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RUNNING HEAD: Lung Cancer
LUNG CANCER
Small-Cell Carcinoma of the Lung
SAMANTHA CROWELL
GRAND VALLEY STATE UNIVERSITY
Lung Cancer 1
Presenting Signs & Symptoms of Patient
Chief Complaint
This patient is a 72 year old male with the diagnosis of limited stage small-cell lung
carcinoma. He had been doing various chores around the garage such as filling his tires with air
when his wife noticed he was more short of breath than usual. She asked him to get evaluated by
a physician. He underwent a chest x-ray on November 5, 2014 which showed opacity within the
left mid lung.
Medical History
The patient has quite a medical history. He has type 2 diabetes and hypertension. There
has also been a pattern of hyperlipidemia and kidney stones in his past. Both of his knees have
been replaced. He has had a bilateral cataract extraction. Also, he has had hernia repair and
lithotripsy. In late November of 2014, he had a bronchoscopy and mediastinoscopy to look at his
condition.
Family History
There is a significant history for the patient’s father with colon cancer. No other family
history known.
Social History
This patient is a retired engineer. He also used to be a volunteer fire fighter. He has about
a 15-pack-year history of smoking and tends to have about 4 to 5 beers per week.
Epidemiology
Lung cancer as a whole, not including skin cancer, is the second most common cancer
after breast cancer and prostate cancer, in both women and men. The American Cancer Society
estimates that for 2015 in the United States there will be about 221,200 new cases of lung cancer,
Lung Cancer 2
comprised of 115,610 men and 105,590 women. They also estimate that there will be 158,040
deaths from lung cancer. This number accounts for about 27% of all cancer deaths for 2015.
These estimations include both small cell and non-small cell lung cancers. Accounting for more
than a fourth of all cancer deaths, lung cancer is considerably the most common cause of death
due to cancer for both genders. The older population makes up the majority of lung cancer
patients. Roughly two-thirds of the patients diagnosed with lung cancer are 65 or older. Also,
less than 2% of all lung cancer patients are under the age of 45. This also puts the average age at
time of diagnosis at roughly 70 years of age. The American Cancer Society claims that the
chance of a man developing lung cancer within his life is around 1 in 13. For a woman they
estimate the risk to be near every 1 in 16. However, those statistics take account of both smokers
and non-smokers. The risk for smokers is much higher than that and the risk for non-smokers is
much lower than that. Race can also plays a role in cancer statistics. Black men are nearly 20%
more probable to get lung cancer than white men are. On the other hand, the percentage is about
10% lower in black women than it is in white women. Women in general, regardless of race,
have lower rates of lung cancer than men, but the break between them is tapering. This is
because the rates of lung cancer among men began to drop much sooner than the rates for
women. The majority of lung cancer statistics consist of both small cell and non-small cell lung
cancers. However, only about 10% to 15% of all lung cancers are small cell carcinoma. The
amount of SCLC cases that make up the quantity of all lung cancers has decreased from 17% to
13% in the past 30 years. In 2007, out of the 213,000 cases of lung cancer predicted to occur, an
estimation of about 27,000 of those cases were predicted to be a diagnosis of SCLC. (DeVita, V.,
Lawrence, T., & Rosenberg, S., 2008) Interestingly, black men are roughly 15% less likely to
Lung Cancer 3
develop small cell lung cancer than white men. The risk is also about 30% lower for black
women than it is for white women. (American Cancer Society)
Etiology
There are many risk factors that increase the chance of developing lung cancer. Some of
these many risk factors include tobacco smoke, radon exposure, asbestos exposure, previous
radiation therapy to the lungs, and having a personal or family history of lung cancer. By far the
biggest risk factor is smoking tobacco. The American Cancer Society estimated that at least 80%
of all lung cancer deaths are due to smoking tobacco. It has also been found that over 95% of
SCLC cases are due to tobacco exposure. The incidence rates of SCLC have been found to
reflect the patterns of smoking rates. (DeVita, V., Lawrence, T., & Rosenberg, S., 2008) Even
just breathing in the secondhand smoke of others can bring the risk of developing lung cancer up
by about 30% and is believed to cause more than 7,000 lung cancer deaths a year. (American
Cancer Society)
Exposure to radon is the second leading cause of lung cancer in the US. Radon is a
radioactive gas that develops organically from the degeneration of uranium soil and rocks. It
does not have a taste or a smell and cannot be seen. In certain geographic areas, there are higher
concentrations of radon in the soil. When people develop a basement or underground living area,
this radioactive gas can build-up and be inhaled. The risk of developing lung cancer from radon
in non-smokers is much lower than the risk of inhaling smoke. Yet, if radon is inhaled by a
smoker, their risk for cancer increases even more. Another risk factor for lung cancer is exposure
to asbestos. Exposure to asbestos is mostly found in people who worked in places where asbestos
can be found like mines, mills, textile plants, and shipyards. These workers have a much higher
risk for dying of lung cancer than people who have not been exposed. Again, if these workers are
Lung Cancer 4
smokers, than their risk even higher than it would be if you added the risks together separately.
