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Small Cell Carcinoma of the Lung

Small Cell Lung Cancer

Small cell carcinoma of the lung is one of the less common types of lung cancer, characterized by aggressiveness, frequent relapses to chemotherapy, and a poor overall survival, particularly when diagnosed in advanced stages. The clinical presentation encompasses cough, hemoptysis, chest pain, and systemic signs of weight loss and fatigue in patients who reached the later stages of the disease. The diagnosis is made through a detailed clinical assessment, imaging studies, and a histopathological examination via bronchoscopy or transthoracic needle aspiration.


Presentation

Small cell carcinoma of the lung (SCLC) comprises approximately 15% of all lung cancer patients and is recognized as a very aggressive form of malignancy [1] [2]. The clinical presentation of patients with lung cancer is centered around respiratory symptoms, but depending on the stage, various systemic signs are observed [1] [3] [4]. Although the diagnosis might be made incidentally, the vast majority of patients experience some symptoms when the disease is recognized [1] [3]. Studies have established a different frequency of symptoms depending on the location of tumor growth [3] [4]. Cough is the most common symptom when the tumor is localized in the bronchi, as are hemoptysis and dyspnea [3] [4]. Stridor and wheezing are less frequent in the initial stages [3] [4]. When intrathoracic spread has occurred, chest pain develops in up to 49% of patients and is often accompanied by pleural/pericardial effusions, dysphagia, Horner's syndrome (ptosis, miosis, anhidrosis), and hoarseness [3] [4]. In the most advanced stages where metastatic spread is evident, systemic findings of weight loss, fever, night sweats, and fatigue are reported, together with headaches, paraplegia, and bone pain [3] [4]. Several paraneoplastic syndromes are well-known to occur in small cell carcinoma of the lung and other types of lung cancer, including Lambert-Eaton myasthenic syndrome (LEMS), syndrome of inappropriate antidiuretic hormone secretion (SIADH), etc [3] [4]. Small cell lung carcinoma is strongly linked with cigarette smoking [1].

