Small-Cell Lung Cancer: Importance of Fiberoptic Bronchoscopy in the Evaluation of Complete Remission

Small-Cell Lung Cancer: An Unusual Therapeutic Approach with More than 10-year Overall Survival. Case Report and Review of the Literature

Small-cell lung cancer is the most aggressive lung cancer, with a dismal prognosis. The authors present a case report of a patient with limited-stage small-cell lung cancer who underwent a thoracotomy for diagnostic purposes, with the diagnosis being made after surgical excision. Combination chemotherapy remains the cornerstone of treatment for both limited and extensive disease. Radiotherapy has been established as an adjunct to chemotherapy in limited-stage disease, while in extensive-stage disease it is mostly reserved for the treatment of brain metastases. As for surgery, the potential benefits of resection are predominantly seen in patients who present with a solitary pulmonary nodule. Since small-cell lung cancer becomes highly resistant to chemotherapy, second-line chemotherapeutic schemes are used for disease progression, with topotecan being the highlighted agent. Despite the unusual therapeutic approach, where surgery was preferred over the standard diagnostic and staging procedures, the patient's more than ten years’ survival makes this case presentation a very interesting one.

Small-cell lung cancer

Small-cell lung carcinoma is an aggressive form of lung cancer that is strongly associated with cigarette smoking and has a tendency for early dissemination. Increasing evidence has implicated autocrine growth loops, proto-oncogenes, and tumour-suppressor genes in its development. At presentation, the vast majority of patients are symptomatic, and imaging typically reveals a hilar mass. Pathology, in most cases of samples obtained by bronchoscopic biopsy, should be undertaken by pathologists with pulmonary expertise, with the provision of additional tissue for immunohistochemical stains as needed. Staging should aim to identify any evidence of distant disease, by imaging of the chest, upper abdomen, head, and bones as appropriate. Limited-stage disease should be treated with etoposide and cisplatin and concurrent early chest irradiation. All patients who achieve complete remission should be considered for treatment with prophylactic cranial irradiation, owing to the high frequency of brain metastases in this disease. Extensive-stage disease should be managed by combination chemotherapy, with a regimen such as etoposide and cisplatin administered for four to six cycles. Thereafter, patients with progressive or recurrent disease should be treated with additional chemotherapy. For patients who survive long term, careful monitoring for development of a second primary tumour is necessary, with further investigation and treatment as appropriate.

Management of small cell lung cancer

Small cell lung carcinoma typically presents as a central endobronchial lesion in chronic cigarette smokers with hilar enlargement and disseminated disease. The diagnostic pathology should be reviewed by a pathologist accomplished in reading pulmonary pathology, and, if any doubt exists in the diagnosis, additional special stains or diagnostic material should be obtained. Patients with extensive stage disease should be managed by combination chemotherapy, whereas patients with limited stage disease should be treated with etoposide/cisplatin plus concurrent chest irradiation. The chemotherapy should be administered for 4 to 6 months and then should be discontinued. Prophylactic cranial irradiation should be given to patients who achieve a complete remission. Patients should be retreated with chemotherapy if they develop a relapse of their small cell lung cancer. The patients who are followed in complete remission should be observed carefully for second cancers, and appropriate therapy should be administered if the cancer reappears.

Obstructive atelectasis in patients with small cell lung cancer. Incidence and response to treatment

STUDY OBJECTIVES

Define the incidence of obstructive atelectasis in patients presenting with small cell lung cancer and their response to treatment.

DESIGN

Retrospective review of clinical records and radiographic studies.

SETTING

Single federal government institution-the National Cancer Institute-Naval Medical Oncology Branch.

PATIENTS

One hundred seventy-two consecutive patients treated between 1983 and 1993.

INTERVENTIONS

Patients presenting with obstructive atelectasis were identified. The incidence of dyspnea, cough, and sputum production before starting treatment and 1, 3, and 6 months later was determined. Fiberoptic bronchoscopy and chest radiographs performed before starting treatment were compared with those obtained later in the patients' clinical course.

MEASUREMENTS AND RESULTS

Thirty-seven of 172 (22%) patients had obstructive atelectasis. Initial symptoms included cough in 25 (68%), dyspnea in 24 (65%), and productive cough in 10 (27%). The patients' symptoms of cough, dyspnea, and sputum production decreased to one third of the initial prevalence 1 month after the start of treatment. Fiberoptic bronchoscopy and chest radiographs performed 3 months after starting treatment demonstrated bronchial patency in 90%.

CONCLUSIONS

Obstructive atelectasis occurs in approximately one fifth of patients presenting with small cell lung cancer. Chemotherapy and chemotherapy plus chest radiotherapy lead to symptomatic, bronchoscopic, and radiographic resolution in similar proportions of patients with obstructive atelectasis.