LUNG CANCER



LUNG CANCERSmall-Cell Carcinoma of the Lungcenter850008549640sAMANTHA CROWELLGRAND VALLEY STATE UNIVERSITY1000000sAMANTHA CROWELLGRAND VALLEY STATE UNIVERSITYPresenting Signs & Symptoms of PatientChief ComplaintThis 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 HistoryThe 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 HistoryThere is a significant history for the patient’s father with colon cancer. No other family history known.Social HistoryThis 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. EpidemiologyLung 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, 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 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)EtiologyThere 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 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 InformationDateProcedureResultsOctober – November 2014Chief ComplaintHaving shortness of breath when doing normal tasks around the garageNovember 5, 2014Chest X-RayOpacity found within the left mid lungNovember 6, 2014CT Scan of Abdomen and PelvisUnremarkableNovember 2014MRI Scan of the BrainNo metastatic disease found November 2014PET/CT Hilar and mediastinal abnormalities found within the left upper lobeNovember 26, 2014Bronchoscopy and MediastinoscopyNo 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 small cell carcinomaDecember 8, 2014Began first cycle of chemotherapy with cisplatin and etoposideHe had some hemoptysis after the bronchoscopy, however, felt well after chemo thus farDecember 11, 2014Examined by Radiation OncologistDecided on standard of care of Chemoradiation therapy, noted to start at the lastest by cycle 2 of his chemotherapy on December 29, 2014December 12, 2014Simulation for Radiation TherapyN/AAnatomy DiscussionThe 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. 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 DrainageThe 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 GraphicsFIGURE 1.Non-Small Cell Lung Cancer Treatment (PDQ?). (2014, June 30). Retrieved April 2, 2015, from 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 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 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 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) StagingAs 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 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 CategoriesDescriptionTXPrimary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopyT0No evidence of primary tumorTisCarcinoma in situT1Tumor 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)T1aTumor 2 cm or less in greatest dimensionT1bTumor more than 2 cm but 3 cm or less in greatest dimensionT2Tumor 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 lungT2aTumor more than 3 cm but 5 cm or less in greatest dimensionT2bTumor more than 5 cm but 7 cm or less in greatest dimensionT3Tumor 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 lobeT4Tumor 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 lobeRegional Lymph Nodes (N)TNM CategoriesDescriptionNXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extensionN2Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)N3Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)Distant Metastasis (M)TNM CategoriesDescriptionM0No distant metastasisM1Distant metastasisM1aSeparate tumor nodule(s) in a contralateral lobe tumor with pleural nodules or malignant pleural (or pericardial) effusionM1bDistant metastasis (in extrathoracic organs)Anatomic Stage/Prognostic GroupsTNM StagesTNMOccult carcinomaTXN0M0Stage 0TisN0M0Stage IAT1aN0M0T1bN0M0Stage IBT2aN0M0Stage IIAT2bN0M0T1aN1M0T1bN1M0T2aN1M0Stage IIBT2bN1M0T3N0M0Stage IIIAT1aN2M0T1bN2M0T2aN2M0T2bN2M0T3N1M0T3N2M0T4N0M0T4N1M0Stage IIIBT1aN3M0T1bN3M0T2aN3M0T2bN3M0T3N3M0T4N2M0T4N3M0Stage IVAny TAny NM1aAny TAny NM1bCompton, 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 (%) criteriaValue (%)Level of Functional Capacity100Normal, no complaints; no evidence of disease90Able to carry on normal activity; minor signs or symptoms of disease80Normal activity with effort; some signs or symptoms of disease70Cares for self; unable to carry on normal activity or to do active work60Requires occasional assistance, but is able to care for most of his personal needs50Requires considerable assistance and frequent medical care40Disabled; requires special care and assistance30Severely disabled; hospital admission is indicated although death not imminent20Very sick; hospital admission necessary; active supportive treatment necessary10Moribund; fatal processes progressing rapidly0DeadTerret, 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.GradingTumor 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 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 DifferentiationGXUndetermined gradeGrade cannot be assessedG1Low gradeWell differentiatedG2Intermediate