Lung Cancer Case presentations Dr. Bassim al Bahrani, FRACP, FRCP - - PowerPoint PPT Presentation

ESMO SUMMIT MIDDLE EAST 2018 Lung Cancer Case presentations

• Dr. Bassim al Bahrani, FRACP, FRCP (GLASG), PhD.

Director, National Oncology Center. Royal Hospital. Oman

6-7 April 2018, Dubai, UAE

CONFLICT OF INTEREST DISCLOSURE

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Advisory Board

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Merck, Roche, Amgen, AstraZeneca , Biocon , BMS, Hospira, Lilly, Sanofi, MSD, Pfizer, Novartis, Bayer

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Honoraria ( Speaker/ Chairperson)

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Amgen, AstraZeneca , Biocon , BMS, GSK, Hospira, Lilly, Novartis, Pfizer, Roche, Sanofi, MSD, Newbridge

LUNG CANCER IN OMAN

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Age standardized incidence rate is 8 /100000 in males and 2.4/100000 in females.

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Only 6 % of lung cancers in Oman are SCLC

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There were 64 new lung cancer cases diagnosed in Oman in 2014

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Despite the presence of different expertise, we lack lung cancer MDT.

CASE 1

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• Mr. R.B

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71 M, Blind for more than 30 years.

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Ex-smoker for 5 years, 20 PY of smoking

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October 2016 : presented with 4 months H/O cough. No hemoptysis

• r weight loss.

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CXR 10/16 : left sided hilar density.

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CT chest 28/11/16 : soft tissue mass related to left main bronchus in addition to mediastinal, left supraclavicular and axillary LNs.

CASE 1

CASE 1

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CT neck 29/11/16: unremarkable.

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CT abdomen 29/11/16 : unremarkable

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Bronchoscopy 22/12/16 : vascular lesion in left main bronchus and scope couldn't’t be passed beyond it. Biopsy tried once, gross oozing happened.

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Cytology from bronchial lavage : Atypical squamous cells.

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HPR : insufficient material.

CASE 1

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OPD 2/1/17 : ECOG 2. Re-biopsy advised. A repeat CT arranged.

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PAN CT 16/1/17 : Growing of the left lung mass causing left lower lobe collapse.

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Tumor Board discussion 23/1/17 : “After revision and discussion between chest physicians and radiologists, the lesion is difficult to

• biopsy. Considering the centrality of the lesion and impending

bronchial blockage, do PET scan, given single fraction radiation, patient not candidate for chemotherapy. He is for BSC “.

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Started on dexamethasone 4 mg BID.

CASE 1

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PET 30/1/17: FDG avid left hilar mass, N3 LNs, liver lesions and bulky left adrenal.

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OPD 1/2/17 : Seen by Med Onc. and referred to Rad Onc.

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OPD 1/2/17 : Agreed to start palliative RT ( 30 Gy in 10 #)

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7-20/2/17 : Received palliative RT. Tolerated well.

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OPD 26/6/17: Stable with no new symptoms.

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Bronchoscopy 5/3/17: mass in left bronchus isn’t seen any more.

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MRI abdomen 4/4/17 : liver lesions are cysts. Adrenal bulky but no define mets.

CASE 1

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May 2017: patient went to Thailand.

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Underwent liquid biopsy : No EGFR mutations or T790M.

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Biopsy from lung : Squamous cell NSCLC

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Molecular biology : ALK negative but ROS1 positive.

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Advised to start Crizotinib.

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Case discussed in Tumor Board 12/7/17. Approved for Crizotinib.

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OPD 9/8/17 : Crizotinib awaited. ECOG 3. Increased SOB. Treated symptomatically

CASE 1

30/8/17: Crizotinib started at 250 mg OD 17/9/17: Seen in OPD. Tolerated Crizotinib well. Dose increased to 250 mg BID OPD 25/10/17 : Low back pain but no numbness or retention. MRI requested. 31/10/17: Started to have numbness and weakness in both legs. Didn’t come to hospital. 6/11/17 : Presented with increased numbness and weakness of both legs. Total Spine MRI 6/11/17 : Cord compression at D7 with multiple bone lesions.

