Features of the course of small cell lung cancer: methods of diagnosis and treatment. Small cell lung cancer Localized small cell cancer prognosis stage 2

The disease, expressed by strong tumor growth and an increase in malignant cells in the lungs of a person, as a rule, implies stage 4 lung cancer and, unfortunately, the prognosis for it is unfavorable. With grade 4 cancer, extensive metastases are formed that grow beyond the lung, affect the lymph nodes, enter the liver, bone tissue, kidneys, and the human brain. As a result of this, the bronchial walls are affected, the mucous membrane and blood vessels are destroyed, more and more often pains appear in the chest. The pain that occurs in such cases is very closely related to the damage to the tissues adjacent to the lungs - oddly enough, the lung tissue itself does not have pain receptors.

The picture of the disease is very pronounced: paroxysmal, hysterical cough with the presence of blood secretions in the sputum. Shortness of breath, angina pectoris develops, heart rhythm is disturbed.

Prognosis for non-small cell cancer

There are several types of lung cancer, these include:

Non-small cell lung cancer - malignant tumors formed from the tissues of the epithelium. In 90% of affected men and 80% of women, the disease occurs due to smoking. There are currently 3 types of non-small cell cancer:

1. Squamous cell carcinoma is the most common, growing in the tissues of the respiratory tract.
2. Adenocarcinoma occurs in the tissues of the glands. Often found in people who do not smoke cigarettes and women.
3. Large cell (undifferentiated carcinoma) is called cancer due to the fact that cancer cells are clearly visible under a microscope. This disease can affect different parts of the body. One person out of ten gets sick.

Symptoms of the disease:

• cough;
• difficulty breathing, even without exertion;
• sputum with an admixture of bloody bodies;
• hoarseness;
• chest pain;
• lack of appetite, fatigue, the weight of a person decreases uncontrollably;
• violation of the swallowing reflex;
• swelling of the face of the body.

The prognosis for stage 4 non-small cell lung cancer is disappointing, since usually the disease already affects both lungs and metastasizes to other organs. 60% of cases are detected very late, the life span of patients for 5 years is no more than 17%. Squamous cell lung cancer arises from flat cells of the epithelium of the bronchi (which are not normally present).

As a rule, smokers and workers in hazardous industries get sick with cancer.

In addition, a number of other reasons affect the occurrence of squamous cell carcinoma:

1. Dust and gas pollution in the air in large cities.
2. Work in the radioactive zone.
3. Frequent diseases of pneumonia, bronchitis, tuberculosis.

The disease is most often detected in people 40-50 years of age, and men are more likely to get sick.

1. The reason for this is:
2. marginal lifestyle.
3. Poor quality food.
4. Lack of vitamins in food.
5. Heredity.

Signs of the disease:

1. Lethargy and lack of interest in life are often mistaken for another disease.
2. Unreasonable, instant weight loss.
3. Constant low temperature.

The prognosis for stage 4 squamous cell lung cancer is unfavorable - it is incurable, since metastases penetrate almost all internal organs and poisoning of the body begins. The organs necessary for human life do not cope with their functions and the person fades away.

Prognosis for small cell carcinoma

Small cell lung cancer stage 4 prognosis: life expectancy without therapy is from 6 to 18 weeks. This tumor is the aggressor. The focus spreads throughout the body with great speed. The characteristic signs of the disease are the same as in other types of cancer, with the addition of speech impairment and headache attacks.

Has two forms:

1. Small cell carcinoma is often an irreversible process that develops at lightning speed and attacks extensively.
2. Combined small cell carcinoma - includes a type of adenocarcinoma with signs of squamous cell and oat cell carcinoma.

Small cell lung cancer is a malignant tumor that occurs due to changes in the cells of the lining of the lungs and airways. It occupies a leading position among the window diseases in men.

It is difficult to diagnose and even more difficult to treat. The disease is characterized by a high rate of tumor growth to neighboring organs and, in the absence of therapy in the early stages, death.

Causes

• Smoking. The older the person and the duration of their nicotine habit, the more likely they are to develop cancer. In this regard, the number of women with this disease is growing;
• For prevention, you can quit addiction, which will reduce the chance of lung cancer, but this will not give a 100% guarantee. A former smoker will always be at risk;
• hereditary predisposition. If there have ever been relatives with this disease, this will affect the possibility of cancer. The gene remains in the blood and can pass oncology by inheritance;
• Poor environment and working conditions. Dust, factory waste, poisonous gases, a large number of cars pollute the air and enter the lungs. Work associated with heavy metals and arsenic also puts a person at risk. These primarily include welders, chemists, and people holding positions in an electronics and glass manufacturing plant;
• Tuberculosis and COPD. Cancer can develop against the background of these diseases;

Symptoms

Small cell lung cancer at the first stage does not bring much discomfort and is not characterized by obvious signs. It can be diagnosed at this stage only by taking an X-ray photograph.

