Erlotinib usage after prior treatment with gefitinib in advanced non-small cell lung cancer: A clinical perspective and review of published literature

Long-term survival of a non-small cell lung cancer patient with EGFR-mutated brain metastases: a case report

Background

Lung cancer is the leading cause of cancer-related death worldwide. Up to 85% of lung cancer is non-small cell lung cancer (NSCLC) and most patients present with advanced disease at first diagnosis. Targeted therapy plays an important role in the treatment of advanced NSCLC. Epidermal growth factor receptor (EGFR) mutation is a predictive marker of sensitivity to EGFR tyrosine kinase inhibitors (TKIs). Patients with EGFR-mutated NSCLC are prone to developing central nervous system (CNS) metastasis and poor prognosis (4-6 months). Brain metastases (BMs) remain a tricky problem in NSCLC patients and impose a distinct challenge for clinicians.

Case Description

This article details a patient with EGFR-mutated BMs accepting a series of treatments but without chemotherapy, resulting in significantly prolonged survival with overall survival (OS) over 8 years and improved clinical symptoms. The patient in our case received four lines of treatments and the progression-free survival (PFS) in each line were longer than the previously reported without exception. It is worth noting that the combination of osimertinib and bevacizumab used in the fourth-line therapy has a PFS of 31 months and has not progressed so far.

Conclusions

Our case demonstrates that it is possible to achieve long-term survival in advanced EGFR-mutated NSCLC with multiple BMs and systemic progression through a reasonable therapeutic schedule.

Erlotinib as a salvage treatment after gefitinib failure for advanced non-small-cell lung cancer patients with brain metastasis: A successful case report and review

RATIONALE

The guidelines recommended gefitinib as a first-line targeted treatment for stage IV non-small-cell lung cancer (NSCLC) patients with EGFR mutations. However, resistance to gefitinib ensues invariably and there is little evidence as for the effectiveness of subsequent salvage treatment for patients without T790m mutation. The case is to evaluate the efficacy of erlotinib, another EGFR-TKI, after failed first-line use of gefitinib.

PATIENT CONCERNS

We described a 55-year-old man with good performance status (PS).

DIAGNOSES

He was histopathologically diagnosed stage IV lung adenocarcinoma with EGFR mutations in November 2018.

INTERVENTIONS

He was administrated with gefitinib daily (250 mg) for activating epidermal growth factor receptor (EGFR) mutations (exon 19 deletions,19del), and combined with platinum-based dual-drug chemotherapy. During the target treatments, the optimal efficacy evaluation was partial remission (PR) with a 12-month progression-free survival (PFS) time. Later, the intracranial progression of the patient rendered the treatment change to erlotinib.

OUTCOMES

It is surprising that the tumor lesion in brain as well as lung relieved obviously. His progression-free survival (PFS)was nearly 11 months, and the overall survival (OS)was>36 months up to now. The adverse events were tolerable.

LESSIONS

This case manifests that re-biopsy of advanced or recurrent NSCLC is beneficial to make a better therapeutic regimen, and erlotinib can be used as a salvage treatment after gefitinib failure.

Biomarkers in Non-Small Cell Lung Cancers: Indian Consensus Guidelines for Molecular Testing

Novel molecular targets and promising targeted therapies have reshaped diagnostics in patients with advanced non-small cell lung cancer (NSCLC). Despite this progress, the implementation of molecular screening to identify predictive biomarkers in Indian clinical and pathology settings has been challenging due to operational and logistical constraints. This consensus guideline brings together medical oncologists, molecular pathologists and pathologists from India to provide a quick and competent reference for biomarker testing in NSCLC. The guideline summarizes the importance of targetable mutations in NSCLC such as epidermal growth factor receptor (EGFR), rearrangements in anaplastic lymphoma kinase and receptor tyrosine kinase encoded by ROS-1 gene, overexpression of programmed cell death ligand-1 and resistant EGFR mutations. It reaffirms recommendations from international working groups, discusses vulnerable pre-analytical procedures and provides a balanced review on the pros and cons of different diagnostic tests (immunohistochemistry, fluorescence in situ hybridization, polymerase chain reaction-based testing and next-generation sequencing). The document also provides an algorithm to aid diagnostic decision-making and a checklist to assess the quality of testing laboratories that will help the medical oncologists make an informed choice. Overall, these recommendations are based on evidence and clinical experience and will aid policymakers, oncologists, health care practitioners and pathologists who strive to implement molecular strategies and make informed decisions for improved care in NSCLC in India.Funding: AstraZeneca Pharma India Limited.

