Case Study On Lung

Cancer

A case of small cell lung cancer treated with

chemoradiotherapy followed by photodynamic
therapy
 ABSTRACT
 Here, we present the case of a 51-year-old man with
limited-stage small cell lung cancer (LS-SCLC) who
received concurrent chemoradiotherapy and photodynamic
therapy (PDT) in Base Hospital delhi cantt .
 The patient was diagnosed as having LS-SCLC with an
endobronchial mass in the left main bronchus. Following
concurrent chemoradiotherapy, a mass remaining in the
left lingular division was treated with PDT.
 Clinical and histological data indicate that the patient has
remained in complete response for 2 years without further
treatment. This patient represents a rare case of complete
response in LS-SCLC treated with PDT.
 Currently, patients with small cell lung cancer (SCLC)
are treated with chemotherapy with or without thoracic
radiotherapy. Radiation therapy is generally accepted as
an essential component of limited-stage SCLC (LS-
SCLC). However, the local failure rate after
chemotherapy and radiotherapy remains high, ranging
from 30% to 70%.
 More effective means are needed to decrease the local recurrence
rate.
 Endobronchial photodynamic therapy (PDT) is used to treat
patients who have central-type lung cancer, with the objective of
palliation in advanced cases and curative intent in patients with
early-stage disease.
  When the extent of the tumour and the depth of the
bronchogenic carcinoma have been evaluated, PDT can be an
effective local treatment modality.
 Moghissietal  reported that 10 of 100 patients with advanced
SCLC underwent PDT for palliation. 
 Katoetal and Okunakaetal  evaluated the effectiveness of PDT in
the treatment of early-stage SCLC. However, none of these
studies detailed a single case of SCLC treated with PDT.
CASE REPORT

 A 51-year-old man presented to Base Hospital delhi cantt

with a 6-month history of worsening dyspnoea on
exertion.
 His symptoms included a nearly constant dry cough,
diminished appetite without weight loss, and fatigue. He
had previously been diagnosed as having diabetes
mellitus with an uncontrolled glucose level and
hypertension.
 The patient was a smoker with a ⩾40 pack-per-year
history.
 The patient had undergone testing at an outside facility
because of his symptoms; a plain chest x ray revealed
opacity in the left lung field (fig 1A). As a result, the
patient was diagnosed with pneumonia and treated with
antibiotics. Despite antibiotic treatment, the resolution of
pneumonic consolidation was delayed. Thus, the patient
was referred to our hospital.
 Chest CT revealed an endobronchial protruding mass in
the distal left main bronchus (LMB) with a near total
collapse of the left lung and a small granuloma in the
posterior segment of the right upper lobe (fig 1B). No
evidence of mediastinal nodal disease or a metastatic
focus was detected. Bronchoscopic examination showed
functional vocal cords and a pedunculated mass in the
LMB (fig 1C).
 Bronchoscopic washing and biopsies failed to
demonstrate a specific cell type. A rigid bronchoscopic
biopsy was performed, and the pathological examination
confirmed the presence of small cell carcinoma based on
immunostaining for CD56, synaptophysin, chromogranin
and leucocyte common antigen (LCA) using the initial
paraffin-embedded biopsy specimen. The results were
consistent with SCLC. CT of the brain was normal.
Therefore, the patient was diagnosed with LS-SCLC.
 Chemotherapy with cisplatin and irinotecan was
initiated, but the chemotherapeutic regimen was changed
to cisplatin and etoposide (EP) after one cycle due to
grade 4 diarrhoea. Concurrent with the second and third
cycles of EP, the total dose of thoracic radiation therapy
was 45.6 Gy in 38 fractions (120 cGy per fraction).
Treatment was given twice daily, at least 6 h apart, on
weekdays. 
 Thoracic radiation therapy was delivered with 6–10 MV
photons using custom-made blocks. With re-expansion
of the lung on plain chest x ray (fig 1D), the patient’s
dyspnoea was found to be greatly improved. Post-
treatment chest CT showed that the endobronchial
protruding mass in the distal LMB was noticeably
smaller, with a residual small soft tissue nodule in the
left upper lobe (fig 1E). Bronchoscopy revealed a
pedunculated mass in the orifice of the lingular division (
fig 1F). 
 To evaluate the size of the tumour and identify any
unknown synchronous cancer, autofluorescence
bronchoscopy was performed. They applied PDT to
remove the remaining tumour completely, because high
dose rate brachytherapy and stereotactic radiation
techniques were not available in their hospital. The
remaining tumour was treated with PDT after wire
basket removal of the pedunculated mass via flexible
bronchoscopy.
 To evaluate the size of the tumour and identify any unknown
synchronous cancer, autofluorescence bronchoscopy was
performed. We applied PDT to remove the remaining tumour
completely, because high dose rate brachytherapy and
stereotactic radiation techniques were not available in our
hospital. The remaining tumour was treated with PDT after
wire basket removal of the pedunculated mass via flexible
bronchoscopy.
  One year after PDT, combined positron emission
tomography (PET) and CT revealed no metabolic evidence of
recurrence. Two years after PDT, chest CT and bronchoscopy
demonstrated a complete response in this patient (fig 1G,H).
The patient refused prophylactic cranial irradiation.
DISCUSSION

 PDT as a local therapeutic modality often results in a CR

of centrally located early-stage lung cancer.
Katoetal reported that PDT resulted in a CR in about
94% of patients with centrally located early lung cancer
(squamous cell type) with a limited longitudinal extent
(<1 cm). Moghissietal suggested that the benefits of PDT
did not differ between patients with SCLC and non-small
cell lung cancer (NSCLC); however, patients with SCLC
may be deprived of PDT because SCLC grows rapidly
and spreads to other organs earlier than NSCLC.
 A combined modality consisting of thoracic radiotherapy
and systemic chemotherapy is widely accepted as the
standard treatment for LS-SCLC. For cases in which a
tumour remains after standard treatment, clinicians
should consider additional treatment modalities,
including pneumonectomy, sleeve lobectomy or
intraluminal brachytherapy. In this study, we had to
consider the specific features of the tumour, which was
located in the bronchial mucosa without invasion into the
cartilaginous layer. Although the adverse effects of PDT
include photosensitivity skin reaction (sunburn) in 5–
28% of cases, respiratory complications in 0–18%. PDT
is a safe method.
 To reduce the local recurrence rate after PDT, both the
extent and the depth of an endobronchial tumour must be
known. Autofluorescence bronchoscopy and
endobronchial ultrasonography (EBUS) may be useful as
additional examination methods.
  PDT should be considered as a treatment option in early
superficial squamous cell carcinoma, especially for
inoperable cases.11 Regarding the extent and depth of an
endobronchial lesion, PDT may be an effective treatment
for superficial airway lesions ⩽1 cm in length, despite a
diagnosis of SCLC.
 In this case, they applied PDT without confirming the
depth of the lesion and without confirming that viable
tumour remained after chemotherapy and radiotherapy,
although radiological findings were highly suggestive of
viable tumour. This case is the first report of the non-
recurrence of SCLC.
 This case suggests that PDT can be effectively used with
curative intent.
THANK YOU
 PRESENTED BY

 A.ABINA SHERIN

 PRESENTING TO

 Mrs.Padamlakshmi M (BIO TEACHER)