In the largest risk group, men aged 40-60 years.

At the first stage, the disease affects the large bronchi, then the lymph nodes and neighboring organs.

Cancer has 4 stages:

• I stage. It is characterized by a 3 cm tumor located in one area of ​​the lung, there are no metastases;
• II stage. The tumor grows up to 6 cm, there are separate metastases that can spread to the lymph nodes;
• III stage. There is a growth of the tumor in neighboring areas. All bronchi are affected;
• IV stage. Cancer captures other organs, extensive metastasis occurs;

According to statistics, in 6 out of 10 people this type of cancer is diagnosed at stages 3 and 4.

First symptoms:

• Prolonged cough. Many people do not pay attention to it, since this is a characteristic phenomenon for smokers.
• Dyspnea. It occurs due to the problem of air entering the lungs and disruption of their work.
• Weight loss for no reason.
• The lack of desire is.
• Weakness and fatigue.

Symptoms in the second and third stages:

• Cough with mixture of sputum and blood.
• Constant pain in the chest and lungs when trying to breathe.
• Pneumonia, a sharp increase in temperature.
• Strong headache.
• Hoarseness, loss or change in voice.
• Bleeding lungs.
• Frequent fever.

Fourth stage

This stage is characterized by metastases that affect neighboring organs. They cause: pain in the spine and ribs, difficulty swallowing, swelling of the extremities, jaundice (when spread to the liver, prolonged hiccups, epilepsy and loss of consciousness (when brain areas are affected).

Timely recognition of symptoms will increase the possibility of getting rid of cancer. The first degrees of the disease are treatable, while stages 3-4 are much less likely.

Diagnostics

Smokers need to be periodically screened for cancer. The first necessary procedure is fluorography, which will show changes in the lungs. The second stage is a comprehensive blood test. Then, bronchoscopy, where the degree of lung damage will be revealed. Next, a biopsy is performed in order to take a sample of the tumor and determine its nature. At the last stage, you will have to undergo several types of tomography, which will determine the stage of cancer and the exact location of the disease. Based on all tests and procedures, further treatment will be prescribed.

Treatment

The treatment plan is determined based on the individual characteristics of the patient, the stage of the disease and general well-being.

There are three main methods that are prescribed individually or in combination:

1. Removal of the tumor by surgery.
2. Chemotherapy.
3. Radiotherapy.

Surgical removal of the tumor is possible only at the first stage of the development of the disease and in the absence of its spread to neighboring organs and the trachea. At the same time, the lymph nodes are also removed to check them in the future. However, this method is rarely used, since cancer is usually diagnosed at a later stage.

Chemotherapy is mandatory at any stage. Without it, within 1-4 months after the discovery of the disease, a fatal outcome will occur. It is prescribed to inhibit the growth and destruction of cancer cells.

Chemotherapy is prescribed only after a thorough diagnosis of cancer and the absence of a possible error in the definition of the disease. It can only be done if:

• There are no bone marrow disorders.
• The person is efficient and able to endure the course of treatment.
• The patient had never received either radiation or chemotherapy.
• There is no hypercapnia, which is characterized by an increased level of carbon dioxide in the blood.
• There are no chronic and severe diseases. The presence of any type of insufficiency (cardiac, hepatic, etc.) is a contraindication to this type of treatment.

Chemotherapy includes taking drugs such as:

• Cyclophosphamide;
• Bleomycin;
• Adriamycin;
• Carboplatin;
• Etopizide;
• Ciplatin;
• Phosphamine Methotrexate;
• Avastin and others

This is a range of hormonal, analgesic, alkylating and metabolic slowing drugs. The course of admission is designed for 1-2 months with interruptions, for remission you need to take drugs in seven approaches, but not more than six months. The specific amount is determined by the doctor.

If the patient's health worsens, then the dose of drugs is reduced.

Chemotherapy can increase the life of a patient in the last stage of cancer, but it does not ensure the complete disappearance of the disease.

Radiation or otherwise radiotherapy is most effective during the first stages of taking chemicals. It is the treatment of affected areas with X-rays or gamma rays, which destroys or stops the growth and development of cancer cells.

This method can be used for tumors of the lung, lymph nodes, or if it is impossible to carry out another method of treatment due to serious human diseases.

Radiation therapy is performed externally using a linear particle accelerator.

If none of the options has worked, palliative care is used to support the physical and psychological state of the person.

Lifespan

This type of disease is more susceptible to radiation and chemotherapy compared to other forms of cancer. With surgical treatment, the chances of getting rid of it are significantly increased.

At stages 1 and 2, the number of patients who have overcome small cell lung cancer is about 80%. The life span without therapy is 3 years. Relapse may occur after 6 years.

At stages 3 and 4 without treatment, it is almost impossible to live longer than two years. When using therapy - 4-5 years. The number of survivors is only 10%.

