Clinical Management of NSCLC With Bone Metastases - Episode 1

Diagnosing A Patient With Stage 4 NSCLC

July 19, 2018

Roy S. Herbst, MD, PhD:The case is unfortunately quite typical for a presentation of lung cancer. This is a 62-year-old patient, smoker, who has lung cancer. On first presentation, the patient is already metastatic in multiple sites. This patient has a tumor in the right lung, but vertebral bodies are involved, presenting with pain in the neck. The way the case is diagnosed is quite typical. It is exactly how I would do it. The patient has tissue obtained, which is positive for adenocarcinoma—that’s TTF—1-positive. So, this is a pretty standard case. Here, you have disease in the lung. You have lymph nodes in the lung, and you have metastatic sites. So, this is stage 4 lung cancer.

This patient had very appropriate molecular pathology work done. That’s really something that has changed in the last decade. Most patients in the community, around the United States, around the world, are getting molecular testing, especially for adenocarcinoma. If there’s a driver mutation, these patients should get one of the oral TKIs. In this case, the patient was unfortunately negative forEGFR,ALK, andROS1—a so-called triple-negative patient. There are some minor mutations that can be looked for as well these days, such asBRAFandHER2, but most of those would not affect what one would do for first-line therapy.

This patient also was tested for PD-L1, which is very important. At the time that this patient was treated, with the PD-L1 status of 0%, this patient would not have been a candidate for immunotherapy.

So, with all those data in hand, this patient was treated with carboplatin and pemetrexed—a very standard, well-tolerated frontline therapy. This is probably what I would have used at that time as well. This patient received those drugs and had some activity but, of course, progressed. In the refractory setting, he received docetaxel with ramucirumab. Again, this is something that I’ve used in my practice quite often. Based on the REVEL trial data, this is a very active combination in the second-line setting.

Transcript edited for clarity.

Case: A 62-Year-Old Man With NSCLC and Bone Metastases

  • A 62-year-old man presents to his PCP complaining of persistent right-sided neck pain. Two months later he developed decreased appetite, lethargy, and a dry cough
  • PMH: Smoker, hypercholesterolemia managed on pravastatin, no allergies, no family history of lung cancer
  • Imaging
    • MRI of the neck revealed spine lesion
    • Chest CT showed a 4.3-cm right upper lung mass with enlarged right hilar and right paratracheal lymph nodes
    • PET scan showed18FDG uptake in the RUL mass, the hilar and paratracheal nodes, and multiple cervical and thoracic vertebrae
    • Brain MRI was negative for metastases
  • CT-guided biopsy of the RUL mass showed stage 4 adenocarcinoma; TTF-1 positive
  • Molecular testing:
    • NGS: negative forEGFRandROS1
    • IHC: negative forALKgene rearrangement
    • IHC: PD-L1 expression in 0% of cells
  • Labs show elevated CEA (26), low albumin (3.4), normal creatinine, CBC, and liver function
  • The patient was started on pemetrexed with carboplatin q3W and vitamin B/folic acid supplement
  • PE/ROS after cycle 1: ECOG PS 1, no palpable lymph nodes, decreased breath sounds in RUL, persistent symptoms
  • CEA increased to 28, CBC shows mild anemia (Hgb 11.0)
  • Imaging after 2 cycles of chemotherapy showed progression in the right lung mass (5.2 cm) and several bone lesions
  • Labs now show increased CEA (34), decreased albumin (3.2), and decreased Hb (10.2)
  • The patient was started on docetaxel with ramucirumab