Diagnosis Of Metastatic Lung Cancer Research Articles

ODP503 Non-Small Cell Lung Cancer Metastatic to the Thyroid Gland

Abstract Introduction Metastatic disease affecting the thyroid gland is an uncommon phenomenon, with the most common primary sites being kidney, breast, lung and gastrointestinal tract. Thyroid metastases frequently occur simultaneously with spread to other sites and are rarely symptomatic. Clinical case: 73-year-old female with remote history of stage IA (T1c, N0, M0) invasive lobular carcinoma of the right breast treated with lumpectomy, radiation and tamoxifen, previous tobacco use, remote exposure to radiation during Chernobyl nuclear accident, developed progressive dyspnea on exertion. She was found to have a large left-sided pleural effusion. Thoracentesis was performed, and the cytology revealed adenocarcinoma with features favoring lung primary. Further imaging showed a left lower lobe mass with central necrosis and left hilar adenopathy, multiple pleural masses, and a small solitary brain lesion. PET-CT also demonstrated, amongst other findings, an FDG avid left lower pole thyroid nodule. Thyroid ultrasound was obtained to further characterize the lesion, which demonstrated a 0.8×1.3×1.3 cm solid hypoechoic nodule in the left mid lobe, which was thought to be corresponding to the PET avid nodule. Two additional nodules, a mixed cystic and solid measuring 1.7×2.1×2.9 cm on the right lobe, and another left-sided solid isoechoic measuring 0.8×0.7×0.9 cm, were noted. Thyroid FNA of the 1.3 cm PET avid nodule revealed rare cells in clusters, with large pale nuclei and prominent nucleoli, some with intracytoplasmic vacuoles, morphologically similar to those seen in the prior pleural fluid. Thin prep was stained with antibody to thyroglobulin, and the malignant cells showed lack of staining, supporting the diagnosis of metastatic lung cancer. Thyroid function tests were normal. Given lack of compressive symptoms, patient was maintained on her primary oncologic treatment with carboplatin and pemetrexed, and stereotactic radiation for the brain metastasis. Repeat PET-CT, performed approximately 8 months after the initial scan, showed mildly decreased focal FDG activity in the thyroid lesion. Discussion In this scenario, a patient with primary lung malignancy was found to have an FDG avid thyroid nodule which on FNA proved to be a metastatic lesion. Per some studies, such lesions can be seen in 1.4%–3% of patients who undergo surgery for suspected malignancy in the thyroid gland. Management of metastatic thyroid cancers depends on multiple factors including the primary malignancy location and staging, patient comorbidities, compressive symptoms, etc. Surgical management may be of benefit in isolated lesions in the thyroid. Conclusion When evaluating thyroid nodules in patients with known history of malignancy, it is important to consider the differential of metastatic lesions and to perform a thorough evaluation including fine-needle aspiration for clinical elucidation and management. Presentation: No date and time listed

Evaluation of direct oral anticoagulant use for cancer-associated venous thromboembolism (VTE) in lung cancer.