The risk of developing mesothelioma, a type of cancer that starts in the lungs but is not usually
considered a type of lung cancer, is much greater after exposure to asbestos. Although asbestos
has been reduced in common areas, it has not been completely eliminated from working
environments. (American Cancer Society)
Comparison of Patient to the Typical
This patient seems to be very typical as a limited stage small cell lung cancer patient. He
is 72 years of age, which is right around the average age of a patient at time of diagnosis. He also
has a long history with smoking. This is the cause for more than 95% of SCLC cases which
makes him fit perfectly with this statistic. The patient is also a white male which is the most
common race and gender for this malignancy.
Patient Work-Up Information
Date Procedure Results
October – November
2014Chief Complaint Having shortness of breath when doing normal tasks
around the garage
November 5, 2014 Chest X-Ray Opacity found within the left mid lung
November 6, 2014
CT Scan of Abdomen and Pelvis Unremarkable
November 2014 MRI Scan of the Brain No metastatic disease found
November 2014 PET/CT Hilar and mediastinal abnormalities found within
the left upper lobe
November 26, 2014
Bronchoscopy and Mediastinoscopy
No palpable lymphadenopathy, left main and lower lobe appeared normal, left upper lobe bronchial
mucosa was inflamed and friable in apical segment, endoluminal tumor ingrowth biopsied—showed
Lung Cancer 5
small cell carcinoma
December 8, 2014
Began first cycle of chemotherapy with
cisplatin and etoposide
He had some hemoptysis after the bronchoscopy, however, felt well after chemo thus far
December 11, 2014
Examined by Radiation Oncologist
Decided on standard of care of Chemoradiation therapy, noted to start at the lastest by cycle 2 of his
chemotherapy on December 29, 2014
December 12, 2014
Simulation for Radiation Therapy N/A
Anatomy Discussion
The lungs are two organs which located on either side of the chest that are mainly
responsible for the exchange of oxygen and carbon dioxide of the air outside of the body and the
blood within. Lungs are divided into sponge-like, air-filled lobes. The right lung has three lobes
called the upper, middle, and lower lobe. However, the left lung only has two lobes, upper and
lower, due to the heart taking up more space on the left side. Air is inhaled through either the
nose or the mouth and brought to the trachea. The trachea, also called the windpipe, brings air
down to the chest where it splits off into two other pipes called the left and right primary
bronchi. The section where the bronchi split off of the trachea is called the carina. The primary
bronchi carry the air until they split off into smaller and even smaller branches called
bronchioles. These branches eventually become microscopic. Ultimately, these branches
conclude into clumps of air filled sacs called alveoli. This complex structure of the lungs is
displayed by Figure 1 in the graphics section below. (WebMD)
Another huge portion of the respiratory system is the involvement of blood circulation.
The pulmonary artery carries deoxygenated blood from the heart and brings it toward the lungs.
It then splits into two branches, one for each of the lungs, and then continues to divide into
smaller and smaller subdivisions. This branching is very similar to the branching of the bronchi.
