A 68-Year-Old Woman with Small-Cell Lung Cancer - Episode 1

Evaluation of a Patient with Small Cell Lung Cancer

February 8, 2021
Kartik Konduri, MD

Kartik Konduri, MD, evaluates the case of a 68-year-old woman with extensive-stage small cell lung cancer.

Kartik Konduri, MD: Welcome to this case presentation of extensive-stage small cell lung cancer.

I’m Kartik Konduri, a thoracic medical oncologist at the Baylor Charles A. Sammons Cancer Center in Dallas, Texas.

This case begins with a patient who is a 68-year-old lady who presents with fatigue and cough with a past medical history of a hysterectomy at the age of 55, a social history of a 55-pack-year smoking history. And, on physical examination, the patient has decreased breath sounds in the left lung and cervical lymph node enlargement.

In the clinical workup of this patient, all labs are within normal limits. The lymph node biopsy shows small cell carcinoma. A chest, abdomen, and pelvic CT [computed tomography] scan shows a 7.4 cm mass above the diaphragm, and a small contralateral lung nodule is visualized with evidence of invasion into the left side of the pericardium. A PET [positron emission tomography] scan shows activity in both lungs above the diaphragm with small hypermetabolic activity in the surrounding area. A contrast enhanced MRI [magnetic resonance imaging] of the head was performed and is negative for brain metastases. The patient is staged as stage IV extensive-stage small cell lung cancer. The patient’s performance status is ECOG [Eastern Cooperative Oncology Group] 0.

Coming to treatment for this patient, the patient is initiated on carboplatin and etoposide, and atezolizumab for 4 cycles, followed by atezolizumab as maintenance therapy. A repeat CT scan shows a suspicious hepatic mass, and the patient then gets initiated on lurbinectedin at 3.2 mg/m2 IV [intravenous] every 21 days.

This case denotes a common presentation for small cell lung cancer. Many of our patients who are initially diagnosed are seen to have stage IV disease, and, unfortunately, this patient also has findings of disease in the contralateral lung as well as in the supraclavicular lymph node. The patient is treated with standard-of-care therapy with chemotherapy and immunotherapy treatments, and because of a progression, the patient is switched over to a second-line treatment.

Small cell lung cancer comprises about 15% of lung cancers in the United States. Of the 220,000 rough number of patients who are diagnosed with lung cancer, 15% to 20% of patients have small cell lung cancer. It is a disease most commonly seen in smokers and predominantly with patients who have a history of heavy smoking, although there is a small proportion of patients who have never smoked or very minimally smoked who also can present with this disease. Many times, patients with small cell lung cancer have tumors which have multiple genetic abnormalities. These may include TP53, RB1, c-MYC amplification.

In general, the prognosis for patients such as this one has been in the range of approximately 8 to 10 months, but with the advent of chemotherapy and immunotherapy recently, we have been able to improve outcomes with a medial overall survival [OS] of approximately 12.5 months. There have been developments of newer therapies that have come into our armamentarium for treatment for small cell lung cancer.

The treatment options for this patient at diagnosis include consideration for chemotherapy with immunotherapy, a clinical trial, or their consideration for straight up chemotherapy alone if there is a contraindication for the immunotherapy.

In the evaluation of our patients who have extensive-stage small cell lung cancer, we usually consider utilization of chemotherapy and immunotherapy as a standard first-line therapy treatment option for our patients. This is based upon a couple of large trials using chemotherapy with immunotherapy which have shown an improvement in OS for our patients. We consider factors such as performance status, brain metastases, as well as end organ function status in our approach to using treatment options for our patients.

Transcript edited for clarity.


Case: A 68-Year-Old Woman with Extensive-Stage Small-Cell Lung Cancer

Initial Presentation

  • A 68-year-old woman presented with fatigue and a cough
  • PMH/PSH: hysterectomy at age 55
  • SH: 55-pack year smoking history
  • PE: decreased breath sounds in the left lung, cervical lymph node enlargement

Clinical Workup

  • Labs: WNL
  • Lymph node biopsy showed small cell carcinoma
  • Chest/abdomen/pelvic CT showed a 7.4 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 both lungs, above the diaphragm with small hypermetabolic activity in the surrounding area
  • Contrast‐enhanced MRI of the head was negative for brain metastases
  • Stage IV extensive-stage small-cell lung cancer; ECOG PS 0

Treatment

  • Initiated carboplatin + etoposide + atezolizumab for 4 cycles; followed with atezolizumab as maintenance therapy
  • Repeat CT scan showed a suspicious hepatic mass
  • Initiated lurbinectedin 3.2 mg/m2 IV q21 Days