243 Background: National Comprehensive Cancer Network recommends direct oral anticoagulants (DOACs) as preferred agents for treatment of cancer associated VTE in patients without gastric or gastroesophageal lesions. Currently at Massachusetts General hospital (MGH), DOACs are used in treatment of cancer associated VTE. This study was performed to evaluate the safety and efficacy of DOACs for treatment of VTE in patients with metastatic lung cancer. Methods: Retrospective chart review of patients at MGH with diagnosis of metastatic lung cancer who were prescribed edoxaban, rivaroxaban, or apixaban for treatment of VTE between January 2018 and January 2021 was performed. Patients were identified using electronic medical record reports. Data was collected on age, anticoagulation regimen, intent of anticoagulation therapy, presence of brain metastasis, renal function, liver function and platelet counts. The primary outcome was to assess the incidence of treatment failure, defined as VTE recurrence or major bleeding leading to a change in anticoagulation therapy. Results: 152 patients were evaluated, of which 57 received apixaban, 44 rivaroxaban, and 7 edoxaban. Most (n = 93) patients received enoxaparin for 14-90 days prior to transitioning to DOACs. Median age and creatinine clearance were 69 years and 63 mL/min, respectively. All patients had platelet count ≥ 50K/uL. Brain metastasis was present in n = 39 patients. Pulmonary embolism (PE)(n = 98), deep vein thrombosis (DVT) (n = 52), or both (n = 2) were the indication for DOAC therapy. Bleeding occurred in 14 patients including gastrointestinal bleeding (n = 5), hematuria (n = 4), epistaxis (n = 1), and hemoptysis (n = 4). Among patients with bleeding events, 7 received rivaroxaban and 7 received apixaban. Major recurrent VTE while on DOACs occurred in 5 of patients, including DVT (n = 2) and PE (n = 3). Patients with recurrent VTE received rivaroxaban (n = 7), apixaban (n = 3) and edoxaban (n = 1). All patient whom experienced bleeding and VTE were ≥ 60 years old. Brain metastasis was present in n = 2 of patients with bleeding events and n = 2 patients with recurrent VTE. Majority of patients (n = 93) received enoxaparin for 14-90 days prior to transitioning to DOACs. The median interval between initiation of DOACs and bleeding was 60 days (range 30-365) and recurrent VTE event was 90 days (range 60‐365). Conclusions: The results of this study suggest that outcomes of DOAC use for the treatment of cancer-associated VTE in patients with metastatic lung cancer are comparable to the results of large randomized controlled trials. DOAC therapy is a safe and effective anticoagulation option for lung cancer patients with cancer-associated thromboembolism.

Genomic alterations and clinical outcomes in patients with lung adenocarcinoma with transformation to small cell lung cancer after treatment with EGFR tyrosine kinase inhibitors: A multicenter retrospective study

BackgroundTransformation to small cell lung cancer (SCLC) is a resistance mechanism to tyrosine kinase inhibitor (TKI) treatment that develops in lung adenocarcinoma. The genomic and treatment outcomes in these populations have not been comprehensively reported in China. MethodsWe performed a retrospective study analyzing patients with advanced non-SCLC (NSCLC) from eight sites who were diagnosed with SCLC transformation after receiving epidermal growth factor receptor (EGFR)-TKI treatment including first/second- or third-generation EGFR-TKIs. We assessed the genomic features and clinical prognosis in these patients with EGFR-mutated lung cancer. ResultsThirty-two eligible patients with EGFR mutations were identified, 25 of whom had sufficient tumor tissues for detection of genes by next-generation sequencing. The median progression free survival (mPFS) for first/second-generation TKIs was 14.0 months. The most common mutations identified in samples with transformation to SCLC were in TP53 (17/25, 68.0 %), RB1 (9/25, 36.0 %), and PIK3CA (3/25, 12.0 %), and the incidence rates of RB1 and TP53 mutations were similar between patients receiving first/second-generation and third-generation TKI treatment. The estimated median time to SCLC transformation was 17.0 months. After SCLC transformation, platinum-etoposide was the most common treatment regimen, and the mPFS after platinum-etoposide treatment was 3.5 months. Anlotinib showed good efficacy in these patients (overall response rate, 66.7 %; mPFS, 6.2 months). The median overall survival after the initial diagnosis of metastatic lung cancer was 34.5 months, and patients with small cell transformation after third-generation TKI treatment had better prognosis than patients with transformation after first/second-generation treatment (49.4 months vs. 20.0 months, P = 0.013). ConclusionWe observed that TP53 and RB1 mutations were common in Chinese patients with SCLC transformation, regardless of whether first/second-generation or third-generation EGFR-TKI treatments were used. Earlier occurrence of small cell transformation after EGFR-TKI treatment was associated with poorer prognosis of patients. After the standard chemotherapy regimens for the management of primary SCLC, anlotinib may be a therapeutic option.

Factors associated with time to targeted therapy for patients with metastatic lung cancer with driver mutations.