Lung Cancer 6
The vessels eventually split into a fine web of super tiny tubes called capillaries. The tubes are
positioned as a web around the alveoli. These capillaries are so small that only one blood cell can
pass through at a time. As the blood cells pass through the capillaries, the exchange of gasses
between blood and air occurs with the neighboring alveoli. Alveoli absorb the inhaled oxygen
into the blood, and take the carbon dioxide from the blood into the exhaled air. After sending the
blood cells by the alveoli, the capillaries start to join together again. They branch together,
opposite of before, and eventually come together and form the pulmonary veins which bring the
oxygenated blood back to the heart in order to pump it through the rest of the body. This
branching of the veins, capillaries, and arteries can also be shown in Figure 1. (Lung Anatomy,
2014)
Regional Lymphatic Drainage
The lungs have quite a few paths for lymphatic drainage, all of which are above the
diaphragm. These include the intrathoracic, recurrent laryngeal, cervical, and supraclavicular
nodes. The intrathoracic nodes that are most relevant are broken into two categories the
mediastinal nodes and the intrapulmonary nodes. The mediastinal nodes include the paratracheal
nodes, pretracheal nodes, retrotracheal nodes, aortic nodes, subcarinal nodes, periesophageal
nodes, and inferior pulmonary ligament nodes. The intrapulmonary nodes include the hilar
nodes, peribronchial nodes, and intrapulmonary nodes. (Small Cell Lung Cancer, 2005) The
regional lymph nodes are shown in Figure 1, Figure 2, and Figure 3 in the graphics section
below.
Anatomy & Lymphatic Graphics
Lung Cancer 7
FIGURE 1.
Non-Small Cell Lung Cancer Treatment (PDQ®). (2014, June 30). Retrieved April 2, 2015, from
http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/Patient/page1
Lung Cancer 8
Lung Cancer 9
FIGURE 2.
Mediastinal Lymph Node Dissection. (2005). In T. Shields, J. LoCicero, R. Ponn, & V. Rusch
(Eds.), General thoracic surgery (6th ed., Vol. 2). Philadelphia, Pennsylvania: Lippincott
Williams & Wilkins. Retrieved April 9, 2015, from
http://flylib.com/books/en/3.98.1.112/1/
FIGURE 3.
Small Cell Lung Cancer. (2005). In T. Shields, J. LoCicero, R. Ponn, & V. Rusch (Eds.),
General thoracic surgery (6th ed., Vol. 2). Philadelphia, Pennsylvania: Lippincott
Williams & Wilkins. Retrieved April 9, 2015, from
http://flylib.com/books/en/3.98.1.136/1/
Lung Cancer 10
FIGURE 4.
Small Cell Lung Cancer. (2005). In T. Shields, J. LoCicero, R. Ponn, & V. Rusch (Eds.),
General thoracic surgery (6th ed., Vol. 2). Philadelphia, Pennsylvania: Lippincott
Williams & Wilkins. Retrieved April 9, 2015, from
http://flylib.com/books/en/3.98.1.136/1/
Pathology
Lung Cancer 11
In order to diagnose small cell lung cancer (SCLC), physicians usually collect small
specimens from either a core biopsy, bronchoscopic biopsy, or a fine needle biopsy. They then
are examine with a light microscopy and characterized by a pathologist. SCLC tumor cells
generally measure to a size less than the diameter of three petite lymphocytes. Their shape can be
round to fusiform and their cytoplasm is meagre. They have a nuclear chromatin that is finely
granular and their nucleoli are discreet or lacking. The typical mitotic rate of SCLC cells is very
high. They also are known for their extensive spreading even at the earliest stages of disease. The
presence of rush artifacts and streaming artifacts are commonly found when looking at SCLC
tumor cells. There are many more pathologies for non-small cell lung cancers (NSCLC). A few
for example are squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and carcinoid
tumors. In general, NSCLC types tend to be much less aggressive than SCLC types. This is one
of the reasons, they are categorized separately. They also look much different under the
microscope than the distinctive structure of a SCLC cell. (DeVita, V., Lawrence, T., &
Rosenberg, S., 2008)
Staging
As a standard way of classifying the degree of a patient’s cancer, the American Joint
Committee on Cancer (AJCC) created the TNM staging system. This staging system can be
applied to staging of small cell, non-small cell, and carcinoid tumors of the lung. Although, it is
used mainly for non-small cell cancers in clinical practice. TNM uses four key concepts which
include the T which refers to the location, size, how far it has spread within the skin and nearby
tissues; the N which describes how much the cancer has spread to nearby lymph nodes; the M
which indicates whether the cancer has metastasized. Each of these three categories have their
Lung Cancer 12
own staging guide. When all three of them are determined, they are combined in a process called
stage grouping to assign an overall stage for the tumor.