Lung cancer is one of the most severe types of cancer with a rapid progression of symptoms. To prevent its occurrence, you need to quit smoking, undergo preventive examinations and carefully listen to your body. It must be remembered that the earlier cancer is detected, the higher the chance of curing it.

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Small cell lung cancer (SCLC), which accounts for 18-30% of all histological forms of this disease, has attracted more and more attention from researchers of various specialties in recent decades.

A quarter of a century ago, small cell lung cancer was singled out as a separate nosological unit due to the biological properties of the neoplasm, the characteristics of the clinical course (rapid progression of the process), extreme malignancy, a tendency to early metastasis, high sensitivity to drug and radiation exposure, expanding diagnostic capabilities and constantly changing views. for treatment tactics.

The biological characteristics of a tumor are known to be determined volume doubling time (VDO) and a tendency to lymphohematogenous metastasis.

For small cell lung cancer, the SVR is on average 33 days, for squamous and glandular cancers - 103 and 189 days, respectively.

In tissue culture, the volume of this tumor doubles within 1 day. In small cell carcinoma, more often than in other histological forms of lung cancer, metastases are detected in the intrathoracic lymph nodes and distant organs.

Almost 2/3 of patients with small cell lung cancer have signs of metastasis already at the first visit, 10% have metastases in the brain (Bunn R.A., 1992).

Features of small cell lung cancer

Similar features of small cell lung cancer are reflected in the features of its course and clinical manifestations. This form of lung cancer is characterized by a short history, a variety of clinical symptoms at the time of diagnosis, due to the significant spread of the process, a high frequency of paraneoplastic syndromes (increased secretion of serotonin, adrenocorticotropic and antidiuretic hormones, calcitonin, somatostatin, etc.).

Studies conducted in recent years have made it possible to clarify a number of neuroendocrine characteristics of small cell lung cancer and to identify markers used to monitor the course of the disease.

CYFRA-21-1 markers have the greatest practical significance in the dynamic monitoring of patients with SCLC, neuron-specific enolase (NSE) and cancer embryonic antigen (CEA).

The importance of "antioncogenes" (tumor suppressor genes) in the development of small cell lung cancer has been shown, and the factors playing a role in its occurrence have been identified.

A number of monoclonal antibodies to surface antigens of small cell lung cancer cells have been isolated, but so far the possibilities of their practical application are limited to the identification of micrometastases in the bone marrow (Goncharskaya M.A. et al., 1991; Lederman J.A., 1994).

The clinical picture of the disease is represented by all the symptoms characteristic of lung cancer, which are more pronounced, accompanied by intoxication and often effusion in the serous cavities.

The erroneous opinion was affirmed that small cell lung cancer is a relatively small primary tumor with an extensive metastatic component in the intrathoracic lymph nodes, which is almost a pathognomonic sign, as well as early and extensive distant metastasis.

The exceptionally malignant course of the disease made it possible to consider small cell lung cancer as a primary generalized process, in which conservative antitumor treatment is the method of choice. To a large extent, this was facilitated by an exaggerated opinion about the extreme sensitivity of such tumors to radiation and chemotherapeutic effects.

Clinical Observations

In MNIOI them. P.A. Herzen surgical treatment was carried out in more than 150 patients with small cell lung cancer. A morphological study of the removed preparations made it possible to study the dependence of the frequency and nature of intrathoracic lymph node lesions on the size of the primary tumor and the histological subtype of small cell lung cancer.

Contrary to popular belief, 25% of operated patients had no metastases in intrathoracic lymph nodes. It should be noted that in most of them, the size of the primary tumor corresponded to T2 and T3, i.e. there was a lesion of the main bronchus in case of central cancer or the diameter of the tumor was more than 6 cm and it grew into neighboring organs in case of peripheral cancer.

In addition, 40.4% of patients had metastatic lesions of only bronchopulmonary lymph nodes or lung root (N1), despite the large size of the primary tumor (T2-3).

These data confirm the fact that small cell lung cancer also has a locoregional stage of development, which determines the treatment strategy. This makes it possible to carry out active diagnostic measures and radical treatment, to detect small cell carcinoma at a relatively early stage, and allows us to recommend using the International classification according to the TNM system to indicate the prevalence of the tumor process and with a given histological structure of lung cancer, especially in surgical patients.

At the same time, there is a need to revise the generally accepted staging scheme for small cell lung cancer. The detection of metastases in 70-90% of patients with stage III-IV SCLC allowed the Veterans Administration Lung Cancer Study Group back in 1973 to propose the following systematization: "localized process" - damage to the hemithorax, ipsilateral mediastinal and supraclavicular lymph nodes, contralateral root nodes, specific exudative pleurisy on the affected side; "common process" - the defeat of both lungs, metastases in distant organs and / or supraclavicular lymph nodes on the opposite side.

