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Small Cell Lung Cancer


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Understanding and Treating Small Cell Lung Cancer

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Small Cell Lung Cancer

  1. 1. Small Cell Lung CancerRobert Miller
  2. 2. Types of Lung Cancer Non-small cell carcinoma (NSCC) (87%)◦ Adenocarcinoma (38%)◦ Squamous cell (20%)◦ Large cell (5%) Small cell carcinoma (13%)
  3. 3. Small cell lung cancer is virtually always causedby smoking and as smoking has decreased theincidence of this cancer has declinedPercent of Lung Cancers that were SmallCell:1978: 20-25%,1986: 17%,2002: 13%NCDB Data for 2000-2010 small cell was 15%
  4. 4. Since women havenot cut back on smoking as much as men,the frequency of small cell in women hasincreasedWomen accounted for 28% in 1973 and in
  5. 5. 0%5%10%15%20%25%30%35%40 50 60 70 8011%31%33%19%5%Age Distribution: NCDB 2000-2010for Small Cell Lung Cancer
  6. 6. Small Cell Lung Cancer• These are classified as a neuroendocrinecancer• These are fast growing cancers and only 1/3are still confined to the chest• Most patients are treated with chemotherapyand radiation but a small number (2- 5%)with early stage I may benefit from surgicalresection• 95% of small cell cancers start in the lungbut 5% arise from outside the lung (e.g.Nasopharynx, gastrointestinal orgenitourinary sites
  7. 7. Biopsy - confirm the cancer anddetermine the typeBronchoscopy CT directed biopsy
  8. 8. Pathology• Cancer cells should stain positive forkeratin, epithelial membrane antigen andTTF-1• Since they are neuroendocrine they shouldalso stain for: chromogranin A, neuronspecific enolase, NCAM and synaptophysin“special stains”
  9. 9. Lung Imaging LungImaging
  10. 10. Lymph Nodes and LungCancer
  11. 11. Lymph Nodes in the Lung
  12. 12. Reading a CT Scan
  13. 13. Cross Section Anatomy of theChest
  14. 14. Nodes on cross section
  15. 15. CT Small CellUsually large mass in the mediastinal lymph nodes andmay compress the superior vena cava
  16. 16. Stages of Lung Cancer Stage I – small spot no nodes Stage II – larger or nodes on theside of the lung (hilar or N1 nodes) Stage III – very large tumor orlymph nodes in the middles of thechest (mediastinum or N2 nodes) Stage IV – metastases to otherorgans
  17. 17. Stage from NCDB0102030405060Stage 1 Stage 2 Stage 3 Stage 4NSCLSCL
  18. 18. Stages for Small CellVeterans Affairs Lung Study Group defined limitedstage (LS disease) as that confined to the ipsilateralhemithorax which could be safely encompassed withina tolerable radiation field and extensive stage (ESdisease) as disease beyond the ipsilateralhemithorax, including malignant pleural or pericardialeffusion or hematogenous metastases.Patients with contralateral hilar or supraclavicularlymph nodes were excluded from some studies of LSdisease, even though modern RT techniques can allowfor high-dose RT to be delivered in selected cases.
  19. 19. Small Cell Stages• Limited Stage: confined tothe chest and regional nodes(1/3)• Extensive Stage: distantmetastases (2/3)
  20. 20. Small Cell Carcinoma of the Lung usuallypresents with a large central tumor (hilar/mediastinal lymphnode mass
  21. 21. Symptoms of Small Cell• Because of the large lymph node swelling inthe chest the patient may have shortness ofbreath, trouble swallowing, hoarseness, facialswelling (superior vena cava syndrome)• Many present with symptoms of spread ormetastases: headaches (brain met) bone pain(bone mets) or eating problems (liver mets)• Some present with neurologic or endocrineparaneoplastic syndrome (e.g. low sodium orelevated calcium)
  22. 22. PET scanshowing atypical small cellcancer with alargemediastinalmass making ithard to evensee the heart onthe left sideSmall Cell Lung Cancer
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  24. 24.
  25. 25. Treatment for Small CellLung CancerLimited Stage: consider surgeryresection for early stage followed bychemotherapy +/-radiation, otherwise most patientsget chemotherapy plus radiationExtensive Stage: unless very weakconsider chemotherapy +/- radiation
  26. 26. The role of surgery in the treatment of limiteddisease small cell lung cancer: time toreevaluate.J Thorac Oncol. 2008 Nov;3(11):1267-71.We identified 59 patients who underwentcomplete resection with nodal dissection forSCLC.overall survival at 1 year of 76%and 5 years 52%Only 2 to 5% are candidates for
  27. 27. Various chemotherapy schemes havebeen evaluated for SCLC;however, Cisplatin and Etoposide iswidely considered as the standard, withobserved response rates of 80–85%and approximately 25% of patientsobtaining a complete responseHowever, most patients experiencedisease relapse. Attempts to improvethe outcome using different or moredose-intensive chemotherapyregimens or maintenancechemotherapy have not led toimproved outcomes.
  28. 28. Chemotherapy forSmall Cell
  29. 29. Carboplatin- or Cisplatin-Based Chemotherapy inFirst-Line Treatment of Small-Cell Lung Cancer: TheCOCIS Meta-Analysis of Individual Patient DataJCO May 10, 2012 vol. 30 no.14 1692-1698
  30. 30. Radiation for Small Cell• Adding radiation to chemotherapywill lower the risk of lung relapse by25 to 30% and increase thesurvival by 5 to 7%• Radiation dose to the lung can betwice a day to 45Gy or daily to 60 –70 Gy
  31. 31. Twice-Daily Compared with Once-Daily ThoracicRadiotherapy in Limited Small-Cell Lung CancerTreated Concurrently with Cisplatin and EtoposideN Engl J Med 1999; 340:265-271total dose of thoracic radiotherapy was 45 Gy for each patient, 1.8 Gy dailyin 25 treatments over a period of five weeks or Accelerated twice-dailythoracic radiotherapy involved the administration of 1.5 Gy in 30 treatmentsover a period of three weeks.
  32. 32. • Low dose prophylactic cranial irradiation (PCI)reduced the risk of brain mets from 58% to 33% andincreased 2y survival from 15% to 21% and anotherstudy showed a decreased risk of brain mets from 49%down to 14% and improved 1 year survival from 13%up to 27%• Brain dose of 24 to 30Gy
  33. 33. Benefits of PCI (prophylactic cranialirradiation) of extensive stage small cellin lowering the risk of developing brainmetastases
  34. 34. Small cell cancer may shrink soquickly, it may be necessary to adjustthe radiation targetDaily CT imageson Tomo willallow for thephysician toadjust theradiation target ifthe cancerchanges in sizeor position
  35. 35. Typical CT Changes for SmallCell after Chemoradiation
  36. 36. PET-CT Changes for Small Cellafter Chemoradiation
  37. 37. Results with ChemoradiationStage Response Survival SurvivalLimitedStage70 – 90% 14 to 20months40%/2yExtensive60 – 70% 9 to 11months< 5%/2y
  38. 38. Stage 2 Year 5 YearI 41.1% 21.5%II 34.4% 17.2%III 23.4% 9.5%IV 5.9% 1.6%Observed Survival for Small Cell Lung CancerNCDB Data (cases diagnosed in 2003 – 2005)
  39. 39. 0%10%20%30%40%50%60%70%80%90%100%0 1 2 3 4 5Stage IStage IIStage IIIStage IVObserved Survival for Small Cell LungCancerNCDB Data (cases diagnosed in 2003 – 2005)
  40. 40. Small Cell Lung CancerRobert Miller