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Lung Cancer Case Studies

Case Studies: Clinical Management of NSCLC With Bone Metastases

Roy S. Herbst, MD, PhD, discusses how emerging data in non–small cell lung cancer (NSCLC) plays a role in his approach to sequencing therapy for a 62-year-old male with NSCLC with bone metastases.

Clinical Management of NSCLC With Bone Metastases

Case: A 62-Year-Old Man With NSCLC and Bone Metastases

  • A 62-year-old man presents to his PCP complaining of persistent right-sided neck pain. Two months later he developed decreased appetite, lethargy, and a dry cough
  • PMH: Smoker, hypercholesterolemia managed on pravastatin, no allergies, no family history of lung cancer
  • Imaging
    • MRI of the neck revealed spine lesion
    • Chest CT showed a 4.3-cm right upper lung mass with enlarged right hilar and right paratracheal lymph nodes
    • PET scan showed 18FDG uptake in the RUL mass, the hilar and paratracheal nodes, and multiple cervical and thoracic vertebrae
    • Brain MRI was negative for metastases
  • CT-guided biopsy of the RUL mass showed stage 4 adenocarcinoma; TTF-1 positive
  • Molecular testing:
    • NGS: negative for EGFR and ROS1
    • IHC: negative for ALK gene rearrangement
    • IHC: PD-L1 expression in 0% of cells
  • Labs show elevated CEA (26), low albumin (3.4), normal creatinine, CBC, and liver function
  • The patient was started on pemetrexed with carboplatin q3W and vitamin B/folic acid supplement
  • PE/ROS after cycle 1: ECOG PS 1, no palpable lymph nodes, decreased breath sounds in RUL, persistent symptoms
  • CEA increased to 28, CBC shows mild anemia (Hgb 11.0)
  • Imaging after 2 cycles of chemotherapy showed progression in the right lung mass (5.2 cm) and several bone lesions
  • Labs now show increased CEA (34), decreased albumin (3.2), and decreased Hb (10.2)
  • The patient was started on docetaxel with ramucirumab
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