I have an 81yo man with stage IIIB RLL adenocarcinoma. The mass is 11.5 cm. Radiation oncology wants me to shrink it before they attempt radiation, so I would plan to treat him as unresectable/advanced/metastatic with carbo/pem/pem. However, due to the carbo shortage I need to find an alternative. His kidney function is perfect so I could use cis/pem/pem but he had MI with stent in 2021, TTE at that time showed normal EF and no mention of diastolic dysfunction but I always worry about the volume that's needed with cisplatin. Any other recommendations for systemic therapy? I considered using split-dose cis but the IVF are the same it seems.
This platinum shortage is terrible!!! Our chemo radiation paradigm is chemoradiation followed by durva for unresectable cases. I would try to get in the cisplatin with pemetrexed at a 30mg p m2 day 1 day 8 if you could do it. if he is not a candidate for definitive radiation then you could treat him as an unresectable case as you suggest in which case PDL1 and molecular profiling would be the next first steps. Because of the NCCN guidelines we are able to obtain nivolumab ipilumumab in PDL1 0 and PDL1 positive. There was recent safely data expansion study Ready NE, et al. J Immunother Cancer 2023;11:e006127 that included PS 2 patients.
