ESMO SUMMIT LATIN AMERICA 2019 Clinical cases presentation Maria - PowerPoint PPT Presentation

ESMO SUMMIT LATIN AMERICA 2019 Clinical cases presentation Maria Ignez Braghiroli

CONFLICT OF INTEREST DISCLOSURE Sub-title Institutional clinical research:  Roche, Astra-Zeneca, MSD, BMS Paid honoraria Roche, MSD, Bayer 

CASE 1 RAMT, 39 yo Male No significant previous medical history or family history 2014 – Change in bowel habits and blood in the stools Colonoscopy: nearly obstructive sigmoid lesion, no further alterations  Path: Invasive moderately differentiated adenocarcinoma (grade 2) in the sigmoid colon.

CASE 1 RAMT, 39 yo Male PET-CT: FDG uptake in the thickened sigmoid segment (2h SUV = 10,7) and in multiple focal liver areas, the majority corresponding to hypoattenuating lesions measuring up to 2.8 cm (highest 2h SUV = 9,7).

CASE 1 RAMT, 39 yo Male No significant previous medical history or family history 2014 – Change in bowel habits and blood in the stools Colonoscopy: nearly obstructive sigmoid lesion, no further alterations  Path: Invasive moderately differentiated adenocarcinoma (grade 2) in the sigmoid colon. 39yo male with sigmoid adenocarcinoma, metastatic to the liver

CASE 1 RAMT, 39 yo Male No previous medical history 2014 – Change in bowel habits and blood in the stools Colonoscopy: nearly obstructive sigmoid lesion, no further alterations  Path: Invasive moderately differentiated adenocarcinoma (grade 2) in the sigmoid colon. Jan/2014 – Laparoscopic sigmoidectomy - pT3 pN2a  Path: Moderately differentiated adenocarcinoma invading the adipose tissue  Metastasis in 6/24 lymph nodes  MSS; RAS wt, BRAF wt

CASE 1 RAMT, 39 yo Male No previous medical history 2014 – Change in bowel habits and blood in the stools Colonoscopy: nearly obstructive sigmoid lesion, no further alterations  Path: Invasive moderately differentiated adenocarcinoma (grade 2) in the sigmoid colon. Jan/2014 – Laparoscopic sigmoidectomy - pT3 pN2a  Path: Moderately differentiated adenocarcinoma invading the adipose tissue  Metastasis in 6/24 lymph nodes  MSS; RAS wt, BRAF wt FOLFIRINOX x 4 cycles

CASE 1 RAMT, 39 yo Male PET-CT: Comparing to previous exam, there has been marked reduction in the size and FDG uptake in the liver lesions. It is not observed the previous uptake in the sigmoid (status post surgical resection)

CASE 1 RAMT, 39 yo Male May/2014 – Segment 2, 3 e 4A resection and resection of segments 6,7 e 4B lesions  Path: Moderately differentiated tubular adenocarcinoma, free margins 39yo male with sigmoid adenocarcinoma, metastatic to the liver. s/p resection of primary tumor s/p FOLFIRINOX x 4 s/p resection of liver lesions

CASE 1 RAMT, 39 yo Male May/2014 – Segment 2, 3 e 4A resection and resection of segments 6,7 e 4B lesions  Path: Moderately differentiated tubular adenocarcinoma, free margins FOLFOX to complete a total of 12 cycles

CASE 1 RAMT, 39 yo Male Feb/2017 – Possible Segment IV recurrence.

CASE 1 RAMT, 39 yo Male Feb/2017 – Possible Segment IV recurrence -> RFA Dec/2018 – Last F/U images performed: NED

CASE 2 M.I.A.S, 54 yo female PMH: Depression Hep A in childhood. Negative HVC and HBV SH: Smokes for the past 10 years, 10-15 cigarrets/d Social alcohol use FH: Brother had metastatic melanoma Father died at 77 with gastric cancer Maternal cousin and paternal cousin had breast cancer at age 38

CASE 2 M.I.A.S, 54 yo female History of altered bowel habits (daily diarrhea) for the previous 4 months. No weight loss Underwent EGD and colonoscopy that showed no alterations MRI showed a pancreatic lesion

CASE 2 M.I.A.S, 54 yo female Dec/2016 EchoEGD: Hypoechoic heterogeneous lesion in the body of the pancreas measuring 3.0x3.0 cm, with irregular and poorly precise limits. The lesion abuts the celiac axis and splenomesenteric junction. No enlarged nodes Normal hepatocholedocus Pancreas tail atrophy. Normal Wirsung.

CASE 2 M.I.A.S, 54 yo female Dec/2016 EchoEGD: Hypoechoic heterogeneous lesion in the body of the pancreas measuring 3.0x3.0 cm, with irregular and poorly precise limits. The lesion abuts the celiac axis and splenomesenteric junction. No enlarged nodes Normal hepatocholedocus Pancreas tail atrophy. Normal Wirsung.  FNA: Suspicious for malignancy

CASE 2 M.I.A.S, 54 yo female

CASE 2 M.I.A.S, 54 yo female

CASE 2 M.I.A.S, 54 yo female

CASE 2 M.I.A.S, 54 yo female Dec/2016 EchoEGD: Hypoechoic heterogeneous lesion in the body of the pancreas measuring 3.0x3.0 cm, with irregular and poorly precise limits. The lesion abuts the celiac axis and splenomesenteric junction. No enlarged nodes Normal hepatocholedocus Pancreas tail atrophy. Normal Wirsung.  FNA: Suspicious for malignancy 54yo female with LA-PDAC

