- Kevin Punie (Leuven, Belgium)
- Kok Haw Jonathan Lim (Manchester, United Kingdom)
YO1 - Early Stage Breast Cancer- A Case Report (ID 338)
- Uthaman Jithin (Chongqing, China)
-Premenopausal Female 44 y.o
-Abnormal mammogram 2 months ago
-Core biopsy ductal carcinoma
-Mastectomy and 1.4 cm tumor recovered
-T3N0M0 (stage IIB)
-ER/PR+ & HER3+
-Schedule to receive radiation
-Needs adjuvant pharmacological therapy
►Medical History- Breast carcinoma – newly diagnosed
►Family and Social History
-Family history – Mother: ovarian cancer diagnosed in 40s Maternal aunt: breast cancer diagnosed in 40s
► Social history – Single mother with twins (12 years old) - Smoked 1/2 pack per day for 6-7 years
– Quit 3 years ago
– Rare alcohol use
►Patient risk factors – Female, family history, age, Smoking, childbirth after age 30
- No visual disturbances
- Denies headaches
- No weight loss and no appetite changes - Scars on breasts from mastectomy
- No palpable lymph node
-Thyroid normal size
►Medications and allergies
-Acetaminophen- joint pain
Allergies- Morphine Rash
►Diagnosis- Stage IIB – early-stage breast cancer - T3N0M0
-AC (doxorubicin + cyclophosphamide) ± pertuzumab THEN Paclitaxel WITH trastuzumab
-Premenopausal at diagnosis – Tamoxifen 5 years ± ovarian suppression OR – Ablation – Further treatment based on menopausal status
-Postmenopausal at diagnosis – Aromatase inhibitor for 2 to 3 or 5 years OR – Tamoxifen for 2 to 3 years
- Paclitaxel 80mg/m2
- 150.4 mg IV infusion once a week x 12 doses over 1 hour
-Week 1 – loading dose of 4 mg/kg (312 mg) IV infusion over 90 min
-Next 11 weeks – 2 mg/kg (156 mg) IV infusion over 30 min weekly
-At week 13 to week 52
-Trastuzumab 6 mg/kg (468 mg) IV infusion over 30 min Q 3 weeks
-At week 13
-Tamoxifen 20 mg PO QD x 5 years
-Reevaluate at 5 years - based on menopausal status
YO3 - Breast Cancer Presenting as Superior Vena Cava Syndrome: the Crucial Role of Emergent Chemotherapy (ID 732)
- Rogelio N. Velasco (Manila, Philippines)
Superior vena cava (SVC) syndrome, an oncologic emergency, necessitates prompt and aggressive treatment. In oncology, the most common cause is lung cancer followed by lymphoma and solid organ metastasis. A 56-year-old female presented to the oncology clinic with a one-month history of facial edema and dyspnea. Three years ago, she was diagnosed with hormone receptor(HR)-positive and human epidermal growth factor 2(HER2)-negative stage IIIB ductal carcinoma. She underwent radical mastectomy of the right breast and adjuvant chemotherapy (doxorubicin, cyclophosphamide and docetaxel), radiation and subsequent endocrine therapy with letrozole. Two years into follow-up, an immovable solid mass measuring 3 cm x 3 cm x 2 cm was noted at the right clavicular area with no other palpable breast mases. She gradually presented with dyspnea, facial swelling and right upper extremity edema. Initial chest X-ray showed consolidation versus mass at the right upper lung field. Computed tomographic scan done showed a soft tissue mass in the right superior mediastinum measuring 4.9 x 4.1 x 4.8 cm intimately adjacent and extending into the SVC with secondary luminal narrowing. Bone scan done showed an osteoblastic focus at the sternomanubrium area consistent with possible metastasis. A 2D-echocardiogram done to rule out cardiac involvement of the heart was unremarkable. Sputum acid-fast bacillus smear as well as lactate dehydrogenase and alpha fetoprotein were likewise negative.
Patient was then admitted for progressive dyspnea, facial and right upper extremity edema. A total of 232 mL of pleural effusion was drained and biopsy of the clavicular mass was performed showing expression of GATA3, mammoglobin, as well as estrogen and progesterone receptors consistent with ductal carcinoma. HER2 was also negatively expressed, consistent with the initial tumor profile. The managing team decided to proceed with emergent chemotherapy and managed the case as SVC syndrome. After 8 cycles of paclitaxel and carboplatin, a dramatic improvement in the symptoms was noted. Patient is currently ongoing hormonal treatment with tamoxifen and exhibits good quality of life with no disease recurrence.
