Presentation of Stage III Non-Small Cell Lung Cancer

Stephen Liu, MD:This case is a 62-year-old man who is a smoker who presented with a 2-month history of respiratory symptoms. He has a 30-pack-per-year smoking history. A relevant social history is that he has his daughter’s wedding in about 11 months, and it’s very important to him. He seeks medical attention and is found to have some wheezing in the lower lobe. He has a CT [computed tomography] scan and shows a 6.1-cm right lower lobe lung mass and enlarged hilar and intrapulmonary lymph nodes. A PET [positron emission tomography] scan shows hypermetabolic activity at those areas but no distant hypermetabolic uptake. An MRI [magnetic resonance imaging] of the brain that’s contrast enhanced showed no brain metastases. Pulmonary function is acceptable with a DLCO [diffusing capacity for carbon monoxide] of 55%.

This patient then underwent bronchoscopy with biopsies of the right lower lobe lung mass and a hilar node that revealed a squamous non—small cell lung cancer. Our final stage here is a T3N1M0 stage IIIa squamous non–small cell lung cancer. He was deemed to be unresectable based on anatomic location.

Because this patient was unresectable but had a good performance status, an ECOG PS, of 1, he was offered definitive therapy with concurrent chemoradiation. He received concurrent cisplatin and etoposide using the SWOG 50/50 regimen after completion of chemoradiation. He then received consolidation durvalumab at 10 mg/kg every 2 weeks, and a CT scan at 2 months did show a good response to therapy.

The management for a stage III non—small cell lung cancer, as in this case, is appropriate. For an unresectable non–small cell lung cancer, our current standard of care is definitive concurrent chemoradiation. Chemotherapy alone, radiation alone, and immunotherapy alone really would be considered substandard treatment. Definitive concurrent chemoradiation offers the chance at long-term survival, offers the chance at cure. Pursued in this manner, I think this gives the patient the best possible outcome.

Despite the fact that this is a potentially curable cancer, the prognosis is not quite as good as we would like. For an unresectable non—small cell lung cancer receiving concurrent chemoradiation, we would expect 5-year survival rates, approximating cure rates, of about 30%. If we look at more recent data from RTOG 0617, this is a randomized trial that looked at 60 Gray versus 74 Gray. The higher doses of radiation were not providing better outcomes, but if you look at the control arm of 60 Gray, we see a 5-year survival rate of about 32%, which would mean that maybe 1 in 3 patients would potentially be cured with this treatment. Unfortunately, the vast majority of patients are not achieving that long-term survival. Those numbers hopefully will be raised, will be buoyed by the addition of durvalumab, which we know does improve survival. We don’t yet have long-term outcomes from that strategy.

Transcript edited for clarity.

Case: A 62-Year-Old Male With Stage III NSCLC

Initial presentation

• A 62-year-old man presented with a 2-month history of cough, wheezing, and loss of appetite
• PMH: Hypertension, medically treated
• SH: 30 pack-year smoking history; daughter to be married in 11 months, and wants to attend the wedding
• PE: Right lower lobe wheezing on auscultation

Clinical workup

• Labs: WNL
• PFT: FEV₁/FVC 60%; DLCO 55%
• Chest/abdomen/pelvic CT showed a 6.1-cm solid pulmonary lesion in the right lower lobe, right hilar and intrapulmonary lymph node involvement; no evidence of distant metastases
• PET scan showed large focal hypermetabolic activity in the right lower lobe and small hypermetabolic activity in the surrounding area
• Contrast‐enhanced MRI of the head showed no brain metastases
• Bronchoscopic biopsy of the RLL mass and hilar node revealed squamous NSCLC
• Staging: T3N1M0 — IIIA; ECOG PS 1
  • Unresectable NSCLC based on the extent and location of disease

Treatment

• Patient was started on cisplatin 50 mg/m²on days 1,8,29 and 36; etoposide 50 mg/m²days 1-5 and 29-33; concurrent RT
• No disease progression after chemoradiation
• Durvalumab 10mg/kg IV q2W was started and dose was tolerated well
• Initial follow-up at 2 months showed partial response, with shrinkage of primary and nodal lesions