ONCAlert | Upfront Therapy for mRCC

Case 4: Upfront Osimertinib in Metastatic EGFR+ NSCLC

Targeted Oncology
Published Online:12:37 PM, Wed October 3, 2018


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:
I may have failed to mention that the patient did have a C797S mutation upon resistance that was T790M loss retention to exon 19. That’s important. So, this patient does have a C797S mutation. We’ll talk about how, as medical oncologists, we may manage what we’re finding on these biopsies, in terms of mechanisms of resistance to osimertinib.

But let’s back up a bit and talk about the patient’s treatment, upfront. Do you feel comfortable starting osimertinib in a patient with asymptomatic brain metastases, and not even sending the patient to radiation oncology?

Anne S. Tsao, MD: I absolutely do. She’s getting a little borderline with that 1.2-cm occipital mass. If it’s a large mass, I will usually do SBRT [stereotactic body radiation therapy] and then start osimertinib. I do not do whole-brain radiation therapy in these patients any more, with the availability of osimertinib.

Benjamin P. Levy, MD: Yes. Paul?

Paul K. Paik, MD: I agree. The great thing about this class of drugs and the experience that we’ve seen for CNS [central nervous system]-specific disease, and this also relates to ALK-rearranged lung cancer, is that we’ve seen phenomenal responses in the brain. This really allows us to spare patients from the toxicity of whole-brain radiation therapy. It also allows us to hold off on SRS [stereotactic radiosurgery], for later on, when we may potentially need it.

Benjamin P. Levy, MD: Is there a threshold for which we think, “OK, it’s symptomatic. There is more edema.” Is there a time when we think, “OK, it’s time.”?

Anne S. Tsao, MD: It takes a little time for osimertinib to work. And so, if the tumor is quite sizable, there’s a lot of edema, and the patient is symptomatic, you don’t have a choice. You have to go with local control with SBRT. But, like I said, she’s very safe—1.2 cm being the largest mass. With the EGFR mutants, we tend to see diffuse small, subcentimeter metastases everywhere. I’m very comfortable treating those patients with osimertinib.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:
I may have failed to mention that the patient did have a C797S mutation upon resistance that was T790M loss retention to exon 19. That’s important. So, this patient does have a C797S mutation. We’ll talk about how, as medical oncologists, we may manage what we’re finding on these biopsies, in terms of mechanisms of resistance to osimertinib.

But let’s back up a bit and talk about the patient’s treatment, upfront. Do you feel comfortable starting osimertinib in a patient with asymptomatic brain metastases, and not even sending the patient to radiation oncology?

Anne S. Tsao, MD: I absolutely do. She’s getting a little borderline with that 1.2-cm occipital mass. If it’s a large mass, I will usually do SBRT [stereotactic body radiation therapy] and then start osimertinib. I do not do whole-brain radiation therapy in these patients any more, with the availability of osimertinib.

Benjamin P. Levy, MD: Yes. Paul?

Paul K. Paik, MD: I agree. The great thing about this class of drugs and the experience that we’ve seen for CNS [central nervous system]-specific disease, and this also relates to ALK-rearranged lung cancer, is that we’ve seen phenomenal responses in the brain. This really allows us to spare patients from the toxicity of whole-brain radiation therapy. It also allows us to hold off on SRS [stereotactic radiosurgery], for later on, when we may potentially need it.

Benjamin P. Levy, MD: Is there a threshold for which we think, “OK, it’s symptomatic. There is more edema.” Is there a time when we think, “OK, it’s time.”?

Anne S. Tsao, MD: It takes a little time for osimertinib to work. And so, if the tumor is quite sizable, there’s a lot of edema, and the patient is symptomatic, you don’t have a choice. You have to go with local control with SBRT. But, like I said, she’s very safe—1.2 cm being the largest mass. With the EGFR mutants, we tend to see diffuse small, subcentimeter metastases everywhere. I’m very comfortable treating those patients with osimertinib.

Transcript edited for clarity.
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