Abstract
Objective:Although concurrent chemoradiation has been the standard of care for unresectable stage III non-small cell lung cancer (NSCLC) due to increased survival and decreased disease progression, patients with poor performance status cannot tolerate chemotherapy toxicity well. Durvalumab, an immune checkpoint inhibitor targeting the programmed death receptor-1 (PD-1) / programmed death-ligand 1 (PD-L1) axis, demonstrated efficacy as maintenance therapy after definitive chemoradiation. However, the role of immunotherapy in those who cannot tolerate chemoradiation is unclear.Methods:This retrospective case series reports adult patients with PD-L1-expressing stage III NSCLC diagnosed at Parkview Cancer Institute from 2019-2021 and treated initially with pembrolizumab followed by sequential consolidation chest radiation (CXRT) without cytotoxic chemotherapy. Results:Four cases of stage IIIA squamous cell carcinoma were disease-controlled by this approach, with two partial and one complete response. One case of stage IIIC adenocarcinoma had progressive disease with brain metastasis prior to CXRT. Conclusion:This case series suggests that pembrolizumab with sequential CXRT may be beneficial for stage III NSCLC patients with high PD-L1 expression, but additional studies are needed to confirm this hypothesis.
Highlights
Lung cancer is the number one cause of cancer-associated mortality in the United States, and the 5-year overall survival rate for non-small cell lung cancer (NSCLC) has remained poor (Duma et al, 2019; American Cancer Society. 2021)
Objective: concurrent chemoradiation has been the standard of care for unresectable stage III non-small cell lung cancer (NSCLC) due to increased survival and decreased disease progression, patients with poor performance status cannot tolerate chemotherapy toxicity well
The role of immunotherapy in those who cannot tolerate chemoradiation is unclear.Methods: This retrospective case series reports adult patients with programmed death-ligand 1 (PD-L1)-expressing stage III NSCLC diagnosed at Parkview Cancer Institute from 2019-2021 and treated initially with pembrolizumab followed by sequential consolidation chest radiation (CXRT) without cytotoxic chemotherapy
Summary
Lung cancer is the number one cause of cancer-associated mortality in the United States, and the 5-year overall survival rate for non-small cell lung cancer (NSCLC) has remained poor (Duma et al, 2019; American Cancer Society. 2021). Previous clinical trials demonstrated that concurrent chemoradiation was superior to sequential chemoradiation in terms of overall survival in patients with locally advanced NSCLC, albeit with increased acute esophageal toxicity (Aupérin et al, 2010; Mörth et al, 2014). This therapy is indicated primarily for patients with good performance status, and factors such as old age, co-morbidities, and poor performance status make it difficult for other patients to tolerate the toxicity of chemotherapy. Pembrolizumab is indicated in patients without EGFR or ALK genomic aberrations in stage III disease where patients cannot receive surgical resection or definitive chemoradiation (i.e., chemotherapy with concurrent radiotherapy), as well as in patients with EGFR or ALK mutations that have continued disease progression even with FDA-approved
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