Metastatic Large Cell Lung Cancer: Optimizing Treatment

Lyudmila Bazhenova, MD:When we use the term “multidisciplinary assessment” in lung cancer, what usually comes to mind is a multidisciplinary assessment of patient with stage 3 disease where it is important for us to get a surgical opinion and radiation oncology opinion. However, in a patient with stage 4 disease, a multidisciplinary approach is very important as well; for example, when we make a decision of what the best site to do the biopsy would be. We want to make sure that we include our pulmonary colleagues and our interventional radiology colleagues. We want to make sure that we get enough tissue for molecular testing. We want to work with our pathology colleagues so that they do not waste the tissue for immunohistochemical stains that are not necessary to make the diagnosis of lung cancer. We also have to work with our palliative care colleagues because we do have data showing that early palliative care for patients with metastatic lung cancer improves outcomes.

In my institution, we have tumor boards. We have a lung tumor board where we talk about cases where multidisciplinary input is necessary. We also have a molecular tumor board where one can present a patient with rare molecular abnormalities to get support from scientists and clinicians who may be more familiar with those rare molecular abnormalities than other providers might be.

As for the liver nodules, because this patient has stage 4 disease, the most important thing we can do for her is give her good systemic therapy. One can consider local treatment of the liver nodules, and we pretty much have 2 modalities. We can do ablation or we can do stereotactic radiation. There is more and more literature emerging for using consolidative radiation therapy for oligometastatic disease, showing that it improves progression-free survival. This patient will qualify as having oligometastatic disease. In the trials looking at the addition of radiation for those patients, oligometastatic disease was described as 3 or less metastatic sites. This patient has 2 sites of metastases. So, after completion of a platinum-based doublet, I think it is reasonable to consider consolidative radiation to the sites of metastases for this patient.

There is no difference in the activity of bevacizumab in patients with metastases in different sites, so I would not treat this patient differently if she did or did not have a liver metastasis or a bone metastasis with the liver metastasis. However, the brain metastasis information is quite important. We have data that giving bevacizumab to patients with treated brain metastasis is safe, and there is no incidence of grade 2 CNS hemorrhages in the patients who receive bevacizumab as long as the brain metastases were treated.

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