Weight Loss
  • A 67-year-old female presenting with a history of weight loss and abdominal distension was noted on examination to have ascites.[ncbi.nlm.nih.gov]
  • The clinical presentation encompasses cough, hemoptysis, chest pain, and systemic signs of weight loss and fatigue in patients who reached the later stages of the disease.[symptoma.com]
  • Generally a patient with small-cell lung cancer notices fatigue, weakness, and weight loss. These lung cancers are notorious for causing paraneoplastic syndromes.[lung-cancer.com]
  • loss Anxiety Pain iStock Smoking greatly increases a person's risk The earlier you begin smoking and the longer you smoke, the greater your risk of developing lung cancer.[healthcentral.com]
  • As the cancer progresses, common symptoms may include: • Persistent or worsening cough; • Frequent lung infections; • Unintentional weight loss.[secure.ssa.gov]
Fatigue
  • The clinical presentation encompasses cough, hemoptysis, chest pain, and systemic signs of weight loss and fatigue in patients who reached the later stages of the disease.[symptoma.com]
  • Generally a patient with small-cell lung cancer notices fatigue, weakness, and weight loss. These lung cancers are notorious for causing paraneoplastic syndromes.[lung-cancer.com]
  • […] coughing up blood or rust-colored sputum. iStock Quality-of-life issues In general, some of the more common problems encountered by cancer patients either as a result of the disease itself or as a side-effect of cancer treatments include: Sleep disorders Fatigue[healthcentral.com]
  • They say the most common side effects grade 3 or higher were fatigue and shortness of breath. Commenting on the findings, the researchers say: " Our results show that thoracic radiotherapy improves long-term survival.[medicalnewstoday.com]
  • These side effects include difficulty swallowing and eating, fatigue, lowering of the blood counts (which can lead to infections and/or bleeding), skin redness, cough, pneumonia, and decreased lung function from scarring of the lungs.[oncolink.org]
Fever
  • Case of a 33-year-old female with AIDS who presented with fevers, chills, lower back pain and a large right hilar mass. Biopsy of the right paratracheal nodes revealed poorly differentiated non-small cell carcinoma with extensive necrosis.[ncbi.nlm.nih.gov]
  • In the most advanced stages where metastatic spread is evident, systemic findings of weight loss, fever, night sweats, and fatigue are reported, together with headaches, paraplegia, and bone pain.[symptoma.com]
  • Clinical presentation can significantly vary and can present in the following ways: constitutional fever weight loss malaise primary tumor cough hemoptysis dyspnea local invasion dysphagia ( esophageal compression ) hoarseness ( recurrent laryngeal nerve[radiopaedia.org]
  • Toxicity was as follows: grade III neutropenic fever in 4 patients (13%), grade IV neutropenia in 13 patients (42%), pneumonia in 6 patients (19%), grade III esophagitis in 4 patients (13%) and severe clinical pneumonitis in 1 patient (3%).[ncbi.nlm.nih.gov]
Malaise
  • Clinical presentation can significantly vary and can present in the following ways: constitutional fever weight loss malaise primary tumor cough hemoptysis dyspnea local invasion dysphagia ( esophageal compression ) hoarseness ( recurrent laryngeal nerve[radiopaedia.org]
  • Charbit A, Malaise EP, Tubiana M (1971) Relation between the pathological nature and the growth rate of human tumors. Eur J Cancer 7: 307 Google Scholar 8.[link.springer.com]
Cough
  • The clinical presentation encompasses cough, hemoptysis, chest pain, and systemic signs of weight loss and fatigue in patients who reached the later stages of the disease.[symptoma.com]
  • The most common symptoms were dyspnea and cough. Histopathologically tumor positive margins were found in 84.8% (A), 10.6% (B), 4.5% (C), and 0% (D).[ncbi.nlm.nih.gov]
  • Source: Medifocus Guidebook iStock The three most common symptoms There are numerous symptoms of lung cancer, but the most common ones are persistent or worsening cough, shortness of breath (dyspnea), and coughing up blood or rust-colored sputum. iStock[healthcentral.com]
  • Palliative care Lung symptoms commonly reported by patients with incurable lung cancer include shortness of breath from pleural effusion , coughing , or haemoptysis (coughing up blood).[myvmc.com]
  • Persistent and intense coughing or coughing blood Pain in chest, shoulder or back Change in color and amount of sputum Shortness of breath Change in voice Weight loss Fatigue Stomach or bone pain Central nervous system (CNS) changes (i.e. one-sided weakness[cancersupportcommunity.org]
