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, • С hronic 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)

III В STAGE COMPLEX TREATMENT Neoadjuvant chemotherapy Healing Surgery or chemoradiation therapy

Nivolumab 5 mg/kg + paclitaxel - carboplatin : 2 year overall survival 62% Drug treatment • Paclitaxel 200 mg/m2 • Carboplatin AUC 5 1 time in 3 weeks • Nivolumab 5 mg/kg

PET-CT 08.02.18 PET-CT 28.12.17 after 2 cycles Recist 1.1: Tumor 53*43*52 mm SUV Tumor 63*52*68 mm SUV SD (- 25%) 16. 9 12.38

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 of tumor

• Continued treatment according to the chosen scheme (5 and 6 cycle) PET-CT 08.02.18 PET-CT 24.04.18 6 cycles 2 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 PET-CT 24.04.18 PET-CT 20.12.18 PR In primary tumor Segmental atelectasis S1-S2, Tumor 53*43 mm SUV 16. 9 in its structure Tumor 40*29 mm SUV 16. 9

Osteoscintigraphy 25.12.18 PET-CT PET-CT 20.12.18 08.02.18 At the base of the right ileum At the base of the right ileum a litic focus with a soft-tissue a lytic focus with a soft-tissue component 49*49*63 mm component 67*61*99 mm SUV 17.2 SUV 17.2 single focus in the projection Patient refused of the right iliac bone (max. in biopsy the anterior superior spine 65%)

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 • 1 st line treatment: Gefitinib 250 mg since 20.07.2015 6 months therapy 12 months therapy

1 st 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 2 nd generation • Best supportive care •

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

2 nd line treatment Pemetrexed + Carboplatin since 26.04.2017 . Before 2 nd line therapy After 4 cycles

 Observation during 12 months after 2 nd line  PD from 28.08.2018  3 rd 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 4 th chemotherapy (oral etoposide) • Best supportive care •

4 th line treatment with Osimertinib since 27.02.19 Before 4 th line therapy After 2 months Before 4 th line therapy After 2 months

THANK YOU FOR ATTENTION!