NSCLC with Multiple Sites of Metastasis and No Driver Mutation - Episode 1
Mark A. Socinski, MD:The case is of a 64-year-old gentleman who presents with a headache and some visual abnormalitieshis left eye in some confusion. He eventually is evaluated by head of CT and is shown to have an occipital lesion on the right side. He subsequently has an evaluation of his chest, initially by chest x-ray and then by chest CT, which shows a 2.2-cm, left-lower lobe mass associated with some mediastinal adenopathy. A PET scan is subsequently done and it shows, in addition to the left lower lobe mass in the mediastinal disease, several boney sites that are highly suggestive of metastatic disease. He ends up having a biopsy of the left lower lobe lesion that shows a moderately differentiated adenocarcinoma on immunohistochemical staining. It is positive for TTF-1 and morphologically consistent adenocarcinoma.
He is a current nonsmoker, but did have a 30-pack-a-year exposure to smoking in the past, having quit about 5 years ago. His adenocarcinoma biopsy was tested forEGFR,ALK,andROS1and they were all negative. He also had a PD-L1 stained that showed it to be about 15% staining percentage. And in follow-up to his CT scan of the brain, he had an MRI of the brain. In addition to the occipital lesion that was noted, there were also 8-mm lesions in the left frontal lobe as well as right temporal lobe. So, he had 3 total lesions in the brain.
This patient obviously had stage 4 adenocarcinoma of the lung. My impression is that this patient has been well evaluated. We are confident about his stage, given the bony metastases as well as the brain metastases. We’re also confident about the diagnosis both from a histologic point of view as well as genetic point of view. He was tested per the current NCCN and other guidelines forEGFR,ALK, andROS1. We also have established his PD-L1 status as being 15% positive. So, I would say my impression is that this gentleman had a very thorough evaluation. We’re confident about the stage, and we’re confident about the diagnosis as well as the molecular aspects of his lung cancer.
In stage 4 adenocarcinoma of the lung, we believe this is a treatable disease, but not a curable disease. This gentleman had an ECOG performance status of 1, which means that he was fully ambulatory and caring for himself. He does, again, not have cure. He would likely have to bebecause of his CNS symptoms and the findings on both the CT and the MRI—put on dexamethasone, a steroid that would have controlled some of the symptoms. His initial treatment should be directed at the CNS disease since he was initially symptomatic there. The prognosis of this patient is, again, he’s not a curable patient but a treatable patient given his good performance status. We’ll talk about the options a little bit later. But nowadays, these patients on average live 1 year or a little longer. About 25% of them live longer than 2 years. So, the prognosis I would describe as limited, but certainly patients with the multiple options that we have nowadays are living longer and longer because of multiple lines of treatment.
Transcript edited for clarity.