What are the current prognosis and treatment options for a patient with adenocarcinoma (a type of non-small cell lung cancer) of the lung, presenting with two lesions in the upper lung and one lesion in the lower lung?

From the Guidelines

The prognosis for adenocarcinoma of the lung with multiple lesions is generally serious, and treatment options should be guided by staging, molecular testing, and patient factors, with a focus on improving morbidity, mortality, and quality of life. The treatment approach for a patient with adenocarcinoma of the lung presenting with two lesions in the upper lung and one lesion in the lower lung should prioritize a combination of systemic therapy, local treatments, and comprehensive molecular testing to identify actionable mutations. According to the most recent guidelines 1, systemic therapy should be offered to all stage IV patients with a performance status (PS) of 0-2, and the standard first-line chemotherapy is a platinum-based doublet chemotherapy. For non-squamous tumors, pemetrexed is preferred to gemcitabine or docetaxel, and its use should be restricted to non-squamous NSCLC in any line of treatment 1. Additionally, bevacizumab combined with a paclitaxel–carboplatin regimen may be offered to patients with non-squamous histology NSCLC and PS 0-1 after exclusion of contraindications 1. Some key considerations in the treatment strategy include:

• The importance of comprehensive molecular testing to identify actionable mutations, such as EGFR mutations or ALK rearrangements, which can significantly improve outcomes with targeted therapies 1
• The role of chemotherapy, radiation therapy, and surgical resection in the treatment of non-small cell lung cancer with multiple lesions
• The need to consider performance status, comorbidities, and patient preferences when making treatment decisions
• The potential benefits and risks of different treatment approaches, including targeted therapies, immunotherapy, and combination regimens. It is essential to discuss treatment decisions within a multidisciplinary tumor board to ensure that all relevant factors are considered and that the patient receives the most appropriate and effective treatment.

From the FDA Drug Label

For the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS ≥1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. As a single agent for the first-line treatment of patients with NSCLC expressing PD-L1 [Tumor Proportion Score (TPS) ≥1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is: Stage III where patients are not candidates for surgical resection or definitive chemoradiation, or metastatic. Docetaxel Injection as a single agent is indicated for the treatment of patients with locally advanced or metastatic non-small cell lung cancer after failure of prior platinum-based chemotherapy For patients with non-small cell lung carcinoma, the recommended regimen, given every 3 weeks, is paclitaxel administered intravenously over 24 hours at a dose of 135 mg/m2 followed by cisplatin, 75 mg/m2

The current treatment options for a patient with adenocarcinoma (a type of non-small cell lung cancer) of the lung, presenting with two lesions in the upper lung and one lesion in the lower lung, may include:

• Pembrolizumab as a single agent for the first-line treatment of patients with NSCLC expressing PD-L1 (TPS ≥1%) as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is Stage III or metastatic 2
• Docetaxel as a single agent for the treatment of patients with locally advanced or metastatic non-small cell lung cancer after failure of prior platinum-based chemotherapy 3
• Paclitaxel in combination with cisplatin for the treatment of patients with non-small cell lung carcinoma 4 The prognosis for this patient is not directly stated in the provided drug labels. However, the treatment options suggest that the patient may have advanced disease, and the prognosis would depend on various factors, including the patient's overall health, tumor characteristics, and response to treatment. Key considerations for treatment include:
• PD-L1 expression: Patients with tumors expressing PD-L1 (TPS ≥1%) may be eligible for pembrolizumab as a single agent.
• Prior platinum-based chemotherapy: Patients who have failed prior platinum-based chemotherapy may be eligible for docetaxel as a single agent.
• Combination therapy: Paclitaxel in combination with cisplatin may be an option for patients with non-small cell lung carcinoma.

From the Research

Prognosis

• The prognosis for a patient with adenocarcinoma of the lung presenting with multiple lesions can vary depending on the stage and characteristics of the disease 5.
• Multifocal lung adenocarcinoma (MFLA) is a distinct subset of lung cancer with a unique biology and disease course, and disease progression typically follows an indolent course measured in years 5.
• The introduction of the IASLC/ATS/ERS adenocarcinoma classification has led to a better understanding of the disease and its subtypes, which can help guide prognosis and treatment decisions 6, 7.

Treatment Options

• Surgical resection is a common treatment option for early-stage lung adenocarcinoma, and limited resection (such as segmentectomy or wedge resection) may be considered for small lesions (≤2 cm) with less invasive histology 6, 7.
• The role of lymph node dissection in the treatment of lung adenocarcinoma is still a topic of debate, and the extent of dissection may depend on the stage and characteristics of the disease 6, 7.
• Immunotherapy, such as pembrolizumab, may be an effective treatment option for patients with advanced lung adenocarcinoma, particularly those with high levels of PD-L1 expression 8.
• Molecular diagnosis and targeted therapy may also play a role in the treatment of multifocal lung adenocarcinoma, particularly in patients with specific genetic mutations such as EGFR or KRAS 9, 5.

Management of Multiple Lesions

• The management of multiple lung nodules is a complex issue, and a multidisciplinary approach is recommended to determine the best course of treatment 7.
• Surveillance and monitoring of lesions may be considered for patients with multiple small lesions, particularly if they are suspected to be pre-invasive or minimally invasive adenocarcinomas 6, 9.
• Surgical resection of multiple lesions may be considered in some cases, particularly if the lesions are large or symptomatic, but the decision to operate should be made on a case-by-case basis and take into account the patient's overall health and disease characteristics 7.