Thoracoscopic Left Lower Lobectomy Following Neoadjuvant Tyrosine Kinase Inhibitor Treatment for Stage IIIB Lung Cancer

PS075 

Case Video Submission 

Roger Zhu (1), Jorge Humberto Rodriguez-Quintero (1), Neel Chudgar (1), Marc Vimolratana (1), Brendon Stiles (1)

(1) Montefiore Health System, Bronx, NY

Roger Zhu    -  Contact Me
Montefiore Health System

Jorge Humberto Rodriguez-Quintero    -  Contact Me
Montefiore Health System

Neel Chudgar    -  Contact Me
Montefiore Health System

Marc Vimolratana    -  Contact Me
Montefiore Health System

*Brendon Stiles    -  Contact Me
Montefiore Health System

Roger Zhu    -  Contact Me
N/A

Tyrosine kinase inhibitor therapy has been demonstrated to significantly improve disease-free survival for completely resected stage IB to IIIA EGFR-mutant non-small cell lung cancer. Although trials are underway, it is unknown whether these drugs will be effective as neoadjuvant therapy for patients with resectable NSCLC. Neoadjuvant therapy can potentially reduce tumor size, improve resectability, and provide earlier systemic control. However, TKIs are sometimes considered cytostatic rather than cytotoxic, and there is no data on how tumors will respond to short courses of treatment.

We present the case of a 52-year-old never-smoker Hispanic female who presented with cT4N2 EGFR-mutated (exon 21 L858R) stage IIIB NSCLC. On workup of a chronic cough and hemoptysis, she was found to have a 9.6 x 6.4 x 5.8 cm left lower lobe mass with SUVmax 15.0 and bulky FDG-avid subcarinal lymphadenopathy. The tumor appeared resectable only by sleeve resection or pneumonectomy. We therefore elected to treat with upfront osimertinib and reassess for local therapy. She tolerated induction TKI therapy well and without toxicity. After eight weeks of treatment, the patient was found to have a major radiographic response. Repeat imaging demonstrated a reduction in the size of the primary lesion as well as improvement of subcarinal adenopathy. Given the favorable response to treatment, the tumor now appeared to be resectable by lobectomy. The patient was taken to the operating room, where we performed a thoracoscopic left lower lobe lobectomy and extensive lymphadenectomy. Intraoperatively, we encountered only mild to moderate evidence of post-induction treatment firborsis. Pathology revealed a significant response with an estimated viable tumor size of 0.9 cm and residual disease in only one of 24 lymph nodes. This 3.3cm subcarinal node harbored only 10% viable tumor with a significant treatment effect. The patient did have visceral pleural invasion and was pathologically staged as ypT2aN2. We highlight this case to demonstrate the importance of early molecular testing and of the successful use of neoadjuvant TKI and subsequent minimally invasive lung resection.

Lung Cancer