Hoarseness
  • When intrathoracic spread has occurred, chest pain develops in up to 49% of patients and is often accompanied by pleural/pericardial effusions, dysphagia, Horner's syndrome (ptosis, miosis, anhidrosis), and hoarseness.[symptoma.com]
  • Clinical presentation can significantly vary and can present in the following ways: constitutional fever weight loss malaise primary tumor cough hemoptysis dyspnea local invasion dysphagia ( esophageal compression ) hoarseness ( recurrent laryngeal nerve[radiopaedia.org]
  • The most common signs and symptoms that may occur with NSCLC and SCLC include cough , shortness of breath , wheezing , fatigue , chest pain , weight loss and loss of appetite , recurring lung infections, hoarseness , coughing up blood , and swelling of[medicinenet.com]
  • Clinical features Hoarseness and vocal cord palsy are more common, stridor and haemoptysis less common, than for squamous cell carcinoma. Clinical symptoms are often attributable to distant metastases. Paraneoplastic effects are common.[e-immunohistochemistry.info]
Hemoptysis
  • The clinical presentation encompasses cough, hemoptysis, chest pain, and systemic signs of weight loss and fatigue in patients who reached the later stages of the disease.[symptoma.com]
  • The diagnosis of small cell carcinoma was based on repeated hemoptysis and cytologic finding of a rapidly growing mass over the forehead.[ncbi.nlm.nih.gov]
  • Precursor lesion - uncommonly seen: Pulmonary neuroendocrine cell hyperplasia. [1] Clinical: /-Hemoptysis. Gross Central location (close to large airways) - typical. Necrosis . Images Small cell carcinoma of the lung - centre of image.[librepathology.org]
  • Clinical presentation can significantly vary and can present in the following ways: constitutional fever weight loss malaise primary tumor cough hemoptysis dyspnea local invasion dysphagia ( esophageal compression ) hoarseness ( recurrent laryngeal nerve[radiopaedia.org]
Pleural Effusion
  • Thoracic washings may provide evidence of cancer beyond the pleura in patients without pleural effusion which may be indicative of advanced disease.[ncbi.nlm.nih.gov]
  • Surprisingly, a chest radiograph revealed a mass in his left lung with ipsilateral pleural effusion.[ncbi.nlm.nih.gov]
  • Palliative care Lung symptoms commonly reported by patients with incurable lung cancer include shortness of breath from pleural effusion , coughing , or haemoptysis (coughing up blood).[myvmc.com]
  • The evidence on the effectiveness of management for malignant pleural effusion: a systematic review, Eur J Cardiothorac Surg, 2006 , vol. 29 (pg. 829 - 838 ) 34. Resection of brain metastases from non-small-cell lung carcinoma.[annonc.oxfordjournals.org]
  • effusion Chest pain Dyspnea Benign pleural effusion may be due to lymphatic obstruction, post-obstructive pneumonitis, or atelectasis Malignant pleural effusion occurs when malignant cells are present in pleural fluid Dysphagia Enlargement of the subcarinal[pathophys.org]
Dysphagia
  • When intrathoracic spread has occurred, chest pain develops in up to 49% of patients and is often accompanied by pleural/pericardial effusions, dysphagia, Horner's syndrome (ptosis, miosis, anhidrosis), and hoarseness.[symptoma.com]
  • Clinical presentation can significantly vary and can present in the following ways: constitutional fever weight loss malaise primary tumor cough hemoptysis dyspnea local invasion dysphagia ( esophageal compression ) hoarseness ( recurrent laryngeal nerve[radiopaedia.org]
  • CASE REPORT A 64-year-old male individual came to our service complaining of dysphagia and odynophagia evolving for six months and a lesion in his left oropharynx.[scielo.br]
  • Oncologic emergencies chapter Pleural effusion Chest pain Dyspnea Benign pleural effusion may be due to lymphatic obstruction, post-obstructive pneumonitis, or atelectasis Malignant pleural effusion occurs when malignant cells are present in pleural fluid Dysphagia[pathophys.org]
Lower Abdominal Pain
  • Acute appendicitis due to metastasis from a distant neoplasm should be considered in the differential diagnosis of right lower abdominal pain in the oncology patient.[ncbi.nlm.nih.gov]
Ocular Flutter
  • However, emotional and behavioral disturbances relapsed and remitted associated with exacerbation of truncal ataxia and ocular flutter, which responded favorably to prednisolone.[ncbi.nlm.nih.gov]
Dysarthria
  • A 59-year-old woman presented with acute-onset, bilateral, painless loss of vision, dysarthria, and ataxia. Ophthalmoscopy showed bilateral optic disc edema. A magnetic resonance scan of the head was normal.[ncbi.nlm.nih.gov]

