Patient Summary: EGFR-Mutant Stage 4 Lung Adenocarcinoma

Corey J. Langer, MD:This is a fairly typical patient that we frequently see—a 61-year-old Caucasian female, never-smoker, who presents with shortness of breath and cough, is found on X-ray to have a large right upper lobe mass as well as some other small vague nodules. Her physical exam is fairly unremarkable. There are no palpable nodes. Her lungs are relatively clear. A CAT scan confirmed a fairly large right upper lobe mass with multiple bilateral pulmonary nodules that measured up to 1 to 2 centimeters. As part of her staging, also routinely done, she undergoes an MRI. The MRI shows multiple, albeit asymptomatic, brain metastases. If we look at our newly diagnosed patients with metastatic lung cancer, upward of 15% to 20% will often present with brain metastases.

As part of her work-up, she undergoes a core biopsy of the right upper lobe. This confirms adenocarcinoma. It’s TTF-1—positive, which is generally the case in about 75% to 80% of those with adenocarcinoma. Our suspicion for a driver mutation goes up, in light of her nonsmoking history. And, in fact, her tumor does harborEGFRmutations, specifically an exon 19mutation. Further workup shows that her tumor isALK-negative, and, of course, she is negative for theKRASmutation.

She starts treatment in June of 2017 with afatinib and does quite well. Updated scans of her chest show a marked shrinkage of the right upper lobe mass and similar shrinkage or disappearance of many of the pulmonary nodules. Her brain metastases, in the absence of whole brain radiation, Gamma Knife, or stereotactic radiation, also reveal shrinkage on a follow-up brain MRI. As of March of 2018, 9 months after the initiation of treatment, she’s continuing to do quite well.

Transcript edited for clarity.

June 2017

• A 61-year-old Caucasian woman presented with persistent cough and shortness of breath
• Patient history:
  • Never smoked
  • Mild hypertension, controlled on diuretic
  • No major cardiovascular disease or diabetes
  • Worked at local jazz club until symptoms forced her to resign
• Physical exam and imaging:
  • No palpable masses
  • CT reveals multiple tumors in right lung and brain metastases
  • ECOG PS: 1
• Biopsy and mutation analysis:
  • Adenocarcinoma
  • EGFRexon 19 deletion
  • No ALK rearrangement
• Started treatment with afatinib 40 mg once daily
  • Developed diarrhea that necessitated dose interruption
  • Recovered and resumed treatment at 30 mg once daily

March 2018

• Patient remains on afatinib, with no apparent progression