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DR KIM: You would almost call this an unknown primary because small cells can originate from many areas. Patients like this can be approached in several ways. If the cancer were small cell lung cancer, chemotherapy would almost be prophylactic in the sense that we don’t know what we’re treating, how many cycles to administer, etc.

If you delivered concurrent radiation therapy to the entire field, you would be adding excessive toxicity without knowing if you missed an extrathoracic primary. I would have a great deal of discussion with my colleagues about this case.

It might be that radiation therapy to the actual site of excision is the only thing needed at this point. Or you could watch and wait with close follow-up with scans to see if a primary manifests itself.

I had a similar situation with a patient who had a subcutaneous abdominal nodule that was excised, and it turned out to be non-small cell lung cancer with no obvious primary. We observed her for more than a year without any indication of a primary and without any additional therapy.

I would probably send this patient to receive radiation therapy in the specific area where the tumor was located and then just watch him closely.

DR HERBST: This is a tough case. Most of the time when small cell lung cancer is the pathologic diagnosis, it’s assumed to be lung cancer, but I’m not so sure in this case. Clearly, it’s extensive disease, wherever it came from. A search for a primary site, within reasonable limits, has not yielded much.

This is a case in which I’d sit down with the pathologist and carefully look at the pathology. If the best diagnosis is SCLC, one could have a number of different options.

This is an elderly gentleman, but it sounds as if his performance status is reasonable. He has extensive disease with an unknown primary, so I probably would opt for some chemotherapy, perhaps three or four cycles of carboplatin and etoposide. Although we don’t know the origin of the primary, this should cover most primary sites. I would back off if he develops significant toxicity.

I’ve had a couple of recent cases like this, and they’re difficult. One patient with presumed SCLC who had disease throughout his body came because of cord compression, but the patient had never smoked, which is unusual for SCLC. That patient ended up having a small bowel primary.

Radiation therapy certainly could be used, but if the surgical resection was good, this is presumably a systemic disease. So I would differ with that a little bit and go more toward systemic therapy.

Sometimes multiple options can be presented to the patient. In this case, I think options could vary from doing nothing to using radiation therapy to administering chemotherapy. As with anything else, you have to see this man in the office to make that decision.

DR LOVE: Steve, what happened with this patient?

DR GRABELSKY: We did have the pathology reviewed, and it confirmed the pathologic diagnosis. He was presented at our local hospital tumor board. On exam, it was unclear whether the biopsy site was indurated or just had residual tumor.

We elected to treat him with combined-modality therapy with etoposide and carboplatin along with involved-field radiation to the supraclavicular area and the adjacent anterior cervical lymph nodes. We did not radiate the lung area. He received an additional two cycles of etoposide/carboplatin after the radiation therapy was completed.

He did beautifully, with some minor radiation dermatitis, and resumed all his normal activities. I saw him just last week, and he’s more than a year out and in complete remission. Still, no primary site has been discovered.

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