Workup

Even if the diagnosis of small cell carcinoma of the lung is made early on, it carries a very poor prognosis [1] [5]. Nevertheless, an early diagnosis will undoubtedly prolong the patient's life and provide an opportunity for more efficient treatment. The first step in the diagnostic workup is a thorough patient history that will cover the onset of symptoms and their progression, followed by auscultation of the lungs and a detailed physical examination. If evident suspicion is raised, imaging studies must be used. Although plain radiography might be useful as a first-line study, computed tomography is recommended [3]. In addition to the lungs, the head, the abdomen, and the extremities should be assessed in order to determine the stage of the tumor [1] [3]. To confirm the diagnosis of a small cell carcinoma of the lung, a sample is needed for histopathological examination [1] [3] [4] [6]. Bronchoscopy and transthoracic needle aspiration (TTNA, which may be guided by ultrasound or CT if necessary) are the two procedures that can obtain a viable sample for testing and subsequent determination of the exact tumor type [3] [4] [6]. TTNA, however, is more prone to inducing pneumothorax compared to standard bronchoscopy [6].

Atelectasis
  • TNM classification TX Positive cytology only T1 3 cm T1a 2 cm T1b 2–3 cm T2 Main bronchus 2 cm from carina, invades visceral pleura, partial atelectasis T2a 3–5 cm T2b 5–7 cm T3 7 cm; chest wall, diaphragm, pericardium, mediastinal pleura, main bronchus[annonc.oxfordjournals.org]
  • Central tumours generally produce symptoms of cough, dyspnea, atelectasis, postobstructive pneumonia, wheezing, and hemoptysis; whereas, peripheral tumours , in addition to causing cough and dyspnea, can lead to pleural effusion and severe pain as a result[pathophys.org]
Pulmonary Infiltrate
  • The patient described herein presented with constitutional symptoms and nodular pulmonary infiltrates associated with noncaseating granulomas without evident neoplasm in both transbronchial and open lung biopsy specimens.[ncbi.nlm.nih.gov]
Hyponatremia
  • On further evaluation, they were found to have hyponatremia secondary to the syndrome of inappropriate secretion of antidiuretic hormone.[ncbi.nlm.nih.gov]
  • […] in Nephrology for details Ectopic secretion of ADH retain free water in collecting ducts Euvolemic hyponatremia and concentrated urine Mild symptoms include headache and weakness, severe symptoms include altered mental status, seizures, respiratory depression[pathophys.org]
Hyperprolactinemia
  • We describe a woman with metastatic small cell carcinoma of the lung who presented with pituitary apoplexy and hyperprolactinemia.[ncbi.nlm.nih.gov]
Pleural Effusion
  • Thoracic washings may provide evidence of cancer beyond the pleura in patients without pleural effusion which may be indicative of advanced disease.[ncbi.nlm.nih.gov]
  • Surprisingly, a chest radiograph revealed a mass in his left lung with ipsilateral pleural effusion.[ncbi.nlm.nih.gov]
  • Palliative care Lung symptoms commonly reported by patients with incurable lung cancer include shortness of breath from pleural effusion , coughing , or haemoptysis (coughing up blood).[myvmc.com]
  • The evidence on the effectiveness of management for malignant pleural effusion: a systematic review, Eur J Cardiothorac Surg, 2006 , vol. 29 (pg. 829 - 838 ) 34. Resection of brain metastases from non-small-cell lung carcinoma.[annonc.oxfordjournals.org]
  • effusion Chest pain Dyspnea Benign pleural effusion may be due to lymphatic obstruction, post-obstructive pneumonitis, or atelectasis Malignant pleural effusion occurs when malignant cells are present in pleural fluid Dysphagia Enlargement of the subcarinal[pathophys.org]

Treatment

  • RESULTS: In 31 patients (66%), resection was complete; 3 patients (6%) received induction treatment and 30 (64%) adjuvant treatment. Five years later, 26% (95% CI 12-40%) of the patients that received surgical treatment were still alive.[ncbi.nlm.nih.gov]
  • Four patients with intramedullary spinal cord metastases from small cell carcinoma of the lung (SCCL) are described, with emphasis on clinical presentation and treatment.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Although no firm conclusions can be made regarding the efficacy of the combined treatment, this prospective study highlights the poor objective response rates and relatively poor symptom control despite standard treatment of brain metastases[ncbi.nlm.nih.gov]
  • This case illustrates the development of multiple painful oral ulcers caused by methotrexate that was one of a combination of chemotherapeutic drugs administered for the treatment of small cell carcinoma of the lung.[ncbi.nlm.nih.gov]
  • […] effect of hypoxia on treatment results.[ncbi.nlm.nih.gov]

Prognosis

  • Patients with pulmonary small cell carcinoma are well known to have a poor prognosis. However, predictors of prognosis and treatment outcome have not been reported for this type of cancer.[ncbi.nlm.nih.gov]
  • Generally, the prognosis of these patients is poor. When brain metastases develop, the prognosis is even poorer. Most of these cases present parenchymal metastases; however, intraventricular dissemination may also occur although it is very uncommon.[ncbi.nlm.nih.gov]
  • The recognition of metastatic ocular tumors is important since they indicate a poor prognosis. Prompt diagnosis and treatment can significantly improve the quality of life for these patients.[ncbi.nlm.nih.gov]
  • The prognosis of the patients with multiple/bulky N2 disease was invariably dismal. However, the prognostic significance of tumor involvement in more than one hilar or intralobar lymph node station has not been fully described.[ncbi.nlm.nih.gov]
  • […] with main bronchial lymph node involvement have a poorer prognosis, and main bronchial lymph node involvement represents more advanced disease.[ncbi.nlm.nih.gov]

