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"Jinling Lung Cancer Network Forum" MDT Case Sharing takes you to see the treatment choices of patients with advanced lung squamous cell carcinoma after benefiting from PFS!
Sun xx, a 64-year-old male with no smoking history in 2021, was diagnosed with stage IV of right lung squamous cell carcinoma in September 2019 for "irritating cough with asthma". The patient received first-line treatment with pambolizumab combined with chemotherapy, followed by two-drug maintenance therapy with pambolizumab plus albumin-binding paclitaxel, followed by pambolizumab monotherapy, and the treatment process can be described as a twist and turn.
On January 5, 2022, at the site of the Jinling Lung Cancer Network Forum MDT, experts discussed the case reported by Ding Lingchi of the Affiliated Cancer Hospital of Nantong University.
A baseline assessment is performed after admission, and imaging tests are as follows:
CT of the chest after admission on 20 September 2019: right hilar mass, atelectasis of the middle lobe of the right lung
Chest CT after admission on September 20, 2019: lesions of small nodule metastases in both lungs, more pronounced in the right lung
CT of the skull after admission on September 20, 2019: no metastatic lesions in the skull
- Bronchoscopy shows: complete blockage of the right main bronchi;
- The first pathological diagnosis shows: squamous epithelial papilloma with atypical hyperplasia and carcinogenesis;
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The second pathological diagnosis showed: papillomatous hyperplasia of the squamous epithelium with high-grade intraepithelial neoplasia, tending to atypical hyperplasia and cancer;
- The third pathological diagnosis showed that the squamous epithelium was atypically hypertrophic and carcinogenous.
- Clinical diagnosis: right lung squamous cell carcinoma stage IV( T4N2M1a).
A glance at the patient's treatment process
■ Pambolizumab + albumin-binding paclitaxel + carboplatin
The KEYNOTE-407 study, based on the first-line treatment of squamous cell carcinoma with pambolizumab combined with chemotherapy, can significantly improve the progression-free survival (PFS) and overall survival (OS) of patients with metastatic squamous non-small cell lung cancer (NSCLC), and the safety is controllable, and patients were given paporizumab (d1) + albumin-bound paclitaxel (d2) + carboplatin (d2) first-line treatment from October 24, 2019 to February 14, 2020, with a total of 6 cycles of treatment.
After 2 cycles of treatment, the patient's lung tissue atelectasis was more pronounced than before treatment, and the hilar lymph nodes and mediastinal lymph nodes showed withdrawal earlier. Chest CT changes are as follows:
September 20, 2019 Chest CT
November 28, 2019 Chest CT
After 4 cycles of treatment, compared with 2 cycles of treatment, the patient's lung tissue atelectasis is more pronounced, and other lesions are in a stable state. Chest CT looks like this:
January 14, 2021 Chest CT
January 14, 2020 Chest CT
In order to further explore whether the patient has significant atelectasis due to false progression or sputum thrombosis, the patient is given to continue the above treatment plan. After 6 cycles of treatment, the patient's lung tissue atelectasis and withdrawal occurred, and the bronchodilatory signs improved. The mediastinal lymph nodes do not change significantly, and the hilar lymph nodes of the lungs appear to be withdrawn. Chest CT looks like this:
March 2, 2020 Chest CT
■ Dual-drug and single-drug maintenance therapy
Considering the patient's slow retraction of the mass, the patient was given dual-drug maintenance therapy from March 9, 2020 to March 31, 2020, using pamberizumab (200 mg, d1) + albumin-bound paclitaxel (300 mg, d2), 21 days for 1 cycle, a total of 2 cycles. From 20 April 2020, patients were given maintenance therapy (200 mg, d1) for 21 days in 1 cycle for a total of 1 cycle. Patients undergo imaging retracement during maintenance, and there is a tendency for lung tissue atelectasis to retreat, and hilar masses also show a tendency to retreat. Chest CT looks like this:
May 8, 2020 Chest CT
On July 10, 2020, the patient's disease status was checked again by imaging, and the patient achieved partial remission (PR).
July 10, 2020 Chest CT
Continuous monitoring of lesion status
After about half a year of treatment, the patient developed an immune rash, and it is not yet clear whether the rash is caused by allergies or drugs. After the patient was treated with hormone + loratadine, the rash was effectively controlled. Patients continue to receive maintenance therapy with pambolizumab, followed by continuous chest CT evaluation, and imaging tests show that the lung tissue is constantly improving.
At 1.5 years of treatment, the patient undergoes a bronchoscopy. The results showed that the right main bronchi and the right middle bronchi were patency, and the tumor tissue disappeared completely. During this process, multiple nodular residual foci appear in the bronchi. Residual lesions were taken for pathological specimen examination, and the results showed: chronic mucositis. The patient was given a single dose to continue maintenance therapy, and chest CT showed that the patient's right lung mid-lobe lesion was stable. Towards the end of treatment, the patient undergoes a PET-CT examination, which suggests a change in lesions after treatment, and no more precise results are given. The patient currently has a progression-free survival (PFS) of 25 months.
Multi-disciplinary expert opinion broadcasting
Is there a more invasive procedure for this patient, such as modified radical resection, if the patient achieves complete pathological remission (pCR)? If the patient still has residual lesions, should treatment be continued according to the postoperative pathological stage, or should follow-up observation be continued? With these questions in mind, a number of experts from the Affiliated Cancer Hospital of Nantong University, the Southern Hospital of Southern Medical University, the Anhui Provincial Cancer Hospital, and the Jinling Hospital Affiliated to the School of Medicine of Nanjing University held discussions.
