YO22 - Durable complete response to Alectinib in a second line setting in metastatic ALK+ve NSCLC patient with poor PS with initial NG tube administration

Case summary

70 year old male who had achieved good partial response on Crizotinib for 2 years for stage IV ALK+ve adenocarcinoma lung with pleural effusion presented in August 2018 with giddiness ,drowsiness and vomiting. MRI of the brain showed multiple cystic lesions with ring like enhancement in bilateral cerebral and cerebellar hemispheres and brainstem. He was initiated on whole brain radiotherapy and following 1 fraction, he developed multiple episodes of seizures. Patient was drowsy, aphasic with pooling of secretions. He was bed ridden with a GCS of 10. He was started on steroids, antiepileptics, and a nasogastric tube was inserted for nutritional support. He then developed hypoxia due to aspiration pneumonia requiring oxygen support and antibiotics.

After counselling family members about prognosis, patient was started on Alectinib. In view of poor sensorium and risk of aspiration, Alectinib at a dosage of 600mg BD was administered via nasogastric tube by crushing 4 tablets in water and flushing the resultant suspension via NG tube. Within 2 weeks , there was improvement in speech and sensorium. Oral feeds were initiated after 3 weeks and alectinib was administered orally. During discharge, patient was fully conscious,oriented and was mobilising.

MRI brain done at 3 months showed a significant reduction in the brain lesions and repeat imaging done at 9 months showed complete response in the brain with areas of gliosis. On follow up in March 2022, PET CT and MRI brain confirmed ongoing complete response at more than 3 years of follow up with patient doing well and carrying out activities of daily living independently. No significant toxicity nor dose delay were noted.

Clinical trial identification

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