Bronchial CA - Small Cell

Oncology

Clinicals - History

Fact Explanation
Asymptomatic Minority of patients can be asymptomatic especially in early stages. Asymptomatic
Minority of patients can be asymptomatic especially in early stages.
Risk factors for the development of lung carcinoma Smoking, occupational exposure to asbestos, radon, arsenic, chromium, nickel, vinyl chloride, and ionizing radiation are known risk factors. Presence of chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and tuberculosis also play a role in development of bronchial carcinoma. Risk factors for the development of lung carcinoma
Smoking, occupational exposure to asbestos, radon, arsenic, chromium, nickel, vinyl chloride, and ionizing radiation are known risk factors. Presence of chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and tuberculosis also play a role in development of bronchial carcinoma.
Cough and or hemoptysis Cough is the most common presenting complain and it is due to the irritation and obstruction of the airway due to the growing tumor. Cough and or hemoptysis
Cough is the most common presenting complain and it is due to the irritation and obstruction of the airway due to the growing tumor.
Bone pain and fractures Malignant metastasis in the bone result in bone pain and pathological fractures. Bone pain and fractures
Malignant metastasis in the bone result in bone pain and pathological fractures.
Nonspecific symptoms These include fatigue, anorexia, and weight loss. Nonspecific symptoms
These include fatigue, anorexia, and weight loss.
Superior vena cava obstruction Due to compression of the superior vena cava. Patients present with shortness of breath, swelling of the face and or arm and distended veins in the upper chest and arms. Superior vena cava obstruction
Due to compression of the superior vena cava. Patients present with shortness of breath, swelling of the face and or arm and distended veins in the upper chest and arms.
Recurrent laryngeal nerve paralysis Due to compression by the tumor or displaced structures, direct infiltration of the recurrent laryngeal nerve. Nerve infiltration results in hoarseness of voice. Recurrent laryngeal nerve paralysis
Due to compression by the tumor or displaced structures, direct infiltration of the recurrent laryngeal nerve. Nerve infiltration results in hoarseness of voice.
Symptoms due to phrenic nerve paralysis Tumor invasion of the phrenic nerve causes nerve paralysis. Most patients are asymptomatic at rest, dyspnea on exertion and decreased exercise tolerance can be the presenting complains. Symptoms due to phrenic nerve paralysis
Tumor invasion of the phrenic nerve causes nerve paralysis. Most patients are asymptomatic at rest, dyspnea on exertion and decreased exercise tolerance can be the presenting complains.
Dysphagia and odynophagia Compression of the esophagus due to the expanding tumor produces dysphagia. Pericardial infiltration and effusion may also contribute to dysphagia. Dysphagia and odynophagia
Compression of the esophagus due to the expanding tumor produces dysphagia. Pericardial infiltration and effusion may also contribute to dysphagia.
Stridor Due to bronchial obstruction. Stridor
Due to bronchial obstruction.
Symptoms of brain secondary Patients present with confusion, seizures, personality change, early morning nausea and vomiting which is relieved by vomiting. Symptoms of brain secondary
Patients present with confusion, seizures, personality change, early morning nausea and vomiting which is relieved by vomiting.
Symptoms of paraneoplastic syndrome Paraneoplastic syndrome occurs in small cell carcinoma. Hypercalcemia , syndrome of inappropriate antidiuretic hormone, Cushing's syndrome (ectopic ACTH production), finger clubbing, hypertrophic pulmonary osteoarthropathy, Eaton-Lambert myasthenic syndrome, subacute cerebellar degeneration, subacute sensory neuropathy and limbic encephalitis (cognitive dysfunction, memory impairment, seizures and psychiatric symptoms are common presenting complains) can manifest in paraneoplastic syndrome. Symptoms of paraneoplastic syndrome
Paraneoplastic syndrome occurs in small cell carcinoma. Hypercalcemia , syndrome of inappropriate antidiuretic hormone, Cushing's syndrome (ectopic ACTH production), finger clubbing, hypertrophic pulmonary osteoarthropathy, Eaton-Lambert myasthenic syndrome, subacute cerebellar degeneration, subacute sensory neuropathy and limbic encephalitis (cognitive dysfunction, memory impairment, seizures and psychiatric symptoms are common presenting complains) can manifest in paraneoplastic syndrome.
Symptoms of lower respiratory tract infection Pneumonia results due to obstruction of the air way due to the tumor. Patients complain of fever, chest pain, cough and shortness of breath. Symptoms of lower respiratory tract infection
Pneumonia results due to obstruction of the air way due to the tumor. Patients complain of fever, chest pain, cough and shortness of breath.
Breathlessness Airway obstruction and associated pleural effusion may result in breathlessness. Breathlessness
Airway obstruction and associated pleural effusion may result in breathlessness.
Chest discomfort or pain Chest discomfort is due to direct pressure effects of the tumor. Infiltration of the intercostal nerves and the parietal pleura cause chest pain. Chest discomfort or pain
Chest discomfort is due to direct pressure effects of the tumor. Infiltration of the intercostal nerves and the parietal pleura cause chest pain.
Horner’s syndrome (Pancoast's tumor) Compression of the cervical sympathetic trunk produces Horner’s syndrome. Patients present with referred pain over the scapula, weak and atrophic hand muscles. Horner’s syndrome (Pancoast's tumor)
Compression of the cervical sympathetic trunk produces Horner’s syndrome. Patients present with referred pain over the scapula, weak and atrophic hand muscles.
Palpable lymphadenopathy Due to metastatic deposits. Small cell lung carcinoma is known to grow rapidly and metastasize in to the lymph nodes early in the illness. Palpable lymphadenopathy
Due to metastatic deposits. Small cell lung carcinoma is known to grow rapidly and metastasize in to the lymph nodes early in the illness.

