ESMO Preceptorship Programme

Metastatic NSCLC

Dr Rosdiana Abd Rahim

Clinical Oncology trainee

University Malaya, Malaysia

Adenocarcinoma – Lung – 22/11/2018

ESMO PRECEPTORSHIP PROGRAMME

� No disclosure

ESMO PRECEPTORSHIP PROGRAMME

History & physical examination

� Mrs T

41 year old Lady

No comorbid/non-smoker

� HOPI;– Patient was noted to have high value of CEA & CA125 during her routine checkup for insurance.

– Otherwise, she had back pain on & off, which were resolved by painkillers.

� Family history– Father diagnosed with advanced protate Ca

� Social history- Housewife; Blessed with 2 children.

� Physical examination

- ECOG 0

- Lung; clear

- p/a; soft, non tender

- No bony tenderness

ESMO PRECEPTORSHIP PROGRAMME

Investigation

� CT THORAX /ABDOMEN/ PELVIS 11/10/2013 ; Cavitating nodule in the anterior segment of right upper lobe, 1.5cm. Enlarged lymph nodes in the right paratracheal & right hilar regions, each measures 1.5cm ~ 3.0cm.

� CT-guided Trucut biopsy of right lung & right hilardone on 19/10/2013.

� HPE showed:Well differentiated adenocarcinoma

ESMO PRECEPTORSHIP PROGRAMME

� EGFR mutation test (9/11/13): No mutation detected in exons 18, 19, 20 and 21 of EGFR gene

� PET/CT scan (15/11/13) showed bone metastases at left ischium, both acetabulum, ilium,sacrum, L1 -L5, T6, T10 – T11, C3 & right 3rd rib anteriorly.

� ALK test(14/12/13) showed positive for ALK gene rearrangement.

ESMO PRECEPTORSHIP PROGRAMME

Treatment

� She had chemotherapy Pemetrexed + Oxaliplatin for 6

cycles, followed by maintenance of pemetrexed as well

as monthly IV zolendronic acid.

� Received radiotherapy to L5 & pelvis 30Gy/10Fr for

pain control.

� Patient had completed 22 cycles of IV Pemetrexed

maintenance on 6/10/2015, when she noted worsening

bone pain at pelvis and lumbar region.

� PET/CT scan (21/10/2015): PD in lung & bone

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� Referred to National Cancer Institute, Putrajaya

� Started on T Crizotinib 250mg BD in 15/01/16

– Grade 1 diarrhea

– Tumour marker

Feb

16

March

16

April

16

May

16

June

16

July

16

Augus

t 16

Sept

16

Oct 16

CEA 174.5 83.7 32.7 17.4 10.1 4.6 5.1 4.2 4.8

CA 125 17.8 15 10.6 18.6 15.5 9.8 9.8 8.4 9.4

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� Repeat PET CT 16/1/17

– Current scan shows good response with small volume

residual disease which is sub-centimeter lung nodule at

anterior segment of RUL (SUV max 4.0). Sub-cm pre-

vascular - station 3A- (SUV max 5.0). Sclerotic lesion at

L3 (SUV max 9.0)

ESMO PRECEPTORSHIP PROGRAMME

� In April 17, Presented with worsening headache

� MRI brain(21/4/2017) - Multiple brain metastases (>10 nodules) with mild to moderate perilesionaloedema. Largest enhancing nodule is seen in right occipital lobe, measuring 3.2x2.6x3.1cm

� Underwent Cyberknife radiotherapy in private hospital & was started on T Ceritinib 450mg OD on 6/7/2017 in private hospital

ESMO PRECEPTORSHIP PROGRAMME

Points of discussion

� Is there any evidence to support replacement of

cisplatin with other platinum when combine with

pemetrexed.

� Can we routinely monitor patient on targeted

therapy with tumour marker?

ESMO Preceptorship Programme

Thank you