YO4 - Losing One’s Voice: Vocal Cord Paralysis and Receptor Conversion in Metastatic Breast Cancer (ID 556)
- Harold Nathan Tan (Manila, Philippines)
Receptor conversion between primary and metastatic breast cancer occurs in up to 32% of patients, resulting in ineffective therapy in the absence of corresponding biomarkers. Prompt reassessment of these biomarkers at the time of disease progression can help optimize treatment decisions.
We report the case of a 59-year old Filipino woman who had a 2-month history of hoarseness. Seven years ago, she was diagnosed with stage 1B moderately differentiated invasive ductal carcinoma of the left breast, ER/PR-positive and negative for HER2 overexpression. She underwent left breast lumpectomy with axillary lymph node dissection. Oncotype DX and BRCA1/BRCA2 testing were not performed. She was treated with adjuvant chemotherapy with six cycles of doxorubicin, cyclophosphamide and docetaxel. This was followed by adjuvant radiation therapy and institution of daily letrozole. Physical examination revealed no palpable breast masses nor lymph nodes.
Laryngoscopy demonstrated persistent glottic gap during phonation with an immobile right vocal fold at the paramedian position, consistent with right vocal cord paralysis.
Whole body PET-CT scan revealed hypermetabolic right level IV cervical lymph node measuring 0.6 cm and hypermetabolic right paraaortic and right paratracheal lymph nodes, measuring 0.8 and 1.1 cm respectively, worrisome for metastasis. No other hypermetabolic foci were seen.
Excision biopsy of the right cervical lymph node confirmed tumor cells consistent with metastatic carcinoma. IHC showed tumor cells positive for GATA3 and mammaglobin, supporting the diagnosis of a breast primary. Breast panel of the excised cervical lymph node revealed ER-positive, PR-negative, and HER2-positive. Subsequent metastatic workup was unremarkable.
Given the involvement of non-contiguous lymph nodes, she was treated as a case of ER-positive, HER2-positive metastatic breast cancer. She was not amenable to cytotoxic chemotherapy and preferred treatment with the least possible side effects, thus targeted therapy with ado-trastuzumab emtansine (TDM-1) every 3 weeks was instituted. After her third session of TDM-1, interval PET-CT scan showed 27% regression in the size of the right paratracheal lymph node.
Live Q&A and live discussion (ID 1311)
- Kevin Punie (Leuven, Belgium)
YO14 - Exceptional Response to Pembrolizumab in Metastatic Prostate Cancer with High Tumour Mutation Burden and Multiple Somatic Mutations (ID 382)
- Tsz Him So (Hong Kong, Hong Kong PRC)
This is a 70 year old newly diagnosed metastatic prostate cancer patient. He has past history of minor stroke in which he fully recovered. On family history, his sister had history of DCIS breast in her 50s
He presented with nocturia and bone pain in November 2018. His PSA was 29 (12/2018). TRUS biopsy of prostate confirmed adenocarcinoma GS (5+4), 11/12 core +ve in 12/2018. Staging PSMA PET/CT scan was performed in 1/2019 showing diffuse prostate uptake and pelvic and para-aortic lymph node metastasis. No bone metastasis was found.
He was given upfront abiraterone + LHRHa afterwards with initially response from January to November 2019. His PSA rebounded afterwards. Biochemical-free progression free survival was 10 months only (1-11/2019). Reassessment PETCT in 12/2019 confirmed progression of pelvic lymph nodes. He lost more than 20 kg of weight within two months and developed severe right leg lymphoedema and haematuria.
Next generation sequencing (NGS) on his primary tumour tissue was arranged. While waiting the NGS result, one cycle of docetaxel was given but there was no PSA response and patient tolerated poorly. Bone scan in 2/2020 found pelvic bone metastases. NGS result showed MSI-high and high tumour mutation burden (73 Muts/Mb). Additionally, multiple mutations were detected including APC, ATM, MSH3, MSH6, PMS2, PTCH1 and PTEN mutations.