Professor Yin Haibing of the Affiliated Cancer Hospital of Nantong University gave an interpretation from the perspective of pathological diagnosis: "The patient's lesions show polypoid masses under endoscopy. Initial biopsy shows squamous epithelial papilloma with atypical hyperplasia and cancer without a precise diagnosis. Therefore, a second biopsy was taken clinically, and the results were similar to the first biopsy. When clinical and pathological opinions are at odds, the patient undergoes a consultation with foreign aid, followed by a third biopsy to determine a precise diagnosis of the middle lobe of the right lung. At the same time, it also provides a direction for patients' follow-up clinical diagnosis and treatment. ”
Professor Duan Shufeng of the Affiliated Cancer Hospital of Nantong University interpreted the patient's efficacy judgment from the perspective of imaging: "The patient has undergone multiple chest CT examinations before and after. After the first treatment, the patient's right hilar mass shrinks and the atelectasis expands, and imaging departments consider that it is caused by mucus impaction after chemotherapy. After continuous treatment, the patient's hilar lesions continued to shrink, the atelectasis gradually improved, and the mediastinal lymph nodes changed almost nothing. Towards the end of treatment, PET-CT shows mild uptake of the right hilar lesion, which is considered by the pathology department to be changed after treatment. ”
Professor Tai Guomei of the Affiliated Cancer Hospital of Nantong University analyzed from the level of radiotherapy: "The patient has high treatment compliance. Unfortunately, pet-CT was not performed during the initial treatment phase of the patient to be compared with pet-CT at the end of treatment, and it was also not possible to indicate whether the patient had a lesion residue or an inflammatory response. Based on this situation, individuals recommend that patients end immunotherapy and receive an elution period of about 2 months, followed by local residual lesion irradiation. If a patient undergoes PET-CT before the first treatment and compares it with PET-CT near the end of treatment, whether there is a lesion residue based on the magnitude of the decrease in SUV values. ”
Professor Liu Laiyu of Southern Hospital of Southern Medical University commented on the case: "Large-scale lesions in the luminal cavity are more common in lung squamous cell carcinoma, and it is not recommended to take surface tissue at this time for biopsy, but should take the deep part as much as possible. In the treatment of tumors, the baseline plays an important role. Unfortunately, the patient did not undergo PET-CT at the beginning of treatment. At this stage, it is impossible to accurately determine whether there are residual lesions according to the patient's PET-CT SUV value, and it is recommended that patients undergo surgery under the condition of general good condition. If the patient is in good financial condition, the interval between medications can be extended. For example, the pembolizumab is adjusted from a 3-week regimen to 6 weeks, but individuals have doubts about the consequent doubling of the dose. If the patient is not financially well-off, discontinuation of the drug is recommended for follow-up observation. ”
Professor Zhang Zhihong of Anhui Provincial Cancer Hospital analyzed: "The appearance of immune rash in the treatment process of this patient has certain enlightenment significance. Immunotherapy-related adverse effects or suggesting better immunotherapy outcomes in patients have been shown to have statistically different predictions of immunotherapy efficacy from immune rashes. Combined with the results of the patient's last bronchoscopy and biopsy, chronic mucositis is suggestive, so I personally believe that the reason for considering the presence of lesion residue in the patient is not sufficient. Patients are then advised to follow up for observation. ”
Professor Shen Qin of Jinling Hospital affiliated to Nanjing University School of Medicine commented on the case: "For the pathological test results of this patient, he may have undergone a process from benign to hyperplasia and then cancerous. Atypical bronchial hyperplasia of the lungs is still relatively rare, and the formation of mass is generally not clearly observed from imaging or bronchoscopy. Once a patient develops a mass, it may indicate malignancy. From a pathological point of view, multiple diagnoses should be made as much as possible in order to provide clinical insight and meaningful pathological results. ”
Professor Zhu Xixu of Jinling Hospital affiliated to Nanjing University School of Medicine talked about his personal opinion from the perspective of radiotherapy: "For the patient's situation, there is no unified conclusion on the choice between immediate intervention, active intervention and non-intervention. Clinicians and radiotherapists need to take into account the patient's goals. If the patient pursues long-term survival, aggressive intervention is required, and if the patient is not aimed at long-term survival or has severe pulmonary insufficiency, it will affect clinical treatment decisions to some extent. ”
Professor Sun Qian of Jinling Hospital affiliated to Nanjing University School of Medicine pointed out: "The pathological test of the patient identified as cancer for the third time was not tested for PD-L1. If the economy is in good shape, it is recommended to perform a second-generation sequencing (NGS) test on the organization. Atypical hyperplasia in this patient may recur and develop slowly. Although the patient's lesions increased during treatment, the condition improved with continued medication. ”
Professor Song Yong of Jinling Hospital affiliated to Nanjing University School of Medicine concluded: "For cases that are difficult to obtain a definite pathological diagnosis due to repeated biopsies, clinicians need to communicate fully with pathologists. After the patient receives a full course of immunotherapy, how should the next treatment be carried out? Combined with the protocol discussed by the above experts, there are two main treatment directions: first, if long-term survival is pursued, it is recommended that the lesion be treated radically; if the patient maintains the status quo, it is recommended to stop treatment, observe and follow up, or continue to receive immune maintenance therapy. Individuals recommend surgical treatment of the mid-lobe site on the basis of the patient's full knowledge. If the patient is unable to undergo surgical resection, immunostamination therapy is considered, and the dose is recommended according to the original therapeutic dose. Immune microenvironment testing and minimal residual lesion (MRD) testing can be performed during immune maintenance therapy. ”
*This article is only used to provide scientific information to medical personnel and does not represent the views of this platform