Etiology

  • The causes of hemorrhagic pericarditis are considered, emphasizing the necessity to know if the effusion has a malignant etiology.[ncbi.nlm.nih.gov]
  • The case demonstrates how difficult it may be to diagnose the etiology of Cushing's syndrome and it emphasizes a unique variation in the presentation of small cell carcinoma of the lung.[ncbi.nlm.nih.gov]
  • It remains to be shown whether these antibodies have an etiologic significance in the development of blindness.[ncbi.nlm.nih.gov]
  • […] bronchus or lung Sites Lung: central / bronchial / hilar; rarely a peripheral nodule Submucosal growth Metastasis to liver, adrenals, bone, bone marrow, brain; often widespread Pathophysiology Arises from neuroendocrine cells of basal bronchial epithelium Etiology[pathologyoutlines.com]
  • Etiology Surg Oncol Clin N Am. 2011 Oct;20(4):605-18. Clin Chest Med. 2011 Dec;32(4):605-44. Biochem Pharmacol. 2011 Oct 15;82(8):1015-21.[pathophys.org]

Epidemiology

  • METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER) database for patients from 1988 to 2007 with SCLC. Survival was determined by Kaplan-Meier analysis and compared using the log-rank test.[ncbi.nlm.nih.gov]
  • Journal of Clinical Epidemiology . 1997;50:21-29.) demonstrated that doctors are very good at predicting which patients would or would not be cured, but we are not very accurate when it comes to predicting how long individual patients with incurable disease[oncolink.org]
  • References Govindan R, Page N, Morgensztern D, Read W, Tierney R, Vlahiotis A, Spitznagel EL, Piccirillo J: Changing epidemiology of small-cell lung cancer in the United States over the last 30 years: analysis of the surveillance, epidemiologic, and end[karger.com]
  • Epidemiology of lung cancer’, Chest. 2003, 123:21S-49S Beckles MA, Spiro SG, Colice GL, Rudd RM.[myvmc.com]
  • Epidemiology Small cell carcinoma accounts for about 20% of primary lung carcinomas. There is a strong associated with cigarette smoking, with a relative risk of 18.3 for heavy smokers 1.[e-immunohistochemistry.info]
Sex distribution
Age distribution

Pathophysiology

  • Symptoms Mechanism and pathophysiology Primary lung lesion symptoms Cough (50-70%) Presence of a mass irritates the cough receptors in the airway More common in squamous cell carcinoma andSCLC (more commonly found in the central airways) Obstruction from[pathophys.org]
  • […] coding ICD-10: C34.90 - malignant neoplasm of unspecified part of unspecified bronchus or lung Sites Lung: central / bronchial / hilar; rarely a peripheral nodule Submucosal growth Metastasis to liver, adrenals, bone, bone marrow, brain; often widespread Pathophysiology[pathologyoutlines.com]

Prevention

  • The aim of this study is to determine the involved margins and safe distances of the resection sites from tumor for prevention of local recurrences.[ncbi.nlm.nih.gov]
  • Causes, Risk Factors, and Prevention Learn about the risk factors for small cell lung cancer and what you might be able to do to help lower your risk. Early Detection, Diagnosis, and Staging Know the signs and symptoms of small cell lung cancer.[cancer.org]
  • Preventive Radiation Therapy to the Brain In more than half of the people with small cell lung cancer, the cancer also spreads to the brain.[lungcancer.org]

References

Article

  1. Jackman DM, Johnson BE. Small-cell lung cancer. Lancet. 2005;366(9494):1385-1396.
  2. Dela Cruz CS, Tanoue LT, Matthay RA. Lung Cancer: Epidemiology, Etiology, and Prevention. Clin Chest Med.. 2011;32(4):10.1016/j.ccm.2011.09.001.
  3. Hammerschmidt S, Wirtz H. Lung Cancer: Current Diagnosis and Treatment. Dtsch Arztebl Int. 2009;106(49):809-820.
  4. Alberg AJ, Brock MV, Ford JG, Samet JM, Spivack SD. Epidemiology of Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2013;143(5 Suppl):e1S-e29S.
  5. Jett JR, Schild SE, Kesler KA, Kalemkerian GP. Treatment of small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e400S-e419S.
  6. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e142S-e165S.

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Last updated: 2019-07-11 20:05