THE ENORMITY OF SMALL CELL LUNG CANCER THAT NEVER CEASES TO AMAZE

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TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lung cancer is the second most diagnosed cancer in the United States and the leading cause of cancer death. Small-cell lung cancer (SCLC) represents about 15% of all lung cancers and is marked by an exceptionally high proliferative rate, strong predilection for early metastasis and poor prognosis. SCLC is strongly associated with exposure to tobacco carcinogens. The presentation of small cell lung cancer is non-specific. Patients can present with rapid-onset symptoms due to local intrathoracic tumor growth, extrapulmonary distant spread, paraneoplastic syndromes, or a combination of these features. While small cell cancer is well known as a rapidly growing cancer, rarely does it present encompassing a whole lung. CASE PRESENTATION: A 46-year-old male who presented with a one month history of productive cough, fatigue, anorexia with 8lbs weight loss, back pain, and palpitations. He had a 20-pack year smoking history. Examination was significant for tachycardia, elevated blood pressure, right sided facial puffiness with engorged distended veins on the neck, anterior chest wall and abdomen. There were absent breath sounds on the right upper and middle lung zones. Supraclavicular and axillary lymphadenopathy were noted. Chest x-ray done showed Complete opacification of the right upper and middle lobes consistent with lung mass . Chest CT showed Large mass within the right upper lobe measures approximately 18.2 x 13.4 x 17.1 cm with mass effect noted on mediastinal structures which are shifted to the left. The mass encased the right mainstem bronchus, right main pulmonary artery with obstruction at the medial to distal aspect of the artery, and compression of the superior vena cava with collateral circulation within the right chest wall and venous drainage through the azygos vein into the inferior vena cava. Lymph node biopsy was done which showed poorly differentiated neuroendocrine carcinoma, favoring small cell type. He was subsequently referred for treatment. DISCUSSION: SCLC is a cancer of neuroendocrine origin, characterized by rapid growth with significant mediastinal adenopathy. Common clinical symptoms are non-specific and sometimes may present with compressive symptoms such superior vena cava syndrome. Here we present a case of a huge SCLC with SVC syndrome presenting only after a short duration of symptoms in a former smoker. Cigarette smoking remains a major culprit and smoking cessation is one of the most important primary preventive measures. CONCLUSIONS: SCLC remains one of the most common causes of cancer death in the United States. The challenge with the diagnosis and management of SCLC continues to be the rapidity of growth and non-specific symptomatology, and as a result most patients present late. Therefore clinicians need to have a high index of suspicion especially in current and past tobacco smokers in order to ensure early diagnosis and prompt intervention. REFERENCE #1: Basumallik N, Agarwal M. Small Cell Lung Cancer. [Updated 2020 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482458/ REFERENCE #2: https://www.healio.com/news/hematology-oncology/20120325/a-45-year-old-male-with-small-cell-lung-cancer-superior-vena-cava-syndrome REFERENCE #3: Rudin, C.M., Brambilla, E., Faivre-Finn, C. et al. Small-cell lung cancer. Nat Rev Dis Primers 7, 3 (2021). https://doi.org/10.1038/s41572-020-00235-0 DISCLOSURES: No relevant relationships by Raji Ayinla, source=Web Response No relevant relationships by Idayat Brimah, source=Web Response No relevant relationships by Ibrahim Omore, source=Web Response No relevant relationships by Yamin Soe-Htwe, source=Web Response