Thread by @ShrutiPatelMD

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell 4/23 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 1👩🏽‍🏫

📚@NCCN based #NSCLC guide for biomarker neg, PDL1 <1% ⤵️

CATEGORY 1 RECOMMENDATIONS
📍Pembro + carboplatin + paclitaxel
📍Pembro + carboplatin + nab-paclitaxel
📍Ipi/Nivo + carbo + paclitaxel
📍Cemiplimab + carbo + paclitaxel

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN 5/23 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 2👩🏽‍🏫

✨KEYNOTE-407✨
♦️Phase III
♦️Untreated metastatic, squamous NSCLC
♦️Pts randomized 1:1 pembro+platinum-doublet vs plat doublet alone
♦️Median OS 15.9 mos vs 11.3 mos
♦️69.8% of grade 3+ AEs in pembro-combo vs 68.2% in placebo-combo

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN 6/23 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 3👩🏽‍🏫
✨CHECKMATE 9LA ✨

♦️ Phase III in untreated metastatic NSCLC
♦️ patients randomized 1:1 nivolumab+ipilimumab + 2 cycles chemo vs 4 cycles chemo

PFS KM Curves in Squamous Pts ⬇️

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana 7/23 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 4👩🏽‍🏫

✨CHECKMATE 9LA ✨
♦️ 32% of all pts squamous
♦️ In squamous pts, OS was 24% for patients in IO+chemo vs 11% in chemo alone
📚 jto.org/article/S1556-…

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana 8/23 #TumorBoardTuesday #NSCLC
👩🏽‍🏫Mini tweetorial 5👩🏽‍🏫

✨CHECKMATE 9LA ✨

⚠️🚨Warning🚨⚠️
Important to note: Control arm in CHECKMATE 9LA- comparison made to chemo monotherapy rather than chemoIO, which is the current SOC

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana 9/23 #TumorBoardTuesday
👩🏽‍🏫Mini tweetorial 6👩🏽‍🏫
✨EMPOWER-Lung03 ✨

♦️Phase III in untreated metastatic NSCLC
♦️ Pts randomized 1:1 Cemiplimab +platinum-doublet vs platinum doublet alone
♦️ 42.9% of all pts squamous
♦️In Squamous Histology ➡️ median OS 21.9 months vs 13.8 months

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr 10/23 #TumorBoardTuesday #LCSM
👩🏽‍🏫Mini tweetorial 7👩🏽‍🏫
Why no Atezo?!

✨IMpower 131 ✨
♦️Phase III study in advanced SQCLC
♦️Atezolizumab + chemo vs chemo alone
➡️ IMPROVED PFS BUT NO OS

Patient selection and crossover

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr 11/23 #TumorBoardTuesday #NSCLC

Unfortunately, there are no head-to-head comparisons and patient population differs across CHECKMATE 9LA, EMPOWER-Lung03, IMPOWER 131.

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr 12/23 #TumorBoardTuesday #NSCLC
👩🏽‍🏫Mini tweetorial 8👩🏽‍🏫

📌Things to think about:
🏋🏻‍♀️Disease burden
🔋Performance Status
😷Autoimmune disease history
💰Financial toxicity
🔬Histologic type
⏳Frequency of infusions
💊Adverse Events
🌍User familiarity

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr 13/23 #TumorBoardTuesday #SCLC
Back to our case 🔎

👨🏼Patient returns to clinic to discuss systemic treatment options
💭Discuss chemo/IO
🏃🏼ECOG 1

👨🏼Patient started on pembrolizumab + carboplatin + paclitaxel for Stage IV Squamous Cell Lung Cancer

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr 14/23 #TumorBoardTuesday
Back to our case🔎

🏥patient returns for 3 month follow up
👨🏼Reports fatigue, irritability, constipation and neuropathy

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr 15/23 #TumorBoardTuesday
🚨IO SE - THINGS TO MONITOR FOR 🚨

👺Rash
💩Diarrhea
🫀Myocarditis
🦋Endocrinopathies - attention to adrenal insufficiency and thyroid
🫁Pneumonitis