120 Background: Targeted therapies are superior to chemotherapy in metastatic lung cancer with driver gene mutations. Delays in initiation of targeted therapies may result in faster symptom progression, decline in quality of life, and shortened survival. We examined factors associated with time to initiation of targeted therapy (TTT) in patients with metastatic lung cancer with selected driver mutations. Methods: In this retrospective cohort study, IBM MarketScan claims data was used to identify patients who had an initial diagnosis of metastatic lung cancer, defined as continuous insurance enrollment 12 months pre- to 6 months post-diagnosis, with tumor biomarker (i.e., EGFR, ALK, ROS1, BRAF V600E, NTRK)-directed targeted therapy performed within 6 months of the initial diagnosis, during the timeframe of 1/1/2013 to 12/31/2018. Trends in TTT were evaluated with Wilcoxon–Mann–Whitney. Quantile regression, a robust model that analyzed factors on different outcome-related quantiles, was used to identify associations among TTT and covariates including age, sex, comorbidity, insurance type, and US region. Results: Among 8977 patients identified with an initial diagnosis of metastatic lung cancer, 710 (7.9%) received targeted therapies within the 6-month timeframe, and 1040 (12%) had tumor biomarker testing performed. The overall median TTT was 21 days (IQR = 36 days). Median TTT decreased from 25 days in 2013 to 18 days in 2018 (p = 0.03). Factors associated with longer TTT (median, 50% quantile) were increasing age (p = 0.04), cardiovascular disease (“CVD”, p = 0.03), HIV (p = 0.04), and mild liver disease (p = 0.05). For the lower quantile ( < = 1 day, 5% quantile), female sex (p = 0.01), HIV (p = 0.04), and mild liver disease (p = 0.002) were associated with longer TTT. Having a PPO health plan extended TTT (p = 0.05) at the upper quantile (79 days, 90% quantile). Conclusions: Our study showed an encouraging 5-year trend of the median TTT decreasing by 28%. Numerous factors associated with longer TTT included increasing age, CVD, HIV, mild liver disease, female sex, and PPO plan. This study provides insights into patient-related factors associated with longer time to initiation of targeted therapies for patients with metastatic lung cancer with driver mutations. Additional research is needed to identify the reasons for longer TTT and to develop strategies to expedite delivery of optimal therapies.

A bumpy road to the diagnosis of metastatic lung cancer

Cardiac tumors pose the uncommon group of disorders and most of them are metastases. They are generally localized in the left heart and may present with non-specific symptoms. Diagnosis may be often difficult due to the presence other heart diseases. The gold standard in diagnosing is non-invasive imaging. We present a case of a 77-year-old male admitted to our hospital due to flu symptoms, headaches and loss of weight in the last 2–3 weeks. The diagnostic process including computed tomography (CT) and magnetic resonance imaging revealed pathological contrast enhancement in the left parietal lobe, whereas subsequent transthoracic echocardiography disclosed a pathological oval mass 2.5 x 3.5 cm in the left heart suspected of a metastasis. Results of echocardiography turned the diagnostic process around and extended to bronchoscopy and abdominal CT. Finally, central left lung tumor with metastases to lungs, pleura, lymphoid nodes of the right hilar, left ventricle, left suprarenal gland and central nervous system was diagnosed.

1877P Fatigue changes according to systemic therapy type in patients with advanced solid cancer

Systemic inflammation and disease progression are proposed causes of cancer-related fatigue. We aimed to investigate longitudinal changes in fatigue burden according to disease progression, systemic inflammation and therapy type. We prospectively collected validated questionnaires on fatigue (EORTC QLQ-C30, QLQ-FA12) and parameters of systemic inflammation (CRP, interleukin 6, procalcitonin) in patients with solid tumors undergoing palliative systemic cancer therapy. Baseline measurements were performed at start of a new therapy and follow-up measurements at the subsequent re-staging. The median follow-up time was 2 months (range 1-4 months). 79 patients (39/79 (49.4%) females; 40/79 (50.6%) males) with diagnosis of metastatic lung cancer (15/79; 19%), colorectal cancer (15/79; 19%), pancreatic cancer (11/79; 13.9%), sarcoma (11/79; 13.9%), breast cancer (7/79; 8.9%) or other cancers (20/79; 25.3%) were included. 35/79 (44.3%) of patients were treated with chemotherapy (CHT), 17/79 (21.5%) with immune checkpoint inhibitors (ICIs), 8/79 (10.1%) with combinational CHT-ICI, 6/79 (7.6%) with targeted therapies and 13/79 (16.5%) with combinational CHT-targeted therapy. Patients receiving ICI showed a significant reduction in the QLQ-FA12 Interference with daily life symptom scale (p=0.031) while a rising QLQ-FA12 Physical fatigue symptom scale was evident in patients receiving CHT (p=0.046). Levels of procalcitonin rised significantly in patients receiving CHT (p=0.04) while decreased in patients receiving targeted therapy (p=0.026). Patients with a progressive disease showed a significant increase in the QLQ-C30-FA symptom scale (p= 0.013), QLQ-FA12 Physical fatigue symptom scale (p=0.005) and QLQ-FA12 Interference with daily life symptom scale (p=0.022). No association between disease control and type of applied therapy or fatigue level and systemic inflammation was observed. A significant change of fatigue scales and procalcitonin level according to treatment type and disease control could be shown in our prospective patient cohort. Further longitudinal investigation is warranted to investigate the association of systemic inflammation and fatigue burden in different treatment types.