Subsequently, this systematization was corrected. G. Abrams et al. (1988) proposed to attribute the defeat of the contralateral root lymph nodes to a "common process", and R. Stahel et al. (1989), K.S. Albain et al. (1990) - exclude ipsilateral pleurisy from the category of "localized process".

This, even improved, scheme of division of small cell lung cancer distracts clinicians and oncologists from a possible solution to the problem of early diagnosis and more effective treatment of this formidable disease.

Meanwhile, many years of research conducted at the Moscow Research Institute of P.A. Herzen, showed that small cell lung cancer can also be diagnosed in stages I-II of development, which determine the possibility of surgical treatment of this group of patients in combination with adjuvant polychemotherapy (Trachtenberg A.Kh. et al., 1984, 1987, 1992).

Later, many domestic and foreign surgeons came to this conclusion (Zharkov V. et al., 1994; Ginsberg R.G., 1989; Karrer K. et al., 1989; Shepherd F.A. et al., 1991; Muller L.C. et al., 1992 ; Davis S. et al., 1993; Wada H. et al., 1995; Shields Th., Karrer K., 1998).

We have established a clear relationship between the frequency and nature of lesions of the intrathoracic lymph nodes on the size of the primary tumor. So, with a primary tumor corresponding to T1, metastases in the intrathoracic lymph nodes were found in 33.3% of patients, T2 - in 68.6%, T3 - in 85% and T4 - in all patients (Fig. 10.1).

Rice. 10.1. The frequency of lesions (in percent) of the intrathoracic lymph nodes in small cell (a) and large cell (b) lung cancer, mediastinal (c) and (d), respectively, depending on the size of the primary tumor (T).

In the primary tumor corresponding to T1, there were no metastases in the lymph nodes of the mediastinum (N2), with T2 the incidence of these nodes was 26%, with T3 - 60%, with T4 - 75%.

Thus, even with a primary tumor corresponding to T3, 15% of patients had intact intrathoracic lymph nodes, 25% had first barrier nodes (N1) affected, and 40% had no metastases in the mediastinal lymph nodes. The frequency of SCLC metastasis to the intrathoracic lymph nodes is higher than in undifferentiated large cell carcinoma.

Indications for surgery

If a mild metastatic lesion of the mediastinal lymph nodes (stage IIIA) is confirmed during the examination of patients with small cell lung cancer, surgery is also not excluded from the plan for possible combined treatment after neoadjuvant chemotherapy.

The operation is performed according to indications, depending on the direct effect of chemotherapy, in connection with which a new term appeared in the English literature - adjuvant surgical treatment (Feld R., Ginsberg R.J., 1995).

In multicomponent therapy, the surgical method is also used for resectable forms of small cell lung cancer in the absence of the effect of chemoradiotherapy, which suggests a combined tumor subtype, i.e. the presence of di- or trimorphic cancer (combination of small cell with other histological structures) or local intrathoracic recurrence after conservative treatment - salvage surgery (Shepherd F.A. et al., 1991).

The nature and frequency of metastasis to the intrathoracic lymph nodes depend on the subtype of small cell lung cancer: with an intermediate cell subtype, mediastinal lymph nodes were affected in 38.4% of patients, oat cell - in 59% and combined - in 57%. The established dependence of lymph node damage on the size of the primary tumor and the subtype of small cell carcinoma is confirmed by the results of treatment.

Clinical characteristics of patients with small cell lung cancer, X-ray and endoscopic semiotics, features of the course of the disease are described in the previous sections. For the diagnosis of lung cancer of this histological type, conventional methods are usually used.

Given the tendency of the tumor to massive metastasis, it is necessary to conduct a detailed study of regional lymph nodes with transtracheobronchial puncture during bronchoscopy, ultrasound examination (ultrasound) abdominal cavity, bone scintigraphy, CT scan (CT) of the brain, sternal puncture, and, according to indications, apply other methods for determining the prevalence of the tumor process, including surgical ones (parasternal mediastinotomy, mediastinoscopy, thoracoscopy, etc.).

Until recently, most publications have been devoted to evaluating the effectiveness of various methods of conservative treatment - chemotherapy and its combination with radiation therapy.

Many domestic and foreign oncologists used to believe that, due to the high malignancy of small cell carcinoma, the nature of metastasis, and poor prognosis, the diagnosis of this disease is a contraindication to surgical treatment.

Small cell carcinoma was considered "therapeutic", fueled by the notion of its relatively higher sensitivity to radiation exposure and the effects of anticancer drugs.

However, total tumor regression in the locoregional zone requires high total doses. Even when the dose is increased to 60-64 Gy, complete tumor regression can be achieved only in 65% of patients. This is due to the fact that in small cell carcinoma the tumor population is heterogeneous.

It contains a pool of cells resistant to ionizing radiation and chemotherapeutic effects and retaining the ability to repopulate even after summing up the so-called carcinocidal doses.

