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The Curious Case of Oligometastatic Lung Adenocarcinoma with Unidentified Primary
Description
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A4089 - The Curious Case of Oligometastatic Lung Adenocarcinoma with Unidentified Primary
Author Block: M. J. Tarar1, P. Ochieng2; 1Internal Medicine, Geisinger Community Medical Center, Scranton, PA, United States, 2Pulmonary and Critical Care Medicine, Geisinger Community Medical Center, Scranton, PA, United States.
Introduction
Oligometastatic (OM) cancer is defined as metastatic cancer to a limited number of organ systems, usually ≤3. Diffusely metastatic Non-Small Cell Lung Carcinoma (NSCLC) carries a poor prognosis and treatment with chemotherapy is mainly palliative. However, OM-NSCLC can potentially be treated with curative intent. We present a case of a 66-year-old woman who presented with OM-NSCLC with a single lesion to the brain with no identified primary malignancy.
Case Presentation
A 66-year-old female smoker presented with dizziness, impaired balance and headaches. Head CT scan showed a hyperdense left cerebellar lesion. Brain MRI of brain revealed a peripherally enhancing 11 x 9 x 14 mm lesion of the medial left cerebellum/vermis with mild vasogenic edema without compression of the 4th ventricle or hydrocephalus. CT of chest, abdomen and pelvis was then performed and did not show any evidence of malignancy. PET scan did not show any evidence of Fludeoxyglucose (FDG) avid lesions anywhere else (other than brain lesion).
She underwent craniotomy with resection of the cerebellar lesion and pathology was consistent with metastatic adenocarcinoma of lung (lmmunostains were positive for CK7, Napsin A and TTF-1; negative for CDX2 and CK20). Markers for ALK, EGFR, KRAS and PD1 were negative. After surgery, she received radiation treatment to the brain and her symptoms improved. No mediastinal or hilar lymph nodes were visualized on EBUS bronchoscopy. She is being considered for adjuvant chemotherapy and continues to be on active surveillance with MRI of brain and chest CT scan.
Discussion
Since it’s proposal in 1995 by Heilman and Weichselbaum, OM concept has been widely accepted. OM-NSCLC presents a potential curative opportunity for patients and occurs in 7% of newly diagnosed NSCLC. Options with curative intent include surgical resection of primary and metastatic lesion(s) or Stereotactic Body Radiotherapy (SBRT), adjuvant chemotherapy and adjuvant radiation therapy. However, the optimal modality or combination of treatment modalities remain unclear. Treatment of primary tumor is a fundamental component of management of this entity since control of primary tumor has been identified as prognostic factor.
Our case represents a challenging situation; with the therapeutic conundrum is whether to give chemotherapy. The major issue with chemotherapy is what parameter to use as measure of response. This case highlights a knowledge gap and need for further investigation on oligometastatic disease even as growing data suggest that a prolonged disease-free survival and potential cure may be possible.
Author Block: M. J. Tarar1, P. Ochieng2; 1Internal Medicine, Geisinger Community Medical Center, Scranton, PA, United States, 2Pulmonary and Critical Care Medicine, Geisinger Community Medical Center, Scranton, PA, United States.
Introduction
Oligometastatic (OM) cancer is defined as metastatic cancer to a limited number of organ systems, usually ≤3. Diffusely metastatic Non-Small Cell Lung Carcinoma (NSCLC) carries a poor prognosis and treatment with chemotherapy is mainly palliative. However, OM-NSCLC can potentially be treated with curative intent. We present a case of a 66-year-old woman who presented with OM-NSCLC with a single lesion to the brain with no identified primary malignancy.
Case Presentation
A 66-year-old female smoker presented with dizziness, impaired balance and headaches. Head CT scan showed a hyperdense left cerebellar lesion. Brain MRI of brain revealed a peripherally enhancing 11 x 9 x 14 mm lesion of the medial left cerebellum/vermis with mild vasogenic edema without compression of the 4th ventricle or hydrocephalus. CT of chest, abdomen and pelvis was then performed and did not show any evidence of malignancy. PET scan did not show any evidence of Fludeoxyglucose (FDG) avid lesions anywhere else (other than brain lesion).
She underwent craniotomy with resection of the cerebellar lesion and pathology was consistent with metastatic adenocarcinoma of lung (lmmunostains were positive for CK7, Napsin A and TTF-1; negative for CDX2 and CK20). Markers for ALK, EGFR, KRAS and PD1 were negative. After surgery, she received radiation treatment to the brain and her symptoms improved. No mediastinal or hilar lymph nodes were visualized on EBUS bronchoscopy. She is being considered for adjuvant chemotherapy and continues to be on active surveillance with MRI of brain and chest CT scan.
Discussion
Since it’s proposal in 1995 by Heilman and Weichselbaum, OM concept has been widely accepted. OM-NSCLC presents a potential curative opportunity for patients and occurs in 7% of newly diagnosed NSCLC. Options with curative intent include surgical resection of primary and metastatic lesion(s) or Stereotactic Body Radiotherapy (SBRT), adjuvant chemotherapy and adjuvant radiation therapy. However, the optimal modality or combination of treatment modalities remain unclear. Treatment of primary tumor is a fundamental component of management of this entity since control of primary tumor has been identified as prognostic factor.
Our case represents a challenging situation; with the therapeutic conundrum is whether to give chemotherapy. The major issue with chemotherapy is what parameter to use as measure of response. This case highlights a knowledge gap and need for further investigation on oligometastatic disease even as growing data suggest that a prolonged disease-free survival and potential cure may be possible.
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