ACQUIRED ICHTHYOSIS: A RARE PRESENTATION OF LUNG CANCER

SESSION TITLE: Lung Cancer 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Acquired ichthyosis (AI) is a skin condition characterized by dry, rough and scaling skin, often described as “fish scale skin”. AI can be either congenital or acquired and can be associated with malignancies, lupus, chronic liver disease, kidney disease, malnutrition, AIDS and certain medications. Cancers associated with AI include but are not limited to: Hodgkin's lymphoma, lung and breast adenocarcinoma. Although AI is associated with underlying malignancy, this skin finding is not always recognized and is often treated independently and thus, a diagnostic evaluation for an underlying malignancy is not always performed. CASE PRESENTATION: A 54-year-old Caucasian male, who is an 80 pack year smoker and type 2 diabetic, presented to the ER with dizziness and syncope. He reported shoulder pain from falling, anorexia and unintentional weight loss. He had no shortness of breath, cough, hemoptysis, night sweats or fatigue. On exam, he was cachectic with severe dry, rough scaling skin especially to the palms and plantar surfaces (Figure1&2). He reported that this skin finding had been present for 2 months. CT of the head showed: a right frontal mass and a second heterogeneous mass within the cerebellum. So, a chest x-ray was obtained to evaluate for a possible primary neoplasm and showed a left peri-hilar mass. CT chest was subsequently completed and showed a left lower lobe mass with mediastinal lymphadenopathy, which CT guided biopsy later confirmed as small cell undifferentiated carcinoma. Podiatry was consulted for his skin findings which were believed to be paraneoplastic acquired ichthyosis and keratolytic therapy with 40% urea cream was ordered. Oncology was consulted and palliative radiation for brain metastasis and chemotherapy were started. Unfortunately, the patient died 4 months after his diagnosis was made. DISCUSSION: Lung cancer is associated with multiple paraneoplastic phenomena, including AI. Early recognition of cancer is very important especially in fast growing small cell lung cancers. As shown in this case, AI presented 2 months before the diagnosis of cancer was confirmed. This diagnosis could have been made earlier if a thorough evaluation by a dermatologist or a podiatrist was obtained. Furthermore review of the current literature and case reports on AI are very limited. Therefore, a high index of suspicion in the appropriate clinical scenario is warranted and can make a difference in the early diagnosis and treatment of associated malignancy. Unfortunately, for our patient his diagnosis of AI was made simultaneously with his diagnosis of metastatic lung cancer and so he lost an opportunity for earlier diagnosis. CONCLUSIONS: Paraneoplastic syndromes might be the first red flag observed with the presentation of cancer. Therefore, it is crucial that rare manifestation such as AI be recognized and investigated to rule underlying malignancy. Reference #1: Okulicz JF, Schwartz RA. Hereditary and acquired ichthyosis vulgaris. Int J Dermatol 2003; 42:95–8. Reference #2: Penven K, Verneuil L, Dompmartin A, Louvet S, Leroy D. An association of paraneoplastic syndromes in a patient. Ann Dermatol Venereol. 2002; 129(8-9):1042-5. Reference #3: Patel N, Spencer LA, English JC, Zirwas MJ. Acquired ichthyosis. J Am Acad Dermatol 2006; 55:647. DISCLOSURES: No relevant relationships by Haytham Adada, source=Web Response No relevant relationships by Mahmoud Amarna, source=Web Response No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by AHMAD HAMMAD, source=Web Response No relevant relationships by Leisa Walker, source=Web Response