All this necessitates a critical rethinking of traditional guidelines for antitumor therapy of small cell lung cancer with an assessment of the feasibility of using methods of local exposure and determining the indications for their use.

In the "common" form of the disease, conservative treatment is usually used -

In the structure of oncological diseases, lung cancer is one of the most common pathologies. It is based on a malignant degeneration of the epithelium of the lung tissue, a violation of air exchange. The disease is characterized by high mortality. The main risk group is smoking men aged 50-80 years. A feature of modern pathogenesis is a decrease in the age of primary diagnosis, an increase in the likelihood of lung cancer in women.

Small cell carcinoma is a malignant tumor that has the most aggressive course and widespread metastasis. This form accounts for about 20-25% of all types. Many scientific experts regard this type of tumor as a systemic disease, in the early stages of which, it is almost always present in the regional lymph nodes. , suffer from this type of tumor most often, but the percentage of cases is growing significantly. Almost all patients have a fairly severe form of cancer, this is due to the rapid growth of the tumor and widespread metastasis.

Small cell lung cancer

Causes of small cell lung cancer

In nature, there are many reasons for the development of a malignant neoplasm in the lungs, but there are the main ones that we encounter almost every day:

• smoking;
• exposure to radon;
• asbestosis of the lungs;
• viral damage;
• dust impact.

Clinical manifestations of small cell lung cancer

Symptoms of small cell lung cancer:

• a cough of a prolonged nature, or a newly appeared cough with changes in the patient's usual;
• lack of appetite;
• weight loss;
• general malaise, fatigue;
• shortness of breath, pain in the chest and lungs;
• voice change, hoarseness (dysphonia);
• pain in the spine with bones (occurs with bone metastases);
• epileptic seizures;
• lung cancer, stage 4 - there is a violation of speech and severe headaches appear.

Grades of small cell lung cancer

• Stage 1 - the size of the tumor in diameter up to 3 cm, the tumor affected one lung. There is no metastasis.
• Stage 2 - the size of the tumor in the lung is from 3 to 6 cm, blocks the bronchus and grows into the pleura, causing atelectasis;
• Stage 3 - the tumor rapidly passes into neighboring organs, its size has increased from 6 to 7 cm, atelectasis of the entire lung occurs. Metastases in neighboring lymph nodes.
• Stage 4 small cell lung cancer is characterized by the spread of malignant cells to distant organs of the human body and causes symptoms such as:

1. headache;
2. hoarseness or even loss of voice;
3. general malaise;
4. loss of appetite and a sharp decrease in weight;
5. back pain, etc.

Diagnosis of small cell lung cancer

Despite all the clinical examinations, history taking and listening to the lungs, quality is also needed, which is carried out using methods such as:

• skeletal scintigraphy;
• chest x-ray;
• detailed, clinical blood test;
• computed tomography (CT);
• liver function tests;
• magnetic resonance imaging (MRI)
• positron emission tomography (PET);
• sputum analysis (cytological examination to detect cancer cells);
• pleurocentesis (fluid collection from the chest cavity around the lungs);
• - the most common method for diagnosing a malignant neoplasm. It is carried out in the form of removal of a particle of a fragment of the affected tissue for further examination under a microscope.

There are several ways to perform a biopsy:

• bronchoscopy combined with biopsy;
• carried out with the help of CT;
• endoscopic ultrasound with biopsy;
• mediastinoscopy combined with biopsy;
• open lung biopsy;
• pleural biopsy;
• videothoracoscopy.

Treatment of small cell lung cancer

The most important place in the treatment of small cell is chemotherapy. In the absence of appropriate treatment for lung cancer, the patient dies 5-18 weeks after diagnosis. To increase the mortality rate to 45 - 70 weeks, polychemotherapy helps. It is used both as an independent method of therapy, and in combination with surgery or radiation therapy.

The goal of this treatment is complete remission, which must be confirmed by bronchoscopic methods, biopsy and bronchoalveolar lavage. As a rule, the effectiveness of treatment is assessed after 6-12 weeks, after the start of therapy, also, according to these results, it is possible to assess the likelihood of a cure and the patient's life expectancy. The most favorable prognosis is in those patients who have achieved complete remission. This group includes all patients whose life expectancy exceeds 3 years. If the tumor has decreased by 50%, while there is no metastasis, it is possible to talk about partial remission. Life expectancy is correspondingly less than in the first group. With a tumor that is not amenable to treatment and active progression, the prognosis is unfavorable.

After a statistical study, the effectiveness of chemotherapy was revealed and it is about 70%, while in 20% of cases a complete remission is achieved, which gives survival rates close to those of patients with a localized form.

limited stage

At this stage, the tumor is located within one lung, and nearby lymph nodes may also be involved.

