68 YO lady with multiple recurrences of lateral tongue SCC removed surgically with initial right neck dissection. Most recently I was involved giving adjuvant cis/RT for high risk features. She had recurrence in the left neck and tongue 5 months later. Had surgery and left neck dissection. Tried to give cetuximab with RT but had grade 3/4 reaction so she only give RT to left neck. I started on pembro and a surveillance CT now shows new small lung nodules 2 weeks into starting Pembro but also gas URTI and port wound infection. I’m thinking I should try to biopsy now to prove Mets instead of following. Let say Mets proved, I would like to add chemo. Which wound you recommend? She recurred within 6 months of platinum and had reaction to cetuximab. Taxotere/pembro?
Before I provide any further suggestions, I would like to know the following 1. Was a scan done right before starting pemrbolizumab? If so, were the nodules not seen? 2. How big are these nodules- are they solid or ground glass (could this be inflammatory, given the fact that patient has infection) 3. What was the PD-L1 on the tumor? 4. Are these nodules amenable to biopsy? 5. Do you have a recent PET/CT? If not, may want to consider one now I do not change treatment based on a scan done just 2 weeks of starting a new treatment. Moreover, with bacteremia and other issues going on, I would probably avoid chemo and continue pembrolizumab for a few more weeks. I look forward to your responses
Questioning Oncologist Response:
1. Unfortunately CT was done 12 days after C1 Pembro. No imaging since prior to most recent surgery. 2. 1cm RUL, 3-4mm in LUL and 1.5 chest wall mass likely at port site.3. PDL1 pending, TMB 3.7. P16 -4. RUL nodule may be amenable 5. Yes plan to do PET in 2-3 weeks and give empiric antibiotics now. I see her soon. So let’s say her imaging remains concerning in a few weeks, and stable from infectious standpoint what chemo can be added to make pembro more efficacious?
Head and Neck Specialist Response:
I would make sure that there is true progression first and then, if you are convinced there is progression, my choice is to add carboplatin and paclitaxel weekly dosing AUC 2 and 50 mg/m2 respectively. There is some data for this. Weekly dosing also allows to carefully follow pt.