Disease-specific graded prognostic assessment lung cancer update

Lung cancer accounts for almost 30% of cancer deaths. Length of survival after diagnosis of metastatic lung cancer, however, spans a significant range today. While some patients still only survive in the order of a few weeks to months, an increasing percentage are living years due to the recognition of different types of lung cancer genetics and the ability to treat patients in a personalized fashion with targeted therapies.

Access to Cancer Specialist Care and Treatment in Patients With Advanced Stage Lung Cancer

BackgroundAccess to specialty care is critical for patients with advanced stage lung cancer. This study assessed access to cancer specialists and cancer treatment in a broad population of patients with advanced stage lung cancer. Materials and MethodsTwo study samples were extracted from 2 claims databases and analyzed independently: patients aged ≥ 18 years with de novo diagnosis of metastatic lung cancer in the MarketScan database between 2008 and 2014 (commercially insured adult patients; n = 22,268); and patients aged ≥ 65 years in the Surveillance, Epidemiology, and End Results–Medicare database with a diagnosis of advanced non–small-cell lung cancer between 2007 and 2011 (Medicare-insured elderly patients; n = 9651). The study period spanned from 6 weeks before the first lung biopsy tied to the initial lung cancer diagnosis until the end of continuous health insurance enrollment, or data availability, or death. ResultsAmong the commercially insured adults (MarketScan), most patients were seen by a cancer specialist within a month of first lung biopsy (80%), 12% were never seen by a cancer specialist, and 6% did not receive cancer-directed therapy. Among the Medicare-insured elderly patients (SEER–Medicare), the proportions were 79%, 4%, and 10%, respectively. Patients seen by a cancer specialist were more likely to receive cancer-directed therapy (95% vs. 92%, P < .001 and 92% vs. 38%, P < .001, respectively). ConclusionBetween 4% and 12% of patients with advanced stage lung cancer do not have appropriate access to cancer specialist, which appears to negatively affect access to optimal and timely treatment.

Integration of palliative care services into standard oncology practice at diagnosis of metastatic lung cancer at VA New York Harbor Healthcare System.

165 Background: The 2012 ASCO provisional clinical opinion addressed the integration of palliative care into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. The inclusion of Palliative Care among the National Quality Forum (NQF) framework represented a major advance in palliative care. NQF metrics include chemotherapy administered in the last 14 days of life, hospice less than 3 days before death, ICU or hospital admission, more than one Emergency Room visit in the last 30 days, and death in hospital. Although the use of hospice and other palliative care services has increased, many are enrolled in hospice less than 3 weeks before death. By improving quality of life, cost, and survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Methods: Retrospective chart review study of lung cancer patients diagnosed at VA from 2010-2013. Inclusion criteria: &gt; 18 years of age with new diagnosis of metastatic lung cancer. Exclusion criteria: &lt; 18 years of age, Stage I-III lung cancer. Results: Total of 125 patients were diagnosed with Stage IV lung cancer. The mean time from diagnosis to death was only 185 days (6.1 months). The VA NYHHS patients were more likely to visit the ED, be admitted to the hospital and ICU in the last 30 days of life, and subsequently die in the hospital. Conclusions: Several confounders were identified, including climate related closure of facilities (2012 Sandy storm), lack of social support, low ICU admission criteria, burial benefits for patients dying in a VA, and delay in transition to Hospice. Currently 392 patients with stage IV solid tumors diagnosed 2010-2014 are being studied. [Table: see text]

Does malnutrition at diagnosis of metastatic lung cancer impacts overall survival?

e19134 Background: The objective of this retrospective study was to assess the impact of malnutrition in patients treated in 2012 at the Integrated Center for Oncology Rene Gauducheau (Nantes, Fran...