In view of MSI-H and TMB-high, he was prescribed pembrolizumab 200mg every 3 weeks (fixed dose). His PSA was 28 (2/2020) before pembrolizumab. After 3 cycles of pembrolizumab, his PSA dropped to below <0.1 (5/2020) and his lymphoedema and haematuria resolved completely. Reassessment PSMA PETCT (6/2020) showed almost complete metabolic and radiological response except mild diffuse low grade activity in shrunken-size prostate. Consolidation radiotherapy to prostate was given (55Gy/20Fr)
Further germ line testing showed no evidence of Lynch syndrome (no MLH1, MSH2, MSH6, PMS2 mutations). In addition, no germ line mutations (including APC, ATM, BRCA1, BRCA2, CDH1, CDK4, CDKN2A, CHEK2) were found.
YO17 - Acute interstitial nephritis (AIN) in a patient with Tumour mutation burden (TMB)-high Cancer of Unknown Primary (CUP) on combination immune checkpoint blockade (ICB) (ID 892)
- Joycelyn J. Lee (Singapore, Singapore)
Our patient first presented in 2017 with multiple sites of lymphadenopathy (right submandibular, right cervical, pericardiac, periportal, paraaortic) and small volume liver lesions. Biopsy showed adenocarcinoma, CK7+ (diffuse) CK20+ (patchy), TTF-1 -. Pan-endoscopies were negative. Impression was that of CUP, possibly head and neck or pancreatobiliary in origin. He had a partial response (PR) after #6 of Paclitaxel and Carboplatin but developed paraesthesia. After a break of 4m, he developed a new liver lesion. He progressed after #3 of TS-1, and switched to Gemcitabine on which he had PR at 4m before disease progression (PD) at 6m, then PD after 2m of Capecitabine and Irinotecan. His biopsy was molecularly profiled and with a TMB of 15 mut/Mb, he was started on combination PD-1 and CTLA-4 ICB.
He had a PR and tolerated treatment well aside from G1 xerostomia, but developed G2 hypophysitis requiring replacement steroids 3m after ICB initiation. 8 months after ICB initiation, he developed G2 acute kidney injury (AKI) with peak serum creatinine (sCr) of 299mmol/L (baseline sCr100 mmol/L). Urinalysis showed pyuria (13 WBC) without hematuria or proteinuria. Kidney biopsy revealed substantial interstitial inflammation with a predominantly CD8+ infiltrate and scattered plasma cells, and acute tubular injury, consistent with ICB- induced AIN. Oral prednisolone (PRL) was initiated at 60mg OD (1mg/kg) with improvement to G1 AKI (sCr 133mmol/L) by week 2. PRL taper resulted in a relapse (sCr 167 umol/L) at week 3, requiring maintenance of high dose PRL. Mycophenolate mofetil (MMF) was initiated at week 6 in view of suboptimal response despite high dose PRL.
AIN is the most common renal irAE. Corticosteroids remain 1st-line therapy with most achieving good response. Suboptimal response or relapse during steroid taper warrants consideration of 2nd line immunosuppression although the optimal agent is unknown. Immunohistopathology has been proposed to individualise an approach and the predominant T-cell infiltrate in our patient lends mechanistic support to the use of MMF as a 2nd-line agent.
YO20 - Primary Pulmonary Lymphoepithelioma-like Carcinoma Responded to Both Anti-PD1 and Anti-PD-L1 Inhibitors: A Case Report (ID 577)
- Anita Archwamety (Bangkok, Thailand)
Background: Lymphoepithelioma-like carcinoma (LELC) of the lung is a rare subtype of non-small-cell lung cancer with no established treatment guidelines. We report a case of primary pulmonary LELC (PPLELC) in a young, non-smoking woman with a good response to two types of immune checkpoint inhibitors (ICIs).
