Tumor Board Discussions: Case 1 David S. Ettinger, MD The Alex Grass Professor of Oncology Johns Hopkins University School of Medicine Baltimore, Maryland Case #1 50-year-old Asian female, never smoker presents with dyspnea on exertion. She is noted to have a large left pleural effusion on chest x-ray. She underwent a thoracentesis: Cytology was positive for adenocarcinoma, TTF1 +, CK7 +, CK20 -. Tissue is insufficient to test for EGFR mutation status.
Case #1 (Cont d) She undergoes talc pleurodesis with resolution of her SOB CT of chest, abdomen, and pelvis, are negative for metastases Brain MRI: negative No comorbidities except hypertension ECOG PS = 0 1 CT = computed tomography; ECOG PS = Eastern Cooperative Oncology Group Performance Status; MRI = magnetic resonance imaging; SOB = shortness of breath. Clinical Decision #1 What therapy would you recommend? A. Pemetrexed/Carboplatin q 3 wks B. Gemcitabine/Carboplatin q 3 wks C. Paclitaxel/Carboplatin q 3 wks D. Platinum doublet with Bevacizumab E. Erlotinib Case #1 (Cont d) Patient was started on pemetrexed and carboplatin. After 4 cycles of chemotherapy, patient had SD. SD = stable disease.
Clinical Decision #2 What would your next step be? A. Continue pemetrexed alone B. Treat with erlotinib C. Switch chemotherapy to docetaxel Case #1 (Cont d) Patient had been doing well on the maintenance pemetrexed for 6 months when she complained to her internist of left flank pain for approximately 2 weeks as well as a decrease in her appetite. An abdominal CT scan demonstrated a 3 cm adrenal mass which was PET +. PET = positron emission tomography. Clinical Decision #3 What will you do? A. Switch chemotherapy to docetaxel B. Treat with erlotinib C. Biopsy the adrenal gland and send tissue for molecular studies (KRAS, EGFR, EML4- ALK)
Case #1 (Cont d) Patient s adrenal gland biopsy demonstrates EGFR Exon 19 deletion. Clinical Decision #4 What will you do? A. Treat with erlotinib B. Treat with erlotinib and bevacizumab C. Start docetaxel
Tumor Board Discussions: Case 2 David S. Ettinger, MD The Alex Grass Professor of Oncology Johns Hopkins University School of Medicine Baltimore, Maryland Case #2 69-year-old Caucasian male with a 50-pack-peryear smoking history presented with a 4-month productive cough, dyspnea on exertion, and no hemoptysis. A CT scan showed a 3.5 cm left lower lobe (LLL) mass with enlarged multiple mediastinal and left hilar lymphadenopathy. A transbronchial biopsy of an N 2 lymph node revealed squamous cell carcinoma. CT = computed tomography.
Case #2 (Cont d) A PET scan showed increased FDG activity in the LLL mass, mediastinal and left hilar lymph nodes as well as sites in the left ischium, femur, and T 4 spine consistent with malignancy. An MRI of the ischium demonstrated a 2 cm lytic bone lesion. A biopsy of the lesion revealed squamous cell carcinoma. FDG = 2-deoxy-2-[F-18]fluoro-D-glucose; PET = positron emission tomography. Clinical Decision #1 What therapy would you not recommend? A. Pemetrexed/cisplatin every 3 weeks B. Docetaxel/cisplatin every 3 weeks C. Gemcitabine/carboplatin D. Paclitaxel/carboplatin every 3 weeks E. Cetuximab/vinorelbine/cisplatin Case #2 (Cont d) The patient received gemcitabine 1000 mg/m 2 IV d1, 8 and carboplatin AUC-5 q 3 weeks. He tolerated therapy well with only mild nausea (no vomiting), minimal fatigue, and mild neutropenia. A chest CT scan after 2 cycles of chemotherapy revealed a decrease in the LLL mass to 2-cm with a decrease in the size of the mediastinal and hilar lymphadenopathy. AUC = area under the curve.
Case #2 (Cont d) He continued with an additional 2 cycles of chemotherapy without significant toxicities. After the fourth cycle, a repeat CT scan of the chest demonstrated an additional decrease in the primary tumor as well as the regional lymph node disease. Clinical Decision #2 Which course of action would you now recommend? A. Two additional cycles of gemcitabine/ carboplatin B. Discontinue therapy and observe for disease progression C. Maintenance therapy Case #2 (Cont d) He received an additional 2 cycles of chemotherapy (Total: 6 cycles). Restaging with scans demonstrate stable disease. The patient has tolerated the therapy and has a PS = 1. PS = performance status.
Clinical Decision #3 What would you do next? A. Continue maintenance gemcitabine B. Switch chemotherapy to pemetrexed C. Switch to erlotinib D. Observe patient only