Roundtable Roundup: Biomarker-Negative Lung Cancer

Case Summary

• A 66-year-old man presented to his physician with:
  • Medical history: well-controlled hypertension on a low-dose angiotensin-converting enzyme inhibitor
  • Lifestyle: active, plays pickleball 2 to 3 times per week, no significant functional limitations
  • Family history: no known cancer history
  • Social history: former smoker (20 pack-year history, quit 10 years ago), occasional alcohol use

Presenting symptoms

• Progressive fatigue over the past 2 months, interfering with his usual activities
• Persistent cough, occasionally productive with streaks of blood
• Unintentional weight loss of 10 lb in 3 months
• Intermittent right shoulder pain, worse at night, not relieved by nonsteroidal anti-inflammatory drugs
• Mild dyspnea on exertion, especially when playing pickleball
• New-onset headaches, worse in the morning

Physical examination findings

• General: appears mildly fatigued but in no acute distress
• Pulmonary: decreased breath sounds over the right upper lung field; no wheezing or rales
• Musculoskeletal: mild tenderness over the right scapular region, no focal deficits
• Neurological: no focal deficits, strength and reflexes intact

Radiologic findings

• Chest X-ray: right upper lobe (RUL) mass (~3.5 cm), possible right hilar involvement
• CT Chest/Abdomen/Pelvis with contrast: 4.2-cm spiculated mass in RUL; right hilar and mediastinal lymphadenopathy (~1.5 cm nodes); multiple sclerotic bone lesions in the right scapula and thoracic spine
• PET-CT scan: FDG-avid RUL mass, hypermetabolic mediastinal nodes, and intense FDG uptake in right scapula and T4-T6 vertebrae
• Brain MRI: negative

Pertinent lab work

• Complete blood count: mild anemia (hemoglobin: 11.8 g/dL)
• Calcium: 11.2 mg/dL
• Alkaline phosphatase: elevated
• Lactase dehydrogenase: elevated
• Carcinoembryonic antigen: elevated
• Endobronchial ultrasound–guided transbronchial needle aspiration: confirmed bilateral nodal involvement with adenocarcinoma
• Molecular testing
  • EGFR, ALK: negative to both
  • PD-L1 testing: pending

CASE UPDATE

• PD-L1 testing results show PD-L1 < 1%​