeks, his original symptoms had almost completely disappeared
• Returned after three months, complaining of severe headaches
• Cells similar to those identified in the bronchial wash specimen were present in
lumbar puncture
• Condition declined despite of chemotherapy
• died six weeks later
• Multiple body sites involved in tumor
• Microscopic examination of the metastases revealed tumor containing multiple
forms of differentiation including small cell, squamous cell and adenocarcinoma
elements
DIFFERENTIAL DIAGNOSIS
Dominique Savio C. Rabasto
SYMPTOMS SMALL CELL ATYPICAL LARGE CELL NSCLC
LUNG CA CARCINOID NEUROENDO
LUNG CRINE CA
TUMOR
Cough + + + +
Chest pain + + + +
Dyspnea + + + +
Hemoptysis + + +
Weight loss + Weight gain + +
Final Diagnosis
Patel Divyangkumar J
Small-cell Carcinoma
• Small-cell carcinoma is a type of highly malignant cancer that
most commonly arises within the lung, it can occasionally arise
in other body sites, such as the cervix, prostate, and
gastrointestinal tract.
• Small-cell carcinoma of the lung usually presents in the central
airways and infiltrates the submucosa leading to narrowing of
bronchial airways.
• Common symptoms include cough, dyspnea, weight loss, and
debility.
• Micrograph of Small-cell carcinoma of the lung
showing cells with nuclear moulding, minimal
amount if cytoplasm and stippled chromatin.
• Histopathologic image of small-cell carcinoma of
the lung. It is sometimes called “oat cell carcinoma”
due to the flat cell shape and scanty cytoplasm.
Pathophysiology
Patel
Jinil
• Small cell lung carcinoma(SCLC) arise in peribrochial
locations and infiltrates the bronchial submucosa.
• SCLC is divided into 2 subtypes: oat cell carcinoma and
combined [Link] SCLC is defined with non-
small cell components such as squamous cell or
adenocarcinoma.
• SCLC shows the strongest association with smoking.
• SCLC carcinogensis can occur by various pathways that
disrupts normal DNA repair mechanism.
• Common mutations in SCLC include loss of RB1 tumor
suppressor gene and TP53 mutations which decrease
the pro-apoptotic activity of cancer cells.
• Almost all SCLC tumors have a deletion in a section of
short arm of chromosome 3p which contains tumor
suppressor gene FHIT.
• Wildspread metastases occur early in the course of the
disease, with common spread to the mediastinal lymph
nodes, liver, bones, adrenal gland and brain.
DIAGNOSTIC MODALITIES
Raghuwanshi Anjali
• Imaging tests:
1. X-ray image of your lungs may reveal an abnormal mass or
nodule.
2. Multidetector CT (Computerized Tomography) scan: A CT scan
is often used as a follow-up to an X-ray, to provide more
detailed images of your lungs and surrounding organs.
3. MRI (Magnetic Resonance Imaging): The MRI allows physicians
to look for any invasion of a tumor into your chest wall,
diaphragm, or other areas.
4. Nuclear imaging: Bone scans or positron emission tomography
(PET) scans may be used to determine the presence of disease
in the bones or elsewhere.
• Sputum cytology: If you have a cough and are producing
sputum, looking at the sputum under the microscope can
sometimes reveal the presence of lung cancer cells.
• Tissue sample (biopsy): biopsy is the only way to confirm the
presence of cancer and identify its type and stage. A sample of
abnormal cells may be removed in a procedure called a biopsy.
• Bronchoscopy:This procedure involves the use of a flexible
tube-like instrument called a bronchoscope to look at the
airways into the lungs and to collect tissue samples.
• Endoscopic Bronchial Ultrasound (EBUS):A
bronchoscope with ultrasound is used to more accurately
find and biopsy cancer in the smaller airways and lymph
nodes. It allows these areas to be seen and biopsied more
accurately.
• Thoracoscopy: This surgical procedure is done using
general anesthesia. An instrument called a thoracoscope is
inserted through a small incision in the chest wall to allow
the doctor to check the lining of the chest wall and the
surface of the lungs for tumors.
