Patient Case Presentation: A 69-Year-Old With Newly Diagnosed EGFR-Mutant mNSCLC and Symptomatic Brain Metastases
Panelists discuss how a 69-year-old woman with newly diagnosed EGFR-mutant mNSCLC and symptomatic brain metastases requires immediate multidisciplinary care including steroids, radiation oncology consultation, and potential hospitalization, with treatment approach favoring stereotactic radiosurgery for dominant lesions followed by combination therapy like FLAURA2, while emphasizing that asymptomatic patients might allow for initial tyrosine kinase inhibitor treatment with close monitoring before considering radiation to potentially reduce treatment field and minimize long-term neurotoxicity.
EP: 1.The Evolution of EGFR-Mutated Advanced NSCLC Treatment: Present Considerations and Future Treatment Options
EP: 2.Has Combination Therapy Become the New Frontline Treatment Standard for EGFR-Mutant Metastatic NSCLC?
EP: 3.Decision Points to Consider When Choosing Treatment With Monotherapy or Combination Therapy for EGFR-Mutant mNSCLC
EP: 4.Evaluating Patient Preferences for the Treatment of EGFR-Mutant mNSCLC
EP: 5.Comparing the Combination Therapies for the Treatment of EGFR-Mutant mNSCLC
EP: 6.Considering Resistance Mechanisms When Choosing Therapy in the Frontline Setting
EP: 7.The Importance of Maintaining Quality of Life and Intervening Early When Adverse Events Occur in the Frontline Treatment Setting
EP: 8.Weighing the 1-Year Projected Overall Survival Benefit With MARIPOSA in the Frontline Treatment of EGFR-Mutant mNSCLC
EP: 9.Discussing the Time and Financial Toxicities Associated With Combination Therapies and Potential Mitigation Strategies
EP: 10.Discussing Potential Combination Therapy Medication-Associated Toxicities With Patients
EP: 11.Evaluating the Clinical Utility of Subcutaneous Amivantamab in the Treatment of EGFR-Mutant mNSCLC
EP: 12.The Importance of Multidisciplinary Collaboration With Subspecialty Physicians in the Toxicity Management With Treatment
EP: 13.Exploring Second-Line Treatment Options Including Targeted Radiation and Surgery for the Management of EGFR-Mutant mNSCLC
EP: 14.Tissue vs Plasma Biopsy After First Disease Progression in EGFR-Mutant NSCLC
EP: 15.Deciding Between a Biomarker-Directed Approach and a Biomarker-Agnostic Approach for Second-Line Treatment of EGFR-Mutant NSCLC
EP: 16.Continuing the Targeted TKI in the Second Line for the Treatment of EGFR-Mutant NSCLC
EP: 17.When to Consider Retreatment With Chemotherapy After FLAURA2 for EGFR-Mutant NSCLC
EP: 18.Patient Case Presentation: A 45-Year-Old With Newly Diagnosed EGFR-Mutant mNSCLC and Liver Metastases
EP: 19.Patient Case Presentation: A 69-Year-Old With Newly Diagnosed EGFR-Mutant mNSCLC and Symptomatic Brain Metastases
This segment presents a case of a 69-year-old never-smoker woman with newly diagnosed EGFR-mutant (exon 21 L858R) stage 4B metastatic non–small cell lung cancer (mNSCLC) presenting with symptomatic brain metastases. The patient has multiple brain lesions including 3 dominant lesions measuring 2.4 to 3.4 cm, plus numerous smaller nontarget lesions. She exhibits neurologic symptoms including gait abnormalities and decreased strength, with a performance status of 1, and is seeking a second opinion. This case highlights the urgent management considerations for patients with symptomatic central nervous system (CNS) involvement.
The immediate management approach emphasizes aggressive, multidisciplinary intervention. Clinicians recommend starting prednisone immediately to address neurologic symptoms, followed by urgent radiation oncology consultation. The symptomatic presentation raises concerns about lesion location, size, and neurologic impact, prompting consideration of hospitalization for intravenous dexamethasone, neurology consultation, and seizure risk assessment. Stereotactic radiosurgery to the 3 largest lesions is preferred over whole brain radiation, with plans to initiate osimertinib soon after completion of CNS radiation. Given the patient’s age (69 years), performance status, and brain involvement, FLAURA-2 combination therapy (osimertinib plus chemotherapy) is favored despite the patient not meeting eligibility criteria for major clinical trials.
For asymptomatic presentations, the approach would be more conservative but still aggressive. While radiation oncology consultation would still be pursued due to lesion size (2.4-3.4 cm), some clinicians prefer attempting systemic therapy first with very close monitoring, including repeat brain MRI at 4 to 6 weeks. This approach potentially allows for reduction in radiation field size if systemic therapy demonstrates efficacy, minimizing long-term neurotoxicity risks like radiation necrosis. However, the decision depends heavily on lesion location, with critical anatomic areas requiring immediate radiation regardless of symptoms. The case emphasizes the importance of multidisciplinary neuro-oncology tumor boards for complex decision-making in brain metastases management.
