Progression or pseudoprogression? Disclousers: no conflict of - - PowerPoint PPT Presentation

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Progression or pseudoprogression?

Brain Tumors – Athens, Greece– 28-29 September 2018

Duarte Machado Clinical Oncology Trainee Institute of Oncology at Lisbon - Portugal

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Disclousers: no conflict of interest.

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Initial Presentation

 Identification

– ♀, 62 years old; – Medical History: Fibromyalgia; – No smoking or alcoholic habits – Medication: Fluoxetine 60 mg od; pregabalin 150 mg + 300 mg;

 Symptoms

– 04/2017: headache in left temporal region and progressive aphasia; – ECOG PS 1;

 Admitted at ER (05/2017)  Brain CT and Brain MRI

– Lesion in the left temporal lobe, well delimited, 5cm antero-posterior dimension, digitiform edema deforming the left temporal sulci and the left posterior ventricle, with midline deviation;

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Brain MRI (05/2017)

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Diagnosis and Staging

 SURGERY (06/2017)

– Left anterior temporal craniotomy with gross total resection

 HISTOLOGY:

– GLIOBASTOMA with micro-calcifications, wild type and Ki67-20%

Test Method Result

GFAP IHC Positive p53 IHC Negative IDH1 NGS Negative IDH2 NGS Negative hTERT NGS Positive: C228T MGMT MLPA Methylated: 57% 1p19q FISH Not deleted EGFR FISH Positive: 94% PTEN FISH Del positive: 68%

Molecular profiling of the tumor

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Treatment and Follow-up

 TUMOR BOARD discussion:

– STUPP Protocol

1) RT plus Temozolomide 75mg/m2 daily

RT 60Gy/30 fr; 2Gy/cycle/day + TMZ  between 07-08 / 2017

2) Temozolomide 200mg/m2 5/28 schedule  start at 09/2017

 No toxicities; Good tolerance;

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Treatment and Follow-up

 After 2 cycles of TMZ:

– No clinical deterioration;

– Brain MRI (11/2017):

• “Tumor lesion persists with heterogeneous and irregular left temporal contrast

enhancement, with a slight decrease in extent compared to the previous MRI dated 05/26/2017 undertaken before surgery; similar edema and slight improvement of mass effect; without other / new anomalies”

• Compared to pos-op brain CT … not brain MRI
• Questions ?

Continue TMZ and repeat MRI in few months?  Surgery?

Continue treatment with TMZ 200mg/m2 5/28

Tumor Board

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 After a total of 5 adjuvant TMZ cycles:

– No clinical deterioration

– Brain MRI (01/2018)

• “Progression of the left temporal-polar enhancing lesion with mass effect”
• Questions?

 Surgery?  No surgery and decide new treatment?

Tumor Board

Surgery (02/2018)

 Fragments

• f

brain tissue with areas

• f

hyalinization, hemosiderosis and deposition

• f

calcium with histiocytic infiltration of the adjacent parenchyma, presenting large and dispersed angular and incipient vascular proliferation.

 IHQ: IDH-1 negative and low proliferative index (Ki67 < 5%).

Histopathology

Brain MRI (01/2018) Brain MRI (11/2017)

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Brain MRI (01/2018) Brain MRI (11/2017)

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 Questions?

 Maintain adjuvant TMZ 200mg/m2 5/28 schedule?  Alternative therapy?

• TMZ 50mg/m2 daily
• Bevacizumab + Chemotherapy (Lomustine)?

 Good adherance and no toxicities

Tumor Board

TMZ 50mg/m2 daily

 After a total of 2 months of TMZ 50mg/m2:

– No clinical deterioration

– Brain MRI (04/2018)

• “Marked reduction in tumor size in related to the surgical procedure and global

improvement in left temporal lobe signal changes.”

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 Last Follow-up in 27/08/2018.

– Alive, stable, tolerating steroid tapering, maintaining metronomic TMZ treatment (6th month). – Brain MRI (07/2018)

• “Stability of the residual lesion and no variability in pericavitary hiperintense

signal in T2 and flair”.

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Brain MRI (04/2018) Brain MRI (07/2018)

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Thank you for your attention