Review Question - QID 100924

The patient described in the question stem has small cell lung cancer with ectopic ACTH secretion. The standard of care for patients with small cell lung cancer is chemotherapy with concurrent radiotherapy.

Small cell lung cancer is inoperable. All other subtypes of lung cancer can be treated with surgery when the disease is localized. This type of lung cancer is more common in male smokers and is frequently metastatic before diagnosis. Tumors are typically centrally located, and paraneoplastic syndromes include Lambert-Eaton syndrome, SIADH, or overproduction of ACTH as in this question. On biopsy, tumor cells (Kulchitsky cells) are small, dark blue, and undifferentiated.

Collins et al. review diagnostic evaluation of patients with suspected lung cancer, including tissue diagnosis via sputum cytology, lymph node biopsy, bronchoscopy, transthoracic needle aspiration, or video-assisted thoracoscopy, or thoracotomy depending on the patient's clinical presentation, and the location of the tumor identified on imaging. They emphasize smoking cessation, rather than screening for lung cancer, as a primary objective of lung cancer prevention.

Ferraldeschi et al. review management of small cell lung cancer. They advocate cisplatin + etoposide with radiotherapy for patients with limited disease, with five-year survival of 25% from this approach. Additionally, if patients respond to treatment in this manner, prophylactic cranial irradiation (for distant metastases) should be offered. Initial management of higher grade disease is more complicated.

Illustration A shows the "salt and pepper" pattern of small, basophilic cells in small cell lung cancer.

Incorrect Answers:
Answer 1: Tamoxifen is anti-estrogen chemotherapy for breast cancer.
Answer 2: Steroids such as prednisone are not a cancer treatment.
Answer 3: Surgical resection alone is appropriate for other lung cancers but not small cell lung cancer.
Answer 5: Watchful waiting is not appropriate for aggressive lung cancer.