Dr.Yu`s 11.23 Diagnosis（Second Opinion）

* FINAL REPORT*

 

BURNABY HOSPITAL

 

Patient Location: BH.ONC

 

OUTPATIENT CLINIC NOTE

 

Name of  Patient: OU.XIAOWEN

 

BH01688224  Medical Record Number

 

BH147134/22

 

Date of Service

 

This 69-year-old woman with well-documented EGFR-mutant lung cancer to brain and  bones is referred for a second medical oncology opinion.

 

For today's appointment, the husband attended on his own and essentially spoke  on the patient's behalf. From what I understand, the patient has been admitted  to Royal Columbian Hospital for at least 3 months now. She has significantly  diminished cognitive function and is essentially unable to speak for herself or  direct medical care, so for all intents and purposes, her husband is acting as  the substitute decision maker today.

 

Before I go onto the history of presenting illness, I will first outline that  the patient was previously under the care of Dr. Janessa Laskin at the cancer  agency in Vancouver. The last assessment with her took place on September 15  2022, where Dr. Laskin suggested transitioning the patient to comfort care  measures only. The patient subsequently requested for a second opinion and  see that a referral was sent to the cancer agency in Surrey on September 27. 2022, but nothing materialized thereafter. I received an email from Dr. Laskin  on October 25, 2022, requesting for myself to do a second opinion on the  patient's request given the cancer agency is too busy to entertain second  opinions, hence the appointment for discussion today.

 

As far as clinical history is concerned. in summary, she was diagnosed with  metastatic non-small cell lung cancer in January 2020. She had radiologic  evidence of leptomeningeal and intracranial metastases at the time. Lumbar  puncture also confirmed adenocarcinoma. This was subsequently sent for  biomarker testing and on immune histochemistry this was ALK/ ROS negative with PD  L1 expression less than 1%. Single-gene EGFR mutation testing was done and she  had L858R mutation. No other biomarkers were subsequently performed.

 

Initial treatment included a ventriculoperitoneal shunt given she has

 

symptomatic hydrocephalus. She was subsequently started on osimertinib end of  January 2020. Three months later, MRI scan showed complete resolution of her  leptomeningeal intracranial metastases. She had a primary lung mass, which was  initially measured 6 x 4 cm in size and this had subsequently shrunk to 4 x 3 cm within several months, but remained stable thereafter and never responded  further or necessarily progressed.

 

She was essentially in stable condition up until July of 2022 when she started  experiencing ataxia, dizziness and nausea. She was having frequent falls and  ended up with a wrist fracture at one point. She was admitted to Royal  Columbian Hospital on August 5, 2022, and remained there ever since. There  a question whether this represented cancer progression, but imaging on MRI  There was  did not show any convincing evidence of leptomeningeal disease or new  intracranial metastases. She did have a lumbar puncture showing normal- pressure. Cytology once again showed adenocarcinoma of lung, but this was neve  necessarily checked to see if it " cleared" between her initial diagnosis and  this particular presentation. The most recent CT chest scan to assess her lung  cancer showed that the right upper lobe mass was once again stable at about 4 x  3 cm with no obvious evidence of progression.

 

The patient ended up stopping osimertinib around middle of September, as there  was a concern that this might be contributing to her nausea and vomiting. Upon  doing so, the husband did mention that her nausea went away completely after  stoppage of the medication.

 

In October, she developed evidence of left-sided hydropneumothorax. She had a  chest tube in place, which is currently still in-situ. Two samples of pleural  cytology fluid did not show evidence of malignant cells, but there was evidence  of empyema and she was treated with antibiotics. Once again, the respirologist  suggested that she most likely developed a bronchopleural fistula secondary to  disease progression, but this was never radiologically confirmed.

 

According to the husband's report, an documentation available from Royal  Columbian Hospital, the patient is currently essentially a total care patient  She is unable to speak on her behalf or direct her own medical care. She is  needing help with almost all basic activities of living. ECOG performance  status graded at 3.

 

She was otherwise obviously not thoroughly examined.

 

In my discussion with the husband today, I asked him bluntly how I can be of  assistance, and he simply said that he wanted a second opinion. He did not come  across necessarily wanting to seek novel treatments for his wife, He actually  did not seem particularly keen to retry osimertinib either.

 

I must admit the entire picture is somewhat puzzling. On the one hand, she had  a better than expected response to osimertinib considering it held her disease  under control for well over 2-1/ 2 years, whereas the median progression-free  survival for patients with brain metastases on the FLAURA study was  approximately 15 months so she lasted at least twice as long as what is expected  on median. Despite clear cut clinical progression, disease progression was  never objectively identified by any sort of imaging. Finally, since her overall  condition seems fairly stable since discontinuation of osimertinib, which is  also unusual, as one would normally expect quite rapid deterioration of  progression of cancer if this is purely a result of progression of lung cancer  with a driver mutation.

 

I propose repeating MRI of the brain to see what is going on intracranially. She did have a CT head scan not that long ago showing slightly worsening

hydrocephalus, but not much else, but understandably the sensitivity for  detecting leptomeningeal disease in the CT scan is rather low. I suppose if  there is evidence of progression, which would be expected when somebody stops  osimertinib 2 months ago, one could consider putting her back on therapy at half  dose at perhaps 40 mg if the full dose was associated with nausea, vomiting. She would not eligible for any additional therapies anyway such as  chemotherapy or immunotherapy given her poor performance status, so there would  be nothing else left to try.

 

On the other hand, if the upcoming scan still shows no obvious evidence of  disease progression, then this seems to be further evidence that her  deterioration may not necessarily be related to cancer progression and perhaps a  formal neurology consultation might perhaps shed more light on what is actually  transpiring here given the whole clinical situation is not necessarily as one  would expect.

 

The patient's husband, seems satisfied with my explanation. I will leave it in  the hands of her primary most responsible physician to organize the MRI scan but  otherwise arrange for telephone followup in about 3 weeks' time.

 

Dictated By: Simon Yu, MD

 

Oncology