Clinicals - Examination

Fact Explanation
Fever Patients can be febrile due to concurrent infection. Fever
Patients can be febrile due to concurrent infection.
Examination of the respiratory system Wheezing in a localized area is due to bronchial obstruction. Centrally located tumors can cause lung collapse resulting absent breath sounds over the affected side. Peripheral tumors cause segmental collapse. This results in dull percussion note and diminished breath sounds in the affected area. Malignant pleural effusions produce reduced chest expansion, stony dull percussion note, and absent breath sounds over the affected segment. Examination of the respiratory system
Wheezing in a localized area is due to bronchial obstruction. Centrally located tumors can cause lung collapse resulting absent breath sounds over the affected side. Peripheral tumors cause segmental collapse. This results in dull percussion note and diminished breath sounds in the affected area. Malignant pleural effusions produce reduced chest expansion, stony dull percussion note, and absent breath sounds over the affected segment.
Palpable lymph nodes Metastatic deposits to the lymph nodes. Palpable lymph nodes
Metastatic deposits to the lymph nodes.
Signs of Horner’s syndrome Patients will have ptosis, miosis, anhidrosis, and enophthalmos. Signs of Horner’s syndrome
Patients will have ptosis, miosis, anhidrosis, and enophthalmos.
Signs of superior vena cava obstruction These include distended neck and facial veins and positive Pemberton's sign. Signs of superior vena cava obstruction
These include distended neck and facial veins and positive Pemberton's sign.
Signs of increased intracranial pressure Examination of the optic fundus will show papilledema. Focal neurological signs can present in some. Signs of increased intracranial pressure
Examination of the optic fundus will show papilledema. Focal neurological signs can present in some.
Signs of pericardial effusion Malignant pericardial effusion produces muffled heart sounds. Some patients have distended jugular veins. Signs of pericardial effusion
Malignant pericardial effusion produces muffled heart sounds. Some patients have distended jugular veins.
Cachexia In advanced disease sever loss of appetite results in significant loss of weight. Cachexia
In advanced disease sever loss of appetite results in significant loss of weight.

Investigations - Diagnosis

Fact Explanation
Chest X-ray Localized emphysema is an early sign. Also shows malignant pleural effusions of more than 500ml. Chest X-ray
Localized emphysema is an early sign. Also shows malignant pleural effusions of more than 500ml.
CT scan Enable visualizing the primary rumor and distant metastasis. CT scan
Enable visualizing the primary rumor and distant metastasis.
PET scanning As the CT, PET scan visualizes the tumor and distant metastasis. PET scanning
As the CT, PET scan visualizes the tumor and distant metastasis.
Bronchoscopy Visualizes the lesion. Biopsy specimen can be obtained by bronchial washings and brushings for confirmation of the diagnosis. Bronchoscopy
Visualizes the lesion. Biopsy specimen can be obtained by bronchial washings and brushings for confirmation of the diagnosis.
Exploratory thoracotomy Not routinely done. Exploratory thoracotomy
Not routinely done.
Pleural fluid full report A blood stained, exudate (pleural fluid protein is more than 30g/l), with pH less than 7.3 (due to increased lactic acid levels) is suggestive of a malignancy. Pleural fluid is rich in lymphocytes and malignant cells. Pleural fluid amylase levels are elevated in adenocarcinoma. Pleural fluid full report
A blood stained, exudate (pleural fluid protein is more than 30g/l), with pH less than 7.3 (due to increased lactic acid levels) is suggestive of a malignancy. Pleural fluid is rich in lymphocytes and malignant cells. Pleural fluid amylase levels are elevated in adenocarcinoma.
Histology This will provide the definitive diagnosis. Histology
This will provide the definitive diagnosis.
Video-assisted thoracoscopy Aids in visualization of the tumor and biopsy specimens can be obtained. Video-assisted thoracoscopy
Aids in visualization of the tumor and biopsy specimens can be obtained.
Sputum cytology Enables detection of malignant cells. Sputum cytology
Enables detection of malignant cells.

