Metastatic Non-Small Cell lung Carcinoma with pleural metastases

Posted by saurabh @saurabh, 4 days ago

Metastatic Non-Small Cell lung Carcinoma (Adenocarcinoma), Right Upper Lobe (TTF-1 positive, P40 negative) with pleural metastases (M1a, Stage IVA)
HISTORY OF PRESENT ILLNESS
68-year-old female, known case of hypertension for the last 2 years, initially presented with fever & cough. evaluation of a right lung lesion detected on imaging. CT chest dated 22/05/2026 revealed a 36 x 31 mm soft tissue lesion in the right upper lobe with adjacent stranding and an additional 10 x 6.6 mm soft tissue lesion in the lateral segment of the right middle lobe, suspicious for malignancy. Subsequent PET-CT dated 02/06/2026 demonstrated a hypermetabolic heterogeneously enhancing soft tissue mass in the right upper lobe bulging into the right oblique fissure, with few metabolically indeterminate nodules along the fissure and a metabolically active right upper paratracheal lymph node suspicious for involvement, with no evidence of distant extrathoracic metastases. CT-guided biopsy of the right lung lesion on 08/06/2026 revealed Non-Small Cell Carcinoma, Adenocarcinoma. Immunohistochemistry showed TTF-1 positivity and p40 negativity, consistent with primary lung adenocarcinoma. CEMRI brain-- age related atrophy, no mets diagnostic thoracoscopy done found to have multiple pleural deposits Further staging with frozen section and biopsy of DIAPHRAGMATIC parietal pleural deposits on 17/06/2026 confirmed metastatic involvernent by adenocarcinoma, establishing Stage IVA (M1a) disease. The patlient was initiated on weekly Paclitaxel (Nanoxel) 100 mg and Carboplatin 150 mg on 18/06/2026 for 9 weeks and subsequently received Cycle 1 Day 8 chernotherapy on 26/06/2026, which was tolerated well without major complications. Next chemotherapy is scheduled for 3/07/2026.
The report of PDL1 Test and lung panel NGS has arrived and has been advised Paclitaxel (Nanoxel) 100 mg and Carboplatin 150 mg with OSIMERTINIB 80 mg once daily for 3 months by Dr.A but Dr. B disagrees and he says that we should not combine Paclitaxel (Nanoxel) 100 mg and Carboplatin 150 mg with OSIMERTINIB 80 and we should complete the chemo then we should conduct the pet ct after that if possible radiation and then targeted medicine. He also said that osimertnib 80 can be combined with platinum-pemetrexed.
Please give advice as we have not started with osimertnib 80, so how we should proceed....

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Lisa, Volunteer Mentor | @lls8000 | 3 days ago

Hello @saurabh, welcome to Mayo Connect. These decisions are always difficult, especially when you have differing opinions. Mayo Connect includes patients and family members, we are not doctors and cannot provide medical advice. We can discuss our own situations.
There many lung cancer survivors taking targeted therapy medications (TKI). I have a different mutation, so I take a different TKI, Alectinib for ALK positive lung cancer, stage IV. These medications target the cancer at the cellular level and have proven to be very effective when we can tolerate them. I never took chemotherapy, I went on the Alectinib and it cleared all of my tumors.
Not everyone can tolerate these medications, especially along with chemo. How are you/your loved one tolerating the chemo? Have the doctors presented the reasoning behind their recommendations?

mamajite | @mamajite | 3 days ago

hi @saurabh - if the oncologists you have met with disagree, my advice would be to seek an opinion from the best cancer center you can access. in the US those places will have a Tumor Board (group of doctors treating lung cancer with differing expertise - ie: surgeon, radiologist, radiation oncologist, medical oncologist) meet and give you an institutional opinion on what the best treatment plan would be.

have you (or the patient) had biomarker testing completed? that is important in identifying which treatments would be most helpful.

in the meantime, you can read the FLAURA2 clinical trial that showed chemo (cisplatin or carboplatin) + permextred + osimertinib had better outcomes than just osimertinib in patients with locally advanced or metastatic non small cell lung cancer.
https://www.nejm.org/doi/full/10.1056/NEJMoa2306434