Thread by @ADesaiMD

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD Alright lets go!
1/18 #TumorBoardTuesday #LCSM #OncTwitter
63 yo 👩🏻
🚭 never smoker
C/O: shortness of breath presents in 2017
PMH: None
🫁 PET: shows a RLL mass and pleural effusion
ECOG PS: 0
🔬cT2, cN2, pM1a (Stage IVA) lung adenoCA

🤨What is the next step?

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD 2/18 #TumorBoardTuesday #LCSM
Case continued..
🦠 Tissue NGS and IHC was sent 🧬
🔬 NGS: EGFR p.A767_V769dup; c.2300_2308dupCCAGCGTGG (exon 20 ins)
🔬 PD-L1 negative

🤨 What treatment plan do you initiate next? @HemOncFellows @OncBrothers @OncoAlert @lcsmchat

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat 3/15.. #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 1 👨🏽‍🏫
🚩🚩 for EGFR mutations
Types of EGFR mutations
🚩Classic Activating EGFR Mut
▫️L858R, del19-Outside US
🚩Uncommon EGFR Muts
▫️G719X, L861Q, S768I
🚩EGFR Exon 20 Ins: bit.ly/3nGc8Yp
@NatRevClinOncol

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat 4/15 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 2👨🏽‍🏫

EGFR ex20ins: 12% of EGFRm, different types: go.nature.com/3NJOmFf

🚩 No clear ethnic pattern
🚩 Higher in NEVER smoker 🚭
🚩 More prevalent in females 👩🏻
🚩 Adeno>>SCC
🚩 Less sensitive to EGFR TKIs

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen 5/15 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 3 👨🏽‍🏫

⚠️Type of EGFR mutation can change treatment plan⚠️

✅ Classic Activating EGFR Mut ⇒ Osimertinib
✅ Uncommon EGFR Muts ⇒ Osimertinib
✅ EGFR exon 20 insertion ⇒ Amivantamab/mobocertinib, etc. @lungcancerjournal

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd 6/15 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 4👨🏽‍🏫

✨Testing for EGFR exon20ins✨

📚NGS testing is needed, @myESMO @NCCN guideline recommended
PCR may not be adequate for detection @APassaroMD @oncoOuLungCA @IASLC @HemOncFellows @MayoHemeOnc @EGFRResisters

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ 7/15 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 5👨🏽‍🏫

✨AMIVANTAMAB✨

👉🏽MOA: Bispecific EGFR-MET Ab, 1050-1400 mg IV wkly/q2wkly
👉🏽CHRYSALIS (post-platinum): ORR: 40%, mDOR: 11.1 mos, G3>AEs:35%
@JCO_ASCO bit.ly/3bXtPzN
👉🏽PhIII 1st line Ami+ Chemo- PAPILLON soon!

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD @Tony_Calles @acmoorephd 8/15 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 6 👩🏽‍🏫

✨MOBOCERTINIB✨

👉🏽 MOA: Oral irreversible TKI, 160 mg QD
👉🏽 Phase I/II/EXCLAIM cohort (post-platinum): ORR: 35%, mDOR: 17.5 mos, G3 > AEs:69%
@JAMAOnc bit.ly/3Armrai @EnriquetaFelip
@BenjaminBesseMD

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD @Tony_Calles @acmoorephd @JAMAOnc 9/15 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 7 👨🏽‍🏫

✨SUNVOZERTINIB✨

👉🏽 MOA: Oral irreversible EGFR/HER2 exon 20 – TKI (not approved)
👉🏽 WU-KONG Phase 1 trial: ORR: 40.4% (all dose levels), mDOR:5.9 mos, G3 > AEs:12-70% @ASCO #ASCO22 bit.ly/3AyMyvN
@OncoAlert

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD 10/15 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 8 👨🏽‍🏫

✨CLN-081✨ presented @ASCO #ASCO22 @HelenaYu923

👉🏽 MOA: Oral, irreversible EGFR-
👉🏽 Phase 1/2a: ORR: 38.4%, 41% at 100 mg BID, mDOR: 10 mos
👉🏽 CNS efficacy in 3 patients! @OncoAlert @OncBrothers @HemOncFellows

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD 11/15 #TumorBoardTuesday #LCSM

👩🏽‍🏫Mini tweetorial 9 👨🏽‍🏫

✨Current @FDAOncology Approved Rx for EGFR ex20 ins: 2nd Line✨

👉🏽 Amivantamab
👉🏽 Mobocertinib

Both with ongoing trials: PAPILLON and EXCLAIM-2 in 1st Line @danieltanmd
@OncoAlert @OncBrothers @HemOncFellows

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD @FDAOncology @danieltanmd @DrSteveMartin @ShirishGadgeel @FawziAbuRous 12/15 #TumorBoardTuesday #LCSM
Back to our case 🔎
👩🏻 Patient returns to clinic,
💊 started Carbo/Pemetrexed/bev
💭 1L chemo until PD
📍Chemo STILL recommended 1st Line Rx.

‼️SOC chemo still has role in this EGFR subset‼️

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD @FDAOncology @danieltanmd @DrSteveMartin @ShirishGadgeel @FawziAbuRous 13/15 #TumorBoardTuesday #LCSM

💊patient began Afatinib 40 mg daily > 20 mg due to diarrhea

Presents to 🏥 with PD - A Phase 1 Study JNJ-61186372 (AMIVANTAMAB!)

🚨Ami- THINGS TO MONITOR FOR 🚨

🫁 Infusion related reactions
🥃Edema
👺Rash, 🖐🏽Paronychia

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD 14/15 #TumorBoardTuesday #LCSM

👩🏻 Patient with PD 6 month after Ami

💭 4L Chemotherapy
📍🔬More work needed in this space, hopefully Sunvozertinib, CLN will improve outcomes??
@OncoAlert @OncBrothers @HemOncFellows @CharuAggarwalMD @HelenaYu923

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD 15/15 #TumorBoardTuesday
 Summary: 💎
📌EGFR exon 20 ins now targetable in 2nd Line
📌Amivantamab and Mobocertinib @FDAOncology approved
📌Question remains on head-to-head, sequencing and post progression on these..@OncoAlert @OncBrothers @HemOncFellows @CharuAggarwalMD

@TumorBoardTues @HwakeleeMD @manalipatelmd @jillfeldman4 @JackWestMD @HemOncFellows @OncBrothers @OncoAlert @lcsmchat @NatRevClinOncol @VivekSubbiah @Al3ssandroRusso @gbanna74 @UmbertoMalapel1 @Alfdoc2 @APassaroMD @DrSanjayPopat @MattGubensMD @ZPiotrowskaMD @HelenaYu923 @RachelSanbornMD @RamalingamMD @ipreeshagul @NarjustFlorezMD @teekayowo @HosseinBorghaei @BenWestphalen @FordePatrick @StephenVLiu @esinghimd @AnaVManana @Latinamd @myESMO @NCCN @oncoOuLungCA @IASLC @MayoHemeOnc @EGFRResisters @peters_solange @n8pennell @AndreaAnampaG @AndresFCardonaZ @JCO_ASCO @DrJNaidoo @DevikaDasMD @FDAOncology @CharuAggarwalMD @MPishvaian @manjuggm @threadreaderapp unroll please!