🗓️Time of Immune-related Adverse Events👇🏽

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 16/23 #TumorBoardTuesday

🚨CHEMO SE - ADDITIONAL THINGS TO MONITOR FOR 🚨

🩸Leukopenia/Anemia/Thrombocytopenia
🧑🏼‍🦲Alopecia
👄Stomatitis
💪🏽🦵🏼Peripheral Neuropathy
😫Muscle/Joint Pain

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 17/23 #TumorBoardTuesday
Back to our case🔎

🏥f/u continued

🥼🧪abnormal 🥼🧪
TSH 14
FT4 0.7

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 18/23 #TumorBoardTuesday
🦋LET’S TALK HYPOTHYROIDISM IN IO TXT 🦋

🕵🏽EVAL: TSH q4-6 weeks if no Sx
TSH+T4 if Sx
➡️ if low TSH + lowT4 ➡️ check for hypophysitis

⚡️GRADING determines treatment plan⚡️

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 19/23 #TumorBoardTuesday
G1: TSH >4.5-10+no Sx
➡️Should continue IO with TSH q4-6wk
G2: Moderate Sx+TSH >10
➡️Continue or hold IO + Rx thyroid 💊 if Sx or TSH>10 & Asx
G3-4: Severe Sx or med significant consequences
➡️Hold IO + ☎️ endocrine + consider 🏥 for IV thyroid 💊 + 👀

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 19.5/23 #TumorBoardTuesday
📌Natural history of IO induced thyroid dysfunction

🦋 Can start with subclinical hyperthyroidism - thyroiditis
🦋 Followed by hypothyroidism
🦋 Patient may require several dose adjustments of levothyroxine

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 20/23 #TumorBoardTuesday
👀 Peep here a study published in @CCR_AACR suggesting a possible genetic risk of immune related adverse events of the thyroid with IO in #NSCLC.

🔗aacrjournals.org/clincancerres/…

Also there may be sex differences in irAEs
academic.oup.com/oncolo/article…

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 @CCR_AACR 21/23 #TumorBoardTuesday
Back to our case🔎

🏥f/u continued
👱🏼‍♂️started on 125ug of levothyroxine daily
🗓️Plan for follow up visit in 3 weeks for symptom check with follow up labs in 8 weeks

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 @CCR_AACR 22/23 #TumorBoardTuesday
Fast forward 9 months
🫁🫁Case outcome 🫁🫁

👱🏼‍♂️ Patient: on maintenance pembrolizumab and chronic levothyroxine replacement
🙏🏽 No new SE or dose adjustments
🎉 scans: interval improvement 🙌🏽

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 @CCR_AACR 23/23 #TumorBoardTuesday
💫Recap💫
📍APPROVED IO in Squamous NSCLC: Pembro or ipi/nivo or Cemiplimab
📍MUST combine w carboplatin + nab-paclitaxel or paclitaxel if PDL1<50
📍Watch for rare & common AEs such as endocrinopathies!
📍Take a good history including h/o autoimmune dz

@NarjustFlorezMD @TumorBoardTues @drRTee @ADesaiMD @esinghimd @FawziAbuRous @ALKpositiveINT @Rothangpuia5 @SamuelKareffMD @AlyaShamsan @LVaezi @n8pennell @NCCN @GlopesMd @Latinamd @LeciaSequist @filimasini @Tony_Calles @BairdAM @mlazqui @FredrikThege @cwilliamszf @AnaVManana @HwakeleeMD @visheshkhanna @SurbhiSinghalMD @JoelNealMD @EleanorKMishra @DrBalukuJoseph @brucekirenga @ksivaprasadk @LungAssociation @LungCancerDr @ReginaBarCar @zen228 @crisbergerot @ranj585 @DasMillie11 @CCR_AACR #PostTest Q1️⃣ #TumorBoardTuesday
👉🏽CME Eval 🔗 integrityce.com/tbtEval
👉🏽ALL🔗 integrityce.com/tbt

🤔@NarjustFlorezMD @ShrutiPatelMD taught us IO combos & irAEs, test your 🧠

What 1L IO in combo w chemo would U pick for met squamous NSCLC no action molecular bio & 37% PD-L1