Case Overview: A 62-Year-Old Woman with Squamous Histology and PD-L1 Negative mNSCLC
Expert oncologist Sandip Patel, MD, discusses treatment decisions for a 62-year-old female with squamous cell lung cancer, highlighting the use of CTLA4 and PD1 inhibitors based on subgroup analysis.
CASE PRESENTATION
62-year-old woman presented to the ED with vague complaints of voice changes and cough.
- She gave a history of a recent, 11-pound weight loss.
Past Medical, Family, and Social History
- Hypertension, controlled with ACEi 10 mg PO QD
- Hyperlipidemia, treated with atorvastatin 20 mg PO QD
- COPD, treated with maintenance fluticasone furoate, umeclidinium, and vilanterol (100/62.5/25 mcg oral inhalation QD)
- Mother: deceased at 65 years-of-age from lung cancer
- Former smoker: 10-15 pack years. Quit tobacco habit 25 years ago.
Physical Examination
- Current weight: 125 lbs.
- ECOG PS 1
Diagnostic Workup
- CT of Thorax: discovered a 4 cm nodule in the left, upper lobe
- CT of Abdomen reveals metastases to the liver
- MRI of Brain: negative for brain metastases
Final Pathology: consistent with squamous cell carcinoma; metastatic stage IV
PD-L1 expression by IHC: 0%
NGS: No actionable mutations
Treatment
- Therapeutic options were reviewed with the patient and family.
- She was initiated on:
- Nivolumab 360 mg IV Q3W + ipilimumab 1 mg/kg IV Q6W + 2 cycles of chemotherapy Q3W
Transcript:
Sandip P. Patel, MD: Hi, I’m Sandip Patel, a professor of medical oncology at the University of California San Diego, and today we’ll be discussing a case of the 62-year-old woman with lung cancer. This is a 62-year-old woman who presented to the [emergency department] with vague complaints of voice changes and cough. She had a history of recent 11-lb weight loss. Her past medical history and family history and social issues are pertinent for hypertension controlled with an ACE inhibitor, hyperlipidemia controlled with a statin, and COPD [chronic obstructive pulmonary disease] controlled with an inhaler. Family history is pertinent. Her mother unfortunately passed at age 65 from lung cancer. The patient herself has a 15-pack-year smoking history and quit 25 years ago.
On physical examination, her body weight was 125 lbs. She’s ECOG performance status 1, and on diagnostic workup, a CT of the chest and pelvis found a left upper lobe nodule as well as multiple suspicious metastases in the liver. MRI was negative for brain metastasis. A biopsy was done at the liver, which was consistent with squamous cell carcinoma of the lung. So, pathologic stage 4. PD-L1 expression by immunohistochemistry was 0%. Therapeutic options were reviewed with the patient and the family, which included chemoimmunotherapy as well as immunotherapy options. The patient was started on the CheckMate 9LA [NCT03215706] regimen, which is 2 cycles of chemotherapy given squamous histology, carboplatin/paclitaxel, given every 3 weeks for 2 cycles with concurrent nivolumab, 30 to 60 mg, every 3 weeks and ipilimumab, 1 mg/kg, every 6 weeks. After the 2 cycles of chemotherapy were administered, a continuation of ipi-nivo by itself.
This is a case about a 62-year-old woman, ECOG performance status 1, with metastatic non–small cell lung cancer and squamous histology with PD-L1–negative or PD-L1–zero immunobiology. In general, patients with squamous cell histology often have lower response rates to chemotherapy and chemoimmunotherapy historically compared with those patients with non-driver mutation adenocarcinoma. The main risk factor for lung squamous cell carcinoma is smoking, and this patient has prior history of smoking. The main factors that we could modulate—this patient quit tobacco 25 years ago—for those patients who are smoking, having smoking cessation counseling can be helpful in modifying the patient’s risk and prompt initiation of systemic treatment. In this instance, the patient received 2 cycles of chemotherapy with a CTLA-4 and PD-1 inhibitor, which may be a more appropriate potential choice for patients with squamous histology and PD-L1 negative biology based on subgroup analyzes, though we don’t have any randomized data that show that a CTLA-4–containing regimen can benefit. This is based on more retrospective subgroup data from these studies.
In my clinic, [for] patients with metastatic non–small cell lung cancer, squamous histology who are PD-L1 negative, similar to the case we discussed, I’ll typically utilize 2 cycles of chemotherapy, CTLA-4 inhibitor and PD-1 inhibitor, such as the CheckMate 9LA regimen or the POSEIDON [NCT03164616] regimen with the CTLA-4–containing drug in those populations, mainly because the subgroup analyses suggests that there is a benefit for the inclusion of CTLA-4 [in] patients with squamous histology who are PD-L1 negative. There’s also potential benefit for those patients with brain metastasis and with those patients with adenocarcinoma histology and STK11/KEAP1 mutations. But those aren’t relevant features for this case.
Transcript is AI-generated and edited for readability.
