The

n e w e ng l a n d j o u r na l

of

m e dic i n e

TEACHING points

MANIFESTATIONS, DIAGNOSIS, AND TREATMENT OF SMALL-CELL LUNG CANCER

Homonymous hemianopia is a visual-field defect marked by loss of half of the field
of view on the same side in both eyes. The condition may be caused by a structural
lesion in the brain posterior to the optic chiasm. Complete congruous homonymous
hemianopia is suggestive of a lesion in the visual cortex of the contralateral occipital
lobe.
The cerebellum plays a central role in the regulation of physical coordination.
Assessment of a patients gait can provide clues to an underlying pathologic condition. Other tests of cerebellar function include finger-to-nose and heel-to-shin testing and assessment of rapid alternating movements.
Computed tomography and magnetic resonance imaging are useful in the differential diagnosis of patients with suspected structural lesions in the brain. Neuroimaging scans obtained with the use of radiocontrast material allow for the identification
of ring-enhancing lesions, which can be caused by infectious, neoplastic, demyelinating, and vascular conditions.
The types of cancer from which primary tumors are most likely to metastasize to
the brain include lung cancer, melanoma, breast cancer, renal-cell carcinoma, and
colorectal cancer.
Small-cell lung cancer arises from neuroendocrine cells and accounts for a minority
of lung cancers. It is strongly associated with smoking.
The majority of patients with small-cell lung cancer present with metastatic disease.
The management of extensive-stage small-cell lung cancer centers on the use of
multiple chemotherapeutic agents. The combination of cisplatin and etoposide is
common and has been well studied. Whole-brain radiation or prophylactic cranial
radiation is an important part of management. Even with treatment, overall survival
is poor.

These teaching points are drawn from the Interactive Medical Case. For more complete information,
see Nambudiri VE, Vaidya A, Cochrane T, Barbie D. Off balance. N Engl J Med 2014;370:e37.