Investigations - Management

Fact Explanation
Chest X-ray Even after successful treatment bronchial carcinoma may recur. Patients should be followed up for at least for two years. Chest X-ray
Even after successful treatment bronchial carcinoma may recur. Patients should be followed up for at least for two years.
Lung function test If the forced expiratory volume in first second (FEV1) or carbon monoxide diffusion in the lung (DLCO) is less than 80% of the predicted, postresection pulmonary reserve should be estimated with ventilation-perfusion scan should be estimated to plan the definitive management. Lung function test
If the forced expiratory volume in first second (FEV1) or carbon monoxide diffusion in the lung (DLCO) is less than 80% of the predicted, postresection pulmonary reserve should be estimated with ventilation-perfusion scan should be estimated to plan the definitive management.
Complete blood count Bone marrow infiltration can cause pancytopenia. Poor appetite may have led to iron deficiency anemia. Complete blood count
Bone marrow infiltration can cause pancytopenia. Poor appetite may have led to iron deficiency anemia.
Serum electrolytes Assesses the renal function. Serum electrolytes
Assesses the renal function.
Serum calcium Paraneoplastic syndrome may cause hypercalcemia. Serum calcium
Paraneoplastic syndrome may cause hypercalcemia.
Liver function test This includes the assessment of hepatic transaminases and alkaline phosphatase levels. Some drugs are metabolized in the liver and liver function may be deranged in the presence of metastasis. Liver function test
This includes the assessment of hepatic transaminases and alkaline phosphatase levels. Some drugs are metabolized in the liver and liver function may be deranged in the presence of metastasis.
Full blood count Pancytopenia may suggest bone marrow infiltration by the tumor. Full blood count
Pancytopenia may suggest bone marrow infiltration by the tumor.
Renal function test Hyponatremia can occur due to syndrome of inappropriate anti-diuretic hormone secretion. It should be corrected prior to surgery. Renal function test
Hyponatremia can occur due to syndrome of inappropriate anti-diuretic hormone secretion. It should be corrected prior to surgery.
Liver function test Liver function is deranged in metastatic disease. Liver function test
Liver function is deranged in metastatic disease.
Computerized tomography (CT) Tumor size can be estimated. CT is helpful in detecting local invasion of the tumor and lymph node metastasis. Can detect small pleural effusions that are not detectable from a chest X-ray. Low dose CT is the investigation of choice for screening of lung cancer. Current smokers or people who have quit smoking with in past 15 years who are in the age group of 55 to 74 years should be screened. Computerized tomography (CT)
Tumor size can be estimated. CT is helpful in detecting local invasion of the tumor and lymph node metastasis. Can detect small pleural effusions that are not detectable from a chest X-ray. Low dose CT is the investigation of choice for screening of lung cancer. Current smokers or people who have quit smoking with in past 15 years who are in the age group of 55 to 74 years should be screened.
PET scanning Findings are similar to CT. imaging studies aid in staging the disease. Small cell lung carcinoma is broadly divided in to either limited (T1-4, N0-3, M0) or extensive disease. In extensive disease tumor metastases involve the ipsilateral lung, distant organs and malignant pleural or pericardial effusion. PET scanning
Findings are similar to CT. imaging studies aid in staging the disease. Small cell lung carcinoma is broadly divided in to either limited (T1-4, N0-3, M0) or extensive disease. In extensive disease tumor metastases involve the ipsilateral lung, distant organs and malignant pleural or pericardial effusion.
Diagnostic thoracentesis Pleural fluid is obtained for the assessment of cell counts, total protein, lactate dehydrogenase, glucose, pH, amylase, and cytology. Diagnostic thoracentesis
Pleural fluid is obtained for the assessment of cell counts, total protein, lactate dehydrogenase, glucose, pH, amylase, and cytology.
Pleural Biopsy Detects pleural deposits. Pleural Biopsy
Detects pleural deposits.
Pericardial fluid aspiration This enables the confirmation of malignant pleural effusion. Pericardial fluid aspiration
This enables the confirmation of malignant pleural effusion.
Bone scan Evaluates bone metastasis. Especially useful in small cell carcinoma because it usually presents with metastatic disease. Bone scan
Evaluates bone metastasis. Especially useful in small cell carcinoma because it usually presents with metastatic disease.
MRI of the head Visualizes cerebral metastasis. MRI of the head
Visualizes cerebral metastasis.