Since small-cell lung cancers are metastatic in about 80% of the cases by the time of
diagnosis, the TMN staging system is not the ideal system for physicians to use. Instead, most
clinical trials and clinical practices use a simpler two-stage system created by the Veterans’
Administration Lung Study Group (VALSG). In the VALSG staging system, a patient is
diagnosed as either having “limited stage” disease or “extensive stage” disease. “Limited stage is
defined as disease confined to one hemithorax that can be “encompassed” in a “tolerable”
radiation field” (DeVita, V., Lawrence, T., & Rosenberg, S., 2008). About one-thirds of SCLC
patients are considered to have limited stage disease. The other two-thirds of the SCLC patients
who do not fall into this category are considered to have extensive stage disease. The VALSG
system does correlate closely to the TNM staging system. The limited stage of SCLC is the same
as stages I through IIIB of the TNM system and the extensive stage is the same as stage IV. For
the use in tumor registries, the TNM system is used for small-cell lung cancers. (Compton, C,
2012)
The following tables were created to show the staging process and all of the different
components involved in it. All of the staging information in the following tables was taken from
the AJCC handbook.
Primary Tumor (T)
TNM Categories Description
TXPrimary tumor cannot be assessed, or tumor proven by the presence of
malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
Lung Cancer 13
T1Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral
pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)
T1a Tumor 2 cm or less in greatest dimension
T1b Tumor more than 2 cm but 3 cm or less in greatest dimension
T2
Tumor more than 3 cm but 7 cm or less or tumor with any of the following features (T2 tumors with these features are classified T2a if 5 cm or less);
Involves main bronchus, 2 cm or more distal to the carina; Invades visceral pleura (PL1 or PL2); Associated with atelectasis or obstructive pneumonitis
that extends to the hilar region but does not involve the entire lung
T2a Tumor more than 3 cm but 5 cm or less in greatest dimension
T2b Tumor more than 5 cm but 7 cm or less in greatest dimension
T3
Tumor more than 7 cm or one that directly invades any of the following: parietal pleural (PL3), chest wall (including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus (less than 2 cm distal to the carina *but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire
lung or separate tumor nodule(s) in the same lobe
T4Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina,
separate tumor nodule(s) in a different ipsilateral lobe
Regional Lymph Nodes (N)
TNM Categories Description
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
Distant Metastasis (M)
Lung Cancer 14
TNM Categories Description
M0 No distant metastasisM1 Distant metastasis
M1a Separate tumor nodule(s) in a contralateral lobe tumor with pleural nodules or malignant pleural (or pericardial) effusion
M1b Distant metastasis (in extrathoracic organs)
Anatomic Stage/Prognostic Groups
TNM Stages T N M
Occult carcinoma TX N0 M0
Stage 0 Tis N0 M0
Stage IAT1a N0 M0
T1b N0 M0
Stage IB T2a N0 M0
Stage IIA
T2b N0 M0
T1a N1 M0
T1b N1 M0
T2a N1 M0
Stage IIBT2b N1 M0
T3 N0 M0
Stage IIIA
T1a N2 M0
T1b N2 M0
T2a N2 M0
T2b N2 M0
T3 N1 M0
T3 N2 M0
T4 N0 M0
T4 N1 M0
Stage IIIB T1a N3 M0
Lung Cancer 15
T1b N3 M0
T2a N3 M0
T2b N3 M0
T3 N3 M0
T4 N2 M0
T4 N3 M0
Stage IVAny T Any N M1a
Any T Any N M1b
Compton, C. (2012). Lung. In AJCC Cancer Staging Atlas: A Companion to the Seventh
Editions of the AJCC Cancer Staging Manual and Handbook (2nd ed., pp. 311-328).
New York, NY: Springer. Retrieved April 2, 2015, from GVSU Online Library.