gradeModerately differentiatedG3High gradePoorly differentiatedG4High gradeUndifferentiatedSmall Cell Lung Cancer Treatment. (n.d.). National Cancer Institute. Retrieved April 7, 2015, from Pathology, Stage & GradeThis 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 PatientThe 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 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-UpSimulation 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 & DeliveryField NameGantry AngleCollimator AngleCouch AnglePlanned SSDPlanned MUEnergyWedge FactorBolusArc 10 to 179 CW30082.8 cm177 MU6 MV1.0NoneArc 2179 to 0 CCW330083.0 cm 131 MU6 MV1.0NoneArc 1.10 to 179 CW30082.7 cm180 MU6 MV1.0NoneArc 2.1179 to 0 CCW330083.4 cm124 MU6 MV1.0NoneArc 3330 to 30 CW9027085.3 cm56 MU6 MV1.0NoneArc 430 to 330 CCW9027085.2 cm32 MU6 MV1.0NoneOther Radiation Therapy Treatment OptionsStereotactic 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 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 & TreatmentFor 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 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)Other Therapies & Complications the Patient ReceivedThis 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 StructureTD 5/5 (cGy)Spinal cord5000Normal lung2000Heart4300Esophagus5000Bone marrow2500Skin5500Liver3500Bone6500Washington, 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 SpreadSmall 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 & SurvivalThe 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 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) Stage5-Year Relative Survival Rate(Limited-stage) I31%(Limited-stage) II19%(Limited-stage) III8%(Extensive-stage) IV2%Small cell lung cancer survival rates by stage. (2015, March 9). Retrieved April 8, 2015, from ’s Prognosis & SurvivalAlthough 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.Sources CitedArticles & WebsitesBryant, J., Meredith, S., Williams, K., & White, A. (2014). Targeting hypoxia in the treatment of small cell lung cancer.?Lung Cancer,?86(2), 126-132. Retrieved April 9, 2015, from pton, 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.DeVita, V., Lawrence, T., & Rosenberg, S. (2008). Section Reprint: Cancer of the Lung. In DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology (8th ed., pp. 60-77). Philadelphia, Pennsylvania: Wolters Kluwer/Lippincott Williams & Wilkins.Gaspar, L., Mcnamara, E., Gay, E., Putnam, J., Crawford, J., Herbst, R., & Bonner, J. (2012). Small-Cell Lung Cancer: Prognostic Factors and Changing Treatment Over 15 Years. Clinical Lung Cancer, 13(2), 115-122. Retrieved April 10, 2015, from ScienceDirect.Hatton, M., & Martin, J. (2010). Continuous Hyperfractionated Accelerated Radiotherapy (CHART) and Non-conventionally Fractionated Radiotherapy in the Treatment of Non-small Cell Lung Cancer: A Review and Consideration of Future Directions. Clinical Oncology, 22(5), 356-364. Retrieved July 19, 2015, from ScienceDirect.Janssen-Heijnen, M., Maas, H., Koning, C., Bruggen-Bogaarts, B., Groen, H., & Wymenga, A. (2014). Tolerance and benefits of treatment for elderly patients with limited small-cell lung cancer.?Journal of Geriatric Oncology, 5(1), 71-77. Retrieved April 10, 2015, from ScienceDirect.Kelley, K., Benninghoff, D., Stein, J., Li, J., Byrnes, R., Potters, L., . . . Zinkin, H. (2015). Medically inoperable peripheral lung cancer treated with stereotactic body radiation therapy. Radiation Oncology, 10(120). Retrieved July 19, 2015, from PubMed.Lung Anatomy: Read About Lung Structure and Function. (2014). Retrieved April 8, 2015, from Cancer. (n.d.). American Cancer Society. Retrieved April 2, 2015, from , U., Badellino, S., & Filippi, A. (2015). Stereotactic radiotherapy for early stage non-small cell lung cancer. Radiation Oncology Journal, 33(2), 57-65. Retrieved July 15, 2015, from PubMed.Schabath, M., Nguyen, A., Wilson, P., Sommerer, K., Thompson, Z., & Chiappori, A. (2014). Temporal trends from 1986 to 2008 in overall survival of small cell lung cancer patients. Lung Cancer, 86(1), 14-21. Retrieved April 10, 2015, from ScienceDirect.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 Lung Cancer. (2014). WebMD. Retrieved April 8, 2015, from Cell Lung Cancer Treatment. (n.d.). National Cancer Institute. Retrieved April 7, 2015, from , B. (2014). Targets in small cell lung cancer.?Biochemical Pharmacology,?87(2), 211-219. Retrieved April 10, 2015, from ScienceDirect.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.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.ImagesNon-Small Cell Lung Cancer Treatment (PDQ?). (2014, June 30). Retrieved April 2, 2015, from 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 Cell Lung Cancer Survival Rates by Stage. (2015, March 9). Retrieved April 8, 2015, from ................
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