|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 4 | Page : 409
The utility of molecular testing in the futility of definite therapy
A Joshi, V Noronha, J Ghosh, K Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||1-Feb-2016|
Dr. K Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Joshi A, Noronha V, Ghosh J, Prabhash K. The utility of molecular testing in the futility of definite therapy
. Indian J Cancer 2014;51:409
The importance of performing epidermal growth factor receptor (EGFR) testing and deciding therapy based on the result has been tested in several n phase III studies, which showed time and again that oral tyrosine kinase inhibitor (TKI) has significantly better responses compared to chemotherapy.,,, Here, we report a case that is a very good example of such a situation where the primary treatment failed but oral TKI has worked as a successful salvage.
This 64-year-old male, without any past co-morbidities, presented with complaints of loss of consciousness in August 2011 at an outside hospital. He was investigated for the same, and magnetic resonance imaging (MRI) brain showed a well-circumscribed lesion in the frontal lobe. Computed tomography (CT) scan of the thorax revealed soft tissue lesion, 3.1 cm in largest diameter in the upper lobe of left lung in close contact with the aorta with multiple enlarged nodes. Positron emission tomography CT scan was done which showed disease in the lung and mediastinum with no distant metastasis. He underwent frontoparietal metastasectomy in August 2011. Histopathology reported it to be adenocarcinoma, 2 cm in size with negative margins. At the same sitting, mediastinoscopy was done, which showed only reactive nodes in the adequately sampled nodes. In view of the R0 resection on the brain metastasis and T2 N0 status of the lung lesion, he was planned for left upper lobectomy and underwent the same on September 2011. Histopathology revealed adenosquamous carcinoma of the upper lobe of left lung with metastasis to regional lymph nodes. pT = 3 cm and total of 12 out of 30 lymph nodes positive. He was seen in joint clinic and was planned for whole brain radiotherapy along with adjuvant chemoradiotherapy for the lung lesion. He completed external beam radiation therapy in November 2011 and chest conformal radiation therapy in December 2011. He received a total of 50 Gy in 25 fractions over 40 days along with 4 cycles of weekly paclitaxel 50 mg/m 2 and carboplatin area under the curve (AUC) 2.
He stayed disease-free for 5 months, after which he presented with new onset hard neck node. CT thorax showed ill-defined soft tissue mass in the paratracheal region 2.2 cm in size with few mediastinal nodes. He was diagnosed with relapsed metastatic adenocarcinoma lung and was given palliative chemotherapy with pemetrexed 500 mg/m 2 and carboplatin AUC 5, every 3 weekly, starting in June 2012. After 3 cycles of chemotherapy, he had stable disease in both contrast-enhanced computed tomography thorax and MRI brain, however, after 6 cycles CT scan showed progressive disease, last dose in October 2012. By that time, EGFR report was available, which was positive for point mutation L858R at exon 21. Hence, he was started on tablet gefitinib 250 mg PO once daily from October 2012. He had good tolerance to gefitinib without any side effects. He was kept on regular follow-up with 3 monthly CT scan. The last follow-up of the patient was in November 2014, and CT scan shows stable disease compared to the baseline scan done at the start of gefitinib.
The above case report highlights the fact that prolonged progression-free interval can be achieved with targeted therapy in EGFR positive patient. The patient relapsed at a very short interval after definitive surgery (5 months) and was started on chemotherapy. Even with chemotherapy, the progression-free interval has been just 4 months. However, once the oral TKI was started, he has been doing well and till date, the progression free interval has been 2 years. This underscores the importance of performing EGFR testing in patients with metastatic adenocarcinoma of lung.
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