A 64-Year-Old Woman With Extensive-Stage Small Cell Lung Cancer - Episode 1

Case Overview: A 64-Year-Old Woman With ES-SCLC

An expert in the management of lung cancer, Jared Weiss, MD, provides an overview of the initial presentation, clinical work-up, treatment, and follow-up of a 64-year-old woman with extensive-stage small cell lung cancer.

Jared Weiss, MD: Hello, and welcome to Targeted OncologyCase-Based Peer Perspectives for a case of a 64-year-old woman with extensive-stage small cell lung cancer. I’m Jared Weiss, an associate professor of medicine at Lineberger Comprehensive Cancer Center [at the University of North Carolina School of Medicine], where I’m also the section chief of thoracic and head and neck oncology. Let’s dive into our case.

A 64-year-old woman presents with a persistent cough, chest discomfort, fatigue, and unintended weight loss. Her past medical history is notable for osteoporosis, a hysterectomy at age 60, and prediabetes that is managed with diet and exercise. Her social history is notable for a 45-pack-year smoking history, and she has 1 or 2 alcoholic drinks a month socially. On physical examination, there are decreased breath sounds in the left lung, wheezing on auscultation, and an axillary lymph node enlargement that’s hard and immobile. [Lab results] show sodium of 132 mEq/L, ALT [alanine aminotransferase] of 54 IU/L, and AST [aspartate aminotransferase] of 58 IU/L; everything else was unremarkable. The axillary lymph node is biopsied and unfortunately reveals small cell carcinoma. Cross-sectional imaging of the chest, abdomen, and pelvis are obtained and demonstrate a 7.2-cm mass above the diaphragm, a small contralateral lung nodule, and evidence of invasion into the left side of the pericardium. PET [positron emission tomography] scan is subsequently obtained, and it shows activity of the left lung above the diaphragm as well as the mediastinum and small hypermetabolic activity in the surrounding area. Contrast enhanced MRI of the brain was negative for brain metastases, so she was staged with stage IV small cell lung cancer with an ECOG performance status of 0. Treatment was initiated with carboplatin, etoposide, and atezolizumab for 4 cycles followed by atezolizumab as maintenance therapy. Seven months after starting treatment, she complained of fatigue, shortness of breath, and right upper quadrant and back pain. A CT scan showed homogeneous metastasis in the liver, and she was started on lurbinectedin, 3.2 mg/m² via IV [intravenous] every 21 days.

Let’s pause and reframe this case in terms of its prognosis and presentation. This is a patient with stage IV small cell lung cancer, otherwise known as extensive-stage small cell lung cancer. Small cell lung cancer is 1 of the most aggressive solid tumors, and the prognosis is poor. From the time of diagnosis, there is a life expectancy of about a year with optimal treatment. This patient has a few unusual elements to her care. The involvement of her pericardium is not unusual, but in a real case, I probably would have gotten a transthoracic echocardiogram and a cardiac MRI to better characterize the anatomy. I would have also discussed in multidisciplinary conversation whether radiation could play a role in her care, particularly as consolidation after chemotherapy. However, for our purposes today, I would like to focus on treatment options for this patient.

Transcript edited for clarity.

Case: A 64-Year-Old Woman with Small-Cell Lung Cancer

Initial Presentation

  • A 64-year-old woman presented with a persistent cough, chest discomfort, fatigue and unintended weight loss
  • PMH: osteoporosis, hysterectomy at age 60, prediabetic managed with diet and exercise
  • SH: 45-pack year smoking history; drinks alcohol 1-2/month socially
  • PE: Decreased breath sounds in left lung, wheezing on auscultation, axillary lymph node enlargement

Clinical Workup

  • Labs: serum Na 132 mEq/L; ALT 54 IU/L; AST 58 IU/L; all others WNL
  • Axillary lymph node biopsy revealed small cell carcinoma
  • Chest/abdomen/pelvic CT showed a 7.2 cm mass above the diaphragm, a small contralateral lung nodule and evidence of invasion into the left side of the pericardium
  • PET scan showed activity in the left lung above the diaphragm, mediastinum and small hypermetabolic activity in the surrounding area
  • Contrast‐enhanced MRI of the head was negative for brain metastases
  • Stage IV small-cell lung cancer; ECOG PS 0

Treatment

  • Initiated carboplatin + etoposide + atezolizumab for 4 cycles; followed with atezolizumab as maintenance therapy

Follow-up

  • 7 months after starting treatment she complained of fatigue, shortness of breath, right upper quadrant pain and back pain
  • CT scan showed hematogenous metastases in the liver
  • Initiated lurbinectedin 3.2 mg/m2 IV q21 days