ESMO SUMMIT MIDDLE EAST 2018 Lung Cancer Case presentations Dr. Bassim al Bahrani, FRACP, FRCP (GLASG), PhD. Director, National Oncology Center. Royal Hospital. Oman 6-7 April 2018, Dubai, UAE
CONFLICT OF INTEREST DISCLOSURE Advisory Board ❖ Merck, Roche, Amgen, AstraZeneca , Biocon , BMS, Hospira, Lilly, Sanofi, ❖ MSD, Pfizer, Novartis, Bayer Honoraria ( Speaker/ Chairperson) ❖ Amgen, AstraZeneca , Biocon , BMS, GSK, Hospira, Lilly, Novartis, Pfizer, ❖ Roche, Sanofi, MSD, Newbridge
LUNG CANCER IN OMAN Age standardized incidence rate is 8 /100000 in males and ❖ 2.4/100000 in females. Only 6 % of lung cancers in Oman are SCLC ❖ There were 64 new lung cancer cases diagnosed in Oman in 2014 ❖ Despite the presence of different expertise, we lack lung cancer MDT. ❖
CASE 1 Mr. R.B ❖ 71 M, Blind for more than 30 years. ❖ Ex-smoker for 5 years, 20 PY of smoking ❖ October 2016 : presented with 4 months H/O cough. No hemoptysis ❖ or weight loss. CXR 10/16 : left sided hilar density. ❖ CT chest 28/11/16 : soft tissue mass related to left main bronchus in ❖ addition to mediastinal, left supraclavicular and axillary LNs.
CASE 1
CASE 1 CT neck 29/11/16: unremarkable. ❖ CT abdomen 29/11/16 : unremarkable ❖ Bronchoscopy 22/12/16 : vascular lesion in left main bronchus and ❖ scope couldn't ’ t be passed beyond it. Biopsy tried once, gross oozing happened. Cytology from bronchial lavage : Atypical squamous cells. ❖ HPR : insufficient material. ❖
CASE 1 OPD 2/1/17 : ECOG 2. Re-biopsy advised. A repeat CT arranged. ❖ PAN CT 16/1/17 : Growing of the left lung mass causing left lower ❖ lobe collapse. Tumor Board discussion 23/1/17 : “After revision and discussion ❖ between chest physicians and radiologists, the lesion is difficult to biopsy. Considering the centrality of the lesion and impending bronchial blockage, do PET scan, given single fraction radiation, patient not candidate for chemotherapy. He is for BSC “ . Started on dexamethasone 4 mg BID. ❖
CASE 1 PET 30/1/17: FDG avid left hilar mass, N3 LNs, liver lesions and bulky ❖ left adrenal. OPD 1/2/17 : Seen by Med Onc. and referred to Rad Onc. ❖ OPD 1/2/17 : Agreed to start palliative RT ( 30 Gy in 10 #) ❖ 7-20/2/17 : Received palliative RT. Tolerated well. ❖ OPD 26/6/17: Stable with no new symptoms. ❖ Bronchoscopy 5/3/17: mass in left bronchus isn’t seen any more. ❖ MRI abdomen 4/4/17 : liver lesions are cysts. Adrenal bulky but no define ❖ mets.
CASE 1 May 2017: patient went to Thailand. ❖ Underwent liquid biopsy : No EGFR mutations or T790M. ❖ Biopsy from lung : Squamous cell NSCLC ❖ Molecular biology : ALK negative but ROS1 positive. ❖ Advised to start Crizotinib. ❖ Case discussed in Tumor Board 12/7/17. Approved for Crizotinib. ❖ OPD 9/8/17 : Crizotinib awaited. ECOG 3. Increased SOB. Treated ❖ symptomatically
CASE 1 30/8/17: Crizotinib started at 250 mg OD 17/9/17: Seen in OPD. Tolerated Crizotinib well. Dose increased to 250 mg BID OPD 25/10/17 : Low back pain but no numbness or retention. MRI requested. 31/10/17: Started to have numbness and weakness in both legs. Didn’t come to hospital. 6/11/17 : Presented with increased numbness and weakness of both legs. Total Spine MRI 6/11/17 : Cord compression at D7 with multiple bone lesions.
