ESMO Preceptorship Programme
Metastatic NSCLC
Dr Rosdiana Abd Rahim
Clinical Oncology trainee
University Malaya, Malaysia
Adenocarcinoma – Lung – 22/11/2018
ESMO PRECEPTORSHIP PROGRAMME
� No disclosure
ESMO PRECEPTORSHIP PROGRAMME
History & physical examination
� Mrs T
41 year old Lady
No comorbid/non-smoker
� HOPI;– Patient was noted to have high value of CEA & CA125 during her routine checkup for insurance.
– Otherwise, she had back pain on & off, which were resolved by painkillers.
� Family history– Father diagnosed with advanced protate Ca
� Social history- Housewife; Blessed with 2 children.
� Physical examination
- ECOG 0
- Lung; clear
- p/a; soft, non tender
- No bony tenderness
ESMO PRECEPTORSHIP PROGRAMME
Investigation
� CT THORAX /ABDOMEN/ PELVIS 11/10/2013 ; Cavitating nodule in the anterior segment of right upper lobe, 1.5cm. Enlarged lymph nodes in the right paratracheal & right hilar regions, each measures 1.5cm ~ 3.0cm.
� CT-guided Trucut biopsy of right lung & right hilardone on 19/10/2013.
� HPE showed:Well differentiated adenocarcinoma
ESMO PRECEPTORSHIP PROGRAMME
� EGFR mutation test (9/11/13): No mutation detected in exons 18, 19, 20 and 21 of EGFR gene
� PET/CT scan (15/11/13) showed bone metastases at left ischium, both acetabulum, ilium,sacrum, L1 -L5, T6, T10 – T11, C3 & right 3rd rib anteriorly.
� ALK test(14/12/13) showed positive for ALK gene rearrangement.
ESMO PRECEPTORSHIP PROGRAMME
Treatment
� She had chemotherapy Pemetrexed + Oxaliplatin for 6
cycles, followed by maintenance of pemetrexed as well
as monthly IV zolendronic acid.
� Received radiotherapy to L5 & pelvis 30Gy/10Fr for
pain control.
� Patient had completed 22 cycles of IV Pemetrexed
maintenance on 6/10/2015, when she noted worsening
bone pain at pelvis and lumbar region.
� PET/CT scan (21/10/2015): PD in lung & bone
ESMO PRECEPTORSHIP PROGRAMME
� Referred to National Cancer Institute, Putrajaya
� Started on T Crizotinib 250mg BD in 15/01/16
– Grade 1 diarrhea
– Tumour marker
Feb
16
March
16
April
16
May
16
June
16
July
16
Augus
t 16
Sept
16
Oct 16
CEA 174.5 83.7 32.7 17.4 10.1 4.6 5.1 4.2 4.8
CA 125 17.8 15 10.6 18.6 15.5 9.8 9.8 8.4 9.4
ESMO PRECEPTORSHIP PROGRAMME
� Repeat PET CT 16/1/17
– Current scan shows good response with small volume
residual disease which is sub-centimeter lung nodule at
anterior segment of RUL (SUV max 4.0). Sub-cm pre-
vascular - station 3A- (SUV max 5.0). Sclerotic lesion at
L3 (SUV max 9.0)
ESMO PRECEPTORSHIP PROGRAMME
� In April 17, Presented with worsening headache
� MRI brain(21/4/2017) - Multiple brain metastases (>10 nodules) with mild to moderate perilesionaloedema. Largest enhancing nodule is seen in right occipital lobe, measuring 3.2x2.6x3.1cm
� Underwent Cyberknife radiotherapy in private hospital & was started on T Ceritinib 450mg OD on 6/7/2017 in private hospital
ESMO PRECEPTORSHIP PROGRAMME
Points of discussion
� Is there any evidence to support replacement of
cisplatin with other platinum when combine with
pemetrexed.
� Can we routinely monitor patient on targeted
therapy with tumour marker?
ESMO Preceptorship Programme
Thank you