Case-Based Peer Perspectives: 57-Year-Old Man With ALK+ Non–Small Cell Lung Cancer - Episode 1

Case Overview: 57-Year-Old Man With ALK+ NSCLC

April 15, 2021
Joshua M. Bauml, MD

Joshua M. Bauml, MD, presents the case of a 57-year-old man with ALK fusion+ non-small-cell lung cancer (NSCLC) and discusses recommended molecular tests to identify patients with molecular driver alterations.

Joshua M. Bauml, MD: Today we’re going to talk about a case of a 57-year-old man who presented with fatigue, anorexia, and rib pain. His past medical history was unremarkable; he was a relatively healthy patient who had laboratory test results that were within normal limits. However, he did have some right-sided chest tenderness on palpation, and a chest x-ray revealed multiple right upper-lobe masses. A CT scan showed 3 masses, with the largest being 6.5 cm, and a PET [positron emission tomography] scan showed they were avid. An MRI of the brain showed multiple metastases. He had a bronchoscopy with endobronchial ultrasound, which showed adenocarcinoma involving mediastinal lymph nodes as well as the masses. He was staged as having stage IV non–small cell lung cancer. He had a good performance status: PS0. He also had a molecular testing profile, which revealed an ALK fusion, and the remainder biomarkers were negative; EGFR, ROS1, BRAF, KRAS, NTRK, MET, RET. And PD-L1 was also negative. This patient was started on brigatinib initially 90 mg daily for 7 days as per the label, and then was dose-escalated to 180 mg daily as per standard of care.

What other kind of test can we do? There are some single gene tests that are utilized, such as PCR [polymerase chain reaction] for mutations and FISH [fluorescence in situ hybridization] for translocations or fusions. My preference is to use next-generation sequencing, utilizing a DNA-based approach for mutations, and an RNA-based approach for translocations and fusions. We’ve found that by incorporating both tests, we are able to identify significantly more patients who have molecular driver alterations.

This transcript was edited for clarity.

A 57-Year-Old Man with ALK+ NSCLC

Initial presentation

  • A 57-year-old man presented with fatigue, anorexia, and occasional rib pain
  • PMH: unremarkable
  • PE: mild right-sided chest tenderness on palpation 

Clinical workup

  • Labs: WNL 
  • Chest x-ray showed multiple right upper lobe masses
  • Chest/abdomen/pelvic CT scan confirmed 3 masses (largest 6.5 cm)
  • PET scan showed activity in the right upper lobe masses
  • MRI of the brain showed multiple scattered lesions, consistent with multifocal brain
  • Bronchoscopy with transbronchial biopsy of the right upper lobe mass confirmed lung adenocarcinoma, invasive mediastinal
  • Stage IV adenocarcinoma; ECOG PS 0
  • Molecular testing: ALK fusion+, EGFR-, ROS1-, BRAF-, KRAS-, NTRK-, MET-, RET-, PD-L1 0% by IHC

Treatment

  • Patient was started on brigatinib 90 mg qDay for 7 days; well tolerated; dose was increased to 180 mg qDay