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CHEMOTHERAPY FOR LOCALLY ADVANCED SMALL CELL LUNG CANCER

A 65-year-old male had a 4-cm lung mass found on positron emission tomography (PET); it was biopsied by core needle. The patient smoked 2 packs of cigarettes per day and has chronic obstructive pulmonary disease (COPD) and hypertension (HTN). The PET reveals positive mediastinal lymph nodes. Magnetic resonance imaging (MRI) of the brain is normal. The pathology shows small cell lung cancer (SCLC). The patient’s performance status is good, and his basic laboratory tests are normal.

Learning Objectives

  1. What is the most common chemotherapy doublet for locally advanced SCLC?

  2. What is the difference between cisplatin and carboplatin in regard to treatment for SCLC?

  3. What treatment options are available for SCLC other than cisplatin or carboplatin plus etoposide?

  4. How often should locally advanced patients be scanned during treatment?

  5. How are disease relapses classified in SCLC?

Small cell lung cancer (SCLC) is the fastest growing solid malignancy so it is not surprising very few patients present with early stage disease. More often, they are diagnosed at the locally advanced or metastatic stage. These patients typically present with cough and dyspnea, but depending on the extent of disease, they can also have weight loss, bony pain, debility, or even neurologic deficits. Imaging usually reveals a large hilar mass and bulky mediastinal lymphadenopathy. Though SCLC is very sensitive to chemotherapy with rapid initial response, the disease most likely will recur.

The incidence of SCLC overall has been decreasing, but the incidence in women has been rising. It is often centrally located and strongly associated with smoking, so smoking cessation should always be discussed with patients. Those already diagnosed with SCLC who continue to smoke are at risk for greater toxicities with treatment and shorter overall survival.1

CLINICAL PEARL

Small cell lung cancer is often centrally located and strongly associated with smoking.

CLASSIFICATION

Unlike other solid malignancies, SCLC often is not classified using the traditional American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging. Instead, it is described by the Veterans Administration (VA) scheme in which SCLC is separated into only two groups: (1) limited stage, in which disease is only present in the ipsilateral hemithorax, and (2) extensive stage, wherein it has spread beyond the ipsilateral hemithorax.

However, classifying patients using the TNM staging helps to define those who would be candidates for surgery and radiation, such as those with T1-2,N0. For the purpose of this book, SCLC is described as early stage, locally advanced, and metastatic. Locally advanced in this case refers to stages IIB-IIIC (T3-4,N0,M0; T1-4,N1-3,M0).

PERFORMANCE STATUS

Due to the aggressive nature of SCLC, many patients present with extensive disease and subsequent disease-related debility. When deciding treatment regimens in general, performance status is a key factor for consideration as it predicts how well the ...

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