Treatment Considerations for Unresectable Locally Advanced NSCLC - Episode 1

Case Overview: Unresectable Stage 3 NSCLC

Heather Wakelee, MD:Our case is on a 64-year-old man who has been in reasonable health but has noticed an increase in cough. He’s also having some hemophthisis. Eventually, he goes in for care and is found to have a mass based on his chest X-ray. Further evaluation through a CT scan reveals that he has a fairly large tumor and some lymph nodes that are suspicious.

He’s in his mid-60s. He’s still actively smoking. Has a little bit of hypertension, but not too many other issues. As part of the evaluation, once they have the tissue, they do additional testing. It turns out that he has an adenocarcinoma. It doesn’t look like it has spread outside the chest, but he does have some mediastinal nodal involvement. He was considered as stage 3A. They do an evaluation at tumor board, as one would hopefully always do for a stage 3 lung cancer case, and the surgeons feel that he’s not an operative candidate based on the size of the mass and location.

Additional testing has come back by the time they’re having that multidisciplinary discussion. They did do full mutational analysis to reveal that he does not have anEGFRmutation, anALKtranslocation, or any other driver mutations. They did test for PD-L1. He has high PD-L1, but it is sort of recognized as medium PD-L1. It is not the highest possible—so in the 25% range.

The decision from his multidisciplinary group was to pursue multidisciplinary care. He wasn’t going to be a surgical candidate, so they decided to do concurrent chemoradiation as the standard of care. As is often chosen, he had weekly carboplatin/paclitaxel. And then, at the end of that, since this was very recent, the decision was made to give him consolidation durvalumab based on the PACIFIC trial.

Transcript edited for clarity.

  • A 64-year-old man presented with shortness of breath and persistent cough of 18 months’ duration; recently, he has experienced chest pain, fatigue, and blood in his sputum. After consulting with his primary care physician, he was referred for oncology evaluation
  • Patient history includes
    • Current smoker (1/2 pack day)
    • Hypertension
    • Acute MI at age 60
  • Evaluation and follow up testing reveal
    • Non-small cell lung cancer in left lung and 2 lymph nodes (Stage IIIa)
    • WHO performance status: 1
    • Histology: adenocarcinoma
    • EFGR, BRAF,andALK/ROS1mutation status: wild-type
    • PD-L1 status: ≥25%
  • He underwent multidisciplinary evaluation and was not a candidate for surgery; he was treated with chemoradiotherapy:
    • Concurrent carboplatin-paclitaxel doublet chemotherapy and radiotherapy (60 Gy)
    • Achieved partial response
  • He had no disease progression 20 days after his last radiotherapy treatment, and began treatment with durvalumab