The management of patients with stage IIIA (N2) non–small-cell lung cancer (NSCLC) is controversial. In this installment of Clinical Quandaries, we present the case of a man with this diagnosis and review the variety of available treatment options.
A 67-year-old male was found to have a mass in the left upper lobe of the lung on a routine chest radiograph that was done as part of preoperative work-up for an elective inguinal hernia repair. Following this, a computed tomography (CT) scan of the chest revealed a 2.0 x 1.4 cm soft-tissue density in the lingula (Figure 1A). An enlarged lymph node (1.4 x 1.1 cm) was also noted in the aortopulmonary (AP) window. A small hypodense lesion was noted in the liver. No other abnormalities were noted on the chest CT scan. The patient subsequently underwent a positron-emission tomography (PET) scan. The lingular soft-tissue density and the AP lymph node were both metabolically active with standardized uptake value (SUV) of 5.0 and 4.8, respectively (Figure 1B). The lesion in the liver was not FDG-avid. There was no evidence of extrathoracic disease.
The patient underwent a CT-guided fine-needle aspiration of the left lingular lesion. The biopsy was consistent with poorly differentiated adenocarcinoma. Immunohistochemical stains were positive for cytokeratin 7 and thyroid transcription factor-1, and negative for cytokeratin 20. These findings were consistent with identifying the lung as the primary site of the cancer. In order to evaluate the liver lesion further, a magnetic resonance imaging (MRI) scan of the liver was obtained. The findings suggested the liver lesion to be a benign cyst.
The patient's past medical history was pertinent for hypertension, peptic ulcer disease, basal cell carcinoma of the skin, and benign prostatic hyperplasia. He was on treatment with atenolol and famotidine for his medical illnesses. The patient did not have known allergy to any medications. He quit smoking cigarettes in 1975 and had a 20 pack-year history prior to that. The patient consumed alcohol on a social basis (two drinks per week). He had no history of exposure to asbestos.
His physical exam was pertinent for a slightly elevated blood pressure of 148/90 mm Hg, reducible right inguinal hernia, and a healed surgical scar in the right upper quadrant of the abdomen from a prior cholecystectomy. His respiratory exam was normal. The patient had an excellent functional status. His performance status on the Eastern Cooperative Oncology Group (ECOG) scale was 0.
Based on the above information, his lung cancer was diagnosed as clinical stage IIIA (T1, N2, Mx). Initial laboratory evaluation revealed normal bone marrow, hepatic, and renal function. Pulmonary function tests revealed a forced expiratory volume in 1 second (FEV1) of 2.6 liters (80% of predicted value).
Management of this patient was discussed at a multidisciplinary conference that was attended by thoracic surgeons, medical oncologists, radiation oncologists, and pulmonologists. The patient underwent an outpatient left video-assisted thoracic surgery (VATS) to sample the enlarged AP window lymph node. The biopsy was positive for adenocarcinoma. Based on this, it was decided to administer neoadjuvant chemotherapy. The patient was treated with the combination of cisplatin (75 mg/m2) and docetaxel (Taxotere, 75 mg/m2) every 3 weeks for a total of three cycles. He tolerated the treatment well overall. The adverse events associated with chemotherapy included grade 2 fatigue and anemia, grade 3 neutropenia, and grade 1 nausea.
Following completion of the chemotherapy, the patient underwent a repeat PET/CT scan. The new imaging studies showed a slight reduction in size of the lingular lesion and a near-complete resolution of the AP window lymph node (Figure 2). The latter was non–FDG-avid on the follow-up scan, whereas the primary lesion continued to be PET-positive with a lower SUV of 2.8. His performance status remained excellent.
Subsequently, the patient underwent a left thoracotomy and upper lobectomy with complete mediastinal lymph node dissection. The surgical pathologic evaluation revealed a 2.2 x 1.7 cm adenocarcinoma of the lung along with involvement of the visceral pleura (T2) (Figure 3A). The bronchial and vascular margins were negative. A total of 28 lymph nodes were removed from N1 and N2 stations; only three lymph nodes were positive for adenocarcinoma in the AP window and subcarinal region (Figure 3B). Final pathologic stage was IIIA (T2, N2, M0) adenocarcinoma of the left upper lobe.
The patient recovered from surgery and presented for discussion of further treatment options 4 weeks postoperatively. It was decided that radiation therapy would be administered. The role of chemotherapy in this setting was discussed with the patient. The absence of data to recommend additional chemotherapy was explained, and the patient made an informed decision not to receive any further chemotherapy. He tolerated radiotherapy well and received a total of 50.4 Gy (1 fraction/d x 5.5 weeks).
The patient has been on routine follow-up care, with no evidence of disease recurrence approximately 1 year later.
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