In addition to these two staging methods, there is another staging scale that is commonly
used to help with treatment planning. This scale is called the Karnofsky Performance Scale
(KPS) and is used to assess the patients’ performance status (PS). It gives the physicians a way to
assess self-described abilities at the time of a patient’s diagnosis. Doctors use this scale to get an
idea of what the quality of life is for their patient. It also helps to develop a plan for treatment
aggressiveness and treatment goals. However, in a study on the use of the Karnofsky
Performance Scale vs. the Physical Performance Test (PPT) to assess the PS of elderly cancer
patients, KPS was not found to be as accurate as the PPT. The KPS is based only on the doctor’s
clinical estimation of the patient and the PPT is based on physical capabilities of the patient
measured through direct observation. So, although KPS is a great representation of overall health
status for predicting mortality of the elderly, it is not the best way to interpret their overall health
status. (Terret, C., Albrand, G., Moncenix, G., & Droz, J., 2011)
Karnofsky Performance Status scale definitions rating (%) criteria
Lung Cancer 16
Value (%) Level of Functional Capacity
100 Normal, no complaints; no evidence of disease
90 Able to carry on normal activity; minor signs or symptoms of disease
80 Normal activity with effort; some signs or symptoms of disease
70 Cares for self; unable to carry on normal activity or to do active work
60 Requires occasional assistance, but is able to care for most of his personal needs
50 Requires considerable assistance and frequent medical care
40 Disabled; requires special care and assistance
30 Severely disabled; hospital admission is indicated although death not imminent
20 Very sick; hospital admission necessary; active supportive treatment necessary
10 Moribund; fatal processes progressing rapidly
0 Dead
Terret, C., Albrand, G., Moncenix, G., & Droz, J. (2011). Karnofsky Performance Scale (KPS)
or Physical Performance Test (PPT)? That is the question. Critical Reviews in
Oncology/Hematology, 77(2), 142-147. Retrieved April 10, 2015, from ScienceDirect.
Grading
Tumor grades are used to help us assess how abnormal a tumor’s cells and tissue appear
through a microscope compared to the normal. A prediction on how fast a tumor is going to
spread or grow can also be given when using a grading system. When a tumor’s construction of
tissue and cells are comparable to those of ordinary cells and issue, it is categorized as well-
differentiated. If a tumor is well-differentiated, it is believed to be less aggressive and to have a
slower growth rate than those that are categorized as undifferentiated. Tumors that are
considered to be undifferentiated or poorly differentiated have irregular shaped cells and can
have abnormal tissue arrangements. They also tend to mature early and spread quickly, much
Lung Cancer 17
quicker than well-differentiated tumors. In order to categorize how differentiated the patient’s
cancer is, a histopathological grading system is used. For small cell lung cancer, there isn’t a
specified grading system. The National Cancer Institute stated that when a grading system is not
specified, there is a general grading system to be used. The following table displays the
information given by the National Cancer Institute over the general grading system used.
(National Cancer Institute)
Histological Grade (G) Degree of Differentiation
GX Undetermined grade Grade cannot be assessed
G1 Low grade Well differentiated
G2 Intermediate grade Moderately differentiated
G3 High grade Poorly differentiated
G4 High grade Undifferentiated
Small Cell Lung Cancer Treatment. (n.d.). National Cancer Institute. Retrieved April 7, 2015,
from http://www.cancer.gov/cancertopics/pdq/treatment/small-cell-lung/Patient/page1
Patients Pathology, Stage & Grade
This patient had a bronchoscopy and a mediastinoscopy performed for diagnosis. The
biopsies found the patient to have small cell carcinoma of the lung at a limited stage. There was
no grade stated in the report or in the patient’s charts. In the pathologist report, they stated that
the cells taken from the left upper lobe of his lungs were quite small and had morphologic
features and distinct immunophenotypes. The nodes were found to be negative for metastatic
disease.
Radiation Therapy Treatment Plan & Rx for Patient
The patient was prescribed to a total of 6600 cGy to his Lung/Mediastinum region. This
was to be delivered in 33 fractions of 200 cGy each. His doctor wanted this patient to be treated
Lung Cancer 18
with a RapidArc technique to target his gross disease and mediastinum. He also wanted to the
patient to be simulated using 4-D equipment to track his breathing patterns.
