Advanced Lung Cancer - Episode 11

Case 3: Extensive-Stage SCLC

June 14, 2019


Benjamin P. Levy, MD:For the sake of time, let’s move on to case 3, which is a patient with extensive stage small cell lung cancer. This is a 47-year-old male who’s referred to pulmonology for chronic cough and left-sided chest pain, exacerbated by deep breathing. From his physical exam, he has decreased breast sounds on the left. He’s a smoker, he has a 30-pack-year history. He has a sputum cytology, which is small cell. I haven’t seen a sputum cytology in forever from small cell, but we can talk about that.

His imaging studies reveal a suspicious mass in the left upper lobe. The chest CT [computed tomography] scan shows, again, a 4.8-cm left upper-lobe mass and large hilar node, as well as invasion into the left pulmonary artery. His MRI [magnetic resonance imaging] shows 3 small nodules. He has a mediastinotomy that confirmed small cell. We can talk about the biopsy approach here. This is extensive stage based on the MRI findings. He has a tumor mutational burden. I don’t know if we’ll have time to talk about that biomarker, in small cell or in non—small cell lung cancer, but nevertheless, it’s done.

Essentially, this is a patient with extensive-stage small cell lung cancer. We’ve had some practice changing data in the past 6 months on this. We’ll start with the surgeon, who historically has been excluded from these conversations about small cell. But there may be a role for surgery in early stage. This is not an early stage patient, but have you been involved in small cell as a surgeon, and who is that patient?

Michael J. Walker, MD:That’s a good question. I have. I probably see a case a year, which is like a T1N0 lesion that shouldn’t be a small cell, but it is. You ask the pathologist to go back and look at it again, and it is. Certainly, those patients need an MRI of the brain to make sure it’s OK. They need invasive mediastinal staging looking at the node staging. Again, I think an EBUS [endobronchial ultrasound] works in there well. If they do a PET [positron emission tomography] scan, and there was really N0 disease—even the literature now says maybe N1 disease, but that’s a little aggressive—they would get a lobectomy and then probably adjuvant chemotherapy.

Benjamin P. Levy, MD:OK. This is a small cell case, and I think we all can agree that systemic therapy in some way, fashion, or form to shrink this disease is important. Let’s extrapolate, though, to engage the radiation oncologist and pulmonologist here. Let’s say this were a non—small cell lung cancer patient with an obstructive lesion—we didn’t get a chance to touch on this in the other case—not a small cell but a non–small cell. In terms of roles for interventional pulmonary approaches, let’s talk about stents versus radiation. Lonny, do you want to talk just briefly about that?

Lonny Brett Yarmus, DO:These are all palliative approaches, and I think there have been mounting data looking really at the combination of both as optimizing the various patients. Patients with initial or early relief of the airway obstruction with a rigid bronchoscope, and potentially stenting followed by radiation, I think has really been now well shown to improve at least patient-centered outcomes.

Benjamin P. Levy, MD:Anshu, your thoughts on this in terms of the role of the radiation oncologist for obstructive lesions for non—small cell?

Anshu K. Jain, MD:Yeah. I agree, and I think that in some of these patients, we typically try to identify whether there are impending obstructions versus actual obstructions. We typically quote about a 50% success rate of reopening that airway if they are already significantly instructed. We try to catch these patients with impending obstructions if we’re starting to see some postobstructive changes. We always like to engage our pulmonary colleagues to see if there’s a significant endobronchial component. In some cases, if these patients have already received radiation in the past, there might be a role for palliative endobronchial brachytherapy, for example, but we would also discuss stenting as a way to kind of provide a more robust response in terms of keeping that airway open.

Transcript edited for clarity.