A combined small cell carcinoma of the lung containing three components: small cell, spindle cell and squamous cell carcinoma, revisited

We read with interest the article titled ‘A combined small cell carcinoma of the lung containing three components: small cell, spindle cell and squamous cell carcinoma’ [1] case report, but we have some comments.

About the rarity of combined small cell carcinomas, Adelstein et al. [2] noted that 10% of their patients with SCLC had another major type of NSCLC present. Other investigators have observed that the incidence of the presence of areas of non-small cell carcinoma in small cell tumors is increased following chemotherapy [3,4]. At times only non-small cell cancer can be identified in a tumor that was a pure small cell cancer on the original biopsy specimen [3]. A thorough examination of multiple samples from any given cancer reveals evidence of a variation of histologic pattern and cell type at least 45–50% of the time. When immunohistochemical and electron microscopic studies are performed, the proportion of combination tumors is even greater [4].

The type of management at the local clinic was wrong in our point of view as blood tinged sputum should not passed for just follow up especially in that old age. We think that brochoscopy was mandatory.

As Masashi et al. mentioned that chest (CT) performed on admission revealed a 4.0×3.5-cm mass in S1-2 of the right lung but you did not mention what numerical designation had been used. Is it Jackson and Huber or the Numina Anatomica.

As was mentioned in the article that bronchoscopy was done and revealed a tumor obstructing the upper lobe bronchus but this will need sleeve resection of the right upper lobe to perform a curative resection. You did not mention that you had performed sleeve resection, also you did not report the distance of the tumor from the mouth of the right upper lobe bronchus.

Our last comment about your interference of that patient. We think that it was better to interfere surgically from the start as your metastatic work up was free, also as you know that CT guided biopsy has a sensitivity of 77–95% in experienced hands with aspecificity reaches up to 95% in differentiation of small cell from non-small cell carcinoma [5]. We also think that surgical excision of the tumor whatever its nature will help as a debulking operation for the efficacy of the chemotherapy.

References