Case of a Patient With ALK+ Non–Small Cell Lung Cancer
Lyudmila Bazhenova, MD: We have a 58-year-old woman who presented with cough, fatigue, and anorexia. She has no other medical history. Her physical exam was unremarkable. Her labs were within normal limits. A chest x-ray showed multiple left upper-lobe masses and mediastinal lymphadenopathy. Then she had a chest CT scan that confirmed presence of a left upper-lobe mass measuring 6.2 cm. A PET [positron emission tomography] scan showed the mass to be PET positive, and mediastinal lymph nodes were positive as well.
An MRI of the brain showed widespread scattered small lesions consistent with multifocal brain metastases. She received a bronchoscopy with transbronchial biopsy of the left upper lobe, and that confirms adenocarcinoma. Molecular testing is positive for an ALK fusion.
In summary, we have a patient with stage IVA adenocarcinoma with a performance status of 1. This patient is ALK positive. The patient was started on brigatinib given as 90 mg once a day for 7 days. The dose was well tolerated. Then the dosage was increased to 180 mg once a day.
This patient, unfortunately, has an incurable cancer. The good news is that there is an ALK fusion that we know predicts efficacy to ALK tyrosine kinase inhibitors. Despite the fact that she has a metastatic lung cancer, her expected progression-free survival is long. Current data estimate the progression-free survival to be anywhere from 25 to 30 months with the use of novel ALK tyrosine kinase inhibitors.
Brigatinib is 1 of the approved treatment options for treatment-naïve ALK-positive metastatic lung cancer patients. Brigatinib is CNS [central nervous system] penetrant, and would be appropriate in any ALK-positive patient—with or without CNS metastases. This approval is based on the ALTA-1L trial.
The ALTA-1L trial was a randomized trial that compared first-line therapy with brigatinib vs crizotinib. The study showed an improvement in progression-free survival with brigatinib—approximately 24 months. The progression-free survival was approximately 13 months if the patient did not have brain metastases and was about 5.6 months if the patient had brain metastases.
Transcript edited for clarity.
Case: A 58-Year-Old Woman With ALK+ NSCLC
Initial presentation
- A 58-year-old woman presented with cough, fatigue and anorexia
- PMH: unremarkable
- PE: unremarkable
Clinical Workup
- Labs: WNL
- Imaging:
- Chest x-ray showed multiple left upper lobe mass and mediastinal lymphadenopathy
- Chest/abdomen/pelvic CT scan confirmed left upper lobe mass measuring 6.2 cm
- PET scan showed PET positivity in bilateral LUL mass and mediastinal LN
- MRI of the brain showed widespread scattered small lesions; consistent with multifocal brain metastases
- Bronchoscopy with transbronchial biopsy of the left upper lobe confirmed lung adenocarcinoma
- Molecular testing: ALK fusion+, EGFR-, ROS1-, BRAF-, KRAS-, NTRK-, MET-, RET-
- Staging: IVA adenocarcinoma; ECOG PS 1
Treatment
- Patient was started on brigatinib 90 mg qDay for 7 days; well tolerated; dose was increased to 180 mg qDay