Applied methods of treatment:

• combined: chemo+radiotherapy followed by prophylactic cranial irradiation (PKO) in remission;
• chemotherapy with or without PCR, for patients who have impaired respiratory function;
• surgical resection with adjuvant therapy for stage 1 patients;
• combined use of chemotherapy and thoracic radiotherapy is the standard approach for patients with limited stage, small cell LC.

According to the statistics of clinical studies, combination treatment compared with chemotherapy without radiation therapy increases the 3-year survival prognosis by 5%. Drugs used: platinum and etoposide. Prognostic indicators for life expectancy are 20-26 months and a 2-year survival forecast of 50%.

Inefficient ways to increase forecast:

• increasing the dose of drugs;
• action of additional types of chemotherapy drugs.

The duration of the course of chemotherapy is not defined, but, nevertheless, the duration of the course should not exceed 6 months.

The question of radiotherapy: many studies show its benefits in the period 1-2 cycles of chemotherapy. The duration of the course of radiation therapy should not exceed 30-40 days.

maybeapplication of standard irradiation courses:

• 1 time per day for 5 weeks;
• 2 or more times a day for 3 weeks.

Hyperfractionated thoracic radiotherapy is considered preferable and contributes to a better prognosis.

Patients of older age (65-70 years) tolerate treatment much worse, the prognosis of treatment is much worse, as they respond quite poorly to radiochemotherapy, which in turn manifests itself in low efficiency and large complications. Currently, the optimal therapeutic approach for elderly patients with small cell carcinoma has not been developed.

Patients who have achieved tumor remission are candidates for prophylactic cranial irradiation (PCR). The research results indicate a significant reduction in the risk of brain metastases, which without the use of PKO is 60%. RCC improves the prognosis of 3-year survival from 15% to 21%. Frequently, survivors show impairments in neurophysiological function, but these impairments are not associated with the passage of PCR.

extensive stage

The spread of the tumor occurs outside the lung in which it originally appeared.

Standard methods of therapy:

• combined chemotherapy with or without prophylactic cranial irradiation;
• +

  Note! The use of higher doses of chemotherapy drugs remains an open question.

  For a limited stage, in case of a positive response to chemotherapy, an extensive stage of small cell lung cancer, prophylactic cranial irradiation is indicated. The risk of formation of metastases in the CNS within 1 year is reduced from 40% to 15%. There was no significant deterioration in health after PKO.

  Combined radiochemotherapy does not improve the prognosis compared to chemotherapy, but thoracic irradiation is reasonable for palliative therapy of distant metastases.

  Patients diagnosed with an advanced stage have a deteriorating state of health that complicates aggressive therapy. Conducted clinical studies have not revealed an improvement in survival prognosis with a decrease in drug doses or with the transition to monotherapy, but, nevertheless, the intensity in this case should be calculated from an individual assessment of the patient's health status.

  Disease prognosis

  As mentioned earlier, small cell lung cancer is one of the most aggressive forms of all. What prognosis of the disease and how long patients live depends directly on the treatment of oncology in the lungs. A lot depends on the stage of the disease, and what type it belongs to. There are two main types of lung cancer - small cell and non-small cell.

  Small cell lung cancer affects smokers, it is less common, but spreads very quickly, forming metastases and capturing other organs. Is more sensitive to chemical and radiation therapy.

  Life expectancy in the absence of appropriate treatment is from 6 to 18 weeks, and the survival rate reaches 50%. With appropriate therapy, life expectancy increases from 5 to 6 months. The worst prognosis is in patients with a 5-year illness. Approximately 5-10% of patients remain alive.

  Informative video

  In the WHO histological classification of lung tumors (1981), small cell carcinoma is represented by three variants: oat cell carcinoma, intermediate cell carcinoma, and combined oat cell carcinoma. The small-cell type accounts for 1-4% of all epithelial neoplasms of the trachea and is a highly malignant tumor consisting of small rather uniform cells with scanty cytoplasm and delicate chromatin diffusely distributed throughout the nucleus, sometimes hypertrophied nucleoli are detected.

  As a rule, no signs of differentiation are detected in tumor cells during a light-optical study, although in some cases single or small groups of cells are found with signs of squamous epithelial or glandular differentiation during electron microscopy. This group of tumors is also characterized by the production of various hormones, such as ACTH, serotonin, antidiuretic hormone, calcitonin, growth hormone, melanocyte-stimulating hormone, estrogen.

  In recent years, it has been especially emphasized in the literature that the group of small cell carcinoma is heterogeneous and is represented by variants that differ in the nature of growth, antigenic composition, production of biomarkers, cytogenetic features, expression and amplification of oncogenes, and different sensitivity to antitumor therapy. The most common and characteristic biological sign is the production of 4 markers in cells, two of which are enzymes of the APUD system (L-DOPA-decarboxylase, neuron-specific enolase), the rest are the peptide hormone bombesin (gastrin-releasing peptide) and BB isoenzyme creatine kinase.

