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Case History

image A 65-year-old ex-smoker presents with a right upper lobe mass and enlarged ipsilateral hilar lymph nodes on computed tomography (CT) scan. Full radiological staging reveals no other metastases. Bronchoscopy shows that he has an endobronchial abnormality in the right upper lobe bronchus that on biopsy shows small cell lung cancer (SCLC).

How will you stage this cancer?

What factors influence prognosis in this disease?

If this patient has no adverse prognostic factors, what treatment(s) would you recommend and on what evidence would that be based?

What are the 2-year and 5-year survival rates for patients like him who have optimum treatment?


How will you stage this cancer?

image On the basis of the Veterans' Administration Lung Cancer Study Group staging, this patient has limited disease, defined as tumour confined to one hemi-thorax and/or that which can be encompassed within a radiotherapy field.1 SCLC is an aggressive form of lung cancer which is often widespread at presentation. Even where radiological staging is negative for metastases, disseminated micro-metastases are often present. Therefore minor differences in tumour stage do not alter prognosis. Reflecting this, there are only two broad stage groupings in clinical use, limited disease or extensive disease. Treatment decisions rely on the distinction of limited disease from extensive disease and on other prognostic factors (see below).

There is some variation in the definition of limited disease. Additional features which may still allow a patient to be staged as having limited disease include ipsilateral pleural effusion, left recurrent laryngeal nerve palsy and superior vena cava obstruction. Extensive disease, as implied by its name, involves disease beyond that defined by limited disease. Extensive disease includes patients with bilateral pleural effusions, pericardial effusions and metastatic disease. Common sites of metastasis are the liver, adrenals, bone and brain.

What factors influence prognosis in this disease?

As well as stage grouping, performance status, sex and biochemical variables affect prognosis. As would be expected, patients with limited disease, good performance status (0–1) and normal biochemical variables fare better. The prognosis for women is better than that for men.

A prognostic scoring system, the Manchester Prognostic Score,2 is used clinically and consists of a five-point system:

  • performance status 2 or worse = +1

  • extensive disease = +1

  • sodium below lower limit of normal = +1

  • alkaline phosphatase >1.5 × upper limit of normal = +1

  • lactate dehydrogenase >upper limit of normal = +1.

A patient can be assessed as having a good, intermediate or poor prognosis based on a score of 0–1, 2–3 and 4–5, respectively.


If this patient has no adverse prognostic factors, what treatment(s) would you recommend and on what evidence would that be based?

image In the absence of adverse prognostic factors and ...

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