Case 1: Locally Advanced NSCLC

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:Thank you for joining us for thisTargeted Oncology™ Virtual Tumor Board^®, which is focused on advanced non—small cell lung cancer. In today’sTargeted Oncology™ Virtual Tumor Board^®presentation, my colleagues and I will review 4 clinical cases. We will discuss an individualized approach to treatment for each patient and will review key trial data that affect our decisions.

I’m Dr Benjamin Levy, an associate professor of oncology and a clinical director of medical oncology at the Johns Hopkins Kimmel Cancer Center at Sibley Memorial Hospital in Washington, DC.

Today I’m joined by:

Dr Anshu Jain, a radiation oncologist at Ashland Bellefonte Cancer Center in Ashland, Kentucky.

Dr Lonny Yarmus, an associate professor of medicine and oncology, the clinical director of the Division of Pulmonary and Critical Care, and the director of the interventional pulmonology research core at Johns Hopkins Medical Institute in Baltimore, Maryland.

Dr Sam Caughron, a molecular pathologist at MAWD Pathology Group and the director of MAWD Molecular Lab in Lenexa, Kansas.

Dr Mickey Walker, associate professor of surgery, Thomas Jefferson University, the chief of thoracic surgery, and the medical director of the cancer program at Main Line Health in Bryn Mawr, Pennsylvania.

And Dr Isabel Preeshagul, an assistant professor and a thoracic medical oncologist at Memorial Sloan Kettering Center in Montvale, New Jersey.

Thank you for joining us. Let’s get started with our first case.

Thanks for everybody joining. I think we have a full house here. We have representation from rad-onc [radiation oncology] and med-onc [medical oncology], surgery, pathology, and pulmonary here, which is more than we sometimes have on our own tumor board, so it’s great to have everyone here. Let’s start with case 1. Case 1 is a 59-year-old woman who presents with dyspnea on exertion. Her past medical history includes hypertension that’s well controlled on medication. She’s a smoker. She has a 25-pack-a-year history, moderate alcohol use, and on physical exam presents with some mild stridor. Her FEV1 [forced expiratory volume] is 78% predicted, and her ECOG [Eastern Cooperative Oncology Group] performance status is 1.

She ends up getting a chest CT [computed tomography] scan that revealed a 6.3-cm spiculate mass in the left upper lobe. She has 2 enlarged left supraclavicular lymph nodes that measure 1.4 and 1.8 cm, respectively. Her PET [positron emission tomography] scan confirms the lung lesions and the supraclavicular lymphadenopathy without any evidence of distant metastases. After her brain MRI [magnetic resonance imaging] is appropriately done; it’s negative.

In terms of how she has tissue procurement, she undergoes a bronchoscopy with a transbronchial lung biopsy and lymph node sampling that reveals grade 2 squamous cell carcinoma with positive nodes and 1, 2R, and 4L. Her staging is a T3N3M0, stage IIIc.

She gets a surgical consult, and we can talk about the utility of that for stage III. The surgeon deems this patient to be unresectable—based on the stage, including the extent of supraclavicular and mediastinal disease. She’s currently being referred now for concurrent chemotherapy and radiation therapy with potential for immunotherapy as consolidation on the back end.

So this is not an uncommon case. I think at all our centers we see these cases. At least for me, it has been rare to find patients who are stage III who are surgically resectable. Many of these patients have either comorbidities that preclude from surgery or multistation N2 disease. Lonny, I’ll start with you here because you’re the beginning of the story in terms of the patient journey. What are the best ways in patients with stage III to get tissue, and how are you getting tissue in these patients as an interventional pulmonologist?

Lonny Brett Yarmus, DO:Sure. Thanks, Ben. There are a couple of factors I think that we can weigh in. Obviously procuring a diagnosis is the primary goal, but also providing as much tissue as necessary for ancillary testing, and inspection of the airways is frequently an important piece. It is especially important to understand the thoracic anatomy in a patient like this who presents with some degree of stridor.

The general approach is to be as minimally invasive as possible. I think in a case like this, with involvement of the supraclavicular node, potentially looking by ultrasound for a fine-needle aspiration is a good start with diagnosing stage IIIc. But also, the importance of bronchoscopy for airway inspection is critical to assess for any extrinsic or intrinsic compression of the airways.

Benjamin P. Levy, MD:In terms of all the patients with stage III, I hear about centers being primarily pulmonary driven in terms of tissue acquisition and others primary driven by either surgery or intervention radiology. What do the referral patterns look like at Johns Hopkins Medicine in Baltimore?

Lonny Brett Yarmus, DO:They generally have transitioned over to pulmonary mainly because of the importance of endobronchial ultrasound for mediastinal staging. We frequently still see referrals, with interventional radiology being the primary for CT-gathered biopsy. But what often happens there is the referral patterns go from a diagnosis to an oncological referral and then back to the pulmonary or thoracic referral for appropriate staging. I think the importance of understanding the mediastinal component is critical.

Benjamin P. Levy, MD:We were talking before we started here about something that, I think, is cool and neat: alternative ways to diagnose patients. And clearly this is not standard of care, but maybe this is the next wave of how we may be looking at diagnosing lung cancer. Also, some of your work looking at breath. Can you briefly just talk about that again? Not standard of care but something that I think we may be seeing in the near future.

Lonny Brett Yarmus, DO:Yeah, sure. So it is definitely not standard of care until we are in the discovery phase. But there has been decades of research looking at volatile organic compounds in breath, trying to better differentiate and define what those different markers are to specified cancer diagnostics.

I think technology has finally caught up. We think we have some promising signals of being able to definitively diagnose early-stage lung cancer patients. It’s even gone on to the fact that now technology has allowed us to devise handheld devices that conceptually might allow patients to tract their own breath analysis and picture a futuristic world.

Benjamin P. Levy, MD:Pretty neat. In my opinion, don’t try this at home.

Lonny Brett Yarmus, DO:Yeah.

Benjamin P. Levy, MD:But, certainly that’s something that is next wave.

Transcript edited for clarity.