ESMO Preceptorship Programme Brain Tumors – Athens, Greece– 28-29 September 2018 Duarte Machado Clinical Oncology Trainee Institute of Oncology at Lisbon - Portugal Progression or pseudoprogression?
Disclousers: no conflict of interest. ESMO PRECEPTORSHIP PROGRAMME
Initial Presentation Identification – ♀ , 62 years old; – Medical History: Fibromyalgia; – No smoking or alcoholic habits – Medication: Fluoxetine 60 mg od; pregabalin 150 mg + 300 mg; Symptoms – 04/2017: headache in left temporal region and progressive aphasia; – ECOG PS 1; Admitted at ER (05/2017) Brain CT and Brain MRI – Lesion in the left temporal lobe, well delimited, 5cm antero-posterior dimension, digitiform edema deforming the left temporal sulci and the left posterior ventricle, with midline deviation; ESMO PRECEPTORSHIP PROGRAMME
Brain MRI (05/2017) ESMO PRECEPTORSHIP PROGRAMME
Diagnosis and Staging SURGERY (06/2017) – Left anterior temporal craniotomy with gross total resection HISTOLOGY: – GLIOBASTOMA with micro-calcifications, wild type and Ki67-20% Test Method Result GFAP IHC Positive p53 IHC Negative IDH1 NGS Negative IDH2 NGS Negative hTERT NGS Positive: C228T MGMT MLPA Methylated: 57% 1p19q FISH Not deleted EGFR FISH Positive: 94% PTEN FISH Del positive: 68% Molecular profiling of the tumor ESMO PRECEPTORSHIP PROGRAMME
Treatment and Follow-up TUMOR BOARD discussion: – STUPP Protocol 1) RT plus Temozolomide 75mg/m 2 daily RT 60Gy/30 fr; 2Gy/cycle/day + TMZ between 07-08 / 2017 2) Temozolomide 200mg/m2 5/28 schedule start at 09/ 2017 No toxicities; Good tolerance; ESMO PRECEPTORSHIP PROGRAMME
Treatment and Follow-up After 2 cycles of TMZ : – No clinical deterioration; – Brain MRI (11/2017): • “Tumor lesion persists with heterogeneous and irregular left temporal contrast enhancement, with a slight decrease in extent compared to the previous MRI dated 05/26/2017 undertaken before surgery; similar edema and slight improvement of mass effect; without other / new anomalies” • Compared to pos-op brain CT … not brain MRI Questions ? Continue TMZ and repeat MRI in few months? Surgery? Continue treatment with TMZ 200mg/m 2 5/28 Tumor Board ESMO PRECEPTORSHIP PROGRAMME
After a total of 5 adjuvant TMZ cycles: No clinical deterioration – – Brain MRI (01/2018) • “Progression of the left temporal-polar enhancing lesion with mass effect” Brain MRI (11/2017) Questions? Surgery? No surgery and decide new treatment? Tumor Board Surgery (02/2018) Histopathology Brain MRI (01/2018) Fragments of brain tissue with areas of hyalinization, hemosiderosis and deposition of calcium with histiocytic infiltration of the adjacent parenchyma, presenting large and dispersed angular and incipient vascular proliferation. IHQ: IDH-1 negative and low proliferative index (Ki67 < 5%). ESMO PRECEPTORSHIP PROGRAMME
Brain MRI (11/2017) Brain MRI (01/2018) ESMO PRECEPTORSHIP PROGRAMME
Questions? Maintain adjuvant TMZ 200mg/m 2 5/28 schedule? Alternative therapy? • TMZ 50mg/m 2 daily • Bevacizumab + Chemotherapy (Lomustine)? TMZ 50mg/m 2 daily Tumor Board Good adherance and no toxicities After a total of 2 months of TMZ 50mg/m 2 : – No clinical deterioration – Brain MRI (04/2018) • “Marked reduction in tumor size in related to the surgical procedure and global improvement in left temporal lobe signal changes.” ESMO PRECEPTORSHIP PROGRAMME
Last Follow-up in 27/08/2018. – Alive, stable, tolerating steroid tapering, maintaining metronomic TMZ treatment (6 th month). – Brain MRI (07/2018) • “Stability of the residual lesion and no variability in pericavitary hiperintense signal in T2 and flair”. ESMO PRECEPTORSHIP PROGRAMME
Brain MRI (04/2018) Brain MRI (07/2018) ESMO PRECEPTORSHIP PROGRAMME
ESMO Preceptorship Programme Thank you for your attention
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