Japanese Journal of Clinical Oncology 32:30-32 (2002)
© 2002 Foundation for Promotion of Cancer Research
Redevelopment of Small Cell Lung Cancer After a Long Disease-free Period: a Case Report
1Department of Radiology and Radiation Oncology, Gunma University School of Medicine, Maebashi, Gunma, 2Department of Radiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, 3Department of Radiology, Tokyo Women’s Medical University, Tokyo and 4Department of Internal Medicine National Nishigunma Hospital, Shibukawa, Gunma, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Although it has been reported that the risk of second malignancies increases in long-term survivors of small cell lung cancer (SCLC) and late recurrence of SCLC is sometimes experienced, it seems uncommon. We recently experienced a case of redevelopment of SCLC after a long disease-free period. The case was considered to be second primary SCLC more than 10 years after the initial treatment. The necessity for lifelong follow-up in long-term survivors of SCLC is emphasized.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Treatment of small cell lung cancer (SCLC) has recently been improved and survival rates are 15–25% at 2 years among patients with limited stage disease (LD) and 0–3% among those with extensive disease (ED) (1,2). Although survival has been improved, it has been reported that the risk of second malignancies increases in long-term survivors of SCLC (3–5). In such cases, if second malignant lesions show the same type of pathology as the initial SCLC, it is difficult to distinguish the second lesion from initial SCLC relapse. Although it has been reported that these recurrences become unusual 6 years after the initial treatment (6–8), most investigators have concluded that redevelopment of SCLC after more than 5 years in the original anatomical site can be considered to be a recurrence of the original SCLC (9–11). We report a case of redevelopment of SCLC after a long disease-free period.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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A 56-year-old man presented with a left hilar abnormal shadow on a chest radiogram in May 1989, complaining of a cough and sputum. His smoking history was 1.5 packs a day for 40 years. Chest X-ray (Fig. 1) and computed tomography (CT) revealed a mass in the left lower lobe and enlargement of lymph nodes from the left hilar to the contralateral mediastinum. Abdominal and cranial CT, bone scintigraphy and bone marrow aspiration did not reveal any distant metastasis. In the biochemical examination, neuron-specific enolase (NSE) in serum increased to 21.5 ng/ml. A transbronchial lung biopsy (TBLB) specimen histologically showed SCLC (Fig. 2). The disease was clinically diagnosed as T4N3M0, stage IIIB (LD). The patient was treated with radiotherapy (40 Gy in 20 fractions) and concurrent combination chemotherapy with cisplatin, etoposide and doxorubicin. The patient stopped smoking after the initial diagnosis. He attended our hospital regularly for more than 10 years until a mass in the left hilar was revealed on a routine chest radiogram in December 1999 (Fig. 3). Chest X-ray and CT revealed a mass in the left upper lobe and enlargement of the left hilar nodes. Other systemic examinations of the abdomen, brain, bone and bone marrow showed no metastases. NSE and pro-gastrin-releasing peptide (proGRP) in serum were 11.4 ng/ml and 169 pg/ml, respectively. Although bronchoscopy revealed a new lesion in the apicoposterior segment of the upper lobe, no abnormal findings were observed in the left lower bronchus where SCLC had initially developed. The new lesion was pathologically diagnosed as SCLC (Fig. 4). We considered that the tumor was second primary SCLC, stage IIA (LD), arising from a previous irradiation field. Combination chemotherapy with cisplatin and etoposide followed by chest radiotherapy (50 Gy in 25 fractions) was performed. Efficacy of the treatment was partial response. The patient was alive with multiple brain metastases 10 months after the start of the secondary treatment.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Second primary small cell carcinoma or redevelopment of the original SCLC in long-term survivors seems uncommon. Tucker et al. reported a risk of second cancer after treatment of SCLC in a multi-institutional study (3). In their report, even though 51 of 87 patients with second malignancies developed lung cancer, no SCLC was observed. Of 578 patients with SCLC, 20 with redevelopment of small cell carcinomas 2.0–12.2 years after the initial treatment were reported by Johnson et al. (4). They considered that two of these patients developed second primary small cell carcinomas of the lung and the esophagus. Heyne et al. (6) experienced three cases of second primary small cell carcinomas in 446 patients with original SCLC, two of whom were bronchogenic and the other was primary unknown. As a recurrent case of original SCLC in long-term survivors, Johnson et al. (4) reported recurrence of SCLC more than 12 years after the initial treatment. We recently saw a case of redevelopment of SCLC about 10 years after the original diagnosis of SCLC. The case was considered to be a second primary lesion because many years had passed before redevelopment, the new lesion was in a different lobe and the original site was clear. Nevertheless, the possibility that the case developed recurrence of the original SCLC cannot be excluded conclusively based on the evidence available. A criterion proposed by Martini and Melamed (12) was used for differentiation of these two events: a new lung lesion will qualify as a second primary carcinoma if it is of a different histological type, if it appears in a different lobe or lung without involvement of lymphatics common to the original site or if a disease-free interval of 2 years has passed. As two lesions in the patient involved a common lymph node, whereas these existed in different upper streams, the patient probably should have been diagnosed with recurrence of SCLC. Several authors have proposed other criteria and some of these, which include the criterion by Martini and Melamed, may be open to criticism and difficulty in differentiating these two events has been discussed. It is most important, however, that the possibility of development of malignancies is very high in long-term survivors of SCLC (4,6). As the results of treatment of SCLC continue to improve, the importance of countermeasures against second primary malignancies or late recurrence may be increased as in brain recurrence. Chemoprevention may be considered one of the measures to decrease the risk of second primary malignancies (13–15).
In conclusion, development of malignant lesions in long-term survivors of SCLC must increase because of improvement of therapy. Sometimes it may be difficult to diagnose precisely, as in our case, but early detection of malignant lesions with careful follow-up and adequate therapy are most important.
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FOOTNOTES |
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+ For reprints and all correspondence: Yoshizumi Kitamoto, Department of Radiology and Radiation Oncology, Gunma University School of Medicine, 3–39–22, Showa-machi, Maebashi, Gunma 371-8511, Japan. E-mail: ykitamot@showa.gunma-u.ac.jp
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REFERENCES |
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Received June 6, 2001; accepted October 10, 2001.
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