Roundtable Roundup: Lung Cancer Molecular Testing and ALK-Targeted Treatment

CASE SUMMARY

History of Present Illness

• A 53-year-old Asian American woman presented to her primary care physician with complaints of a persistent, productive cough mixed with scant amounts of blood and associated with chest discomfort upon deep inspiration.
• She denied fever, night sweats, headache, or recent upper respiratory infection.

Medical, Family, and Social History

• The patient had 1 pregnancy and delivered once.
• Negative medical surgical history; no prescription medication use
• Never smoker; employed full-time; 16-year-old son in high school
• Caregiver for elderly mother
• No family history of malignancy; occasional use of alcohol
• COVID-19 vaccine: up to date

Focused Physical Examination

• ECOG performance status: 0
• Neurological: alert and oriented times 3; no signs of neurological compromise; mental status intact
• Pulmonary: diminished breath sounds on auscultation over the posterior, right, upper lung field; scattered crackles and expiratory wheezes
• Remainder of physical examination: unremarkable

Initial Diagnostic Assessment

• Chest x-ray: right, upper lobe opacity and mediastinal enlargement
• Patient is referred to a thoracic oncologist for further evaluation.
• CT of chest, abdomen, and pelvis: multiple, peripheral nodules in right upper lobe, the largest measuring 3.7 cm × 3.4 cm in diameter with ipsilateral mediastinal lymphadenopathy of varying nodal size between 2.2 cm and 2.8 cm.
• No evidence of hepatic involvement
• Staging MRI of brain: discreet intracranial lesions in the parietal (2.6 cm) and frontal (1.2 cm) lobes
• T2aN2M1b (metastatic)

Diagnostic Procedure

• Patient underwent endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration of lung and mediastinal lymph nodes.

Histopathology

• Tumor cell clusters with high nucleus to cytoplasmic ratio; pleomorphic nuclei and granular chromatin; acinar structure with signet-ring cell morphology consistent with adenocarcinoma; short axis diameter of mediastinal node specimen: 2.1 cm
• Immunohistochemistry: TTF-1+, napsin A+; CEA+

CASE UPDATE

• Tissue next-generation sequencing (NGS) molecular profile report: EML4::ALK fusion

• Remainder of the broad-based panel: negative