RTP On Demand — Head & Neck/Thyroid | Research To PracticeCase: A 55-year-old man with metastatic papillary thyroid cancer who experienced a response followed by disease progression on sorafenib
5:43 minutes.
TRANSCRIPTION:
DR COHEN: So this is a gentleman who came to us referred from his endocrinologist, who had been seeing him for, at that point, several years, had followed him from his initial diagnosis and treated him with radioactive iodine. And then the disease got to the point where he clearly was refractory to radioactive iodine. He had actually had 2 full doses of ablative radioactive iodine and his tumor no longer took up radioactive iodine. DR LOVE: And where was the tumor located at that point? DR COHEN: He had extensive lung metastases. And as typical of many patients with papillary thyroid cancer, it wasn’t that he had large masses, but he had so many small nodules, the largest ones about 2 centimeters, but very many of them. And then he had some mediastinal lymphadenopathy as well, mediastinal and hilar lymphadenopathy. DR LOVE: Any symptoms from the disease? DR COHEN: Very minimal. He would occasionally say that he had a cough, but in truth he was doing fairly well. But on scanning it was clear that his disease was progressing. DR LOVE: Now, was this man working? DR COHEN: He was. He was working as a laborer, so fairly intensive, vigorous occupation. And so he’s working. He’s relatively asymptomatic from his disease. I remember him being an avid Chicago Bears fan. He was going to the games. So he was living essentially a full life knowing that he had progressive disease on CT scans. DR LOVE: So what were the options that you thought through at that point? DR COHEN: When we saw him initially we talked about observing him and doing CT scans at shorter intervals to get a better sense of the pace of his disease. And in fact, as we’ll talk about in a second, that’s what we did initially. And then we talked about tyrosine kinase inhibitors and, specifically, VEGF receptor tyrosine kinase inhibitors, and a couple of options there, but primarily sorafenib, because at that point the sorafenib data had matured and clearly this was an effective drug in this disease. DR COHEN: Eventually, we initiated treatment with sorafenib. He did fairly well from a disease perspective. He also did have side effects. But overall, he did actually quite well. DR LOVE: In terms of the disease, did he actually respond? DR COHEN: He did. He had a RECIST-defined response. So his largest lesions shrank considerably. They didn’t disappear. And that’s one thing to keep in mind about the majority of these tyrosine kinase inhibitors is that they don’t induce complete responses. And that’s something that we have to be aware of as a medical community, and the patients need to be aware of as well. We’re not going to make their disease disappear, but we have a very good chance of shrinking it. And that’s exactly what happened with this gentleman. He had a partial response and a partial response that was quite durable. DR LOVE: And how long was he actually on treatment? DR COHEN: He was on treatment for about 18 months. DR LOVE: And then he had progression in the lungs? DR COHEN: And he did. He had progression at the same site of disease, so the same lesions that had shrunk eventually started to grow. And then it was clear that the sorafenib was no longer working. DR LOVE: You mentioned side effects. What exactly happened? DR COHEN: Yes. So he did experience the typical side effects, or some of the typical side effects of the drug. He did have hypertension, and we were able to manage that quite easily. He did have diarrhea, which for him was probably the most concerning side effect, because the diarrhea you get with these agents can sometimes be unpredictable. And, of course, it can interfere with day-to-day activities. And he did have that. Now, he could live with that. He learned to manage that. He modified his diet a little bit. He did have some significant weight loss, which included muscle loss, although he was able to continue working, although probably not as vigorously and he would even admit that. He wasn’t able to lift as much and do as much, but he was able to continue working full time. And one thing he didn’t get was the hand-foot syndrome that sometimes we see with sorafenib, but he didn’t have that at all. DR LOVE: And so what were the alternatives you thought through at that point, now that he’s progressing on sorafenib? DR COHEN: Right. So again, we went back and had a – a conversation that was similar to our initial conversation. He remained relatively asymptomatic from his disease. And at that point he was happy to have a break from therapy. And what we decided to do was actually do that, was give him a break. We discussed other options. We discussed molecular testing to see if other agents would be appropriate. We discussed other tyrosine kinase inhibitors that targeted VEGF receptor. But at the end of the day, he said, “I’ve had the diarrhea for 18 months. I haven’t felt myself. I’ve felt tired. I would like to take a break.” DR LOVE: So in terms of next steps for this man, if he decides or you decide that he wants to be treated, what other TKIs are out there and what about the possibility of getting lenvatinib? Is that something you’d want to see him get? DR COHEN: Absolutely. And at the end of the day, our main therapy option for this gentleman became another VEGF receptor TKI. Lenvatinib is an interesting drug. It’s a drug that inhibits not only VEGF receptor but also FGF receptor, with potent anti-angiogenic activity. |