Inavolisib for PIK3CA-mutant non-small cell lung cancer: A case report

PIK3CA mutations are oncogenic drivers in 2-4% of non-small cell lung cancers (NSCLC), often co-occurring with other drivers and conferring therapeutic resistance. This report is unique in describing the efficacy of the novel, highly selective PI3Kα inhibitor inavolisib in two heavily pre-treated patients with PIK3CA-mutant NSCLC harboring divergent co-drivers (EGFR and KRAS).

We present a 71-year-old male with EGFR/PIK3CA-mutant adenocarcinoma and brain metastases, and a 54-year-old female with KRAS/PIK3CA-mutant squamous cell carcinoma. Both patients reported rapid symptomatic improvement (hoarseness and shoulder pain, respectively) within two weeks of initiating inavolisib.

Both patients received oral inavolisib (6 mg daily). Follow-up imaging after one month revealed significant tumor reduction. Notably, regressing intrapulmonary lesions exhibited tumor cavitation, and the male patient demonstrated a marked regression of central nervous system (CNS) metastases. The treatment was well-tolerated, with only Grade 1 oral mucositis reported.

The primary take-away lesson is that selective PI3Kα inhibition with inavolisib can induce potent systemic and intracranial responses in PIK3CA-mutant NSCLC, regardless of the primary oncogenic co-driver. The observed tumor cavitation suggests a potential anti-angiogenic mechanism, warranting further investigation.