Roundtable Roundup: Biomarker-Negative Lung Cancer

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Key Takeaways

The patient presented with symptoms including fatigue, cough with hemoptysis, weight loss, and shoulder pain, indicating possible malignancy.
Imaging revealed a spiculated right upper lobe mass, lymphadenopathy, and sclerotic bone lesions, suggesting metastatic disease.
Lab results showed mild anemia and elevated tumor markers, supporting the diagnosis of adenocarcinoma.
Molecular testing was negative for EGFR and ALK mutations, with PD-L1 expression <1%, guiding potential treatment options.

In separate, live events, Sandip P. Patel, MD; David P. Carbone, MD, PHD; and their event participants considered treatment options for a patient with metastatic non–small cell lung cancer.

Case Summary

A 66-year-old man presented to his physician with:
- Medical history: well-controlled hypertension on a low-dose angiotensin-converting enzyme inhibitor
- Lifestyle: active, plays pickleball 2 to 3 times per week, no significant functional limitations
- Family history: no known cancer history
- Social history: former smoker (20 pack-year history, quit 10 years ago), occasional alcohol use

Presenting symptoms

Progressive fatigue over the past 2 months, interfering with his usual activities
Persistent cough, occasionally productive with streaks of blood
Unintentional weight loss of 10 lb in 3 months
Intermittent right shoulder pain, worse at night, not relieved by nonsteroidal anti-inflammatory drugs
Mild dyspnea on exertion, especially when playing pickleball
New-onset headaches, worse in the morning

Physical examination findings

General: appears mildly fatigued but in no acute distress
Pulmonary: decreased breath sounds over the right upper lung field; no wheezing or rales
Musculoskeletal: mild tenderness over the right scapular region, no focal deficits
Neurological: no focal deficits, strength and reflexes intact

Radiologic findings

Chest X-ray: right upper lobe (RUL) mass (~3.5 cm), possible right hilar involvement
CT Chest/Abdomen/Pelvis with contrast: 4.2-cm spiculated mass in RUL; right hilar and mediastinal lymphadenopathy (~1.5 cm nodes); multiple sclerotic bone lesions in the right scapula and thoracic spine
PET-CT scan: FDG-avid RUL mass, hypermetabolic mediastinal nodes, and intense FDG uptake in right scapula and T4-T6 vertebrae
Brain MRI: negative

Pertinent lab work

Complete blood count: mild anemia (hemoglobin: 11.8 g/dL)
Calcium: 11.2 mg/dL
Alkaline phosphatase: elevated
Lactase dehydrogenase: elevated
Carcinoembryonic antigen: elevated
Endobronchial ultrasound–guided transbronchial needle aspiration: confirmed bilateral nodal involvement with adenocarcinoma
Molecular testing
- EGFR, ALK: negative to both
- PD-L1 testing: pending

CASE UPDATE