Non-Small Cell Lung Cancer (April 2019): Multidisciplinary Molecular Tumor Boards

ASCO University
Apr 10, 2019 3:29 PM

Participant Instructions: Welcome to the Multidisiplinary Molecular Oncology Tumor Board Series! This educational initiative is a collaboration between the American Society of Clinical Oncology (ASCO), College of American Pathologists (CAP), and Association for Molecular Pathology (AMP).

A new case will be presented bi-monthly with discussions led by an expert pathologist and medical oncologist. This month’s topic is led by Drs. Lecia Sequist (Hematologist/Oncologist from Massachusetts General Hospital) and Mitra Mehrad (Pathologist from Vanderbilt).

Do you have an interesting case in mind? Submit your hypothetical patient cases for consideration in an upcoming Multidisciplinary Molecular Tumor Board discussion forum.

Participants are encouraged to leave comments and post questions about the case in order to generate a wide discussion among the cancer care community. You can also receive email notifications when new comments are posted by clicking the “Follow this Conversation” option located at the bottom of this page.

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ASCO University
Re: Non-Small Cell Lung Cancer (April 2019): Multidisciplinary Molecular Tumor Boards
Apr 10, 2019 3:32 PM

Patient Case

Mrs. B is a 62-year-old female who smoked ½ pack per day for three years while in college. Her past medical history consists only of back surgery for osteoarthritis. She presented with two-to-three months of steadily worsening non-productive cough and dyspnea on exertion. She has not had hemoptysis or fevers, pain or headaches. She has noticed an unintentional 5lb weight loss.

Her vital signs and physical exam are essentially normal, with the exception of scattered coarse breath sounds bilaterally. Her O2 saturation on room air is 95%.

CT scan of the chest and abdomen revealed bilateral, diffuse, innumerable small lung nodules in a miliary pattern IMAGE . There are no enlarged lymph nodes. There are no abnormalities outside of the chest.

A CT-guided lung biopsy of an area in which lesions are particularly dense reveals invasive adenocarcinoma with PD-L1=0%, but there is insufficient material for sequencing and/or FISH analyses. The patient experienced discomfort during the biopsy and a very small pneumothorax, which resolved spontaneously after four hours of observation. Because of this, she is not enthusiastic to repeat a biopsy for genotyping.


ASCO University
Re: Non-Small Cell Lung Cancer (April 2019): Multidisciplinary Molecular Tumor Boards
Apr 10, 2019 3:41 PM

Discussion Questions

  1. What other options are available for genotyping?
  2. Would you begin therapy without genotyping and, if so, what would you recommend?


Re: Non-Small Cell Lung Cancer (April 2019): Multidisciplinary Molecular Tumor Boards
Apr 12, 2019 12:55 PM

Would discuss with patient, and order liquid biopsy and check for circulating tumor DNA with either comprehensive genomic profiling or targeted gene profiling for EGFR, ALK, ROS, BRAF, HER2 and NTRK, depending on insurance and available vendor. If turn around time for gene profiling will be 1-2 weeks, would hold off on starting  systemic treatment until genomic study results available given there is no impending clinical crisis. If turnaround will be longer than 2 weeks, would give one cycle of a platinum doublet, preferably cisplatin-pemetrexed, pending results of genomic profiling.