David Berz, MD, PhD, and Philip Bonomi, MD Discuss Molecular Diagnostics in NSCLC

David Berz, MD, PhD, and Philip Bonomi, MD Discuss Options After an Initial EGFR Exon 19 TKI Therapy

David Berz, MD, PhD, and Philip Bonomi, MD Discuss Use of Liquid Biopsies Over Surgical Biopsies

David Berz, MD, PhD, and Philip Bonomi, MD Discuss Liquid Biopsies Versus Tissue Biopsies

David Berz, MD, PhD, and Philip Bonomi, MD Discuss Benefits of Urine-Based Mutational Screening

Naoko T. is a 74-year-old retired high school teacher originally from Nagoya, Japan. She currently lives in San Diego, California and enjoys tennis and traveling with her husband.

In July of 2013, the patient was diagnosed with NSCLC after presenting to her PCP with dyspnea and intermittent back and chest pain; cardiac workup was negative, and the patient has no history of smoking

Initial CT scan showed a large mass in the right lower lobe and 2 small lesions in the T9 and T10 vertebra, suspicious for metastatic disease

Biopsy and histology of the primary mass and metastatic lesion showed TTF-1+, p40 -, p60 - consistent with bronchogenic adenocarcinoma NSCLC

Mutational analysis on the primary mass showed EGFR exon 19 deletion and no other actionable mutations

She is initiated on systemic therapy with erlotinib for metastatic disease

After 5 cycles, the patient displays good response, with clinical improvement and radiologic improvement in primary and metastatic lesions

In November 2014, after several months of stable disease, the patient returns for follow-up visit with worsening back pain, and her CT scan is consistent with progression of metastatic lesions.

Biopsy and mutational analysis of the thoracic lesion is unsuccessful due to limited DNA content, and the patient is initiated on a second-generation EGFR TKI, with presumed resistance to erlotinib

After 2 cycles, the patient developed severe diarrhea and fatigue requiring hospitalization and was not reinitiated on therapy

A brief trial of systemic chemotherapy was also unsuccessful due to febrile neutropenia requiring hospitalization

At this point, the patient declined further treatment, and by March 2015, she returned with worsening dyspnea and declining performance status

A second biopsy of the thoracic lesion is attempted, and allelotyping shows no actionable mutation; sample is T790M negative

Patient is also screened for circulating tumor DNA in urine, which shows T790M-positive disease

She is initiated on a third-line TKI and shows clinical and radiologic improvement following 3 cycles