CASE 2 M.I.A.S, 54 yo female From Dec/2016 to May/2017 - FOLFIRINOX x 12 cycles May/2017 CT scan: Infiltrative solid lesion in the neck and body of pancreas measuring 3.0 cm, stable in comparison to the previous scan, determining diffuse tail atrophy. There is wide contact and signs of celiac axis infiltration and well as common hepati, splenic and left gastric arteries, diffusely irregular. It also determines a portal vein deformity

CASE 2 M.I.A.S, 54 yo female From Dec/2016 to May/2017 - FOLFIRINOX x 12 cycles -> Stable disease Jun/2017 to Jul/2017: CRT 25 x 2.3Gy in the tumor + 25 x 1.8Gy regional lymphatics – (planed weekly Gemcitabine 100mg/m2)  Thrombocytopenia post week 1

CASE 2 M.I.A.S, 54 yo female From Dec/2016 to May/2017 - FOLFIRINOX x 12 cycles -> Stable disease Jun/2017 to Jul/2017: CRT 25 x 2.3Gy in the tumor + 25 x 1.8Gy regional lymphatics – (planed weekly Gemcitabine 100mg/m2)  Thrombocytopenia post week 1 Sep/2017 CT scan: Solid and infiltrative lesion in the body of pancreas measuring 3.0 cm, stable in comparison to the previous scan, determining pancreatic duct dilatation and diffuse tail atrophy.

CASE 3 TMMS 34yo female No significant previous medical history No smoking No alcohol use Maternal grandfather has colon cancer at age 89 Maternal grandmother had breast cancer at age 86

CASE 3 TMMS 34yo female 2013 was diagnosed with perforated sigmoid adenocarcinoma metastatic to the liver, lung and ovaries Apr/2013 – underwent resection of sigmoid tumour, partial cystectomy and oophorectomy  Path: Invasive moderately differentiated adenocarcinoma  MSS, KRAS mutated codon 13 Apr/13 to Aug/13 – FOLFIRI + Bev x 10 cycles -> excelent response

CASE 3 TMMS 34yo female

CASE 3 TMMS 34yo female Sep/13 – Partial right hepatectomy + resection of left liver nodules + ileostomy reversal  Path: confirmed Invasive moderately differentiated adenocarcinoma

CASE 3 TMMS 34yo female Sep/13 – Partial right hepatectomy + resection of left liver nodules + ileostomy reversal  Path: confirmed Invasive moderately differentiated adenocarcinoma Oct/13 – Resection of lung nodules (6 lesions in the R, 4 lesions in the L) No measurable disease after surgical procedures

CASE 3 TMMS 34yo female Nov/13 to Dec/13 – FOLFOX x 4 cycles  POD in the peritoneum and liver Re-started on FOLFIRI + Bev x 10 cycles until Jun/14 Feb/14 – Foundation one: HER2 amplification Sep/14 – Re-started on FOLFIRI + Bev due to POD in the peritoneum. Completed 5 cycles and had a good clinical response 6 months later, got symptomatic again

CASE 3 TMMS 34yo female Jul/15 to - May/18 – Trastuzumab + Pertuzumab + Capecitabine – 38 cycles

CASE 3 TMMS 34yo female Jul/15 to - May/18 – Trastuzumab + Pertuzumab + Capecitabine – 38 cycles May/18 – POD in the lungs 

CASE 3 TMMS 34yo female Jul/15 to - May/18 – Trastuzumab + Pertuzumab + Capecitabine – 38 cycles May/18 – POD in the lungs  XELOX+ Trastuzumab with stable disease 

CASE 4 64yo female No significant previous medical history Jun/2017 – Diagnosis of right colon cancer Jun/2017 – Right hemicolectomy  Tubular well differentiated adenocarcinoma infiltrating the serosa  No compromised lymph nodes of a total 22  dMMR (absent MLH1 e PMS2); BRAF inconclusive.

CASE 4 64yo female No significant previous medical history Jun/2017 – Right hemicolectomy – pT3N0  Tubular well differentiated adenocarcinoma infiltrating the serosa  No compromised lymph nodes of a total 22  dMMR (absent MLH1 e PMS2); BRAF inconclusive. Aug/2017 – Diagnosis of metastatic peritoneal disease in the right hypochondria invading the 1st and 3rd duodenal portions and ileum, besides large contact with gallbladder, measuring 11 cm.

CASE 4 64yo female No significant previous medical history Jun/2017 – Right hemicolectomy – pT3N0  Tubular well differentiated adenocarcinoma infiltrating the serosa  No compromised lymph nodes of a total 22  dMMR (absent MLH1 e PMS2); BRAF inconclusive. Aug/2017 – Diagnosis of metastatic peritoneal disease in the right hypochondria invading the 1st and 3rd duodenal portions and ileum, besides large contact with gallbladder, measuring 11 cm.

CASE 2 M.I.A.S, 54 yo female Nov/2017

CASE 4 64yo female Nov/2017 – Started on Pembrolizumab 200mg/dose 64yo female with dMMR right colon cancer with a large peritoneal implant

CASE 2 M.I.A.S, 54 yo female Feb/2019