The National Comprehensive Cancer Network (NCCN) guidelines outline several options for localized or symptomatic localized recurrent NSCLC. If the patient presents with endobronchial obstruction, options include laser therapy, stenting, surgery, external-beam radiation, brachytherapy, or photodynamic therapy. If a recurrence is resectable, the preferred treatment is re-resection; however, external-beam radiation and stereotactic ablative radiotherapy are also options. If a patient presents with mediastinal lymph node recurrence without prior radiation, the NCCN recommends concurrent chemoradiation. If the patient has received prior radiation, the recommendation is for systemic therapy. If a patient presents with superior vena cava (SVC) obstruction, several options are available, including concurrent chemoradiation with or without SVC stenting, external-beam radiation with or without SVC stenting, or SVC stenting alone. To treat severe hemoptysis, any combination of external-beam radiation, brachytherapy, laser, photodynamic therapy, embolization, or surgery is recommended.
After any of these interventions, imaging with CT with contrast, brain MRI with contrast, and PET/CT are indicated to determine whether disseminated disease exists. If no evidence is present, options include observation versus systemic therapy. If present, the NCCN guidelines suggest pursuing systemic therapy.
If a patient presents with diffuse distant metastasis to the brain, the recommendation is to pursue palliative external-beam radiation. If lesions are limited, options include stereotactic radiosurgery alone or surgical resection; if symptomatic or warranted for diagnosis, this is followed by stereotactic radiosurgery or whole-brain radiotherapy.
Identifying genetic mutations that affect therapy selection in NSCLC is increasingly important. Important gene alterations include EGFR mutation, ALK gene rearrangements, ROS1 gene rearrangements, BRAF point mutation, KRAS point mutation, and PD-L1 mutation. These can be obtained on surgical or biopsy specimen or liquid blood biopsy. Other emerging biomarkers include high-level MET amplification, RET rearrangements, ERBB2 (HER2) mutations, and tumor mutation burden; however, the latter remains controversial owing to a lack of standardization.
The patient in this case was evaluated by a neurosurgeon and was started on dexamethasone. Invasive surgery was not attempted. His symptoms improved, and repeat MRI revealed that areas of necrosis and brain edema significantly improved as well. Further imaging studies revealed no clear evidence of disease elsewhere; however, given the patient's high expression of PD-L1 and the fact that cancer had metastasized to his brain, he was started on treatment with a PD-1 inhibitor (pembrolizumab). He was stable at last follow-up.
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