NSCLC: Initial Impressions of Patient Profile and Biomarker Testing Practices

Opinion
Video

A medical oncologist offers his initial impressions of the patient profile of a 60-year-old with early-stage NSCLC and discusses biomarker testing practices, highlighting types of testing and challenges.

Case: A 60-Year-Old Woman with Early-Stage Non–Small Cell Lung Cancer

Initial presentation and Clinical Workup

  • Healthy 60-year-old Caucasian woman, 45 pack-year smoker, presented with a nonproductive cough
    • Physical exam revealed ECOG PS 0, BP: 120/93, HR: 74 bpm, BMI: 22
    • Pulm: lungs CTA bilaterally
    • Chest X-Ray: 5.5-cm right mass in right upper lobe
    • CT chest/abdomen: lobulated 5.5 x 5.1-cm mass in right upper lobe
    • Biopsy of Right Upper Lobe: adenocarcinoma, TTF1 (+) consistent with NSCLC
    • Labs are WNL; PET Imaging: negative for any lymph nodes or distant metastasis; Brain MRI: negative; PFTs: Normal

Treatment 

  • Mediastinoscopy with negative lymph nodes on frozen section, followed by right upper lobectomy without complications
  • Current ECOG PS remains 0
  • Histopathology reveals 5.5-cm tumor with negative margins; 0 nodes positive for malignancy (2R, 4R, 7, and 11R are all negative)
  • Patient is diagnosed with stage IIA (pT3N0M0) lung adenocarcinoma
  • Molecular testing shows EGFR exon (19del) and PD-L1 expression of 40%.
  • Post operation, the patient completes 4 cycles of adjuvant chemotherapy with cisplatin + pemetrexed. Her ECOG PS is 1.
  • Patient begins treatment with osimertinib. 20 months after initiating osimertinib, the patient reports headaches and worsening fatigue.
  • CT scans revealed 3 new liver lesions and Brain MRI visualized 1 new lesion.

This is a video synopsis/summary of a Case-Based Peer Perspectives featuring Sandip P. Patel, MD.

This case involves a 60-year-old woman with newly diagnosed stage IIA lung adenocarcinoma who underwent appropriate surgical and adjuvant treatment, including platinum-based chemotherapy (pemetrexed) and osimertinib per the ADAURA trial regimen. However, she developed progression after almost 2 years, with new liver and brain metastases.

Key discussion points focus on the importance of timely, guideline-concordant molecular testing to help guide treatment decisions in early-stage non–small cell lung cancer (NSCLC). At minimum, Patel advocates for PD-L1 immunohistochemistry, EGFR mutation analysis, and ALK fusion testing. In the metastatic setting, he uses next-generation sequencing to assay a wider range of targetable alterations.

He notes logistical issues with testing, including financial coverage, lower yields of cell-free DNA in early-stage disease, and turnaround times that may delay treatment. Rapid single-gene assays for EGFR mutations and PD-L1 testing can facilitate quick neoadjuvant decisions when needed. Ultimately, selecting the right test for actionable results and sequencing therapies appropriately is advocated.

Video synopsis is AI-generated and reviewed by Targeted Oncology™ editorial staff.

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