Radiation Therapy Treatment Information & Patient Set-Up
Simulation for the patient took place on September 8, 2014. He was to lie head first on
the table in a supine position with a wingboard covered with a small vaclok to keep his upper
body in place. Under the vaclok was a size ‘B’ headrest and his hands were to be up on the pegs
to keep his arms out of the field. He also had a large knee sponge under his legs with his feet
banded to keep him still and in place. He used metronome track 1 to keep his breathing even.
There were three tattoos placed. One on his central reference point which is mid-sagittal on his
chest, and one on both of his sides lateral to his central reference point. For treatment he was to
be leveled with his tattoos and then brought right to his central reference point. His SSD needed
to be set to 82.8. This patient was prescribed to 6 different Arcs with image guidance. Images
were to be taken every day to accommodate to the changes in the patients positioning.
Radiation Therapy Treatment Type & Delivery
Field Name
Gantry Angle
Collimator Angle
Couch Angle
Planned SSD
Planned MU Energy Wedge
Factor Bolus
Arc 1 0 to 179 CW 30 0 82.8 cm 177 MU 6 MV 1.0 None
Arc 2 179 to 0 CCW 330 0 83.0 cm 131 MU 6 MV 1.0 None
Arc 1.1
0 to 179 CW 30 0 82.7 cm 180 MU 6 MV 1.0 None
Arc 2.1
179 to 0 CCW 330 0 83.4 cm 124 MU 6 MV 1.0 None
Arc 3 330 to 30 CW 90 270 85.3 cm 56 MU 6 MV 1.0 None
Arc 4 30 to 330
90 270 85.2 cm 32 MU 6 MV 1.0 None
Lung Cancer 19
CCW
Other Radiation Therapy Treatment Options
Stereotactic body radiotherapy (SBRT) is a treatment option available for patients who
are high risk for surgery or are medically inoperable. If a tumor is small enough and confined
with enough distance from critical structures, the delivery of larger ablative doses, anywhere
from 12-30 Gy per fraction, can be given in a single to a few fractions. SBRT delivers
remarkable primary tumor control along with toxicity being minimal. However, when working
with higher doses per fraction it is even more important to avoid critical structures, especially the
heart, spinal cord, and remaining healthy lung. Tolerance doses for each structure become much
smaller, meaning they cannot take as much radiation before they are at an increased risk of
irreversible late effects. Also, increasing the volume of treatment will decrease the limit of
maximum point dose to a structure, which also increases risks. The total dose given, the amount
of dose per fraction, and the volume of the treated area are all factors that can change the limits
of critical tissue as well as the outcome of treatment. This is the reason only patients with small
tumors in an ideal location can have SBRT as their treatment. It becomes a challenge to create a
plan that will not succeed the max point dose limit of the normal structures. The planning
process grows more complex containing several fields, involving multiple angles, and
calculating several dose points. Although more intricate, this plan is also much more precise.
(Hatton, M., & Martin, J., 2010)
In an article published in the Radiation Oncology Journal, the authors explain that that
are multiple reasons that SBRT is thought to be an ideal alternative to surgery. Due to the fact
the total dose is delivered in only a few treatments, the total treatment will be done within a week
or so. The treatments are outpatient and only last up to a half hour per treatment. This makes it
Lung Cancer 20
much easier for the patient to maintain a higher quality of life. Also, the use of sedation or
anesthesia is not needed due to it being a painless non-invasive procedure. (Ricardi, U.,
Badellino, S., & Filippi, A., 2015) The practice of SBRT has tightened the gap in survival rates
among operable and inoperable patients with early stage NSCLC. With improved control rates
and lowered toxicity to normal tissues and organs at risk, SBRT is now a standard when caring
for inoperable patients with early stage non-small cell lung cancer. (Kelley, K., et al., 2015)
Radiation Therapy Complications, Side Effects & Treatment
This patient had very few complications from radiation therapy. After 24 Gy in 12
fractions, he mentioned that his breathing had gotten easier and that the rattling in his chest was
gone. Once he reached 54 Gy in 27 fractions the patient began to have a little bit of catching
when he would swallow cold liquids, however, nothing too concerning. The patient had some
mild discomfort when swallowing and a little bit of a cough when he reached 64 Gy in 32
fractions. When the patient was finished with his treatment of 66 Gy in 33 fractions, he did not
have any other complaints or side effects to be noted.
