Case Presentation: Early-Stage Non-Small Cell Lung Cancer

The patient is a 63-year-old woman, current smoker, who initially presented with complaints of persistent cough despite a course of levofloxacin for bronchitis. Additional work-up included CT scan of the chest that revealed a spiculated left upper lobe mass (measuring 4.2 cm) abutting the pleura and aortic isthmus and no evidence of hilar or mediastinal adenopathy. It also showed centrilobular and periseptal pulmonary emphysema. PET/CT demonstrated an FDG-avid left upper lobe pulmonary mass measuring 3.8 cm x 3.5 cm x 4.6 cm with max SUV 12.8 and an FDG-avid left hilar node measuring 1.5 cm x 1 cm with max SUV 5.2. Otherwise, no other FDG-avid mediastinal, hilar, or axillary lymphadenopathy. Bronchoscopy with endobronchial ultrasound did not reveal any endobronchial lesion. The left upper lobe transbronchial biopsy revealed adenocarcinoma, TTF1-positive. Fine-needle aspirate of the left hilar lymph node demonstrated adenocarcinoma and the subcarinal lymph node was negative for malignancy. Additional staging work-up included a negative brain MRI. Her pulmonary function test and functional status (ECOG performance status) were good. 

This patient’s case was discussed in our multidisciplinary thoracic tumor board. She was deemed to have resectable and operable disease. After discussion, recommendation was made to proceed with a perioperative chemoimmunotherapy approach in her case. After informed decision-making discussion with patient, she agreed with the approach. The patient was counseled on the importance of quitting smoking, was motivated to quit smoking, and followed smoking cessation recommendations. Biomarker testing revealed PD-L1 25% and no actionable mutation. She underwent 4 cycles of cisplatin plus pemetrexed and pembrolizumab. Overall, she tolerated chemoimmunotherapy well with main side effects of mild fatigue and anemia. She underwent pre-operative PET/CT that showed stable FDG-avid left upper lobe lung mass with slight interval decrease in size without significant change in metabolic activity when compared to the comparison PET/CT exam, and stable FDG-avid left hilar adenopathy, compatible with known nodal metastasis. She then underwent left upper lobectomy and mediastinal lymphadenectomy. Pathology revealed adenocarcinoma, acinar predominant (80% acinar, 10% micropapillary, 10% solid), 4.3 cm, with treatment effect present (60% viable), matted left hilar peribronchial lymph node positive for tumor and negative margins. She did well post-operatively and was discharged home without complications. 

She returns to clinic to discuss next steps in her care.