A 64-Year-Old Male with Untreated Stage IV EGFR-Mutated NSCLC - Episode 1

Case Overview: Newly Diagnosed EGFR+ NSCLC

February 20, 2020

Charu Aggarwal, MD, MPH:I have a 64-year-old gentleman who presented to me for further management. The patient came to me with shortness of breath, productive cough, chest pain, fatigue, was having some weight loss and some anorexia. On account of his past medical history, not very significant, only hypertension, very well controlled with medications. He was a never smoker and no illicit drug or substance abuse. On physical exam he appeared tired but really nothing remarkable. On chest auscultation there were decreased breath sounds on the left side.

We proceeded with further imaging. Chest x-ray showed a left lower lobe mass. This was followed by a CT scan that showed a 4.7-cm left lower lobe mass with hilar and mediastinal lymphadenopathy.

A PET scan was subsequently done that showed FDG [fluorodeoxyglucose] avidity in the left lower lobe mass. In the mediastinal and hilar lymph nodes. In addition there was a left adrenal metastasis that was confirmed. MRI of the brain was subsequently done that did not show any gray metastases.

Putting all these pieces together the patient was staged to have a stage IV non­—small cell lung cancer, T3N2M1a with an ECOG [Eastern Cooperative Oncology Group] performance status of 1. Bronchoscopy was performed and transcribed, bronchial biopsy of the left lower lobe showed preliminary adenocarcinoma. However, the tumor tissue was minimal, insufficient for gene sequencing, and subsequently a plasma-based next generation gene sequencing was performed that showed anEGFRexon 19-deletion.

This patient was then started on first-line osimertinib at 80 mg a day. I saw the patient back in about 3 weeks for follow-up and tolerating it beautifully. Shortness of breath had improved, and so we continued therapy. The first CT scan was done the 3-month time point that showed a partial response of therapy, and the patient continued with restaging scans performed every 3 months with follow-ups with us. Scans at 6 and 9 months continued to show our response. Unfortunately at the 18-month time point we saw the presence of a new solitary liver nodule that was highly suspicious for metastatic disease.

The initial impressions of this case are a 64-year-old gentleman with metastatic non­—small cell lung cancer with a driver mutation in theEGFRdomain. Even though stage IV non­—small cell lung cancer is not curable, it is highly treatable, especially in the setting of driver mutations that we can target with very active drugs.

Transcript edited for clarity.


Case: A 64-Year-Old Male with Untreated Stage IVEGFRMutated NSCLC

Initial presentation

  • A 64-year—old man presented with shortness of breath, productive cough, chest pain, fatigue, anorexia and an 8-lb weight loss.
  • PMH: HTN, medically controlled
  • SH: non-smoker, social alcohol use
  • PE: tired-appearing man, decreased breath sounds on auscultation

Clinical workup

  • Imaging:
    • Chest x-ray showed a left lower lobe mass  
    • Chest/abdomen/pelvic CT scan confirmed a node extension, a 4.7-cm left lower lobe mass with mediastinal and hilar lymphadenopathy; left-sided adrenal metastases noted
    • PET scan showed activity in the left lower lobe mass and hilar nodal areas
    • Brain MRI showed no evidence of metastases
  • Staging: T3N3M1a - IVA adenocarcinoma; ECOG PS 1
  • Bronchoscopy with transbronchial biopsy of the left lower lobe was minimal and insufficient, subsequent plasma testing showedEGFRexon 19 deletion mutation

Treatment

  • Patient was started on osimertinib 80 mg PO qDay
    • At 3-week follow-up the patient had been tolerating treatment well; continued on therapy
  • Repeat Imaging at 3 months showed partial response
  • Follow-up at 6 and 9 months showed stable disease
  • At 18-months, CT scan revealed a new solitary liver lesion