Adjuvant Therapies, Complications, Side Effects & Treatment
For small-cell lung cancer, treatment options vary according to their cancer stage.
Patients with limited-stage SCLC can be treated with a combination of chemotherapy and
radiation therapy, they could have chemotherapy alone, they could have surgery followed by
chemotherapy, they could receive an endoscopic stent, and they could even have a preventative
treatment of radiation to the brain if they have a complete response to primary treatment.
Chemotherapy is used to stop the growth of the cancerous cells. It is a systemic treatment
making it a great option for cancers that have spread or are known to spread throughout the body.
When chemotherapy is used in combination with radiation therapy, the two treatments work
Lung Cancer 21
together to maximize the outcomes. In a study over tolerance and benefits of treatment in elderly
patients, the survival rate was significantly higher even though the toxicity rate was higher as
well. This is the favorable treatment combination. Surgery can be used for a few limited-stage
patients because their cancer is found in one confined spot. However, this cancer is known to
spread fast. Due to this, surgery is not commonly used. Also, it is dangerous to remove tumors
from this area because it can be in a risky spot. If the doctor has difficulty removing the tumor or
if the tumor has a lot of vascularity, the patient could bleed out. Although it isn’t the best option
for most patients, some SCLC patients might have surgery to remove at risk nodes or to resect
samples of the cancer tissue for pathology. For patients with blocked airways due to their SCLC,
they can have an endoscopic stent placed. This helps the doctors view the tissue directly and also
help them open up blockages. Patients who are diagnosed with extensive-stage SCLC tend to
have less options for treatment. Surgery is not an option because the cancer has already spread
into their system. They often have combination chemotherapy to slow the growth and to relieve
any symptoms they may be having. They can also have radiation to various parts of the body as a
palliative treatment for improving their quality of life. SCLC in its extensive stages usually
recurs. When this happens the treatment options are about the same as they are for the first time
around, chemotherapy to help control the disease and radiation therapy as palliative treatment.
(National Cancer Institute) Since recurrent SCLC can come back with resistance to their chemo
drugs, a new drug might have to be used second time around. There was a study done over target
chemotherapy for hypoxia in small cell cancers. Hypoxia is a micro-environmental pressure that
is present in and important to most solid tumors. It helps the tumor cells adapt to the environment
to survive and reproduce. The study had mixed results with the hypoxia targeted therapy,
however, it could be of use in the near future. (Bryant, J et al., 2014)
Lung Cancer 22
Other Therapies & Complications the Patient Received
This patient had a bronchoscopy and a mediastinoscopy to help the doctors with
diagnosis. This left the patient with a sore throat and some bleeding, but overall it did not have
many complications. He also had chemotherapy along with his radiation therapy. The doctors
prescribed him to cisplatin and etoposide. He did not have any significant side effects due to his
treatment. He actually had a pretty good reaction to it. The doctor mentioned that he plans on
potentially prescribing this patient with prophylactic cranial irradiation to assure no metastasize
to the brain. Although, he has not met with the patient for his 6 month follow-up yet to discuss it.
Critical Structures & Dose Tolerances
When treating patients with small cell lung cancer, there are three main critical structures
that need to be focused on which are the spinal cord, the heart, and the healthy lung. The reason
these three are primarily focused on is because they are frequently radiated beyond their
tolerance dose when treating SCLC with radiation therapy. Patients with SCLC are usually going
through chemotherapy alongside of radiation giving potential other reaction as well. For these
reasons, radiation to the spinal cord, the heart, and the healthy lung need to be constrained and
the Dosimetrist needs to create a plan that will not exceed their tolerance dose. If the spinal cord
is to exceed its tolerance dose it could result in infarction or necrosis. For the heart and the lung,
after exceeding their tolerance dose they could have pericarditis and pneumonitis. These are to
be avoided at all cost. Although, esophagus, bone marrow, skin, vessels, liver, and bones also
should be paid attention to.
Critical Structure TD 5/5 (cGy)
Spinal cord 5000
Normal lung 2000
Lung Cancer 23
Heart 4300
Esophagus 5000
Bone marrow 2500
Skin 5500
Liver 3500
Bone 6500
Washington, C., & Leaver, D. (2010). Respiratory System Tumors. In Principles and Practice of
Radiation Therapy (3rd ed., pp. 667-681). St. Louis, Mo.: Mosby Elsevier.
