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Optimizing Symptom Management in VA Oncology: A Workflow-Based Quality Improvement Initiative
Background
Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).
Methods
Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.
Results
A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.
Conclusions
Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.
Background
Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).
Methods
Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.
Results
A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.
Conclusions
Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.
Background
Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).
Methods
Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.
Results
A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.
Conclusions
Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.
Enhancing Workforce Practices to Achieve Commission on Cancer Accreditation
Background
The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.
Methods
In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.
Results
TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).
Conclusions
Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.
Background
The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.
Methods
In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.
Results
TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).
Conclusions
Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.
Background
The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.
Methods
In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.
Results
TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).
Conclusions
Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.
Centralized Psychosocial Distress Screening Led by RN Care Coordinator
Background
Unmet psychosocial health needs negatively impact cancer care and outcomes. The American College of Surgeons’ Commission on Cancer (CoC) accreditation requirements include Psychosocial Distress Screening (PDS) for all newly diagnosed patients. To enhance cancer care and meet CoC standards, the Tibor Rubin Veterans Affairs Medical Center (TRVAMC) developed and implemented a closed-loop, centralized PDS pathway.
Objectives
Develop processes/methods to: (1) identify all newly diagnosed cancer patients; (2) track initiation of first course of treatment; (3) offer and complete PDS at initiation of first course of treatment; and (4) ensure placement of appropriate referrals.
Methods
All staff members were trained in PDS and competency completed. A standard operating procedure (SOP) was created to identify patients meeting criteria for PDS. Newly diagnosed patients were identified from cancer registry lists, tumor boards, radiology and pathology reports. Patients were placed on a tracking tool by the nurse care coordinator (NCC) and monitored to facilitate timely workup and initiation of treatment. Nurses in the cancer program offered and completed PDS and placed all necessary referrals (to > 11 services). Patients were removed from the tracker only after confirmation of PDS and referrals.
Results
Prior to implementation of PDS, no patients received comprehensive screening and referrals. After implementation, data were collected over a 2 year period. In 2023 and 2024, 277/565 (49%) and 256/526 (48.7%) newly diagnosed patients were eligible for PDS, respectively. All eligible patients were offered PDS (100%). Of patients who underwent PDS, 37% scored their distress at a level of 4/10 or higher, underscoring the severity of distress and unmet need. Referrals to various services were indicated and made in 43.8% patients, most frequently to Social Work, Primary Care or Psychology/Mental Health. More recently, nurses in the Infusion Clinic and Radiation Oncology were trained in and also started conducting PDS on patients coming for treatment.
Conclusions
Implementation of comprehensive and timely PDS resulted in early identification and interventions to address diverse facets of distress that are known to interfere with quality of life, compliance with cancer treatments and outcomes. The program also met the CoC standard for accreditation of TRVAMC in 2024.
Background
Unmet psychosocial health needs negatively impact cancer care and outcomes. The American College of Surgeons’ Commission on Cancer (CoC) accreditation requirements include Psychosocial Distress Screening (PDS) for all newly diagnosed patients. To enhance cancer care and meet CoC standards, the Tibor Rubin Veterans Affairs Medical Center (TRVAMC) developed and implemented a closed-loop, centralized PDS pathway.
Objectives
Develop processes/methods to: (1) identify all newly diagnosed cancer patients; (2) track initiation of first course of treatment; (3) offer and complete PDS at initiation of first course of treatment; and (4) ensure placement of appropriate referrals.
Methods
All staff members were trained in PDS and competency completed. A standard operating procedure (SOP) was created to identify patients meeting criteria for PDS. Newly diagnosed patients were identified from cancer registry lists, tumor boards, radiology and pathology reports. Patients were placed on a tracking tool by the nurse care coordinator (NCC) and monitored to facilitate timely workup and initiation of treatment. Nurses in the cancer program offered and completed PDS and placed all necessary referrals (to > 11 services). Patients were removed from the tracker only after confirmation of PDS and referrals.
Results
Prior to implementation of PDS, no patients received comprehensive screening and referrals. After implementation, data were collected over a 2 year period. In 2023 and 2024, 277/565 (49%) and 256/526 (48.7%) newly diagnosed patients were eligible for PDS, respectively. All eligible patients were offered PDS (100%). Of patients who underwent PDS, 37% scored their distress at a level of 4/10 or higher, underscoring the severity of distress and unmet need. Referrals to various services were indicated and made in 43.8% patients, most frequently to Social Work, Primary Care or Psychology/Mental Health. More recently, nurses in the Infusion Clinic and Radiation Oncology were trained in and also started conducting PDS on patients coming for treatment.
