Clinical Management of NSCLC With Bone Metastases

Case: A 62-Year-Old Man With NSCLC and Bone Metastases

• A 62-year-old man presents to his PCP complaining of persistent right-sided neck pain. Two months later he developed decreased appetite, lethargy, and a dry cough
• PMH: Smoker, hypercholesterolemia managed on pravastatin, no allergies, no family history of lung cancer
• Imaging
  • MRI of the neck revealed spine lesion
  • Chest CT showed a 4.3-cm right upper lung mass with enlarged right hilar and right paratracheal lymph nodes
  • PET scan showed¹⁸FDG uptake in the RUL mass, the hilar and paratracheal nodes, and multiple cervical and thoracic vertebrae
  • Brain MRI was negative for metastases
• CT-guided biopsy of the RUL mass showed stage 4 adenocarcinoma; TTF-1 positive
• Molecular testing:
  • NGS: negative forEGFRandROS1
  • IHC: negative forALKgene rearrangement
  • IHC: PD-L1 expression in 0% of cells
• Labs show elevated CEA (26), low albumin (3.4), normal creatinine, CBC, and liver function
• The patient was started on pemetrexed with carboplatin q3W and vitamin B/folic acid supplement
• PE/ROS after cycle 1: ECOG PS 1, no palpable lymph nodes, decreased breath sounds in RUL, persistent symptoms
• CEA increased to 28, CBC shows mild anemia (Hgb 11.0)
• Imaging after 2 cycles of chemotherapy showed progression in the right lung mass (5.2 cm) and several bone lesions
• Labs now show increased CEA (34), decreased albumin (3.2), and decreased Hb (10.2)
• The patient was started on docetaxel with ramucirumab