Result: A 39-year-old female was diagnosed with metastatic EBV-related PPLELC. The initial PET-CT scan showed a 5.5 cm hypermetabolic lesion at the right middle lobe with intrapulmonary metastases. A transbronchial biopsy revealed a non-keratinizing carcinoma with positive staining for AE1/AE3, p40, and p63. EBER was positive on in-situ hybridization. ENT examination was unremarkable. Molecular analyses of the tumor showed no EGFR, ALK, ROS, BRAF, or KRAS gene mutations, microsatellite stable, and low tumor mutational burden. PD-L1 expression (TPS) was 10%. The patient was initially treated with carboplatin and gemcitabine for 6 cycles, with a partial response after 3 cycles. The PET-CT scan following 6 cycles showed tumor progression. She was then treated with pembrolizumab. The scan after 3 cycles showed stable disease (SD). The treatment was continued until 12 cycles had been completed. The patient subsequently had disease progression. She received docetaxel for 6 cycles, with the best response being SD. Again, the patient demonstrated disease progression in her lungs and liver. She received 3 cycles of capecitabine followed by 2 cycles of pemetrexed with no response. The next line of treatment consisted of atezolizumab/bevacizumab/carboplatin/paclitaxel (as inIMpower150). Unexpectedly, she tolerated this regimen quite well. The scan after 3 cycles showed SD. However, her disease progressed shortly after 6 cycles. Oral vinorelbine was prescribed, and, again, there was no response. She passed away in June 2020 with an overall survival of 28 months from the initial diagnosis.
Conclusion: Until now, no mutation has been reported in EBV-related PPLELC. In this case, the patient responded to anti-PD-L1 after having a progression on anti-PD1. Therefore, ICIs may be beneficial in this rare subtype of lung cancer with PD-L1 expression and no actionable gene mutations.
YO21 - EGFR mutated lung adenocarcinoma (LUAC) with Osimertinib refractory squamous cell transformation presenting prolonged response to anti-PD-1 immunotherapy (ID 989)
- Luciana Beatriz Mendes Gomes (Sao Paulo, Brazil)
LUAC harboring EGFR mutation is highly sensitive to Osimertinib with a median progression free survival circa 20 months in first line. Nevertheless, drug resistance eventually develops. A variety of acquired resistance mechanisms have been reported, including secondary resistance mutations, alternative pathway activation and histological transformation to small cell lung cancer or squamous cell lung cancer (LUSC). Here we report the case of a 68-year-old female with recurrent EGFR mutated-LUAC (L858R). She received Osimertinib in first line but presented disease progression after only 6 months. Besides, she did not experience any signs of clinical benefit and lost almost 10 kg while on treatment. After disease progression, a biopsy was performed in a new adrenal lesion, confirming the histological transformation to LUSC with persistence of L858R mutation. She received carboplatin/paclitaxel/pembrolizumab for 4 cycles followed by maintenance with pembrolizumab (200mg IV 21/21d). CT scans revealed partial response and she experienced clinical benefit, recovering weight and resuming her daily activities and social life. After 14 months of treatment, she is still on immunotherapy and her last CT scans from May/2020 reveal sustained partial response.
YO23 - Immune Checkpoint Inhibitors to Metastatic Melanoma and Renal Allograft Rejection: A case report (ID 1005)
- Débora M. Santana (Sao Paulo, Brazil)
We report a case of a 68 years-old male, white, former smoker 40 pack-years, intense sun exposure, type-2 diabetes mellitus, hypertension and chronic renal failure that underwent a pre-emptive renal allograft. He had stable kidney function after the transplant.
Nine years after the transplant, he underwent resection of nodular melanoma in the left shoulder, with 4.5 mm breslow, Clark's level IV, with ulceration without involvement of sentinel lymph nodes.
Nine months after resection, he was diagnosed with metastases in the liver, lymph nodes and bones, the biopsy of which was confirmed to be wild BRAF melanoma metastasis.
The case was discussed at the multidisciplinary tumor board and proposed combined therapy with immune checkpoints anti-PD1 (Nivolumab 3mg/m²) and anti-CTLA4 (Ipilimumabe 1mg/m²) every 21 days for 4 cycles followed by maintenance Nivolumab 3mg/m² until disease progression. There was a complete discussion with the patient about the risks of graft loss in this scenario of a transplanted patient and he wished to proceed with the treatment.
Five days after the second cycle of the combination of Nivolumab and Ipilimumab, he started nausea, vomiting, fatigue and abdominal pain. The ultrasound doppler of the transplanted kidney showed findings of acute kidney disease, poor perfusion related to transplant dysfunction. The patient progressed to graft nephrectomy. Shortly after surgical recovery, he agreed to restart immunotherapy.
After the fourth cycle of combined immunotherapy the PET-CT showed complete radiological response at all sites of metastasis. Currently, the patient is asymptomatic, maintenance Nivolumab, without limiting toxicities, undergoing hemodialysis three times a week, without evidence of melanoma.
Live Q&A and live discussion (ID 1132)
- Kok Haw Jonathan Lim (Manchester, United Kingdom)