A RARE PRESENTATION OF AN EXTENSIVE STAGE SCLC DIAGNOSED BY AN ADVANCED DIAGNOSTIC METHOD

SESSION TITLE: Lung Cancer SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Small cell lung cancer (SCLC) is a poorly differentiated neuroendocrine tumor that represents about 15% of all lung cancers. It is distinguished from NSCLC by its rapid doubling time, high growth fraction, and the early development of metastases. SCLC typically arises in the central airways, infiltrating the submucosa, and gradually narrowing the bronchial lumen through extrinsic or endobronchial spread. The most common presentation of SCLC is usually in the central region of the lungs and mediastinum often presenting with a large hilar mass or bulky mediastinal adenopathy. Approximately 70% of patients present with overt metastatic disease; SCLC has a particular propensity to spread to liver, adrenals, bone, bone marrow, and brain. Potential clinical consequences include cough, dyspnea, weight loss, and debility.We report a case of a patient with a complex small pleural effusion and ipsilateral pleural based pulmonary nodules without mediastinal lymphadenopathy. After serial unsuccessful diagnostic attempts at thoracentesis, diagnosis was achieved with pleuroscopic biopsy revealing advanced peripheral SCLC. CASE PRESENTATION: An 81-year-old ex-smoker female presented with several months of progressive cough, dyspnea, and weight loss. She had right-sided pleural effusion and pleural-based nodules very suspicious for malignancy. PET showed hyper-metabolic activity around pleura, as well as mild bilateral lymphadenopathy. We were unable to make a diagnosis through thoracentesis and analysis of the pleural fluid. A medical pleuroscopy was performed as a safe alternative option that has a higher diagnostic yield than a thoracentesis and less invasive than surgical VATS for possible metastatic disease. Ultimately, pleuroscopy confirmed SCLC which was an extensive stage disease. With consideration of the patient's comorbid illness and side effects of chemotherapy, the patient declined any treatments. DISCUSSION: Predominantly peripheral presentation of SCLC is extremely uncommon. Pleural fluid analysis from thoracentesis is often not able to establish a diagnosis especially in a complicated pleural effusion with loculations. Diagnosis and staging of this extensive disease with small peripheral pulmonary nodules and a small complicated effusion with moderate sedation and a single 1 cm trocar incision required by pleuroscopy allowed for a timely diagnosis in this rare presentation of SCLC. CONCLUSIONS: Peripheral SCLC is rare. We report a rare presentation of a peripheral SCLC where we were able to establish the diagnosis via pleuroscopy after thoracentesis failed to achieve a diagnosis. Although thoracentesis is the preferred first minimally invasive diagnostic test in pleural effusions, in rapidly progressive malignancies such as SCLC, pleuroscpic biopsy is a safe and effective minimally invasive technique for staging and diagnosis even in complicated patients with complex pleural disease. Reference #1: Junker K, Wiethege T, Müller KM. Pathology of small-cell lung cancer. J Cancer Res Clin Oncol 2000; 126:361 Reference #2: Guinee DG Jr, Fishback NF, Koss MN, et al. The spectrum of immunohistochemical staining of small-cell lung carcinoma in specimens from transbronchial and open-lung biopsies. Am J Clin Pathol 1994; 102:406. Reference #3: Travis, WD.. The concept of pulmonary neuroendocrine tumours.. In: Pathology & Genetics: Tumours of the Lung, Pleura, Thymus, and Heart., Travis, WD, Brambilla, E, Muller-Hermelink, HK, Harris, CC. (Eds), IARC Press, Lyon 2004. p.19. DISCLOSURES: No relevant relationships by Haydar Al-Eid, source=Web Response No relevant relationships by Robert Browning, source=Web Response No relevant relationships by Sean McKay, source=Web Response