A patient has no significant mutations in all available driving oncogene, and a PD-L1 negative state(Although it may be a false negative result from IHC).Worse still,he has pericardical metastasis.Can anyone give me some instructions?
The optimum treatment for advanced non small lung cancer will be Paclitaxel plus Carboplatin especially for Squamous cell carcinoma and non specified histology.
If it is adenocarcinoma, then Pemetrexed +Carboplatin 3 weekly may be given if there are no significant mutations in all driving oncogenes and PD-L1 negative states...
Hi Arrhenius Lin,
First, there is a clear distinction in management between squamous and non-squamous NSCLC.
Secondly, even with negative PD-L1 expression, immune checkpoint inhibitors (ICI) can still be used in both Sq & non-Sq NSCLC combined with chemotherapy or chemotherapy plus anti-VEGF. That is based on the following studies: KEYNOTE-189, KEYNOTE-407, IMpower150, IMpower130, IMpower131, CheckMate-9LA, and CheckMate-277.
If the patient is not eligible for ICI (due to autoimmune disease, organ transplantation, etc.) the chemotherapy is the answer if the patient's performance status allows. generally. Platinum doublet is better if the patient is fit for it. For non-sq NSCLC the option is usually platinum + pemetrexed ± an Anti-angiogenic agent (Bevacizumab) and maintenance therapy with pemetrexed ± Bevacizumab
If the histopathology is sq NSCLC, then it would be platinum + Taxane.
Lastly, if pericardial metastases due to local invasion, then there might be abutment to the great vessels such as the inferior vena cava ( that can be identified clinically and radiologically), which consequently can lead to the formation of thrombi! if that is the case, then consultation of palliative radiation therapy should be sought.
Dear Anil,
According to the guidelines (NCCN, ASCO, ESMO, etc), if PD-L1 is < 1% which means negative, it's recommended and preferred to combine chemotherapy with an immune checkpoint inhibitor for both Sq. and Non-sq. advanced NSCLC with no genetic aberrations as long as there is no contraindication for ICI. These recommendations by guidelines are based on the clinical trials mentioned in my previous answer.
One more point to add, in certain circumstances where chemotherapy is not an option, then ICI (Pembrolizumab) can be given as a single agent if PD-L1 expression is 1% or more. And that is based on KEYNOTE-042.
So in absence of all the mutations of in available oncogenes, for adenocarcinoma I think we should go for Pemetrexed plus Carboplatin if PS-2 and adenocarcinoma......
2D echocardiography should be done to know the LV ejection fraction........
if percardial effusion is large, then tapping should be done and then chemotherapy should be started ...
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