TREATMENT
Regis, Reina
DEPENDS ON:
• Location of cancer
• Stage of cancer (how far it has grown or spread)
• The patient's general health and level of fitness
6 TYPES OF STANDARD TREATMENT
• Surgery
• Chemotherapy
• Radiation therapy
• Immunotherapy
• Laser therapy
• Endoscopic stent placement
TREATMENT OPTIONS BY STAGE
Extensive Stage Small Cell Lung
Limited Stage Small Cell Lung Cancer
Cancer
• Combination chemotherapy and
radiation therapy to the chest
• Combination therapy
• Combination therapy alone for
patients who cannot be given • Radiation therapy to the brain,
radiation therapy spine, bone, or to other parts of
the body where cancer has spread
• Surgery followed by chemotherapy
• Radiation therapy to the chest
• Surgery followed by chemotherapy
and radiation therapy • Radiation therapy to the brain
• Radiation therapy to the brain • Clinical trials of new treatments
with chemotherapy or
• Clinical trials of new immunotherapy with immune
chemotherapy, surgery, and checkpoint inhibitors
radiation treatments
Recurrent Small Cell Lung Cancer
• Chemotherapy
• Immunotherapy with immune checkpoint inhibitors
• Radiation therapy (palliative therapy to relieve symptoms and improve life
quality)
• Laser therapy, stand placement (keep airway open) and internal radiation
therapy
• Clinical trials of new chemotherapy treatments
LONG TERM MONITORING
• Require close monitoring for adverse effects and response to therapy
• Blood work (CBC) with differential
• needed BEFORE each cycle of chemotherapy to ensure marrow recovery before
next dose of chemotherapy is done
• Renal function
• For nephrotoxicity from cisplatin
• LDH
• if elevated before start = good marker of
response
• CT scan
• should be obtained after 2 cycles of therapy;
asses response before chemotherapy is
continued
• Patients who smoke should be encouraged to quit
PROGNOSIS
POOR
Small-cell carcinoma is very responsive
to chemotherapy and radiotherapy, and in particular,
regimens based on platinum-containing agents.
However, most people with the disease relapse, and
median survival remains low.
The overall five-year survival rate for people with
small-cell lung cancer is less than 20%. People with
small cell lung cancer have the highest rate of
developing a second primary cancer.
JOURNAL
Small Cell Lung CA
CONFIRMED: OS BETTER WITH IMMUNOTHERAPY IN
SMALL CELL LUNG CANCER
PAM HARRISON
SEPTEMBER 13, 2019
• BARCELONA, Spain — A second phase III trial supports an overall
survival (OS) benefit from adding a programmed cell death ligand
(PD-L1) inhibitor to standard chemotherapy compared with
standard chemotherapy alone for patients with extensive stage,
small cell lung cancer (ES-SCLC), the CASPIAN study indicates .
• Last year, investigators from the IMpower133 trial showed for
the first time that atezolizumab (Tecentriq, Genentech), another
PD-L1 inhibitor, improved OS in patients with ES-SCLC,
prolonging life by 30% compared with standard chemotherapy
alone, the first advance in the treatment of this disease in many
decades. The presentation took place at the IASLC 2018 World
Conference on Lung Cancer.
• At 12 months following study enrollment, 53.7% of patients in
the additional PD-L1 group were still alive compared with 39.8%
of those in the EP alone group; at 18 months, 33.9% of patients
in the additional durvalumab group were still alive compared
with 24.7% of patients in the EP group, for a hazard ratio (HR) of
0.73, Paz-Ares noted.
APATINIB IN PATIENTS WITH EXTENSIVE-STAGE
SMALL-CELL LUNG CANCER AFTER SECOND-LINE OR
THIRD-LINE CHEMOTHERAPY
YANJUN XU
Published: 16 September 2019
• Background
• Small-cell lung cancer (SCLC) remains an aggressive cancer with
short-term survival due to limited therapeutic options. Apatinib
is a small-molecule tyrosine kinase inhibitor that selectively
inhibits vascular endothelial growth factor receptor-2. This study
aimed to investigate the efficacy and safety of apatinib in
patients with extensive-stage (EC) SCLC who had progressed
after two or three previous therapies.
• Methods
• Eligible patients were histologically confirmed ES-SCLC after two
or three previous treatments, including a platinum-based
regimen. Patients received apatinib at an initial dose of 500 mg
once daily. The primary endpoint was the objective response
rate.
• Results
• Forty patients were enrolled. At the data cut-off time (November
15, 2018), the median follow-up was 7.4 months; no patients
remained on treatment, and five were still in follow-up. An
objective response was achieved in 7 of 40 patients (17.5%) in
the intention-to-treat population, and 7 of 38 patients (18.4%) in
the per-protocol population. The median progression-free
survival and overall survival were 3.0 months and 5·8 months,
respectively. The most commonly observed grade 3 or greater
treatment-related adverse events were hypertension, hand–foot
syndrome, increased L-gamma-glutamyltransferase.
• Conclusions
• Apatinib exhibited efficacy and an acceptable safety profile in
previously heavily-treated ES-SCLC patients. Further exploration
of apatinib in phase III trials is warranted.
