A Patient Case of PD-L1–High Metastatic NSCLC: First-Line Treatment Options

Expert oncologist Marina Chiara Garassino, MD, reflects on a patient case of PD-L1–high metastatic NSCLC and outlines first-line treatment options in this setting.

Case: A 72-Year-Old With Advanced NSCLC Cancer

Initial presentation

  • KD is a 72 y/o female who presents to her primary care physician complaining of fatigue and a persistent cough.
    • PMH:
      • Hyperlipidemia (controlled)
      • Anxiety (controlled)
      • COPD (controlled)
    • SMH: quit smoking 3 years ago and enjoys social drinking with her family
    • FH: she lives alone but her kids and grandkids live nearby

Clinical workup

  • Current Labs:
    • CBC panel: Normal
    • Liver function/Renal function: Normal
  • PD-L1: 85%
  • ECOG 1
  • Molecular testing: (-) EGFR, ALK, ROS1
  • CT scan of the head and neck showed a 5cm nodule in the right upper lobe of lung
    • CT guided biopsy of the upper lobe confirms non-squamous cell carcinoma
  • Abdominal CT scan shows liver metastases
  • Diagnosis consistent with Stage IV non-small cell lung adenocarcinoma


Marina Chiara Garassino, MD: Hello everyone. My name is Marina Chiara Garassino. I’m a professor of medicine at the University of Chicago [in Chicago, Illinois]. I’m the director of the thoracic oncology program. Today we’re going to discuss a typical clinical case in our practice, and we can discuss them with some questions.

Here’s our case study. Katie is a 72-year-old woman who presented to her primary care physician complaining of fatigue and persistent cough. In her pathological medical history, she has some comorbidities that are very well controlled, such as hyperlipidemia and anxiety. She has a history of smoking and has COPD [chronic obstructive pulmonary disease]. The patient stopped smoking 3 years ago. She drinks wine with her family and lives alone, but her kids and grandkids live nearby to take care of her.

She has normal labs. She did a diagnosis of non–small cell lung cancer with a PD-L1 of 85%. The molecular testing was negative for all of the most relevant molecular genomic alterations. Her ECOG performance status is very good. Her ECOG performance status is 1, and in the CT scan, there was a nodule of 5 cm in the right upper load of the lung. It was diagnosed with nonsquamous, non–small cell lung cancer. We also found some liver metastases in the abdominal CT scan. Overall, she has stage IV non–small cell lung cancer without actionable mutations. She has a PD-L1 of 85%, and she stopped smoking about 3 years ago. She is in the category of patients who smoked in the past.

This is a very important case because we found that the PD-L1 was very high, at 85%. It’s important to not immediately start the immunotherapy for the daily clinical practice in these patients and to wait for the NGS [next-generation sequencing] tests. We’re aware that patients have actionable mutations in the DNA of their tumor. In general, with some exceptions, they don’t respond to the immunotherapy. It’s important to wait for the complete work-up for these patients. When you’re sure that the patient is PD-L1 high, like in this case, you can start the oncological treatment with immunotherapy and with chemotherapy. This can be part of the discussion.

We have data for this population from at least 3 clinical trials, and all the options are FDA approved. The first that was approved was pembrolizumab [Keytruda] single agent, and the results were published in the New England Journal of Medicine. The name of the trial was the KEYNOTE-024, and it showed that there was a clear increase in terms of overall survival when patients with PD-L1 more than 50% were treated with single-agent pembrolizumab. Similar results were found with atezolizumab. This was the trial called IMpower010. Recently we saw that the data that were recently updated of cemiplimab [Libtayo] single agent. The trial was EMPOWER-Lung1. The patients we included were PD-L1 more than 50%. There was a small thing that was different from the KEYNOTE-024, and it was that the patients were all smokers.

Cemiplimab was approved by the FDA. The results of the short- and long-term therapy are very similar to the results of pembrolizumab.

Transcript edited for clarity.

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