Stage IV NSCLC: Staging, Treatment and Survival
Author: Paul Schipper, MD
Institution: OHSU
Date Reviewed: June 2025
Original Case: Stephen C. Yang, MD
Learning Domain: General Thoracic
Learning Objective: Stage IV NSCLC: staging, treatment and survival
PowerPoint File: Stage IV NSCLC: Staging, Treatment and Survival
Case Discussion Points for Conference
- PET/CT shows high avidity in RUL nodule only
- What are the next diagnostic steps?
- Further staging modalities?
- Treatment approaches?
Case Discussion Points for Conference
- Specific case scenario/outcomes:
- Multiple brain metastases but clinical T1-2N0 in the chest
- PET shows activity in the mediastinum (hilar and/or mediatinal)
- Instead of brain met, patient has solitary adrenal met
- During VATS exploration for lobectomy, you find pleural effusion and small pleural nodules
This scenario evaluates the benefit of resection of the lung primary with a solitary brain metastasis. T1-2N0M1b (solitary brain only, the M1b stands for single extrathoracic metastasis in a single organ, including a single non-regional node). This treatment algorithm may rapidly enlarge or change depending on advances in systemic therapy.
Targeted Therapy
- Non-squamous NSCLC: test for ALK (tyrosine kinase), EGFR, KRAS, HER2 and MET
| Genetic Alterations | Available Targeted Agents |
|---|---|
| ALK rearrangements | Crizotinib |
| EGFR mutations | Erlotinib, gefitinib |
| HER2 mutations | Trastuzumab, afatinib |
| MET amplification | Crizotinib |
- If both ALK/EGFR negative, unknown, or treatment failure with above regimens: cisplatin-based doublet +/- bevacizumab
- KRAS+ cancers: generally poor response to EGFR inhibitors and chemotherapy
- Squamous cell carcinoma: cisplatin-based doublet +/- bevacizumab (no testing for ALK/EGFR)
Learning Points
- Staging modalities for end-stage disease: EBUS, EUS, MRI, VATS
- Sites of metastases
- Indications for surgery for stage IV disease
- Use of targeted therapy