A Chemoimmunotherapeutic Approach to Nondriver NSCLC

A 66-Year-Old Man With NSCLC

May 2018: H&P

• A 66-year-old man presented to primary care with complaints of persistent cough and shortness of breath with easy exertion.
  • PE: Average height, very thin (BMI = 18 kg/m²); says he has been losing weight although not dieting; mild fever (100.6 degrees); intermittent hemoptysis
  • Lab results: CrCL 75 mL/min; A1C 6.8%; WBC 15K/µL
  • PMH: HTN managed on atenolol; former smoker (30 pack-years); attributes cough to smoking but has persisted for 3 years now since he quit
• Primary care suspected bronchitis and prescribed amoxicillin; referred to pulmonology

June 2018: Pulmonology evaluation

• Pulmonologist evaluated patient for COPD: diminished lung function on spirometry
• CT revealed a 3-cm mass in left lung and multiple (<2 cm) masses in right lung, pleura, and axial lymph nodes; patient referred to oncology.

July 2018: Oncology exam

• Biopsy identified adenocarcinoma in left lung with lymph node and pleural involvement
• Molecular testing:
  • ALK& ROS1 rearrangement, negative
  • EGFR, KRAS wild-type
  • KRAS negative
  • PD-L1 TPS: 45%
• Additional testing: Abdominal CT, NED; Brain MRI, NED
• Diagnosis: Stage IVA lung adenocarcinoma without molecular drivers

August 2018

• Patient begins treatment with pemetrexed/carboplatin plus pembrolizumab 200 mg q3 wks