CASE 1 Spinal Surgeons were reluctant to operates as the patient has stage IV ❖ NSCLC and in their opinion his expected survival is less than 6 months. Given single fraction of radiation to the area. ❖ Discharged home on 15/11/17. ❖ Remained at home and was reluctant to come back to hospital. ❖ Passed away peacefully 11/1/18 ❖
DISCUSSION
CASE 2 Mrs. MM ❖ 54 F, never smoked, insignificant PMH. ❖ July 2016 : presented with 2 months H/O cough. No hemoptysis or ❖ weight loss. CXR 20/7/16 : right sided mid lung field opacity. ❖ CT chest 20/07/16 : infiltrative mass right hilum mass infiltrating RML ❖ and RLL. Features of lymphangitis carcinomatosis.
CASE 2 Bronchoscopy 20/7/16 : grossly inflamed RUL bronchus with thick ❖ secretions. Biopsy 21/7/16 : Adenocarcinoma of the lung. ❖ CT abdomen 27/7/16 : abdominal LNs ❖ On 2/8/16 : Right sided VAT lower lobe mass excision and wedge ❖ resection. HPR : papillary adenocarcinoma with multiple vascular emboli. Positive ❖ resection margin. Bone scan 15/8/16 : No bone mets. ❖ OPD 15/8/16 : send EGFR and ALK ❖
CASE 2 OPD 31/8/16: EGFR non mutated. ALK sent. Patient advised to ❖ start palliative chemotherapy with carboplatin and pemetrexed. C1 carboplatin and pemetrexed 31/8/16. ❖ ALK result : ALK translocation positive on 5/10/16. ❖ Decision to carry on with chemotherapy till Crizotinib is approved. ❖ Follow up CT post 4 cycles: good response to treatment. ❖ Received 4 doses of maintenance pemetrexed till 1/2/17. ❖
CASE 2 PAN CT 14/2/17 : disease progression. Bone mets +. ❖ OPD 12/3/17 : Crizotinib available. Patient started on 250 mg BID. ❖ Developed backache . ❖ MRI: Possible L5 hemangioma. Biopsy taken. ❖ OPD 12/4/17: Biopsy resulted as metastatic adenocarcinoma from ❖ lung. Zoledronic acid given. Referred to radiation oncologist. Radiation deferred by radiation oncologist as patient was ❖ asymptomatic.
CASE 2 PAN CT 18/9/17 : Resolution of pleural effusion, regression of adrenal ❖ and lymph node metastasis. New metastatic nodule in right psoas muscle. Received palliative RT L5 spine ( 20 Gy in 5 #) from 8 till 15 /10/2017. ❖ During radiotherapy, she developed hard subcutaneous lesions overall ❖ her body. Biopsy showed adenocarcinoma , lung origin. ❖ OPD 23/10/18 : Considered as progressive disease. ❖ Asked to continue Crizotinib till ceritinib becomes available. ❖
CASE 2 Kept under follow up in OPD. ❖ Became more symptomatic. ❖ PAN CT 6/12/17 progressive disease. ceritinib wasn’t available yet. ❖ Decision taken to start patient on docetaxel to control her disease till ❖ ceritinib becomes available. Taken C1 on 12/12/17. Admitted from 18 till 27 th of December for optimization as she ❖ presented with painful swallowing, oral thrush , poor oral intake and edema.
CASE 2 Ceritinib started at 750 mg OD . ❖ OPD 3/1/18 : patient intolerant to 750 mg dose. Advised to take 450 mg ❖ with low fat meal. OPD 15/1/18: Subcutaneous nodules regressed. LFTs normal. ❖ PAN CT 14/2/18 : mixed response. Bone disease progressive with new ❖ bone lesions. Advised to continue ceritinib. ❖
CASE 2 Frequent OPD visits with nausea and poor appetite. No vomiting. No • motor deficit. Reported facial twitching on 6/3/18. CT head requested but family • preferred to wait. Presented with forgetfulness on 26/3/18. CT head : multiple brain mets. •
CASE 2 Patient and family refused whole brain radiation, however, they are ❖ willing to try a different treatment. Family counselled about alectinib and they agreed to try it. ❖ Alectinib still awaited. ❖
DISCUSSION
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