Reinitiating Chemotherapy beyond Progression after Maintenance Immunotherapy in Extensive-Stage Small-Cell Lung Cancer

Abstract

Introduction: Small-cell lung cancer (SCLC) is an aggressive form of cancer with a poor prognosis. The two-year survival rate is 8% of all cases. Case presentation: We present the case of a male patient who was 50 years old at the time of diagnosis in May 2022. He was diagnosed with extensive-stage small-cell lung cancer, treated with immunotherapy in combination with chemotherapy (Durvalumab in combination with Etoposide plus Carboplatin) as a first-line treatment, followed by maintenance immunotherapy. In December 2023, a PET-CT scan revealed progressive disease with multiple metastases. Chemotherapy was reinitiated with Etoposide plus Cisplatin in January 2024. After two cycles of chemotherapy, the patient developed post-chemotherapy anemia, for which treatment with Epoetinum alpha was initiated. Chemotherapy was continued for another five cycles, until May 2024, with the maintenance of hemoglobin at a level within 9.9 mg/dL-11 mg/dL. Upon assessment at the end of May 2024, the patient presented an ECOG = 2 performance status, with a moderate general state, moderate-intensity fatigue, no pain, no anxiety or depression and no dyspnea. Discussions, Literature Review and Conclusions: Reinitiating chemotherapy after the failure of maintenance immunotherapy may be an option in patients with SCLC. Epoetinum allows oncological treatment by preventing chemotherapy-induced anemia.

Keywords: Epoetinum alpha; first-line immunotherapy; reinitiating chemotherapy; small-cell lung cancer.

Figure 1

CT scan chest (October 2022): An expanding nodular mass in the apical segment of the right upper lobe with maximum axial diameters of 1.7/0.7. An expanding nodular mass plated in the posterior pleura of the posterior segment of the right upper lobe with maximum axial diameters of 2.2/1.5 mm.

Figure 2

The cranial MRI (March 2023): Right parietal nodule that is compatible on imaging with a secondary hematogenous mass with intralesional bleeding.

Figure 3

Cerebral MRI (June 2023): Dimensional regression of the right parietal tumor mass and of the perilesional edema.

Figure 4

Chest CT scan (June 2023): A small nodular tissue lesion in the pulmonary parenchyma in the posterior segment of the right upper lobe with axial diameters of 18/15 mm and a dense tissular micro-nodular lesion located above the right posterior hilum with axial diameters of 17/15 mm. A small nodular lesion located in the right posterior apex with axial diameters of 9.6 mm The pulmonary lesions exhibit minimal regression from the previous CT scan. Several mediastinal adenopathies with diameters of up to 22 mm and in the right pulmonary hilum with diameters of up to 30/26 mm.

Figure 5

PET-CT (December 2023): A bulky tumor mass in the right mediastinal–pulmonary area that includes the right main bronchus, with maximum dimensions of 13.4/10.2/8.5. Multiple bilateral pulmonary micronodules. Liver with greatly increased dimensions, almost completely occupied by multiple nodular and macronodular lesions, the largest with dimensions of 68/45 mm, compatible with secondary determinations. Two lesions in the pancreas, the largest of 25/20 mm. Bulky adenopathies in the celio-mesenteric and retrocrural areas, the largest inferior to the perigastric cardia and 25/20 mm in dimension. The skeletal system: multiple metabolically active lesions. Disseminated metastatic oncologic disease with secondary determination in the lungs, supra- and subdiaphragmatic ganglia, liver, pancreas, muscles and bones.

Figure 6

Skull CT (June 2024): At the cerebral level, in the right para-sagittal parietal vertex, a secondary brain metastasis is evident, in regression compared to March 2023.

Figure 7

Chest CT (June 2024): Lung metastases located apically and right supra-hilar, with maximum axial diameters of 85/22 mm and 42/20 mm, respectively, in progression compared to June 2023.

Figure 8

Abdominal CT (June 2024): Liver with slightly increased dimensions, with multiple liver metastases and with a diameter of up to 35 mm.