Non Small Cell Lung cancer, Stage 4, S/P Right Pneumonectomy
Short summary
A 74 years old male was diagnosed 3 years ago with non small cell lung carcinoma. Accordingly, it was decided that no chemotherapy should be given at that stage. Year and a half later, a new SOL was found in right lung, and right pneumonectomy was performed. On pathology a well to moderately differentiated adenocarcinoma was found. Lymphatic invasion was identified in lung and mediastinum. A revision on previous specimen was performed and it was concluded that the tumor was morphologically different from the previous specimen. The disease was staged as 3 A and the patient was given a course of Vinorelbine. Half a year ago, on CT a new lymphadenopathy in the mediastinum and hematogenous metastatic spread in left lung was demonstrated. Chemotherapy with Alimta and Carboplatinum was initiated.Currently ,the patient is in a good general condition but suffers from cough and weakness.
Patient's questions
- Suggested treatment?
- Any other options of chemotherapy? Tarceva? Avastin?
- Any experimental treatment or protocols? The patient is willing to travel anywhere.
Medical Background
Chronic diseases:
NIDDM (Non Insulin Dependent Diabetes Mellitus)– on diet and oral hypoglycemic.
Hypertension – Controlled by medical treatment.
SEVERE COPD.
Past illness: Heavy Smoker until 7 years ago
Present Illness:
3 years ago an SOL in right lower lobe of lung was found on incidental chest x-ray. A right lower lobectomy was performed. Pathological diagnosis was Non-Small Cell Carcinoma with extensive necrosis. Tumor size 3cm. No malignancy was found in surrounding tissue and lymph nodes and PET CT was negative. A diagnosis of NSCLC stage 1B was made. Accordingly, after several consultations, it was decided that no chemotherapy should be given at that stage. Routine follow-up by CT and PET CT was carried.
Year and a half later, a new SOL was found in right lung. A right pneumonectomy was performed. On pathology a well to moderately differentiated adenocarcinoma (papillary, micropapillary and bronchoalveolar patterns), was found. Size 2.7 cm. Lymphatic invasion was identified and five out of 17 lymph nodes in lung and mediastinum showed metastatic invasion. A revision on previous specimen was performed and it was concluded that the tumor was morphologically different from the previous specimen. No other metastases were found anywhere on CT and PET CT. The disease was staged as 3 A and the patient was given a course of Vinorelbine.
Half a year ago, on CT a new lymphadenopathy in the mediastinum and hematogenous metastatic spread in left lung was demonstrated. Chemotherapy with Alimta and Carboplatinum was initiated. Erythropoetin injections were given due to anemia (9.8 gr Hb). Currently ,the patient is in a good general condition but suffers from cough and weakness.
Medical opinion
A 74 year-old man who is referred online for discussion of systemic therapy options. The available history is provided by the referring physician. The patient suffers from recurrent, now metastatic non-small cell lung cancer, adenocarcinoma. He is currently receiving therapy with carboplatin plus pemetrexed.
Based on the information provided thus far, I would make the following recommendations:
1. Staging:
- It is difficult to assess the extent of disease without having the radiology images or reports, but I did not come across any mention of brain imaging in the provided history. If this has not already been done, he should undergo brain imaging to exclude presence of CNS disease.
2. Current therapy (carboplatin plus pemetrexed):
- If tolerating without significant toxicity, would continue on treatment, with plans to restage after completion of 2-3 cycles of treatment. If stable or improved, and if tolerating well, would consider continuing to a total of 4-6 cycles of combination therapy.
- If the patient is having clinical benefit but is experiencing dose-related toxicity, could consider dose reductions of both agents, or could consider pemetrexed monotherapy.
3. Regarding second-line therapy options:
- Second-line therapy options and beyond in non-small cell lung cancer are generally monotherapy. Options could include docetaxel, erlotinib, vinorelbine, or gemcitabine.
- The referring physician specifically asked about use of bevacizumab. I would not recommend bevacizumab in this patient; in a subset analysis of the ECOG4599 trial, patients over the age of 70 experienced a significantly increased risk of toxicity, an increase in treatment-related death, and an absence of survival benefit with the addition of bevacizumab to standard chemotherapy.
- To inform later treatment options, the patient may be interested in having his tumor tissue sent for assessment of EGFR and KRAS mutations, as well as for the EML4-alk translocation. A number for commercial entities provide this service commercially, including Genzyme in Cambridge, MA. While it is less likely that this "heavy smoker" will harbor an EGFR mutation or EML4-alk translocation, it is possible. Moreover, the presence of such a mutation would have significant potential treatment implications for him with a targeted therapy.
