Case Overview: A Man With Stage IIIA NSCLC

Mark A. Socinski, MD:The case for discussion today is a 52-year-old gentleman who presented with some weight loss and some chest symptoms. He was found to have a left upper lobe mass. On his CT [computed tomography] scan there was a suggestion of some left paratracheal adenopathy. The patient had a PET [positron emission tomography] scan, which did show the absence of activity outside the chest. The patient also had a brain MRI [magnetic resonance imaging], which was appropriate to do, showing no metastatic disease involvement in the brain. That’s my standard workup, a brain MRI and a PET scan to exclude extrathoracic disease. This was done, and in this patient there was no evidence of extrathoracic disease.

I think one of the important aspects of this case is that the patient had an EBUS [endobronchial ultrasonography] and there was documentation that the enlarged lymph nodes we saw in the CT and PET scans were actually cancer. The squamous carcinoma was detected at the EBUS in the left paratracheal lymph nodes. And so we had a firm diagnosis and we had a firm stage. This patient was a T2N2, well-staged with a secure diagnosis of squamous carcinoma. So the physicians in charge of this patient did their job. They defined the diagnosis beyond a shadow of a doubt. It’s squamous carcinoma, and they defined the stage. It was T2N2, stage IIIA. Because it had multistation N2 disease that was on the bulky side, this was by definition not a patient who should undergo surgical resection. So it would be in our vernacular unresectable stage IIIA disease.

In stage III disease we don’t know how to use the molecular markers or PD-L1 [programmed death-ligand 1] status. Now, I can tell you that many stage III patients do undergo molecular testing and PD-L1 testing. I don’t think it’s wrong to do that. What I do think is we should be honest and admit that we don’t know how to use that information clinically, and we don’t know whether any of those should factor into our decision making about what to do with a patient like this.

When we went to the 8th edition of the staging system, there were several changes. Size has always been an important aspect in how big your primary tumor is. And there was lots of detail about that in the T-staging of this. One of the areas that we saw improvement in—certainly not a perfection of the staging system—was in stage III disease. Where formerly we had stage IIIA and IIIB disease, in the 8th edition we added stage IIIc disease, which was based upon more extensive primary tumor or N3 contralateral disease. So it further subcategorized the very heterogeneous group of stage III patients.

Now this is the 8th edition, and it is in stage III disease far from perfect. I applaud the committee doing this for thinking more critically about different subsets in stage III disease. One of the things that we don’t yet have in the staging system, and this is particularly pertinent to stage III disease, are the size of the lymph nodes, the number of lymph nodes, the exact location of lymph nodes, those sorts of things, which I think are important in stage III disease but aren’t accounted for in the staging system. I think as we get to a 9th edition or 10th edition and gather more information about that, that’s where we need to be going into further subsets, the stage III disease.

There have been a number of publications in the past that suggested you really could define 5 or 6 different subsets of stage III disease. Right now in the official AJCC [American Joint Committee on Cancer] staging system we have stage IIIA, IIIB, and IIIC, which I think is the right direction, but certainly not a perfection of the staging system. Categorically I don’t think it’s changed practice. I don’t think we necessarily use the changes or treat stage III any differently than we did before based on the staging system. But, again, I do think that we are going in the right direction in terms of improving our staging of non—small cell lung cancer [NSCLC].

As for the prognosis of this particular patient, if I saw this patient in my practice with bulky T2N2, stage IIIa disease and he was going to be treated with nonsurgical treatment—and that would be with chemoradiation, but I think there are a couple of different platforms that we’ll talk about in a moment—my counsel to this patient would be that you have about a 25% chance of being cured with standard concurrent chemoradiotherapy. If patients were to ask me, “On average how long would I live?” I would say probably about 2 years.

The issue with that is the patient would then ask me, “Well, am I above average or am I below average?” And as doctors at that point we aren’t very good at prospectively prognosticating. We do know that if we were to see 100 patients like this, 25 of them would be cured. But when we see 100 patients we wouldn’t know whether it was 1 through 25, 35 through 60, or just scattered patients throughout who were the curative patients. Now the PACIFIC trial has changed that, which we’ll talk about, but in terms of the standard of care pre-PACIFIC trial, those would be the discussions I would have with patients like this.

Transcript edited for clarity.

Case: A 52-Year-Old Male With Stage IIIA NSCLC

Initial presentation

• A 52-year-old man presented with a 15-lb weight loss and worsening dyspnea
• PMH: HTN
• SH: Computer programmer; Smoked a pack/day for 30 years; Quit smoking 2 years ago; Married with 4 kids
• PE: Unremarkable

Clinical workup

• Imaging:
  • Initial CT showed a 5-cm left upper lobe mass with aortopulmonary window and left paratracheal adenopathy measuring up to 2.5 cm
  • Subsequent PET scan showed activity in the left upper lobe mass and all nodal areas
  • No extrathoracic disease was identified
  • MRI showed no brain metastases
• Mediastinal sampling: EBUS was performed and documented squamous carcinoma in the left paratracheal lymph nodes
• Staging: T2N2M0
• ECOG PS 1
• Multidisciplinary tumor board deemed his tumor unresectable due to multistation N2 disease

Treatment

• Concurrent cisplatin/etoposide with external-beam radiotherapy
• Repeat CT 4 weeks after completion of concurrent chemoradiotherapy showed a PR with no new sites of disease