Dr. Koh (Chair, Medical Oncologist)
Right, let's move on to the next case. This is a 68-year-old gentleman, Mr. Rajesh Kumar, with a diagnosis of locally advanced non-small cell lung cancer, stage IIIB. Dr. Tan, could you present the case?
Dr. Tan (Presenting Registrar)
Thank you, Dr. Koh. Mr. Kumar presented with a three-month history of progressive cough, hemoptysis, and a 10-kilogram weight loss. CT thorax showed a 5.2 centimeter right upper lobe mass with mediastinal lymphadenopathy. Biopsy confirmed adenocarcinoma. PET-CT shows FDG-avid mediastinal nodes but no distant metastases.
Dr. Koh (Chair, Medical Oncologist)
What about molecular markers? Do we have the EGFR, ALK, and PD-L1 results?
Dr. Tan (Presenting Registrar)
EGFR is wild-type, ALK rearrangement is negative, but PD-L1 expression is high at 80 percent. His ECOG performance status is 1.
Dr. Wong (Radiation Oncologist)
From a radiation oncology perspective, the tumor is technically unresectable due to the extensive mediastinal involvement. However, the primary mass and nodal disease are encompassable within a radical radiotherapy field. I would recommend concurrent chemoradiation as the standard approach for stage IIIB disease.
Dr. Koh (Chair, Medical Oncologist)
I agree. With the high PD-L1 expression, he would be an excellent candidate for durvalumab consolidation after chemoradiation, following the PACIFIC trial protocol. That's shown a significant improvement in progression-free survival.
Dr. Soh (Cardiothoracic Surgeon)
I concur that surgery is not an option here. The N2 and N3 nodal disease rules out a curative resection. However, if there's a significant response after chemoradiation, we could potentially reassess operability, though that would be unusual for this extent of disease.
Dr. Yeo (Palliative Medicine)
May I also raise the issue of advance care planning? Mr. Kumar has significant comorbidities including COPD and diabetes. Given the stage of disease, I think it would be appropriate to initiate an ACP discussion early, even as we proceed with active treatment.
Dr. Koh (Chair, Medical Oncologist)
Absolutely. That's a very important point. Early palliative care integration has been shown to improve quality of life outcomes. Dr. Yeo, would your team be able to see him in clinic next week?
Dr. Yeo (Palliative Medicine)
Yes, we'll arrange a slot. We'll also assess his symptom burden — the weight loss and cough are likely significantly impacting his daily functioning and mood.
Nurse Specialist Chen
Dr. Koh, I should mention that Mr. Kumar's family has expressed concerns about treatment side effects. His wife is particularly worried about him losing more weight during chemoradiation. Should we arrange a family meeting before starting treatment?
Dr. Koh (Chair, Medical Oncologist)
Yes, that's essential. Let's set up a family conference with the oncology team, palliative care, and our dietitian. We need to discuss realistic expectations, the treatment plan, nutritional support, and potential side effects.
Dr. Tan (Presenting Registrar)
One more thing — his lung function tests show an FEV1 of 1.8 liters, which is about 65 percent predicted. The radiation oncologists may need to be mindful of radiation pneumonitis risk given his underlying COPD.
Dr. Wong (Radiation Oncologist)
Noted. We'll plan the radiation fields carefully to minimize lung V20, and I'll use IMRT technique to spare as much healthy lung tissue as possible. Let's proceed with concurrent chemoradiation, with close monitoring of respiratory function throughout treatment.