Management - Supportive

Fact Explanation
Cessation of smoking Smoking is a main causative factor for the development of lung carcinoma. Counseling and nicotine replacement therapy whenever necessary will be helpful. Cessation of smoking
Smoking is a main causative factor for the development of lung carcinoma. Counseling and nicotine replacement therapy whenever necessary will be helpful.
Management of malignant pleural effusions Therapeutic thoracentesis and fluid aspiration will provide symptomatic relief. Chemical pleurodesis will prevent the recurrences. Management of malignant pleural effusions
Therapeutic thoracentesis and fluid aspiration will provide symptomatic relief. Chemical pleurodesis will prevent the recurrences.
Management of superior vena cava obstruction Stent placement or balloon dilatation can establish the patency of the vein. Management of superior vena cava obstruction
Stent placement or balloon dilatation can establish the patency of the vein.
Management of malignant pericardial effusion Pericardiocentesis is done if the patient is in hemodynamic compromise. Management of malignant pericardial effusion
Pericardiocentesis is done if the patient is in hemodynamic compromise.
Treatment of respiratory tract infection Lower respiratory tract infection is a common complication either due to tracheal obstruction and aspiration due to the tumor or secondary to immune suppression due to treatment. Treatment of respiratory tract infection
Lower respiratory tract infection is a common complication either due to tracheal obstruction and aspiration due to the tumor or secondary to immune suppression due to treatment.
Management of hypercalcemia Intravenous fluids, loop diuretics and bisphosphonates are used in the treatment. Management of hypercalcemia
Intravenous fluids, loop diuretics and bisphosphonates are used in the treatment.

Management - Specific

Fact Explanation
Surgical resection of the tumor (lobectomy and pneumonectomy) Patients with early limited disease benefit from surgical excision of the primary tumor. Surgical resection of the tumor (lobectomy and pneumonectomy)
Patients with early limited disease benefit from surgical excision of the primary tumor.
Chemotherapy Combinations of chemotherapeutic agents are used in chemotherapy. For limited disease etoposide/platinum and etoposide/cisplatin combinations are used. Extensive disease is treated with cisplatin or carboplatin in combination with etoposide. Chemotherapy after the surgical resection improves survival. Prognosis of extensive disease is considered very poor. (median survival of 10 months and a 2-year survival rate of 10%) Chemotherapy
Combinations of chemotherapeutic agents are used in chemotherapy. For limited disease etoposide/platinum and etoposide/cisplatin combinations are used. Extensive disease is treated with cisplatin or carboplatin in combination with etoposide. Chemotherapy after the surgical resection improves survival. Prognosis of extensive disease is considered very poor. (median survival of 10 months and a 2-year survival rate of 10%)
Radiotherapy Useful to control the primary tumor and skeletal metastasis. Often chemoradiation therapy is used in treatment. Prophylactic cranial irradiation is given for patients with limited disease to prevent the occurrence of intracranial metastasis. It is proven to improve the survival. Radiotherapy
Useful to control the primary tumor and skeletal metastasis. Often chemoradiation therapy is used in treatment. Prophylactic cranial irradiation is given for patients with limited disease to prevent the occurrence of intracranial metastasis. It is proven to improve the survival.
Surgical resection of the metastasis Resectable brain metastasis can be surgically removed in stage IIIB and IV. This is combined with removal of the T1 primary tumor. Surgical resection of the metastasis
Resectable brain metastasis can be surgically removed in stage IIIB and IV. This is combined with removal of the T1 primary tumor.
Molecular targeted therapy There are identified genetic mutations in small cell lung carcinoma. These mutations cause unregulated cellular proliferation and disease can recur even after successful chemoradiotherapy. Molecular targeted therapy has proven value in treatment of small cell lung carcinoma. Molecular targeted therapy
There are identified genetic mutations in small cell lung carcinoma. These mutations cause unregulated cellular proliferation and disease can recur even after successful chemoradiotherapy. Molecular targeted therapy has proven value in treatment of small cell lung carcinoma.

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