|LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 3 | Page : 365
Utility of driver mutation
V Sharma, VM Patil, V Noronha, A Joshi, K Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||24-Feb-2017|
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma V, Patil V, Noronha V, Joshi A, Prabhash K. Utility of driver mutation. Indian J Cancer 2016;53:365
We highlight a patient of epidermal growth factor receptor (EGFR) mutant adenocarcinoma lung with solitary brain metastasis who relapsed early after curative treatment but had prolonged disease control on gefitinib.
A 43-year-old male, presented in June 2011 with headache for 2 months and recent episode of altered sensorium. Magnetic resonance imaging brain revealed single right frontal lobe enhancing lesion 2.4 cm × 1.8 cm. The lesion was excised. Histopathology revealed metastatic adenocarcinoma. The postoperative positron emission tomography scan revealed single fluorodeoxyglucose avid right upper lobe lung lesion 2.2 cm × 1.7 cm and no distant metastasis. He underwent the right upper lobectomy. Histopathology showed adenocarcinoma, EGFR exon 19-1 deletion, pT 2.5 cm × 1 cm, all cut margins negative, pN 0/27 (pT1N0M1b). Subsequently, the patient remained in follow-up.
In December 2011, after a disease-free interval (DFI) of 5 months, he had tumor recurrence in the brain-right frontal lobe and left cerebellar hemisphere. Contrast enhanced computed tomography thorax showed no lung lesion. He received whole brain radiotherapy (WBRT) 25 gray in ten fractions and remained in follow-up.
In October 2012, after a DFI of 10 months, he developed malignant pleural effusion. Tablet gefitinib 250 mg OD was started. In September 2013, after a progression-free interval of 11 months, the disease progressed in brain (frontal lobe and leptomeningeal enhancement), new subdural metastases at the dorsal cord, and multiple bony metastases. He was planned WBRT 25 gray in ten fractions. After four fractions of radiotherapy, he developed increasing drowsiness, quadriparesis and ultimately succumbed to aspiration pneumonia.
In selected patients, surgical removal of brain metastases can prolong survival. Two randomized trials by Patchell et al. and Vecht et al. demonstrated a significant survival benefit in patients treated with surgery plus WBRT compared to WBRT alone. Surgical excision should be considered for patients with good performance status, minimal or no evidence of extracranial disease, and a surgically accessible single brain metastasis amenable to complete excision.
EGFR mutation status has prognostic implications in nonsmall cell lung cancer (NSCLC) patients who develop brain metastases. Porta et al. demonstrated the efficacy of erlotinib in this subgroup. Median time to progression in the brain in EGFR mutants and controls was 11.7 months and 5.8, months respectively (P < 0.05). Median overall survival was 12.1 months and 3.1 months, respectively (P < 0.001).
Park et al. demonstrated the efficacy of gefitinib or erlotinib in EGFR mutant NSCLC with brain metastases. Eighty-three percent patients had partial response, and 11% had stable disease. Median progression-free survival and overall survival were 6.6 months and 15.9 months, respectively.
This case highlights that with appropriate treatment approach, prolonged overall survival can be achieved in patients of NSCLC with brain metastases.
We are grateful to the patient and his family members for cooperating in his treatment and providing us his medical records.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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