Conclusions
Implementation of comprehensive and timely PDS resulted in early identification and interventions to address diverse facets of distress that are known to interfere with quality of life, compliance with cancer treatments and outcomes. The program also met the CoC standard for accreditation of TRVAMC in 2024.
Background
Unmet psychosocial health needs negatively impact cancer care and outcomes. The American College of Surgeons’ Commission on Cancer (CoC) accreditation requirements include Psychosocial Distress Screening (PDS) for all newly diagnosed patients. To enhance cancer care and meet CoC standards, the Tibor Rubin Veterans Affairs Medical Center (TRVAMC) developed and implemented a closed-loop, centralized PDS pathway.
Objectives
Develop processes/methods to: (1) identify all newly diagnosed cancer patients; (2) track initiation of first course of treatment; (3) offer and complete PDS at initiation of first course of treatment; and (4) ensure placement of appropriate referrals.
Methods
All staff members were trained in PDS and competency completed. A standard operating procedure (SOP) was created to identify patients meeting criteria for PDS. Newly diagnosed patients were identified from cancer registry lists, tumor boards, radiology and pathology reports. Patients were placed on a tracking tool by the nurse care coordinator (NCC) and monitored to facilitate timely workup and initiation of treatment. Nurses in the cancer program offered and completed PDS and placed all necessary referrals (to > 11 services). Patients were removed from the tracker only after confirmation of PDS and referrals.
Results
Prior to implementation of PDS, no patients received comprehensive screening and referrals. After implementation, data were collected over a 2 year period. In 2023 and 2024, 277/565 (49%) and 256/526 (48.7%) newly diagnosed patients were eligible for PDS, respectively. All eligible patients were offered PDS (100%). Of patients who underwent PDS, 37% scored their distress at a level of 4/10 or higher, underscoring the severity of distress and unmet need. Referrals to various services were indicated and made in 43.8% patients, most frequently to Social Work, Primary Care or Psychology/Mental Health. More recently, nurses in the Infusion Clinic and Radiation Oncology were trained in and also started conducting PDS on patients coming for treatment.
Conclusions
Implementation of comprehensive and timely PDS resulted in early identification and interventions to address diverse facets of distress that are known to interfere with quality of life, compliance with cancer treatments and outcomes. The program also met the CoC standard for accreditation of TRVAMC in 2024.
Metastatic Pulmonary LCNEC With Pancreatic Involvement in a Young Non-Smoker: An Unusual Presentation
Background
Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive lung cancer subtype, comprising ~3% of lung malignancies. It commonly affects older, heavy smokers and presents at an advanced stage. Prognosis is poor, with a 5-year survival rate of 15–25% in metastatic disease.
Case Presentation
A 33-year-old previously healthy male presented with a month of abdominal and lower back pain, along with significant weight loss. Lab tests revealed elevated lipase (378), and he was initially treated for acute pancreatitis. Imaging revealed a 1.9 cm pancreatic head mass and three hypodense hepatic lesions. MRI confirmed these findings but remained inconclusive. An incidental 8 mm right lower lobe pulmonary nodule led to chest CT, identifying a dominant left lower lobe mass and mediastinal lymphadenopathy, raising suspicion for primary lung malignancy. The patient was discharged but returned three days later with worsening symptoms and a lipase of 754. Endoscopic biopsy of the pancreatic mass was deferred due to ongoing pancreatitis. A liver biopsy revealed neuroendocrine differentiation, positive for CK AE1/AE3, CK7, CK19, and synaptophysin. Molecular profiling showed PD-L1 (TPS 50%), low tumor mutational burden, microsatellite stability, and high loss of heterozygosity. Bronchoscopy revealed a left hilar mass, and lymph node biopsy confirmed LCNEC (CK7+, chromogranin+, TTF- 1+, synaptophysin+), establishing a diagnosis of stage IV pulmonary LCNEC with pancreatic and liver metastases. The patient began treatment with bevacizumab, paclitaxel, carboplatin, and atezolizumab, resulting in improvement in hilar, hepatic, and pancreatic lesions on further imagings. The patient was continued on chemoimmunotherapy.
Discussion
This case highlights an uncommon presentation of LCNEC in a young, non-smoking male, initially manifesting as pancreatitis due to pancreatic metastasis. The absence of pulmonary symptoms complicated the diagnosis. Histopathology and immunohistochemistry were essential. While no standardized treatment exists for LCNEC, platinum-based chemotherapy with immunotherapy remains the mainstay. PD-L1 expression may guide immunotherapy decisions.
Conclusions
Pulmonary LCNEC should be considered in metastatic neuroendocrine tumors, even in young, non-smoking patients without pulmonary symptoms. Early tissue diagnosis and molecular profiling are key to guiding management.
