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SURGERY FOR EARLY STAGE SMALL CELL LUNG CANCER

A 73-year-old gentleman with a past medical history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), and a 50 pack-year cigarette smoking history presents to your office after a screening computed tomographic (CT) scan found a 1-cm mass in the right lung lower lobe. His primary care physician orders a percutaneous biopsy, which returns as small cell lung cancer (SCLC). What further workup does this patient need? Which subgroup of patients would be surgical candidates?

Learning Objectives

  1. Understand the diagnostic workup for patients with SCLC.

  2. How is SCLC staged, and what are the recent changes to the staging system?

  3. What is the ideal treatment approach to patients with early stage SCLC?

In the United States, there are approximately 234,000 patients diagnosed with lung cancer annually, with only 10%-15% of cases being SCLC.1 Despite SCLC being less common, it is a particularly deadly and aggressive type of lung cancer, with patients often having metastatic disease at the time of diagnosis.2 SCLC has been traditionally staged as extensive stage (ES) or as limited stage (LS) disease; the purpose of this simple dichotomous staging system is to identify patients who may be candidates for local control of disease.3 The cornerstone of treatment for SCLC has been chemotherapy due to the majority of patients having ES disease at the time of diagnosis.4 The focus of this chapter is on patients with LS disease and what role surgery plays in the treatment of SCLC.

PRESENTATION

Unfortunately, for patients diagnosed with SCLC over two-thirds will have metastatic disease at the time of diagnosis.5 Symptoms of SCLC are typically broken down into either local or distant symptoms. Symptoms of local disease include shortness of breath, cough, hemoptysis, and chest pain. Symptoms of metastatic or advanced disease include weight loss, weakness, lymphadenopathy, and anorexia. In addition to the traditional symptoms mentioned, SCLC can present with a variety of paraneoplastic syndromes.6

Over two-thirds of patients with SCLC will have metastatic disease at the time of diagnosis.

  • Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH): Affects approximately 15% of patients with SCLC. SIADH is characterized by hyponatremia along with high urine osmolality. This is caused by ectopic production of antidiuretic hormone. Symptoms and laboratory values typically improve with treatment of SCLC.6,7

  • Cushing Syndrome: Present in less than 5% of patients with SCLC, Cushing syndrome is caused by ectopic production of corticotropin.6 Symptoms can include obesity, hirsutism, glucose intolerance, and acne.

  • Lambert-Eaton Syndrome: Results in proximal muscle weakness and is caused by antibodies that target calcium channels.6

Screening CT scans have become increasingly more prevalent after the conclusion of the National Lung Screening Trial demonstrated a reduction of lung cancer mortality with the implementation of screening CT scans in at-risk patients.8 Recent reports ...

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