A 60-Year Old Man With Untreated Stage IV EGFR-Mutated Non-Small Cell Lung Cancer - Episode 1

A 60-Year-Old Male With Stage IV EGFR+ NSCLC

March 4, 2020

Martin Dietrich, MD, PhD:In today’s session, we’re discussing a 60-year-old Caucasian male with a new diagnosis of non—small cell lung cancer. He presented initially to the emergency department with mild dyspnea and worsening dry cough. He had no significant past medical history, only hypercholesterolemia and hypertension. He had a social history that was interesting because he was a never-smoker, but he had occupational exposure in the shipbuilding industry for 40 years. On physical examination, he was nervous and appeared anxious. He had mild dyspnea with tachypnea, roughly 22 respirations per minute, but otherwise it was an unremarkable exam.

On initial imaging, the patient was found to have a right hilar mass on chest x-ray. This was confirmed on the CT [computed tomography] scan of the chest, abdomen, and pelvis, in which he was found to have a large right hilar mass of 4.6 cm, a subcarinal lymph node conglomerate, and a right hepatic lobe lesion of roughly 2 cm that was deemed to be suspicious. He further underwent a PET [positron emission tomography]/CT scan that was positive for avidity in the liver lesion, and then he underwent biopsy of the right liver lobe lesion and was found to have a pulmonary adenocarcinoma. His molecular markers demonstrated a PD-L1 [programmed death-ligand 1] level of 50% and anEGFRexon 21 L858R substitution, a phenotype that is quite uncommon, a combination of 2 markers. And he was started, based on the FLAURA trial data, on osimertinib, 80 mg daily.

He tolerated the medication well, and he had a very good response for about 19 months, at which point he was found to have a new isolated liver metastasis and underwent further work-up for additional treatment recommendations.

The patient’s diagnosis is a stage IV adenocarcinoma of the lung. It’s the most common subtype of lung cancer histologically,EGFRbeing the only large, targetable—currently at least—subtype, which is a positive finding for the patient. And that translates into an improved prognosis prior to previous treatments, with an expectation of roughly 36 months in median overall survival.

Transcript edited for clarity.


Case: A 60-Year-Old Male with Untreated Stage IVEGFR+NSCLC

Initial presentation

  • A 60-year—old Caucasian man presented with shortness of breath, mild dry cough
  • PMH: hyperlipidemia, hypertension, medically controlled
  • SH: non-smoker, worked 40 years in ship-building industry
  • PE: Lungs clear on auscultation bilaterally; anxious-appearing; acknowledges feeling nervous about his health

Clinical workup

  • Imaging:
    • Chest x-ray showed a right bronchial lung mass
    • Chest/abdomen/pelvic CT scan revealed a 4.6-cm mass on the right main bronchus and ipsilateral subcarinal lymphadenopathy; positive for a single suspicious 2-cm hepatic lesion on the right lobe
    • PET scan showed activity in the right main bronchus and subcarinal nodal area, hepatic lesion was shown to be avid
    • Brain MRI negative for metastases
  • Patient underwent bronchoscopy with TBNA
  • Diagnosis and staging: Biopsy showed high-grade lung adenocarcinoma; T2N2M1b — IVA
  • Molecular testing:EGFRexon 21 L858R, PD-L1 TPS 50%
  • ECOG PS 0

Treatment

  • Patient started on osimertinib 80 mg PO qDay
    • At 3-week follow-up the patient had been tolerating treatment well; continued osimertinib
  • Repeated chest/abdomen/pelvic CT with contrast after every 2 cycles,
    • Partial response after 4 cycles, no disease progression at 3, 6 and 12 months
  • Imaging at 19-month follow-up revealed a new solitary liver lesion