Background
Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive lung cancer subtype, comprising ~3% of lung malignancies. It commonly affects older, heavy smokers and presents at an advanced stage. Prognosis is poor, with a 5-year survival rate of 15–25% in metastatic disease.
Case Presentation
A 33-year-old previously healthy male presented with a month of abdominal and lower back pain, along with significant weight loss. Lab tests revealed elevated lipase (378), and he was initially treated for acute pancreatitis. Imaging revealed a 1.9 cm pancreatic head mass and three hypodense hepatic lesions. MRI confirmed these findings but remained inconclusive. An incidental 8 mm right lower lobe pulmonary nodule led to chest CT, identifying a dominant left lower lobe mass and mediastinal lymphadenopathy, raising suspicion for primary lung malignancy. The patient was discharged but returned three days later with worsening symptoms and a lipase of 754. Endoscopic biopsy of the pancreatic mass was deferred due to ongoing pancreatitis. A liver biopsy revealed neuroendocrine differentiation, positive for CK AE1/AE3, CK7, CK19, and synaptophysin. Molecular profiling showed PD-L1 (TPS 50%), low tumor mutational burden, microsatellite stability, and high loss of heterozygosity. Bronchoscopy revealed a left hilar mass, and lymph node biopsy confirmed LCNEC (CK7+, chromogranin+, TTF- 1+, synaptophysin+), establishing a diagnosis of stage IV pulmonary LCNEC with pancreatic and liver metastases. The patient began treatment with bevacizumab, paclitaxel, carboplatin, and atezolizumab, resulting in improvement in hilar, hepatic, and pancreatic lesions on further imagings. The patient was continued on chemoimmunotherapy.
Discussion
This case highlights an uncommon presentation of LCNEC in a young, non-smoking male, initially manifesting as pancreatitis due to pancreatic metastasis. The absence of pulmonary symptoms complicated the diagnosis. Histopathology and immunohistochemistry were essential. While no standardized treatment exists for LCNEC, platinum-based chemotherapy with immunotherapy remains the mainstay. PD-L1 expression may guide immunotherapy decisions.
Conclusions
Pulmonary LCNEC should be considered in metastatic neuroendocrine tumors, even in young, non-smoking patients without pulmonary symptoms. Early tissue diagnosis and molecular profiling are key to guiding management.
Background
Pulmonary large-cell neuroendocrine carcinoma (LCNEC) is a rare, aggressive lung cancer subtype, comprising ~3% of lung malignancies. It commonly affects older, heavy smokers and presents at an advanced stage. Prognosis is poor, with a 5-year survival rate of 15–25% in metastatic disease.
Case Presentation
A 33-year-old previously healthy male presented with a month of abdominal and lower back pain, along with significant weight loss. Lab tests revealed elevated lipase (378), and he was initially treated for acute pancreatitis. Imaging revealed a 1.9 cm pancreatic head mass and three hypodense hepatic lesions. MRI confirmed these findings but remained inconclusive. An incidental 8 mm right lower lobe pulmonary nodule led to chest CT, identifying a dominant left lower lobe mass and mediastinal lymphadenopathy, raising suspicion for primary lung malignancy. The patient was discharged but returned three days later with worsening symptoms and a lipase of 754. Endoscopic biopsy of the pancreatic mass was deferred due to ongoing pancreatitis. A liver biopsy revealed neuroendocrine differentiation, positive for CK AE1/AE3, CK7, CK19, and synaptophysin. Molecular profiling showed PD-L1 (TPS 50%), low tumor mutational burden, microsatellite stability, and high loss of heterozygosity. Bronchoscopy revealed a left hilar mass, and lymph node biopsy confirmed LCNEC (CK7+, chromogranin+, TTF- 1+, synaptophysin+), establishing a diagnosis of stage IV pulmonary LCNEC with pancreatic and liver metastases. The patient began treatment with bevacizumab, paclitaxel, carboplatin, and atezolizumab, resulting in improvement in hilar, hepatic, and pancreatic lesions on further imagings. The patient was continued on chemoimmunotherapy.
Discussion
This case highlights an uncommon presentation of LCNEC in a young, non-smoking male, initially manifesting as pancreatitis due to pancreatic metastasis. The absence of pulmonary symptoms complicated the diagnosis. Histopathology and immunohistochemistry were essential. While no standardized treatment exists for LCNEC, platinum-based chemotherapy with immunotherapy remains the mainstay. PD-L1 expression may guide immunotherapy decisions.
Conclusions
Pulmonary LCNEC should be considered in metastatic neuroendocrine tumors, even in young, non-smoking patients without pulmonary symptoms. Early tissue diagnosis and molecular profiling are key to guiding management.