A 72-year-old man comes to the office due to cough and hemoptysis. The patient has had a nonproductive cough for 3 months and began to cough up scant sputum with flecks of blood 4 days ago. He also notes anorexia and a 7-kg (15-lb) weight loss over this period. He has a history of hypertension and osteoarthritis. The patient is a former smoker with a 54-pack-year history.
Temperature is 37 C (98.6 F) , blood pressure is 132/80 mm Hg, pulse is 72/min, and respirations are 16/min. BMI is 22 kg/m². The patient appears thin. Breath sounds are reduced over the left lower lung field. Abdominal examination is normal. Finger clubbing is noted. There is an enlarged left supraclavicular lymph node but no cervical, axillary, or inguinal lymphadenopathy.
CT scans of the chest, abdomen, and pelvis reveal a 4-cm left perihilar mass, several enlarged mediastinal lymph nodes and right lung nodules, and 2 liver lesions. Bronchoscopic biopsy confirms small cell lung cancer. PET/CT scan and brain imaging reveal no evidence of other metastasic lesions.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Small cell lung cancer (SCLC) is a neuroendocrine tumor seen primarily in heavy smokers. Most cases involve the central airway (eg, hilar mass) and manifest with cough, dyspnea, hemoptysis, weight loss, and fatigue. Doubling times are short, and nearly 70% of cases are overtly metastatic (eg, bone, adrenals, liver, brain) at diagnosis. Patients with SCLC are categorized based on radiograph and physical examination findings as follows: Limited stage - tumor limited to the ipsilateral hemithorax and regional lymph nodes (although subclinical metastases are usually present)Extensive stage - involvement of contralateral lymph nodes, malignant pericardial/pleural effusion, or distant metastases (as in this patient with liver and contralateral lung lesions) Limited stage - tumor limited to the ipsilateral hemithorax and regional lymph nodes (although subclinical metastases are usually present) Limited stage - tumor limited to the ipsilateral hemithorax and regional lymph nodes (although subclinical metastases are usually present) Extensive stage - involvement of contralateral lymph nodes, malignant pericardial/pleural effusion, or distant metastases (as in this patient with liver and contralateral lung lesions) Platinum-based chemotherapy (eg, etoposide plus cisplatin) is highly effective for inducing remission in SCLC. Patients with limited-stage SCLC are treated with curative intent and usually receive concurrent chemotherapy and thoracic radiation; 5-year survival is ~20%. Extensive-stage SCLC is generally treated with 6 cycles of chemotherapy alone; those who respond to chemotherapy often receive subsequent chest and/or prophylactic cranial irradiation (Choice E). Five-year survival is ~5%. (Choice A) Patients with non-small cell lung cancer (NSCLC) usually undergo molecular profiling in order to determine first-line treatment (eg, endothelial growth factor receptor tyrosine kinase inhibitors). As targeted drug therapy is not currently part of first-line treatment for SCLC, molecular profiling is not typically performed. (Choice C) Pulmonary function testing is required prior to lobectomy. Although lobectomy is often a first-line therapy for patients with early-stage NSCLC, the surgical management of SCLC is usually restricted to patients with limited-stage SCLC who have no mediastinal lesions or contraindications to surgery. This patient with extensive disease (contralateral lung and liver lesions) would not undergo surgery and does not need pulmonary function testing. (Choice D) Patients with SCLC typically have tumor regression with chemotherapy. Most patients, even those with poor functional status, should have a trial of platinum-based chemotherapy prior to a consideration of hospice. Educational objective: Small cell lung cancer is very responsive to systemic platinum-based chemotherapy (eg, etoposide plus cisplatin). Patients with localized disease (limited to the ipsilateral hemithorax) also typically receive concurrent thoracic radiation. Those with extensive disease (metastatic, contralateral lymph nodes, malignant pericardial/pleural effusion) initially receive systemic chemotherapy alone. __________ References: Platinum-etoposide chemotherapy in elderly patients with small cell lung cancer. (http://www.ncbi.nlm.nih.gov/pubmed/15659503) Chemotherapy versus best supportive care for extensive small cell lung cancer. (http://www.ncbi.nlm.nih.gov/pubmed/14583943)

A 72-Year-Old Man Comes to the Office Due to Cough