CASE 1

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Spinal Surgeons were reluctant to operates as the patient has stage IV NSCLC and in their opinion his expected survival is less than 6 months.

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Given single fraction of radiation to the area.

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Discharged home on 15/11/17.

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Remained at home and was reluctant to come back to hospital.

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Passed away peacefully 11/1/18

DISCUSSION

CASE 2

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• Mrs. MM

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54 F, never smoked, insignificant PMH.

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July 2016 : presented with 2 months H/O cough. No hemoptysis or weight loss.

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CXR 20/7/16 : right sided mid lung field opacity.

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CT chest 20/07/16 : infiltrative mass right hilum mass infiltrating RML and RLL. Features of lymphangitis carcinomatosis.

CASE 2

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Bronchoscopy 20/7/16 : grossly inflamed RUL bronchus with thick secretions.

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Biopsy 21/7/16 : Adenocarcinoma of the lung.

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CT abdomen 27/7/16 : abdominal LNs

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On 2/8/16 : Right sided VAT lower lobe mass excision and wedge resection.

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HPR : papillary adenocarcinoma with multiple vascular emboli. Positive resection margin.

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Bone scan 15/8/16 : No bone mets.

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OPD 15/8/16 : send EGFR and ALK

CASE 2

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OPD 31/8/16: EGFR non mutated. ALK sent. Patient advised to start palliative chemotherapy with carboplatin and pemetrexed.

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C1 carboplatin and pemetrexed 31/8/16.

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ALK result : ALK translocation positive on 5/10/16.

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Decision to carry on with chemotherapy till Crizotinib is approved.

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Follow up CT post 4 cycles: good response to treatment.

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Received 4 doses of maintenance pemetrexed till 1/2/17.

CASE 2

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PAN CT 14/2/17 : disease progression. Bone mets +.

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OPD 12/3/17 : Crizotinib available. Patient started on 250 mg BID.

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Developed backache .

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MRI: Possible L5 hemangioma. Biopsy taken.

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OPD 12/4/17: Biopsy resulted as metastatic adenocarcinoma from

• lung. Zoledronic acid given. Referred to radiation oncologist.

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Radiation deferred by radiation oncologist as patient was asymptomatic.

CASE 2

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PAN CT 18/9/17 : Resolution of pleural effusion, regression of adrenal and lymph node metastasis. New metastatic nodule in right psoas muscle.

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Received palliative RT L5 spine ( 20 Gy in 5 #) from 8 till 15 /10/2017.

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During radiotherapy, she developed hard subcutaneous lesions overall her body.

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Biopsy showed adenocarcinoma , lung origin.

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OPD 23/10/18 : Considered as progressive disease.

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Asked to continue Crizotinib till ceritinib becomes available.

CASE 2

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Kept under follow up in OPD.

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Became more symptomatic.

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PAN CT 6/12/17 progressive disease. ceritinib wasn’t available yet.

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Decision taken to start patient on docetaxel to control her disease till ceritinib becomes available. Taken C1 on 12/12/17.

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Admitted from 18 till 27th of December for optimization as she presented with painful swallowing, oral thrush , poor oral intake and edema.

CASE 2

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Ceritinib started at 750 mg OD .

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OPD 3/1/18 : patient intolerant to 750 mg dose. Advised to take 450 mg with low fat meal.

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OPD 15/1/18: Subcutaneous nodules regressed. LFTs normal.

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PAN CT 14/2/18 : mixed response. Bone disease progressive with new bone lesions.

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Advised to continue ceritinib.

CASE 2

• Frequent OPD visits with nausea and poor appetite. No vomiting. No

motor deficit.

• Reported facial twitching on 6/3/18. CT head requested but family

preferred to wait.

• Presented with forgetfulness on 26/3/18. CT head : multiple brain mets.

CASE 2

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Patient and family refused whole brain radiation, however, they are willing to try a different treatment.

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Family counselled about alectinib and they agreed to try it.

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Alectinib still awaited.

DISCUSSION

THANKS

Questions?