Targeted Proteomics Pipeline Reveals Potential Biomarkers for the Diagnosis of Metastatic Lung Cancer in Pleural Effusion

The ability to discriminate lung cancer malignant pleural effusion (LC-MPE) from benign pleural effusion has profound implications for the therapy and prognosis of lung cancer. Here, we established a pipeline to verify potential biomarkers for this purpose. In the discovery phase, label-free quantification was performed for the proteome profiling of exudative pleural effusion in order to select 34 candidate biomarkers with significantly elevated levels in LC-MPE. In the verification phase, signature peptides for 34 candidates were first confirmed by accurate inclusion mass screening (AIMS). To quantify the candidates in PEs, multiple reaction monitoring mass spectrometry (MRM-MS) with stable isotope-labeled standards (SIS) peptides was performed for the 34 candidate biomarkers using the QconCAT approach for the generation of the SIS peptides. The results of the MRM assay were used to prioritize candidates based on their discriminatory power in 82 exudative PE samples. The five potential biomarkers (ALCAM, CDH1, MUC1, SPINT1, and THBS4; AUC > 0.7) and one three-marker panel (SPINT1/SVEP1/THBS4; AUC = 0.95) were able to effectively differentiate LC-MPE from benign PE. Collectively, these results demonstrate that our pipeline is a feasible platform for verifying potential biomarkers for human diseases.

A case of lung cancer metastasized to the gastrointestinal anastomosis site where the primary gastric cancer was resected 17 years ago

Metastasis from lung cancer, often found in the adrenal glands, bone, liver, brain, and kidneys, have been thought to be rare in the digestive system. When a metastatic tumor is found in the intestine, it is most commonly metastatic melanoma or carcinoma of the cervix uteri, ovary, or breast. Yet, intestinal metastases have been described in 11% of lung cancers at autopsy. These metastases may induce gastrointestinal perforation, obstruction, or bleeding. Patients with bleeding from small intestinal metastases secondary to lung cancer almost uniformly have poor prognoses. The lung cancer metastasized to the gastrointestinal site or location where a first primary cancer was once resected is never reported in the literature. We report the case of a 76-year-old man with a history of gastric adenocarcinoma treated by subtotal gastrectomy seventeen years ago who presented with lung cancer metastatic to the bone. One month later, he developed persistent melena due to duodenal metastases. Upper gastrointestinal endoscopy showed an ulcerative duodenal mass with bleeding. The pathohistological and immunohistochemical examinations of tissue from the pathologic fracture and the endoscopic biopsy specimen revealed metastatic poorly differentiated adenocarcinoma consistent with lung origin. The diagnosis of metastatic lung cancer can be rendered based on pathologic examination and immunohistochemical analysis, even without access to the primary lung tumor. In this case, the anastomosis site where a gastrectomy for gastric cancer was once performed might be a good niche or microenvironment for cancer cells or tumor stem cells to metastasize to.

A Case of Pulmonary Siderosis Mimicking Metastatic Lung Cancer

Pulmonary siderosis is a pneumoconiosis caused by chronic iron inhalation. A diagnosis of pulmonary siderosis is based on a patient history of iron inhalation, on chest radiographic findings, and on accumulation of iron oxide in macrophages within the lung. A typical radiographic finding of pulmonary siderosis includes ill-defined micronodules that are diffusely distributed in the lung. We experienced a 52-year-woman with a 1.3×1.5-cm mass in the left upper lobe with multiple nodules in both lungs. Because the radiographic findings were atypical, we conducted a video-assisted thorascopic lung biopsy procedure to exclude the diagnosis of metastatic lung cancer. After confirming iron deposition in the lung tissue and knowing the patient's occupational history of welding iron, we concluded that this was a case of pulmonary siderosis.

Perirenal metastases from lung cancer: CT diagnosis.

Three patients with primary lung cancer had perirenal metastases detected with CT. In two cases a symptomatic perirenal mass was the first evidence of metastatic spread and CT-guided biopsy of the perirenal lesion confirmed the diagnosis of metastatic lung cancer. The perirenal space is an unusual but potentially significant site of metastasis from lung cancer as well as other tumors such as malignant melanoma. It is suggested that connections between perirenal and intrathoracic lymphatics are the most probable mechanism of this pattern of spread by lung cancers.