Treatment Regimen for Patients With ALK+ Non-Small Cell Lung Cancer - Episode 1

Case Presentation: Patient With ALK+ NSCLC

Jonathan W. Riess, MD, MS:This is a 69-year-old woman who presented with dyspnea, cough, and fatigue in March of 2017. She was evaluated with a chest X-ray that showed a lung mass. Biopsy showed non—small cell lung cancer, adenocarcinoma histology. The patient had an MRI that was negative for intracranial metastatic disease. She had molecular testing that was positive, through a next-generation sequencing panel, for anALKrearrangement but negative forEGFR,ROS1,BRAF,and other molecular aberrations. She was started on crizotinib, with initial response to treatment at 3 months and at 6 months.

So, in January of 2018, the patient developed worsened cough, dyspnea, and bone lesions. Imaging studies showed worsening lymph nodes and bone lesions. MRI of the brain showed disseminated brain metastases, and crizotinib was discontinued. The patient was started on brigatinib.

Transcript edited for clarity.

CASE:ALK+ Non—Small Cell Lung Cancer

March 2017

  • A 69-year-old female never-smoker presented with dyspnea, cough and fatigue
  • PMH: hypertension managed on losartan 100 mg
  • Chest X-ray showed multiple bilateral lung nodules
  • Brain MRI, negative for intracranial metastases
  • Bronchoscopy was performed with a fine needle aspirate biopsy
    • Pathology revealed adenocarcinoma, consistent with a lung primary tumor
    • Molecular testing:
      • NGS: positive for ALK gene rearrangement
      • NGS: negative forEGFR, ROS1, RET, BRAF, KRAS
      • IHC: PD-L1 expression in 0% of cells
  • The patient was started on therapy with crizotinib
  • Follow-up imaging at 3 and 6 months showed marked regression of the lung mass, nodal spread, and bone lesions

January 2018

  • After 10 months on crizotinib, the patient reported worsening fatigue, back pain, and dyspnea
  • CT showed increased size of the pulmonary masses and bone lesions
  • Brain MRI showed disseminated small lesions
  • Crizotinib was discontinued and the patient was started on brigatinib