Case Overview: A 57-Year-Old Man With ALK+ mNSCLC

Stephen Liu, MD: This case is about a 57-year-old man with ALK-positive non–small cell lung cancer. He initially presented with fatigue, anorexia, and occasional rib pain. He has an unremarkable past medical history and, on exam, mild right-sided chest tenderness on palpation. His laboratory evaluation is unremarkable, and he’s sent for imaging.

An x-ray shows multiple right upper-lobe lung masses. A CT scan confirms a 7.3-cm mass and 2 others in the right upper lobe, all active on PET [positron emission tomography]. An MRI shows widespread multiple brain metastases.

He is referred for bronchoscopy, and a biopsy of that right upper-lobe lung mass confirms adenocarcinoma. Molecular testing reveals an EML4-ALK fusion. No other actionable targets are identified. PD-L1 expression was 100% by 22C3 DakoLink stain. This is a stage IVA lung adenocarcinoma with an ECOG performance status of 0.

This patient was started on treatment with brigatinib, given at 90 mg a day for 1 week, which was well tolerated. The dosage was then increased to 180 mg per day.

This is unfortunately a fairly typical presentation for patients with ALK-positive non–small cell lung cancer. This is a tumor with a remarkable tropism for CNS [central nervous system] involvement. The incidence of brain metastases is markedly high for this particular subtype. And if brain metastases are not identified in someone with an ALK fusion-positive non–small cell lung cancer, it’s important that an MRI of the brain be done regularly, because the risk of relapse in the brain is quite high.

This particular subtype, fortunately, has a good prognosis with the proper treatment. Prognosis is really guided now by molecular subtype. In an ALK fusion-positive non–small cell lung cancer, the prognosis is quite good. With proper treatment, data suggest that survival extends out many years. In a recent retrospective analysis of data from the University of Colorado by Dr Jose Pacheco in 2019, median survival approached 7 years. There are many reasons to think those numbers could be even greater now.

Transcript edited for clarity.

Case: A 57-Year-Old Man with ALK+ NSCLC

Initial Presentation

• A 57-year-old man presented with fatigue, anorexia and occasional rib pain
• PMH: unremarkable
• PE: mild right-sided chest tenderness on palpation
  
  

Clinical Workup

• Labs: WNL
• Imaging:
  • Chest x-ray showed 3 right upper lobe masses
  • Chest/abdomen/pelvic CT scan confirmed 3 masses (largest 7.3 cm)
  • PET scan showed activity in the right upper lobe masses
  • MRI of the brain showed widespread scatter small lesions; consistent with brain metastases
• Bronchoscopy with transbronchial biopsy of the right upper lobe confirmed lung adenocarcinoma
• Molecular testing: EML4-ALK fusion+, EGFR-, ROS1-, BRAF-, KRAS-, NTRK-, MET-, RET-, PD-L1 100%
• Staging: IVA adenocarcinoma; ECOG PS 0

Treatment

• Patient was started on brigatinib 90 mg qDay for 7 days; well tolerated; dose was increased to 180 mg qDay