Best Management Practices for a Patient With Early-Stage Non-Small Cell Lung Cancer

Ticiana Leal, MD, Winship Cancer Institute, Emory University, Atlanta, Georgia, discusses the course of treatment she would take for a patient with early-stage non-small cell lung cancer (NSCLC). 

Transcript 

Hello, I'm Dr Ticiana Leal, I’m an associate professor and director of the thoracic oncology program at the Winship Cancer Institute of Emory University. Today we'll be discussing a clinical case. 

This patient is a 63-year-old female current smoker who initially presented with complaints of persistent cough despite a course of antibiotics for possible bronchitis. This led to additional work-up which included a CT scan of the chest that revealed a spiculated left upper lobe mass measuring 4.2 cm abutting the pleura. There was no evidence of hilar or mediastinal adenopathy and in addition, it also showed emphysema. The PET/CT was done for further staging, which demonstrated a hypermetabolic left upper lobe mass, measuring 3.8 cm by 3.5 cm by 4.6 cm with a max SUV of 12.8. It also showed a hypermetabolic left hilar lymph node measuring 1.5 cm with max SUV of 5.2. Otherwise, no hypermetabolic mediastinal adenopathy. The bronchoscopy with endobronchial ultrasound did not reveal endobronchial lesion and the left upper lobe transbronchial biopsy revealed adenocarcinoma TTF1-positive, consistent with lung primary. The [fine needle aspiration] FNA of the left hilar lymph node was positive for adenocarcinoma and the subcarinal lymph node was negative. Additional staging included a brain MRI, which was negative. She underwent [pulmonary function test] PFTs which demonstrated good lung function, and the patient had good performance status of ECOG 1. 

This patient's case was discussed in multidisciplinary thoracic tumor board, and she was deemed to have recsectable and operable disease. After discussion, recommendation was made to proceed with perioperative chemoimmunotherapy approach in her case. After formed decision-making discussion with the patient she agreed with this approach as well. She was counseled on the importance of quitting smoking, was motivated to quit, and followed smoking cessation recommendations. The patient did undergo biomarker testing prior to initiation of chemoimmunotherapy, PD-L1 was 25% and there was no actual driver mutation. She then underwent 4 cycles of chemoimmunotherapy with carboplatin, pemetrexed, and pembrolizumab and overall, she tolerated chemoimmunotherapy well with main side effects of mild fatigue and anemia that did not require red blood cell transfusion. Her pre-operative PET CT after completion of 4 cycles of chemoimmunotherapy showed a stable hypermetabolic left upper lobe lung mass with slight decrease in size without significant change in the hypermetabolism when compared to the baseline PET/CT, and stable hypermetabolic left hilar solid adenopathy consistent with the known nodal metastases. She then underwent a left upper lobe lobectomy and mediastinal lymphadenectomy. Post-operatively, she did well, pathology revealed adenocarcinoma with 80% acinar component, 10% micropapillary, 10% solid with a 4.3 cm lesion with treatment effect present with 60% viable tumor. The margins were negative. She did well post-operatively and was discharged home without complications. She then comes to clinic to discuss the next steps in her care.

When the patient comes back, she is doing well and as we noted in the case, the patient's tumor had still 60% viable tumor. This was consistent with the fact that the patient did not achieve a [pathological complete response] pCR or major pathologic response. We discussed then the adjuvant component of her treatment and the patient underwent 1 year of adjuvant pembrolizumab based on the KEYNOTE-671 trial.