A Case of Advanced Squamous NSCLC

Benjamin Levy, MD:So, this is a 72-year-old female with a 40-pack year history of smoking who presented to her primary care physician with progressive shortness of breath and increased cough. Given her smoking history, the primary care physician ordered a chest x-ray, which revealed a right upper lobe opacity. Based on those findings, the patient went on to get a CAT scan of the chest, abdomen, and pelvis that revealed a 3-cm right upper lobe mass, pleural thickening, as well as a left adrenal gland nodule. Based on the pattern of spread and to both stage and diagnose the patient, a core needle biopsy was performed on the left adrenal mass, which came back as a squamous cell carcinoma that was p40-positive and p63-positive.

Based on the fact that this occurred in April 2013, the initial presentation, the PD-L1 testing, was not performed at that time. After the diagnosis was made, a PET scan was done to confirm the findings on the CAT scan, and the patient, indeed, had stage 4 squamous cell lung cancer. Based on the histology and the stage, the patient was started on carboplatin/Abraxane. The patient received 2 cycles, and a subsequent CAT scan showed disease response on all sites. The patient felt better and had improved quality of life, as well as improved shortness of breath and cough. The patient went on to receive a total of 6 cycles of carboplatin/Abraxane, and after the sixth cycle, she had achieved stable disease when compared to the CAT scan after 2 cycles.

The patient was then just monitored and did quite well up until roughly a year later. In June/July of 2014, a surveillance scan picked up on a new left upper lobe mass that was roughly 2 cm. Given how long the patient had had stable disease, that lesion was biopsied and confirmed to be squamous cell. At that time, the patient was presented in a tumor board because she was going to be considered for local therapies. This was done because she had such a long interval of disease stability and had done quite well, and the decision rendered at the multidisciplinary tumor board was to give her local therapy to the left upper lobe lesion. She received stereotactic radiosurgery and did quite well with that modality.

The patient was then followed again and did not receive any further systemic chemotherapy up until around 9 months later, where she developed more symptoms of shortness of breath and cough. At that time, a CAT scan revealed that all sites of disease were growing in the lung, with the adrenal gland remaining fairly stable. The decision was rendered that she warranted subsequent therapy and, based on that, was offered a checkpoint inhibitor with nivolumab.

This patient presents like many squamous cell patients present: with shortness of breath and cough. And oftentimes, squamous cell presents with masses that are centrally located. In this patient, it was a little different. She presented with a mass that was more peripheral; however, she had pleural thickening as well as an adrenal metastasis. And unfortunately, this is not uncommon. Most patients, whether they have squamous cell or adenocarcinoma, 60% of them present with advanced stage disease, and this patient is no different than the patients that I see in my clinic every day.

Transcript edited for clarity.

April 2013

• A 72-year-old female presented to her primary care physician with symptoms of shortness of breath and increased cough.
• The patient has a 40-year (1 pack/day) smoking history.
• Chest X-Ray revealed a right upper lobe opacity.
• CT of the chest and abdomen showed a 3 cm. right upper lobe mass, pleural thickening, and a left adrenal gland nodule.
• She underwent core needle biopsy, the left adrenal mass showed squamous cell carcinoma that was p40+ and p63+.
• PET/CT indicated stage IV squamous cell lung cancer.
• The patient began chemotherapy with carboplatin/nab-paclitaxel.
• CT after 2 cycles of therapy indicated that her tumor burden decreased significantly. At that point the patient reported improvement of her symptoms.
• After 6 cycles the patient had stable disease.

October 2015

• Routine follow up imaging showed a new left upper lobe mass of 2 cm.
• The lung lesion was biopsied and confirmed to be of squamous cell histology.
• Based on multidisciplinary assessment, the new lung lesion was treated with stereotactic radiosurgery.

June 2016

• The patient reported symptoms of coughing and shortness of breath.
• CT showed increased diameter in both lung masses. The adrenal mass remained stable.
• The patient was subsequently started on nivolumab.