A Case of Nondriver Metastatic Lung Large Cell Carcinoma

Lyudmila Bazhenova, MD:We have a 70-year-old woman who presents with cough and congestion lasting for approximately 6 months. She is a nonsmoker and a light drinker who drinks about 1 to 2 drinks per week. She has a history of Crohn’s disease, which is currently managed by infliximab. She has a history of hypothyroidism and a history of osteoarthritis. Her physical exam was normal, her laboratory tests are normal, and her performance status is 2. She gets a chest x-ray, which showed a mass in the right upper lung. A CT scan showed a 6-by-8 cm mass in the right upper lobe. There is no mediastinal adenopathy, but there are 2 lesions in the liver: one measuring 1.5 cm and a second one measuring 2 cm.

The patient got a bronchoscopy and biopsy of the mass that showed large cell carcinoma. Molecular testing showed an absence of major driver mutations. She got PD-L1 testing by immunohistochemistry, which shows her PD-L1 expression to be 2%. A brain MRI showed no evidence of CNS disease, and therefore our working diagnosis is patient who has stage 4, or metastatic, lung cancer. The patient was started on chemotherapy with carboplatin, paclitaxel, and bevacizumab.

In summary, we have a relatively healthy patient with comorbidities that will change our decision on what the most appropriate therapy is for her. I’d like to concentrate on her having a history of Crohn’s disease, and the Crohn’s disease appears to be active because she is currently receiving treatment with infliximab. This patient has 2 lesions in the liver, but so far, a PET scan has not been performed. As we all know, there are other abnormalities in the liver that can be shown on the CT scan that do not necessarily represent metastatic disease. So, at the minimum, I would recommend doing a PET scan to confirm that those lesions are PET-positive.

If I were the one picking the site of the biopsy, I would go for the liver biopsy because this is a procedure that can make a diagnosis and stage the patient at the same time. There are other abnormalities in the liver that can look like metastasis on a CT scan, notably a hyperplasia of the liver, and therefore I believe that we need to confirm that this patient truly has metastatic disease before we decide on treatment.

Assuming a PET scan shows increased uptake in the liver nodules, we confirm that this patient has a metastatic disease. What that means for us is that this patient is not curable, but she’s treatable, and the goal of treatment for her situation would be to improve survival and improve quality of life. Based on the fact that she was treated with carboplatin, paclitaxel, and bevacizumab, I would code her as a 1% survival of about 50% and a median survival of about 12.3 months.

Transcript edited for clarity.

• A 70-year old woman presented with persistent cough and congestion lasting more than 6 months
  • She is a non-smoker; drinks alcohol 1-2 times/week
  • PMH: Crohn’s disease managed on infliximab; hypothyroidism, moderately well-managed on levothyroxine; osteoarthritis managed PRN on naproxen
  • Her physical exam and cardiac workup were normal
  • CBC; WNL
  • PS by ECOG assessment is 2
• Chest X-Ray showed mass in the upper right lung
• CT of the chest, abdomen, and pelvis showed a solid 6 X 8 cm. Right-sided pleural mass abutting the apical aspect of the chest wall and 2 small hepatic nodules measuring 1.5 cm and 2 cm.
• Bronchoscopy and biopsy of the lung mass was performed; pathology was consistent with large cell carcinoma
  • Genetic testing was negative for known driver mutations
  • PD-L1 testing by IHC showed expression in 2% of cells
• Brain MRI showed no evidence of CNS disease
• Diagnosis; stage IV NSCLC
• The patient was started on therapy with carboplatin and paclitaxel and bevacizumab