Case Report: Can this 90-year-old patient with cT4N3M0 NSCLC have concurrent chemoradiation for cure? Learning from a representive case.

It is challenging to manage locally advanced non-small cell lung cancer (NSCLC) in patients older than 85 years, as there is neither a guideline nor evidence for guidance. Most clinical trials excluded this population for enrollment. Here we report a case of a 90-year-old former smoker with squamous cell carcinoma of the left upper lung, FDG-PET/CT staged IIIC cT4N3M0 (the 8th Edition of the UICC/AJCC Staging System). The patient, representing the population of older patients, was remarkable for extensive vertebrae body invasion with the primary tumor abutting the true spinal cord. Our multidisciplinary team consultation rendered him with unresectable tumors in a medically inoperable condition. The patient was treated with concurrent chemoradiation therapy to a tumor dose of 60 Gy in 30 fractions, using an imaging-guided adaptive technique to keep the cord in a safe dose limit, similar to that of RTOG1106. The patient had quick and lasting pain relief and tumor shrinkage during the course of therapy, which allowed adaptive cord-sparing therapy. The patient completed the definitive course of chemoradiation with Grade I/II radiation esophagitis and Grade IV neutropenic fever. He did not have subsequent immunotherapy maintenance. He is now almost 6 years out from the lung cancer diagnosis, with excellent performance status without any evidence of disease progression. His tumor continuously shrunk 3 years after the completion of radiotherapy; the destroyed bone recovered to a normal appearance. He has no evidence of disease progression nor any notable side effects. The success of this case implicates that the curative potential of concurrent chemotherapy with precision personalized adaptive therapy alone without adjuvant immunotherapy in the extremely old population. Future prospective studies are needed.