How to manage non-small cell lung cancer at 71?

Question

Hello doctor,

My father is 71, and we received the devastating news of stage 4 NSCLC last week after a chest CT revealed a large right upper lobe mass with what appear to be liver lesions and possible adrenal involvement.

The pulmonologist who gave us the diagnosis said that further imaging is needed, but there seems to be some back and forth within the team about the next steps, and we feel like we are losing precious time.

The molecular profile of his biopsy is pending, and we are awaiting PD-L1 and mutation results. LDH is elevated – 310, albumin – low -2.9 and it's putting us under huge stress because of the progression speed. We are from a small town, and seeing specialists on time is difficult for us.

My question is whether I should order a PET scan at the moment when he was diagnosed with stage 4 NSCLC, or whether it is possible to start treating him without this test? There were some data that PET-scan reveals more zones than CT and biopsy does and I am scared that without PET-scan his treatment will be affected negatively.

Moreover, his cardiologist mentioned on his echocardiogram that there is a small pericardial effusion, and we do not know whether it's related to NSCLC or not. Every single day of waiting is absolutely terrible for us. Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

In stage 4 non-small cell lung cancer (NSCLC), the most important first steps are confirming the diagnosis with a biopsy and sending the tumor for molecular testing. Tests such as epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS proto-oncogene 1 (ROS1), Kirsten rat sarcoma viral oncogene homolog (KRAS), and programmed death ligand 1 (PD-L1) are very important because they help determine whether targeted therapy or immunotherapy can be used.

In many patients, these treatments can work better than traditional chemotherapy, so doctors usually wait for these results before starting treatment unless the patient is very unstable.

Regarding the positron emission tomography scan (PET scan), since the computed tomography scan (CT scan) has already shown distant metastases such as liver or adrenal lesions, the disease is already considered stage 4. In such situations, a PET scan is not always necessary before starting systemic treatment. Some centers still perform it to better map the disease, but skipping it usually does not change the treatment plan.

The high LDH and low albumin may be present in various diseases, like severe cancer, inflammation, or nutritional problems. The results themselves do not reflect the aggressiveness of the disease. Sometimes, the presence of a slight pericardial effusion may have nothing to do with the disease and may be the consequence of other factors, like inflammation of the heart muscle. If it is small and asymptomatic, the physicians simply observe it.

The most important step now is waiting for the molecular and programmed death ligand 1 (PD-L1) test results because these results will guide the best treatment choice. If a targetable mutation is found, oral targeted therapy may be very effective. If no mutation is present, immunotherapy with or without chemotherapy is usually considered.

If possible, please share the biopsy report and molecular or next-generation sequencing (NGS) report. I will be happy to guide you further regarding treatment options.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.