Small cell carcinoma of the lung diagnostic study of choice

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]Rim Halaby, M.D. [3]

Overview

The confirmation of the diagnosis of SCLC relies on the histopathological findings of the tumor biopsy. All patients with confirmed diagnosis of SCLC by histopathological findings should undergo a CT scan of the abdomen for staging purposes. CT scan of the abdomen helps identify metastasis to organs, such as the liver or the adrenal glands. Staging schemes for small cell lung cancer (SCLC) have been developed by the Veterans Administration Lung Study Group (VALG), the American Joint Committee on Cancer (AJCC), and the National Comprehensive Cancer Network (NCCN).

Diagnostic Study of Choice

Biopsy

• The confirmation of the diagnosis of SCLC relies on the histopathological findings of the tumor biopsy.
• In SCLC, the tumor cells are small and round, but they can sometimes be ovoid or spindle shaped. They have a scant cytoplasm with a high mitotic count and a hyperchromatic nuclei. Nearly all SCLC are immunoreactive for keratin, thyroid transcription factor 1, and epithelial membrane antigen. Neuroendocrine and neural differentiation result in the expression of molecules like dopa-decarboxylase, calcitonin, neuron-specific enolase, chromogranin A, CD56 (also known as nucleosomal histone kinase 1 or neural-cell adhesion molecule), gastrin-releasing peptide, and insulin-like growth factor 1. One or more markers of neuroendocrine differentiation can be found in approximately 75% of SCLC.

Histopathologic image of small cell carcinoma of the lung. CT-guided core needle biopsy. H & E stain.By No machine-readable author provided. KGH assumed (based on copyright claims),via Wikimedia Commons	Micrograph of a small-cell carcinoma of the lung showing cells with nuclear moulding, minimal amount of cytoplasm and stippled chromatin. FNA specimen. Field stain.By No machine-readable author provided. KGH assumed (based on copyright claims), via Wikimedia Commons

CT

Chest CT scan, preferably with intravenous contrast administration, may be helpful in the diagnosis of small cell carcinoma. Findings on CT scan suggestive of small cell carcinoma include:

• Hilar mass
• Mediastinal involvement
• Numerous lymphadenopathy
• Direct infiltration of adjacent structures
• Necrosis
• Hemorrhage
• The most common cause of SVC obstruction is SCLC, because of both compression or thrombosis and or direct infiltration.
• CT is used to stage small cell lung cancer.
• CT scan of the abdomen helps identify metastasis to organs, such as the liver or the adrenal glands.
• Brain imaging is also mandatory for staging however a brain MRI is preferred over brain CT scan due to its superior sensitivity for the detection of brain metastasis.
• PET CT scan should be performed if limited stage small cell lung cancer is suspected.

Staging

The Veterans Administration Lung Study Group (VALG) staging, also known as VA staging, is an old staging system that has been previously used in most clinical trials. Shown below is a table depicting the VA staging system which classifies SCLC into two stages.

Stage	Characteristics
Limited SCLC	Limited SCLC is characterized by the strict involvement of the ipsilateral lung.
Extensive SCLC	Extensive SCLC extends beyond the ipsilateral lung and may involve the contralateral lung, or can be associated with pleural effusion, pericardial effusion, or hematogenous spread.

AJCC and TNM Staging

Shown below is a table summarizing the staging of lung cancer according to the American Joint Committee on Cancer (AJCC). This staging scheme is the same for both SCLC and non small cell lung cancer.

For more information about the TNM staging, click here.

Stage	T	N	M
Occult carcinoma	TX	N0	M0
Stage 0	Tis	N0	M0
Stage IA	T1	N0	M0
Stage IB	T2	N0	M0
Stage IIA	T1	N1	M0
Stage IIB	T2	N1	M0
	T3	N0	M0
Stage IIIA	T1, T2	N2	M0
	T3	N1, N2	M0
Stage IIIB	Any T	N3	M0
	T4	Any N	M0
Stage IV	Any T	Any N	M1

NCCN Staging

The National Comprehensive Cancer Network (NCCN) staging system combines the staging scheme of the AJCC and that of the VALG. Although the AJCC staging scheme is newer than that of the VALG, clinicians commonly use the VALG staging system because it has been commonly referred to in clinical trials. Shown below is a table depicting the NCNN staging which classifies SCLC into two stages.

Stage	Characteristics
Limited SCLC	Limited SCLC includes lung cancer cases of stage I, II, or III which can be treated with radiation therapy. This stage does not include tumor T3 or T4 with multiple lung nodules, as well as tumor or lymph nodes that are too large to fit in the radiation plan.
Extensive SCLC	Extensive SCLC includes all SCLC categorized as stage IV, or Tumor T3 or T4 with multiple lung nodules, or Tumor or lymph nodes that are too large to fit in the radiation plan

References

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