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Lung Cancer Case Studies

Diagnosis and Prognosis of Stage 4 Lung Adenocarcinoma

Mark A. Socinski, MD
Published Online:May 26, 2017
In this case-based interview, Mark Socinski, MD, describes the case of a patient with metastatic non-driver lung adenocarcinoma with brain and bone metastases.

NSCLC with Multiple Sites of Metastasis and No Driver Mutation


Mark A. Socinski, MD: The case is of a 64-year-old gentleman who presents with a headache and some visual abnormalities—his left eye in some confusion. He eventually is evaluated by head of CT and is shown to have an occipital lesion on the right side. He subsequently has an evaluation of his chest, initially by chest x-ray and then by chest CT, which shows a 2.2-cm, left-lower lobe mass associated with some mediastinal adenopathy. A PET scan is subsequently done and it shows, in addition to the left lower lobe mass in the mediastinal disease, several boney sites that are highly suggestive of metastatic disease. He ends up having a biopsy of the left lower lobe lesion that shows a moderately differentiated adenocarcinoma on immunohistochemical staining. It is positive for TTF-1 and morphologically consistent adenocarcinoma.
 
He is a current nonsmoker, but did have a 30-pack-a-year exposure to smoking in the past, having quit about 5 years ago. His adenocarcinoma biopsy was tested for EGFR, ALK, and ROS1 and they were all negative. He also had a PD-L1 stained that showed it to be about 15% staining percentage. And in follow-up to his CT scan of the brain, he had an MRI of the brain. In addition to the occipital lesion that was noted, there were also 8-mm lesions in the left frontal lobe as well as right temporal lobe. So, he had 3 total lesions in the brain.
 
This patient obviously had stage 4 adenocarcinoma of the lung. My impression is that this patient has been well evaluated. We are confident about his stage, given the bony metastases as well as the brain metastases. We’re also confident about the diagnosis both from a histologic point of view as well as genetic point of view. He was tested per the current NCCN and other guidelines for EGFR, ALK, and ROS1. We also have established his PD-L1 status as being 15% positive. So, I would say my impression is that this gentleman had a very thorough evaluation. We’re confident about the stage, and we’re confident about the diagnosis as well as the molecular aspects of his lung cancer.
 
In stage 4 adenocarcinoma of the lung, we believe this is a treatable disease, but not a curable disease. This gentleman had an ECOG performance status of 1, which means that he was fully ambulatory and caring for himself. He does, again, not have cure. He would likely have to be—because of his CNS symptoms and the findings on both the CT and the MRI—put on dexamethasone, a steroid that would have controlled some of the symptoms. His initial treatment should be directed at the CNS disease since he was initially symptomatic there. The prognosis of this patient is, again, he’s not a curable patient but a treatable patient given his good performance status. We’ll talk about the options a little bit later. But nowadays, these patients on average live 1 year or a little longer. About 25% of them live longer than 2 years. So, the prognosis I would describe as limited, but certainly patients with the multiple options that we have nowadays are living longer and longer because of multiple lines of treatment.

Transcript edited for clarity.
  • A 64-yr old gentleman presented with headache, impaired vision in left eye, and intermittent confusion that had begun a few weeks ago
  • He is a current non-smoker with a 30-pack-year history
  • Past medical history: hypertension diagnosed 3 years ago, well-controlled on losartan
  • His cardiac workup is negative
  • His PS by ECOG assessment is 1
  • Head computed tomography demonstrated a mass (1.0 cm) in left occipital lobe with associated edema
  • Full body CT scan revealed a left lower lobe lung mass (2.2 cm), and ipsilateral mediastinal lymphadnopathy
  • Whole body 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) scan revealed increased FDG uptake in the primary left lower lobe lung mass, mediastinum, and several bony sites
  • Core biopsy of the lung mass was performed and indicated
    • A histopathological diagnosis of adenocarcinoma (staining for TTF-1 was positive)
    • Genetic testing was negative for known driver mutations
    • PD-L1 testing by IHC showed expression in 15% of cells
  • Brain MRI revealed 2 additional 8 mm lesions in the left frontal and right temporal lobes
  • He was diagnosed with stage IV NSCLC adenocarcinoma
  • He was treated with stereotactic radiosurgery (SRS) for brain metastases
  • Two weeks following SRS
    • A follow up MRI scan showed no evidence of new brain metastases
    • CT scan showed:
      • 4 smaller nodules in the left upper lobe
      • The left lower lobe lung mass increased in size to 3.3 cm
      • Ipsilateral mediastinal lymph node swelling
  • The patient was started on therapy with carboplatin/paclitaxel and bevacizumab
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