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Lung Cancer Case Studies

Case Studies: Metastatic Lung Adenocarcinoma Without a Driver Mutation

In this case-based interview series, Heather Wakelee, MD, describes the case of a patient who is diagnosed with metastatic non-small cell lung cancer with adenocarcinoma histology.

Metastatic Lung Adenocarcinoma Without a Driver Mutation

  • A 70-year-old Caucasian female presented with mild dyspnea and no chest pain.
  • She has also experienced recent, rapid weight loss (>10 pounds in 1.5 months) without any changes in her diet or exercise pattern.
  • She gave up smoking 7 years ago (2 packs per day for 35 years).
  • Her medical history is unremarkable:
    • A few years ago, she was diagnosed with gastroesophageal reflux disease that was clinically and endoscopically confirmed.
    • She has no history of cancer in the family.
    • Her cardiac workup is negative.
  • Her PS by ECOG assessment was 0.
  • Chest x-ray showed a 2.5-cm lesion in her right lower lobe.
  • CT scan of the chest and abdomen confirmed the presence of the lung mass in addition to numerous bilateral nodules, all about 5 to 9 mm, in the right upper and lower lobes and the left upper and lower lobes, as well as enlargement of hilar lymph nodes. In addition, 3 small nodules were seen in the liver, measuring 1 to 2 mm.
  • PET/CT imaging showed 18F-FDG uptake in the lung mass, left hilar lymph nodes, and liver.
  • MRI of the brain was negative for intracranial metastases.
  • A core biopsy of the lung nodule was performed:
    • Its morphology and molecular phenotype (TTF-1-positivity) supported a diagnosis of lung adenocarcinoma.
    • Mutational testing showed absence of driver mutations (i.e., was negative for EGFR, ROS, and ALK).
    • PD-L1 testing showed PD-L1 expression of 35%.
  • The patient was diagnosed with stage IV metastatic NSCLC.
  • The patient was started on therapy with a chemotherapy doublet and bevacizumab (Avastin).
  • At her next follow-up 2 months later, her CT scan showed the right lung mass to be stable, with no new lesions. She has improved symptomatically.
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