63-Year-Old Female with Vision Disturbances and Headaches
Evelyn, who is 63, presents to her primary care physician, complaining of headaches, visual disturbances, and fatigue. Her medical history includes hypertension and hyperlipidemia, both under control with medication. She is a former smoker with a 40-pack year history.
Her physical exam is relatively unremarkable, except for decreased breath sounds at the right lower lung base. Her blood chemistries and CBC are within normal range.
Brain imaging reveals a 1.1 cm parietal mass. CT chest, abdomen, and pelvis demonstrates a 3.3 cm mass in her right lower lobe and three small masses in her liver. A CT-guided biopsy of the lung nodule shows a grade 2 adenocarcinoma of the acinar subtype. Her ECOG score is 1.
Her 22C3 test shows that she has a 70% expression of PD-L1. Although the patient is anxious to begin treatment, her treatment team insists on molecular testing before developing a treatment plan. Results reveal the KRAS G12C mutation.
Knowing the presence of the KRAS mutation, would you initiate immunotherapy?
Would you consider recommending Evelyn enroll in a clinical trial investigating KRAS G12C inhibitors?
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Muhibur RahmanMay 15, 2021The patient has a small solitary met in the brain that needs resection. Recently approved Cemiplimab would be one of the choice and of course Clinical trials. RA inhibitor may also be considered.
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Herman TongMay 13, 2021I would trial a clinical trial given her 70% expression of PD-L1
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Robert Krochalis-SolianiMay 10, 2021Is the gene mutation specific to risks from smoking/nicotine use/second-hand exposures, or present in non-smoking, low risk of exposure populations as well?
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Kumar AbhishekMay 09, 2021I would treat her with IO + chemotherapy in absence of FDA approved KRAS inhibitors on the market. There is no evidence to say that IO agents don't work in KRAS mutated lung cancer. If I do have RA inhibitor on trial or access to a trial, I would be happy to refer her in second line.
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Sherif BadawyMay 09, 2021I think pembroluzumab might be the best next step for treatment options, unless there is a clinical trial op and patient is willing to participate in it.
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Vijay RaoMay 09, 2021If an appropriate clinical trial is available then I would enroll her in it. She appears to have a small solitary met in the brain and is symptomatic from it and needs to be addressed with either resection or SRS. Given that there is 70% PD-L1 expression, single agent pembroluzumab or the recently approved Cemiplimab are my choices.