  Small cell carcinoma is characterized by a pronounced tendency to metastasize already in the early stages of tumor development, a poor prognosis and a short life expectancy of patients.

  Thus, small cell tracheal cancer is characterized by the presence of the following main features: small cell size, absence of light-optical signs of differentiation, rapid growth, early and extensive metastasis, high sensitivity to specific therapy, the presence of specific biomarkers, production of various hormones. The first five features distinguish small cell carcinoma from hormone-producing non-small cell types of tracheal cancer and carcinoids.

  Currently, there are two points of view regarding the histogenesis of small cell carcinoma of the respiratory tract.

  According to the first hypothesis, small cell carcinoma develops from cells of the diffuse endocrine system (APUD system), which in the embryonic period migrate to the lungs from the neural crest.

  The second hypothesis states that this group of tumors arises from cells of the bronchial lining, which are of endodermal origin and have the same morphological and biochemical features as small cell carcinoma cells.

  Proponents of the first point of view substantiate their hypothesis by the fact that morphological structures (neuroendocrine granules ranging in size from 50 to 500 nm) are found in the elements of small cell respiratory tract cancer, as well as biochemical markers inherent in the cellular elements of the APUD system, the origin of which is associated with the neural crest. In humans, the presence of such cells in the bronchial glands, large bronchi and bronchioles has been proven. These data led to the widespread opinion that small cell carcinoma of the trachea belongs to tumors of the APUD system and is an extremely aggressive type of malignant carcinoid. At the same time, it is postulated that neuroendocrine differentiation is inherent only in cells that are derivatives of the neural crest.

  Proponents of the second hypothesis believe that small cell carcinoma of the trachea, like other histological types, develops from cells of endodermal origin. This hypothesis is confirmed by the presence in the elements of small cell respiratory tract cancer of common features characteristic of all histological types, the difference between small cell carcinoma of the trachea and other neuroendocrine neoplasms. In addition, experimental data indicate that signs of neuroendocrine differentiation may also be inherent in cellular elements of endodermal origin.

  In recent years, a number of experimental studies have shown that enterochromaffin cells of the gastrointestinal tract, islet cells of the pancreas, previously considered to be derivatives of the neuroectoderm, actually have an endodermal origin, which is common with other epithelial elements of these systems.

  It is currently believed that the APUD cells of the gastrointestinal tract are not derived from the neural crest. So far, we do not have convincing data on the migration of neural crest cells into the trachea. At the same time, neuroendocrine granules are often found in mucus-producing cells of the normal bronchial lining. However, the possibility of migration of neuroectoderm elements into the trachea cannot be completely denied, since the development of such a tumor in the trachea as melanoma testifies in favor of this.

  To the above facts, it should be added that small cell carcinoma of the trachea differs significantly from carcinoid (including its atypical variety) by etiological factors (smoking, radiation exposure, exposure to chloro-methyl-methyl ether). Often, in small cell carcinoma of the trachea, tumor elements with neuroendocrine differentiation are combined with non-endocrine malignant cells with signs of squamous epithelial or glandular differentiation (G. Saccomano et al., 1974). Such heterogeneity may indicate the presence of a single stem cell for all types of tracheal cancer (A. Gazdar et al., 1985).

  At the same time, heterogeneity is not typical for tumors of the APUD system. Small cell airway cancer usually does not occur as a manifestation of multiple endocrine neoplasia syndrome. With regard to the morphological similarity of small cell tracheal cancer with other tumors of the APUD system, neuroendocrine granules are also detected in a small number of tumor cells of non-small cell airway cancer, the number of granules in small cell type cells is smaller and they are small in size. It is important to emphasize that the cellular elements of many tumors, clinically and morphologically regarded as small cell tracheal cancer, do not contain neurosecretory granules at all, but have well-developed desmosomes and tonofilaments, that is, in fact, they are poorly differentiated squamous cell forms of cancer (Mackay et al., 1977). In addition, it has been shown that the secretion of hormones is inherent not only in small cell, but also in other types of respiratory tract cancer.

  Thus, there are currently no sufficiently convincing data indicating the priority of the first or second hypothesis. In this regard, small cell carcinoma of the trachea should be considered as a type of bronchogenic cancer originating from the bronchial epithelium, but having biochemical and ultrastructural features similar to tumors of the APUD system.

  Cytological characterization. In the study of sputum, the most characteristic cytological sign of small cell carcinoma is the small size of tumor cells (about 1.5-2 times larger than a lymphocyte), located either in the form of massive clusters or in chains (“goosebumps”) along the strands of mucus (Fig. 18). In the bronchoscopic material, peculiar clusters of tumor cells are often found. Cell nuclei are round, oval, semi-lunar or irregularly triangular in shape with the presence of flattening or depressions on the adjacent surfaces of neighboring cells, designated as “facets” or “congruent areas”. This feature can be considered pathognomonic for small cell carcinoma.

