A 61-Year-Old Man With Small Cell Lung Cancer - Episode 1

Presentation of a Patient with Small Cell Lung Cancer

December 18, 2020
Ticiana Leal, MD

Dr Ticiana Leal, MD, outlines the specific demographic and diagnosis of a patient with small cell lung cancer.

Ticiana Leal, MD: Hi. My name is Ticiana Leal. I’m a medical oncologist and a thoracic oncologist at the University of Wisconsin Carbone Cancer Center. I’m the lead on our thoracic oncology program. Today we’ll be talking about a case of a patient who is a 61-year-old man with small cell lung cancer. Here is our initial presentation.

This is a 61-year-old man who presented with cough, fatigue, and progressive shortness of breath. His past medical history is unremarkable. Social history is significant for a 25-pack-year smoking history and social alcohol use.

On physical exam, his vitals are stable. There is some wheezing in the right lower lobe auscultation and axillary lymph node enlargement. Labs demonstrate that his renal and hepatic function are within normal limits, as well as his CBC [complete blood count]. Sampling of the axillary lymph node demonstrates small cell carcinoma. Staging included a CT scan of the chest, abdomen, and pelvis, which showed a large 7.1-cm mediastinal mass with invasion into the right main and lobar pulmonary arteries, 2 small left pulmonary nodules, and hypermetabolic activity of the lymph node in the axillary region.

Additional imaging included a PET [positron emission tomography] scan, which showed large focal hypermetabolic activity in the mediastinum and small hypermetabolic activity in the surrounding area and the axillary lymph node. Contrast-enhanced MRI of the head showed no CNS [central nervous system] metastatic disease. This patient was staged to have stage IV small cell lung cancer or extensive-stage disease with an ECOG performance status of 0.

His initial treatment included 4 cycles of platinum with carboplatin plus etoposide and atezolizumab followed by atezolizumab as maintenance therapy. In follow-up, this patient had treatment for 7 months but unfortunately developed shortness of breath, right upper quadrant pain, and back pain.

Follow-up imaging with a CT scan showed metastasis in the liver and right adrenal gland. This patient initiated lurbinectedin at 3.2 mg/m2 IV [intravenous] every 21 days.

This is our initial case. We’ll talk a little more about the decisions during the treatment for this patient and also their prognosis. In summary, this patient has been diagnosed with extensive-stage small cell lung cancer. Unfortunately, this is how the majority of the patients present with advanced disease; therefore, the disease is not curable. However, the disease is treatable, and this patient initiated treatment with platinum in combination with immunotherapy.

This is a very standard presentation. One good thing about this clinical case is this patient presents with good performance status and good organ function and is stable enough to maintain his initial treatment in the outpatient setting. Those are definitely good prognostic factors that allow us to treat this patient in the outpatient setting.

We can estimate the prognosis for this patient based on the data we currently have and the advancements we’ve made in the treatment of small cell lung cancer. With the regimen that this patient initially received—a combination of carboplatin-etoposide with atezolizumab—based on the phase 3 trial in IMpower133, we know that the median overall survival for this patient is approximately 10 months or 12.3 months in the durvalumab arm with a 12-month overall survival of approximately 51%. So 51% of the patients are alive at 1 year receiving this regimen.

One thing that is consistent with what we see in the data is that the median progression-free survival with this regimen is about 5 months, and this patient also had progression of his disease within that period of time.

That tells us that the majority of patients at that time point are actually faced with the decision of whether to continue on to second-line treatment. In the case of this patient, he went on to receive lurbinectedin.

Transcript edited for clarity.


Case: A 61-Year-Old Man With Small-Cell Lung Cancer

Initial Presentation

  • A 61-year-old man presented with a cough, fatigue, progressive shortness of breath
  • PMH: unremarkable
  • SH: 25-pack year smoking history; social alcohol use
  • PE: Right lower lobe wheezing on auscultation, axillary lymph node enlargement

Clinical Workup

  • Labs: WNL
  • Axillary lymph node biopsy revealed small cell carcinoma
  • Chest/abdomen/pelvic CT showed a 7.1 cm mediastinal conglomerate mass, with invasion into the right main and lobar pulmonary arteries; 2 small left pulmonary nodules; hypermetabolic axillary lymph node
  • PET scan showed large focal hypermetabolic activity in the mediastinum and small hypermetabolic activity in the surrounding area
  • Contrast‐enhanced MRI of the head showed no brain metastases
  • Stage IV small-cell lung cancer; ECOG PS 0

Treatment

  • Initiated carboplatin + etoposide + atezolizumab for 4 cycles; followed with atezolizumab as maintenance therapy

Follow-up

  • 7 months after starting treatment he complained of shortness of breath, right upper quadrant pain and back pain
  • CT showed hematogenous metastases in the liver and right adrenal gland
  • Initiated lurbinectedin 3.2 mg/m2 IV q21 Days