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Lung Cancer Case Studies

David Spigel, MD: Use of TKI Therapy in Patients with EGRF Exon 21 Substitutions (L858R)

David Spigel, MD
Published Online:Oct 22, 2015
Sarah W is a 58-year old physical therapist from Brooklyn, New York. After showing chest X-ray abnormalities on a routine visit to her PCP, she is referred for further evaluation.

Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 2

Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 2
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 2
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 2
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1
Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 2

 

What efficacy data support the use of this TKI therapy in a patient such as Sarah with EGFR exon 21 substitutions (L858R)?

 

To borrow from the literature at large, we know that in both 19 and L858R mutations  there’s efficacy for all of the TKIs compared to chemotherapy in terms of PFS. In the L858R population with afatinib, this efficacy versus chemotherapy, particularly the pemetrexed chemotherapy, the question is whether or not we see a survival advantage in favor of afatinib versus chemotherapy. So that argument kind of is out the window, but we do have efficacy data that the drug is active and effective in the overall intent-to-treat population.

CASE 2: mNSCLC

Sarah W. is a 58-year old physical therapist from Brooklyn, New York who is also active in a community theater group; her prior medical history is notable for mild GERD controlled with diet and proton pump inhibitor, and hyperlipidemia, controlled with atorvastatin.

She has a 12-pack-year smoking history but quit about 20 years ago after developing a severe respiratory infection. After showing chest x-ray abnormalities on a routine visit to her PCP, she is referred for further evaluation.

  • Her initial CT scan shows multiple bilateral lung nodules, a large 8-cm mass in the left upper lobe (LUL), suspicious for malignant pleural effusion, and several hepatic nodules
  • Transbronchial biopsy of the LUL mass shows adenocarcinoma T3 (based on size); biopsy of the hepatic nodules was consistent with metastatic disease, and she was deemed unresectable on surgical consult
  • Mutational status was reported as EGFR exon 21 (L858R) substitution; no other actionable mutations detected
  • At the time of diagnosis the patients performance status is 0

Sarah wishes to continue with her normal work schedule and rehearsals for an upcoming community theater production. Her oncologist initiates her on afatinib 40 mg/day.

  • At her 2-week follow-up, she shows symptoms of increasing diarrhea (≥6 stools/day), which has not improved with antidiarrheals, and a papular rash on her upper arms
  • Rash is not very itchy or bothersome, however, diarrhea interferes with both her work schedule and rehearsals
  • Diet modifications and loperamide are recommended for diarrhea, and topical corticosteroids for her rash; she continues therapy at 40 mg/day
  • At 3 months, while other symptoms have begun to improve, she shows symptoms of gingival stomatitis, and the nursing team recommends diet modifications and a mouth rinse as needed; she continues therapy at 40 mg/day

At her next follow-up, CT scan shows stable disease, with shrinkage in the primary mass and no new hepatic nodules.

  • Her diarrhea has improved to grade 1 with loperamide and diet; stomatitis and rash have been effectively managed with prior recommendations
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