ESMO SUMMIT RUSSIA 2019 CLINICAL CASE OF TREATMENT A PATIENT WITH - - PowerPoint PPT Presentation

ESMO SUMMIT RUSSIA 2019

CLINICAL CASE OF TREATMENT A PATIENT WITH NON-SMALL CELL LUNG CANCER

CONFLICT OF INTEREST DISCLOSURE

67 y.o. male ECOG 1 (due to comorbidity) Smoking for 40 years Comorbidty:

• Ischemic heart disease. Atherosclerotic cardiosclerosis.
• Hypertonic disease,

Сhronic obstructive pulmonary disease, mild severity ANAMNESIS :

• October 2017 – cough
• December 2017 – shortness of breath, fever up to 38C
• December 2017 – radiography of the organs of the chest - tumor of the

root of the right lung

PET-CT 28.12.17

Tumor 63*52*68 mm SUV 12.38 Metabolic inactive formations 8*8*4 мм и 21.5*29*34 мм

Pathological report (with) IHC 28.12.17 : lung adenocarcinoma

Diagnosis:

Centrally localized adenocarcinoma of the right lung with metastases in the intrathoracic lymph nodes cT3N3M0 (stage IIIB)

IIIВ STAGE COMPLEX TREATMENT

Neoadjuvant chemotherapy

• r

chemoradiation therapy Surgery

Healing

Drug treatment

• Paclitaxel 200 mg/m2
• Carboplatin AUC 5

1 time in 3 weeks

• Nivolumab 5 mg/kg

Nivolumab 5 mg/kg + paclitaxel - carboplatin : 2 year overall survival 62%

Recist 1.1: SD (- 25%)

PET-CT 28.12.17 PET-CT 08.02.18

Tumor 63*52*68 mm SUV 12.38 Tumor 53*43*52 mm SUV 16.9

after 2 cycles

Further treatment tactics?

• Continuation of therapy according to the chosen scheme.

(the result is obtained, it is necessary to continue further)

• Switching to chemoradiotherapy

(increased toxicity, better objective response)

• Surgery

(possibility of radical treatment at this stage)

• Continued treatment according to the chosen

scheme (3 and 4 cycle)

• After 4 cycles - surgical treatment?
• Endobronchial ultrasonography (EBUS) - for

staging purposes

• EBUS done on the 21.03.18: biopsy of enlarged

mediastinal l / n.

• Transbronchial biopsy - l / n tissue with no signs
• f tumor

• Continued treatment according to the chosen scheme (5 and 6 cycle)

PET-CT 08.02.18

2 cycles

PET-CT 24.04.18

6 cycles

PD ?? ? in S5 of the right lung lesion 20 * 16 * 14 mm SUV 8.5

03.05.18 – the biopsy was done of the lesion S5 right lung Histological examination : lung tissue columns with lymphoid infiltration, no tumor cells were detected.

• After 6 cycles - surgical treatment?
• Bronchoplastic sleeve lobectomy or pulmonectomy
• Respiratory function test: : Total perfusion ratio in lungs –> right - 50,7% > Left-

49,3%

• Patient apprehension (impossibility of pulmonectomy due to low functional status)
• 2 administrations of maintenance therapy Nivolumab 5 mg / kg 1 time in 3 weeks

• From 10.06.18g receives a course of proton radiation therapy

for the primary tumor and regional lymph nodes

Molecular genetic study Genomic sequencing TMB – 11 mut/Mbp

Further treatment tactics?

• To Continue maintenance therapy with Nivolumab
• Transition to ALK inhibitors – Crisotinib
• Observation

CONTINUED MAINTENANCE THERAPY WITH NIVOLUMAB №12 TILL 20.12.18

Tumor 53*43 mm SUV 16.9 Segmental atelectasis S1-S2, in its structure Tumor 40*29 mm SUV 16.9

PET-CT 20.12.18 PET-CT 24.04.18

PR In primary tumor

PET-CT 08.02.18

At the base of the right ileum a lytic focus with a soft-tissue component 49*49*63 mm SUV 17.2 single focus in the projection

• f the right iliac bone (max. in

the anterior superior spine 65%)

Osteoscintigraphy 25.12.18 PET-CT 20.12.18

At the base of the right ileum a litic focus with a soft-tissue component 67*61*99 mm SUV 17.2

Patient refused biopsy



Continued maintenance therapy with Nivolumab + bisphosphonate



03.-04.19 radiotherapy on the right iliac region because of the increase of pain syndrome.



03.05.19y. Appearance of solitary brain metastatic lesion



Radiosurgery procedure on the “Ciber knife” 07.05.19



22.05.19 – Nivolumab № 20

Further treatment tactics?

THANK YOU FOR ATTENTION!

ESMO SUMMIT RUSSIA 2019

CLINICAL CASE OF TREATMENT A PATIENT WITH NON-SMALL CELL LUNG CANCER

• Female, 70 y.o.
• Never smoked
• 01.07.2015:Thoracotomy on the left, marginal resection of the lung,

pleural biopsy, pericardial fenestration

• Pathological report (with IHC) 04.07.15 : lung adenocarcinoma
• Molecular tests: EGFR ex19del
• Diagnosis:

Adenocarcinoma of the upper lobe of the left lung (c) T2N2M1, IVA. Metastases in the lungs, pleura, mediastinal lymph nodes. Left-sided hydrothorax.

Drug treatment

• 1st line treatment: Gefitinib 250 mg since 20.07.2015

6 months therapy 12 months therapy

1st line treatment

12 months therapy PD after 22 months therapy 01.04.17

Further treatment ?

• Rebiopsy with assessment of T790M
• Switching to chemotherapy
• Switching to ITK 2nd generation
• Best supportive care

 Rebiopsy. Tracheobronchoskopy 10.04.17  Molecular test 17.04.2017: EGFR, Т790М - negative

2nd line treatment Pemetrexed + Carboplatin since 26.04.2017.

Before 2nd line therapy After 4 cycles

 Observation during 12 months after 2nd line  PD from 28.08.2018  3rd line treatment: TC since 27.09.2019-20.12.2018  In 3 months (16.02.19) a sharp deterioration:

• growing weakness
• shortness of breath,
• disorientation
• ECOG 3

 CT from 19.02.2019: PD( increase of the primary tumor,

metastases in the lungs, bones, pleura.)

 Liquid biopsy 24.02.2019: EGFR T790M (+)

Further treatment ?

• Osimertinib
• Switching to 4th chemotherapy (oral etoposide)
• Best supportive care

4th line treatment with Osimertinib since 27.02.19

Before 4th line therapy After 2 months Before 4th line therapy After 2 months

THANK YOU FOR ATTENTION!