  It is important to note that the use of different stains (tissue or hematological) gives different staining results for nuclear chromatin. When stained according to the Papanicolaou method (or its modifications), the nuclei of elements of small cell carcinoma are hyperchromic with reticulated or coarse-grained chromatin. When stained by the Pappenheim method, the chromatin in the nuclei appears finely dispersed, the nuclei are pale, optically empty. It is this feature that makes it possible to reliably distinguish this tumor from poorly differentiated squamous cell carcinoma. The rim of the cytoplasm is very narrow, in most tumor cells it is practically not detected. Particular difficulties arise in the differential diagnosis of this form of cancer with the lymphoblastic variant of lymphosarcoma in cases where there is a metastatic lesion of the mediastinal lymph nodes without a primary focus identified in the trachea.

  Another variant of small cell carcinoma is intermediate cell type cancer. We diagnose this variant when the material is represented by anaplastic tumor cells, the nuclei of which are approximately equal in size to the nuclei of oat cell carcinoma, but the chromatin is more compact, granular or stranded, and the rim of the cytoplasm is rather wide. In the cells of this tumor, as a rule, a large number of pathological mitoses, which distinguishes it from poorly differentiated squamous cell carcinoma. It should be emphasized that in metastatically affected lymph nodes of the mediastinum in oat cell carcinoma, areas of cancer are often found, consisting exclusively of cells of an intermediate type.

  The cytological characterization of combined oat cell carcinoma is based on the simultaneous presence of features characteristic of oat cell carcinoma and squamous cell carcinoma or adenocarcinoma.

  Histological characteristics. Oat cell carcinoma consists of rather monomorphic, small-sized cells of a round, polygonal or elongated shape (Fig. 19). However, there may be mild polymorphism in cell size and shape. As a rule, cells are twice as large as a lymphocyte, contain a centrally located nucleus with fine chromatin and inconsistent nucleoli. Individual cells have denser hyperchromic nuclei, especially in fields with degenerative and necrotic changes. The cytoplasm is sparse, usually basophilic. Despite rapid tumor growth, mitosis is rare.

  Cellular elements are located, as a rule, loosely, the stroma is scanty, there is no lymphocytic or other inflammatory infiltration, even in areas with necrotic changes. Usually the tumor grows in the form of wide strands, in some areas there is the presence of trabecular, alveolar structures or palisade-shaped cells around delicate blood vessels - pseudorosettes. Necrotic and degenerative changes in the tumor have a characteristic appearance: along the walls of blood vessels and other connective tissue structures, there is an accumulation of basophilic substance due to the deposition of nuclear material, which is not found in other types of cancer and carcinoids.

  Intermediate-type cancer is represented by rather polymorphic tumor elements of a polygonal or spindle shape, larger than in classical small cell cancer, the cell size is three times larger than a lymphocyte. The nuclei of these cells contain a noticeable amount of clumps of chromatin and unstable nucleoli. Some cells have scant cytoplasm, while others have a more pronounced soft basophilic or light-optically transparent cytoplasm. In cells of this type, pronounced mitotic activity is noted.

  In separate neoplasms, along with small cell carcinoma, areas can be detected where tumor elements have the structure of squamous or glandular cancer of various differentiation - combined oat cell carcinoma.

  The greatest difficulties in the differential diagnosis of small cell tracheal cancer with other histological types arise when evaluating bronchobiopsy material, where tumor elements, due to their high sensitivity to mechanical stress, can be severely destroyed and resemble lymphocytic accumulations or inflammatory infiltration. Particular difficulties arise in the differential diagnosis of small cell tracheal cancer with atypical carcinoid and other poorly differentiated forms of cancer.

  Most often, small cell carcinoma has to be differentiated from poorly differentiated squamous cell carcinoma, whose cells, as a rule, have abundant, well-defined cytoplasm. With the help of a green light filter, intercellular bridges can also be detected in some areas. The nuclei are more hyperchromic and the cytoplasm is eosinophilic, indicating epidermoid differentiation. In some cases, without the use of special research methods, the differential diagnosis of small cell tracheal cancer with other microscopically similar tumors is practically impossible.

  Ultrastructure. Small rounded, oval or elongated cells are detected, lying separately or in small groups in the collagen fiber stroma (Fig. 19). Irregularly shaped nuclei with large clumps of chromatin. The cytoplasm is sparse with a small number of organelles (ribosomes, polysomes, small mitochondria, short SER profiles) and single rounded or polymorphic neurosecretory granules. Solitary neurosecretory granules may occur in non-small cell types of cancer, consisting predominantly of larger undifferentiated cells and elements with weak signs of glandular differentiation (microvilli). The cytoplasm in these cells is more abundant, contains ribosomes, polysomes, mitochondria, multiple profiles of the rough and smooth endoplasmic reticulum.