CNS Surveillance and Long-Term Management in EGFR-Mutant NSCLC With Brain Metastases

Dr. Rodriguez discusses CNS surveillance for Mr. Smith, who has selected subcutaneous (SC) amivantamab plus lazertinib for his 4 brain metastases. His wife asks how often he will need brain MRIs and what to watch for. Dr. Rodriguez contrasts current practice with the pre-targeted-therapy era, when she would have imaged at 6 to 8 weeks primarily to document response and offer radiation if a patient had not responded. Patients with symptomatic brain disease are still appropriate candidates for upfront radiation, as was the case for many patients in MARIPOSA.

Once a patient is on combination therapy, Dr. Rodriguez recommends serial brain MRI every 8 to 12 weeks initially to document the intracranial response. She emphasizes the value of integrating a neuro-oncology or general neurology team into care, particularly for patients on antiseizure medications, to optimize the duration of seizure prophylaxis and select the most appropriate agent given the patient’s comorbidities.

Per the NCCN guideline, if a patient progresses in the CNS while on amivantamab plus lazertinib, options include local radiation or transition to another systemic regimen with intracranial activity. Dr. Rodriguez closes by stressing that CNS monitoring should be proactive, with documented imaging on schedule rather than waiting for symptoms to develop.

In the next episode, “Safety Profiles and Proactive Therapy Management of First-Line Regimens in EGFR-Mutant NSCLC,” Dr. Rodriguez walks through the prophylactic regimens she uses with amivantamab plus lazertinib and compares safety with FLAURA2.