Routes of Spread
Small cell carcinoma of the lung has several different routes of spread. These different
types include through direct extension, through lymphatics, and through the circulatory system.
When the SCLC continues to grow and take over tissue, it can start to take over surrounding
structures as well. This is called direct extension or local extension. The sites that are at risk of
direct extension are the remaining healthy lung, ribs, heart, ribs, vertebral column, and
esophagus. The SCLC cells can break off of the cancerous tumor and travel through the
lymphatic system. If this happens the cells can become stuck within certain nodes until the
lymphatic fluid builds up and pushes the cancerous cells through to other nodes. This can also be
called regional extension. In other cases of lymphatic spread, the cancerous cells can spread
throughout a lymph node and enter the circulatory system supplying the node. If the disease gets
into the circulatory system it can travel all over. Nearly any part of the body can be a metastatic
site for this disease. The most commonly found sites of spread are the brain, liver, kidneys,
bones, pericardium, adrenal glands, subcutaneous tissues, and contralateral lung. (National
Cancer Institute)
Prognosis & Survival
Lung Cancer 24
The prognosis of patients with small cell carcinoma of the lung in general is not good.
However, it varies by patient. In a study analyzing the University of Toronto database survival
was found to be decent in patients with ‘very limited’ disease. This means that the disease was
confined only to the pulmonary parenchyma. Survival in that group of patients was found to be
50%-60%. They also found that with a combination of chemotherapy and radiation therapy the
‘very limited’ stage patients had a more favorable outcome of survival than the ‘limited’ stage
patients. Also, in this study the median survival was 16 months and the projected 5-year survival
was at about 18%. If the patient’s had mediastinal involvement their 5-year survival went down
to 6% and if they had supraclavicular lymphadenopathy, pleural effusion, pneumonic
consolidation, or atelectasis, their 5-year survival rate went down to 2%. There have been many
other trends found that can help with prognosis of SCLC patients. It has been found that patients
70 years of age and older have responded in the same way to having multiple modalities of
treatment as patients of a younger age and they also have comparable survival rates. Though, the
older patients were found to have a greater toxicity. There is also an association for older patients
with decreased performance status and more comorbid sicknesses. Due to this correlation, there
can be a negotiation of chemotherapy dose intensity. This could be a reason for its prognostic
associations. It is surprising that even though the majority of patients with small cell lung cancer
are over age 65, they comprise only 39% of individuals enrolled on lung cancer clinical trials. It
is very important that physicians are aware of this when attempting to use clinical trial data to
actual care of the growing population. (DeVita, V., Lawrence, T., & Rosenberg, S., 2008) In
another clinical trial, SCLC patient survival rates were found to have improved considerably
between the years of 1986 to 2008. These improvements on survival rate throughout the years
Lung Cancer 25
are likely due to advancements in technology for treatment and management. (Schabath, M. et
al., 2014).
The numbers below have been taken from the American Cancer Society website. They
are based on patients diagnosed with SCLC between 1988 and 2001. The relative survival rate is
a number representing the comparison of survival rates for people with SCLC to people without
SCLC. The stage of the patient at time of diagnosis is the stage used in these statistics.
(American Cancer Society)
Stage 5-Year Relative Survival Rate
(Limited-stage) I 31%
(Limited-stage) II 19%
(Limited-stage) III 8%
(Extensive-stage) IV 2%
Small cell lung cancer survival rates by stage. (2015, March 9). Retrieved April 8, 2015, from
http://www.cancer.org/cancer/lungcancer-smallcell/detailedguide/small-cell-lung-cancer-
survival-rates
Patient’s Prognosis & Survival
Although this patient’s small cell cancer is limited stage, I do not think that his prognosis
is good. In best case scenario his 5-year relative survival rate is 31%. This is still terrible. SCLC
is known to be aggressive and deadly. After discussing this patient with his radiation oncologist,
I think that the chances of his SCLC recurring are high. Once the cancer recurs, he will not have
very high chances of survival after that. He is a smoker and a white male. He also is old in age.
These are all pointing to recurrence. I believe that his chance of survival are at about 13%. I
think that he will not live longer than a couple years longer.
Lung Cancer 26
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