A 68-Year-Old Man With Metastatic EGFR+ NSCLC - Episode 1

A 68-Year-Old Man With Metastatic EGFR+ NSCLC

John Heymach, MD, PhD: Today I’ll be presenting the case of a 68-year-old man with metastatic EGFR-mutant–positive non–small cell lung cancer.

The patient initially presented with recent onset shortness of breath and unintentional weight loss. He didn’t have any nausea, vomiting, or neurologic symptoms.

His past medical history was relatively unremarkable−hyperlipidemia that was controlled by a statin. He had been a former smoker but quit 10 years ago after a 30-pack year of smoking. And his physical exam was notable only for decreased breath sounds, most notably in the left lower lung field on auscultation. In terms of his clinical workup his labs were unremarkable. Pulmonary function was moderately reduced with an FEV1/FVC of 55%, and the DLCO [diffusing capacity of the lung for carbon monoxide] is 65%.

The chest x-ray showed a left lower lobe mass, and on the CT scan it confirmed the presence of a
3.3-cm pulmonary mass involving the left main bronchus, and ipsilateral and subcarinal lymph nodes. In addition, the CT showed adrenal metastases, and CT-core needle biopsy revealed lung adenocarcinoma. An MRI of the brain was negative.

I think every patient with nonsquamous histology and, in fact, I think every patient with non–small cell lung cancer in general should get molecular profiling. And, in this case, this patient had an exon 19 deletion, and ALK, ROS1, and BRAF were all negative. PD-L1 testing showed a TPS [tumor proportion score] of 20%, the other typical mutation being an exon 21 point mutation, and L858R alteration. And if you have any of those typical mutations, an exon 19 deletion, or an L858R point mutation, then treatments for typical EGFR mutations would be indicated.

So, at the end of the day this was a stage IV non–small cell lung cancer.

In terms of his treatment, he was started on erlotinib at 150 mg daily, and ramucirumab at 10 mg per kilogram IV [intravenous] every 2 weeks. After 3 months, imaging showed a partial response with decreased size of the lung metastases and the adrenal metastasis. And imaging at 6, 12, and 18 months showed continued stable disease.

Transcript edited for clarity.


Case:A 68-Year-Old Man With Metastatic EGFR+ NSCLC

Initial presentation

  • A 68-year-old man presented with recent onset shortness of breath and unintentional weight loss; he denies nausea, vomiting or headaches
  • PMH: Hyperlipidemia controlled on a statin; former smoker, quit 10 years ago with a 30 pack-year history
  • PE: Decreased breath sounds in left lower lung field on auscultation

Clinical workup

  • Labs: WNL
  • PFT: FEV1/FVC 55%; DLCO 65%
  • Chest X-ray showed a left lower lobe soft tissue mass
  • Chest/abdominal/pelvic CT showed a 3.3-cm solid pulmonary mass involving the left main bronchus and ipsilateral subcarinal lymph nodes, and adrenal metastases
  • CT-guided core needle biopsy lung lesion and lymph nodes revealed grade 2 lung adenocarcinoma
  • Contrast‐enhanced MRI of the brain was negative
  • Molecular testing: EGFR exon 19 deletion, ALK-, ROS1-, BRAF-, PD-L1 TPS 20%
  • Stage IVA – T2N2M1a; ECOG PS 1

Treatment

  • Patient was started on erlotinib 150 mg PO qDay + ramucirumab 10 mg/kg IV q2weeks
    • Imaging at 3-month showed partial response with decrease size of lung and adrenal lesions
    • Imaging at 6-, 12- and 18-month follow-up showed stable disease