New Biological Insights and Recent Therapeutic Advances in the Management of Lung Cancer: A Clinical Investigator Think Tank
A 61-year-old man after lobectomy for T2AN0M0, EGFR-mutant adenocarcinoma of the lung
3:35 minutes.
TRANSCRIPTION:
DR LANGER: So this is a 61-year-old gentleman, history of mild COPD, presented with a cough, 40 pack-year smoker, had a fine needle aspirate of a left upper lobe lesion, which was adenocarcinoma. Clinically he was staged as a T2A N0M0. He had a CT and PET, which were otherwise negative. It just lit up at the primary site, no nodes. I didn’t mention in my scenario, but he did have a preop EBUS — we should argue whether it should be EBUS or mediastinoscopy — that was negative. He ultimately underwent a left upper lobectomy and sleeve resection, August of 2014, surg path 3.6-cm, poorly differentiated adenosquamous carcinoma, T2A N1M0. He did have peribronchial nodal involvement. The final path really was predominantly adenocarcinoma. Baseline creat 1.9. EGFR mutant-positive, exon 19. DR LOVE: So Dave, what would you be thinking outside of a trial setting? DR SPIGEL: Oh, gosh. It’s hard. It’s hard. I mean, the answer I’m supposed to give is that erlotinib or gefitinib or afatinib has not been shown to be of definitive value in this setting and that this patient should get cisplatin/vinorelbine in the adjuvant setting. The problem is, I don’t know how long it’s going to take for us to get proof that that’s the right strategy for this patient. DR LOVE: Is cisplatin/vinorelbine what you’d usually use in — DR SPIGEL: Absolutely not. I don’t use that. In a patient like this, actually, I use pem. Carbo/pem. DR LANGER: He had a 1.9. DR SPIGEL: I’m sorry. I missed that point. DR LOVE: So then what would you use? DR SPIGEL: Probably a taxane. DR LOVE: Just in general before we get more in, we’ll talk a little bit about the RADIANT trial, but as long as we brought this thing up, what about selection of chemo in general in a patient with normal renal function in the adjuvant setting, younger patient? Dave? DR CARBONE: I may be old fashioned, but I still use cis/vinorelbine outside of a trial, generally. DR LOVE: Mark? DR KRIS: I use cis/vin. I use the slightly modified — the BR-10, whatever the trial was, 16 weeks. DR LANGER: Pem/cis if they have decent renal function, based — we only have a randomized Phase II trial, but directly compared vinorelbine/cis to pem/cis, the TREAT trial, and at least showed that drug delivery was better, fewer side effects, better quality of life. Of course, we don’t have long-term survival, but I can’t believe it’s going to be worse than vinorelbine/cisplatin. I could be proven wrong, but I doubt that would be the case. Vinorelbine/cisplatin is a tough combination to give even with the modified schedule that was used in the ECOG adjuvant trial with 75 mg/m2 of cisplat every 3 weeks and 25 or 30 mg/m2 days 1 and 8 of vinorelbine. Giving it weekly without interruption is virtually impossible. DR CARBONE: Yes, I don’t do that. DR LOVE: Any thoughts about the TREAT trial that compared vinorelbine to pemetrexed in terms of it looked like a lot fewer patients got through the cis/vinorelbine. DR LANGER: That’s my justification for using pem/cis. DR LOVE: Jeff, what’s your usual adjuvant therapy, adjuvant chemotherapy? DR OXNARD: Our center uses cis/pem for adeno and cis/docetaxel for nonadeno. DR TSAO: Same thing as Dana-Farber. |