Rounds with the Investigators 2012 | Lung
QUESTION: My second case is a 67 y/o F with an incidental finding of an RUL mass on CXR with enlargement on CT at a 3-month follow-up scan. PET only slightly hypermetabolic. Bronch showed question of bronchoalveolar carcinoma. She underwent RUL resection and was found to have a 3.0-cm adenocarcinoma with some areas of poorly differentiated disease and areas of lymphovascular invasion. Three out of 6 peribronchial LNs were positive. She was EGFR positive. What is the “preferred” adjuvant regimen for this patient? I have treated her with cisplatin and vinorelbine, and it has been relatively poorly tolerated. Is there any role for adjuvant erlotinib?
DR MARGARET DEUTSCH: This is a 67-year-old woman who was found, incidentally, on a chest x-ray to have an ill-defined mass in the right upper lobe. And she underwent repeat imaging at 3 months, and it showed enlargement in the area of the abnormality. A PET scan was performed, which showed slight FDG activity in the right upper lobe but no mediastinal lymphadenopathy. And she underwent a bronchoscopy, and washings were consistent with adenocarcinoma, with the possibility of bronchoalveolar carcinoma.
She was taken to the OR and had a right upper lobe resection. She had a 3- by 1.5- by 1-cm adenocarcinoma with some areas of poorly differentiated disease and what was reported as peripheral changes of bronchoalveolar carcinoma. I don’t know what that means. She had lymphovascular invasion. Three of 6 peribronchial lymph nodes were positive for metastatic disease, and no mediastinal lymph nodes were sampled.
DR NEIL LOVE: What type of surgeon did this? Was it a thoracic surgeon, thoracic oncologist?
DR DEUTSCH: He is a CT surgeon who I would say does far more hearts than lungs and so not dedicated to lung surgery.
DR LOVE: How did the patient do postop?
DR DEUTSCH: Postoperatively it was difficult for her. She had a persistent air leak that required a chest tube for about 10 days but eventually was able to close her air leak and get the chest tube taken out. And she is a reformed smoker, smoked in college but hasn’t smoked since then. She’s also a former nurse, now retired.
DR LOVE: What would you say her pack-year history was when you say, “she smoked in college”?
DR DEUTSCH: Pretty small. Maybe smoked 2 or 3 years in college and then quit. So really quite minimal smoking history.
DR LOVE: So just again to follow up on something we talked about this morning, Greg, would you want to see her tumor tested for EGFR or ALK or ROS1?
DR GREGORY RIELY: We as a group have made the decision that we think all patients who have lung cancer should have molecular testing done. One can argue about the relevance of this mutation testing, molecular analysis in patients with early-stage disease. Unfortunately, the reality is that many of these patients have recurrent disease. With a patient with Stage II lung cancer like this, it’s a 50% chance of recurrent disease. And when you have the tissue and you have the time, it’s a reasonable thing to try to get that analysis done now.
DR LOVE: How often, Corey, do you see patients having these kind of postop problems: persistent air leak with a chest tube for 10 days?
DR COREY LANGER: Not uncommon, 10, 20%. This is the cost of doing business in the thorax. Unfortunately, probably 40 to 50% of patients that I’ve seen, not specifically with it at Penn but within the Delaware Valley, have had what I consider to be a noncancer operation. This person did not have mediastinal node sampling.
As a community, at least as oncologists, we tolerate a level — and I’ll call it, frankly, malpractice — that would never be tolerated in breast cancer. This person has not been completely staged. We do not know the status of the mediastinum. Presumably, the PET and the CT were negative in the mediastinum preop.
DR DEUTSCH: They were.
DR LANGER: But I haven't heard you mention of either EBUS or mediastinoscopy. I gather the tumor was probably too small to warrant an automatic mediastinoscopy preop, but certainly larger tumors might.
DR DEUTSCH: And I think the fact that her PET scan was negative. Although, having said that, her primary wasn’t particularly positive on PET either. It was only slightly —
DR LANGER: So only vaguely positive.
DR DEUTSCH: — hypermetabolic.
DR LANGER: So a cardiothoracic surgeon, someone who spends more time dealing with the hearts, to do a cancer operation, and these folks need to be retrained. This patient did not have, as far as I mean technically, you could call it an R0 resection, but they didn’t have all the node samples. So that’s not a full cancer operation. And we struggle with this. Should we sample the mediastinum somehow? Should we do an EBUS? Should we do a mediastinoscopy? How will it alter what we do if there’s extant, actual viable tumor? It’s an R1, R2 resection and you would approach that patient completely differently. If you knew that there was active disease in the mediastinum, you would approach this patient potentially as a IIIA and give them concurrent chemoradiation.
So I think there's a lot of education that needs to go on out there, particularly in the surgical community and the thoracic surgical oncology community.
DR LOVE: Now when did you see her for the first time?
DR DEUTSCH: I saw her postop.
DR LOVE: And what was her general condition and attitude?
DR DEUTSCH: Her general condition is really pretty good. She does not have any other chronic medical illnesses except for very mild hypertension. She’s very active. Actually, the first thing she said to me was, “I want to go take care of my horse and ride it.” And that’s what she does. She has a horse that she takes care of, and that’s her hobby and her life. And that was what she wanted to do as soon as she got over her air leak.
DR LOVE: So, Greg, what would you be thinking about in this lady at this point?
DR RIELY: Right. So the patient has at least a Stage II lung cancer, based upon the nodes that we assessed. And it’s quite possible, given that she has 3 out of 6 positive nodes, and it’s quite possible that there’s mediastinal lymph node involvement. Both of those things, with what we have in the pathology lab already, the patient should get adjuvant chemotherapy or at least should be offered adjuvant chemotherapy, with the idea of reducing the risk of recurrence in a statistically and clinically significant amount.
DR LOVE: So what would be the options and what do you think you most likely would offer her, specifically?
DR RIELY: So the use of adjuvant chemotherapy in lung cancer is really, I think, all over the map in terms of the types of chemotherapy people use, with one hopeful point of agreement — most people, I think, agree that cisplatin should be a part of the adjuvant chemotherapy regimen, if it can be. All the data that we have showing improved overall survival for adjuvant chemotherapy are with cisplatin and a vinca alkaloid or cisplatin and etoposide. Many people have made an extrapolation from treatment of Stage IV lung cancer that cisplatin/pemetrexed or cisplatin/docetaxel or cisplatin/gemcitabine would be appropriate. And I think the evidence of that is that in the large ECOG trial randomizing patients to chemotherapy with or without bevacizumab, all those chemotherapies are standard options in that clinical trial.
Given that we are in a curative setting, I do kind of lean back on data that show actual improvement in overall survival and my tendency is to use cisplatin/vinorelbine as my primary chemotherapy of choice. If there are things that push me away from it then I certainly am flexible. But if I’m given my choice, I will pick cisplatin/vinorelbine.