A Case of Five-Year Survival After Combined-Modality Treatment for Non-Small Cell Lung Cancer With Intraspinal Metastasis

Abstract

This case report describes the treatment approach and outcome in a 69-year-old female patient with non-small cell lung cancer (NSCLC) diagnosed with T4 N2 M1b (intraspinal) disease. The two most common targets for tyrosine kinase inhibitors (epidermal growth factor receptor and anaplastic lymphoma kinase) were not expressed. Programmed death-ligand 1 (PD-L1) was expressed in <50% of the tumor cells. In 2016, initial guideline-concordant treatment with carboplatin/vinorelbine chemotherapy was initiated. Between the first two cycles, all positron emission tomography (PET) positive lesions were irradiated with 30 Gy in 10 fractions (lung, nodes, thoracic spinal manifestation). After nine months with excellent response (at least partial remission, possibly fibrosis only), bilateral lung metastases were diagnosed. The patient was started on nivolumab monotherapy (later atezolizumab due to a change in National practice) and completed two years of treatment. She is currently in continued complete remission with regular follow-up examinations. This case illustrates that outcomes comparable to those observed in patients with limited brain metastases may be observed in patients with localized intraspinal disease and that immune checkpoint inhibitors play an important role in the management of metastatic NSCLC.

Keywords: 5-year overall survival; central nervous system metastasis; cytotoxic chemotherapy; immune check-point inhibitor; intradural extramedullary spinal metastasis; long-term outcome; metastatic non-small cell lung cancer; radiotherapy (rt).

Figure 1. Axial PET-CT scan (tracer 18F-fluorodeoxyglucose) showing intraspinal tracer uptake at the level of the seventh thoracic vertebra, clearly separated from the lung primary.

PET-CT, positron emission tomography-computed tomography

Figure 2. Axial CT scan at the level of the primary lung tumor in the right upper lobe.

CT, computed tomography

Figure 3. Sagittal contrast-enhanced T1 TSE MRI scan of the intraspinal lesion.

MRI, magnetic resonance imaging; TSE, turbo spin echo

Figure 4. Axial contrast-enhanced T1 TSE MRI at the level of the primary lung tumor.

The tumor invades the spine and the spinal canal at the right-hand aspect of the spinal cord. MRI, magnetic resonance imaging; TSE, turbo spin echo

Figure 5. Sagittal treatment field view showing two of four treatment fields.

The clinical target volumes are displayed in orange (red contours: planning target volumes).

Figure 6. Axial CT scan showing the largest of five lung metastases (anterior part of the left lung, indicated by arrow).

CT, computed tomography

Figure 7. Axial CT scan (September 2021) corresponding to the baseline image before treatment (RECIST criteria: complete remission)

CT, computed tomography