Comparison of Symptom Score and Bronchoscopy-Based Assessment With Conventional Computed Tomography-Based Assessment of Response to Chemotherapy in Lung Cancer

PURPOSE

There is a paucity of literature on symptom score (SS) plus fiberoptic bronchoscopy (FOB) -based response evaluation (RE) to chemotherapy for lung cancer. This study aimed to compare the reliability of RE by SS, chest radiograph (CXR), and FOB with computed tomography (CT) -based assessment (Response Evaluation Criteria in Solid Tumors (RECIST) and WHO criteria) for lung cancer chemotherapy.

METHODS

This was a prospective observational study involving treatment-naïve patients with lung cancer planned for chemotherapy, with one or more lesions on FOB and CT. Patients underwent assessment twice by SS, CXR, FOB, and CT (at baseline and after chemotherapy). Six symptoms (dyspnea, cough, chest pain, hemoptysis, anorexia, and weight loss) were noted on visual analog scale. Respiratory symptom burden (RSB) and total symptom burden (TSB) were calculated from the first four and all six symptoms, respectively, as the mean of individual SS. Bronchoscopic findings were recorded as per European Respiratory Society classification for tracheobronchial stenosis. Responses were classified as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD) by each method. For FOB and SS, improvement or worsening by ≥ 20% was taken as PR or PD, respectively, whereas < 20% change was considered SD. Agreements were tested using Cohen's κ statistic.

RESULTS

All individual SS, RSB, and TSB scores, and the number and distribution of FOB lesions improved significantly after chemotherapy. Individually, CXR and SS had no or minimal agreement with FOB-based and CT-based responses. RECIST and WHO criteria had strong agreement overall (Cohen's κ = 0.872) and perfect agreement for PD (Cohen's κ = 1.000). Cohen's κvalues for FOB-based assessment with RECIST and WHO were 0.324 and 0.349, respectively for overall RE, and 0.462 and 0.501 for differentiating responders (CR and PR) from nonresponders (SD and PD), respectively. Cohen's κvalues for PD were 0.629 (FOB alone), 0.672 (FOB and RSB), 0.739 (FOB and TSB), and 0.764 (FOB and CXR).

CONCLUSION

CT-based assessment should remain the reference for objective RE of chemotherapy in lung cancer. A combination of FOB and CXR may be used as a surrogate to diagnose PD if CT is not feasible.

USP8: a novel therapeutic target for Cushing's disease

Cushing's disease (CD), caused by an adrenocorticotropin-secreting pituitary adenoma, leads to hypercortisolemia and causes serious morbidity and increased mortality when suboptimally treated. Currently, the genetic events have rarely been reported in this disease. Recently, the recurrent activating mutations in the gene encoding ubiquitin-specific protease 8 (USP8) in CD have been independently reported by two teams. These hotspot mutations sustain epidermal growth factor receptor (EGFR) signaling and expand the pathogenic role of USP8 in corticotroph adenoma. This review summarizes current knowledge of USP8 and its substrate EGFR in cancer therapy and possible application of them in CD.

Clinical analysis of sixty-four patients with T1aN2M0 stage non-small cell lung cancer who had undergone resection

Background

The aim of this study was to evaluate the clinical features of T1aN2M0 stage non‐small cell lung cancer (NSCLC).

Method

From November 2008 to May 2013, 498 patients with T1a‐stage NSCLC who visited the Shanghai Cancer Center were included in the study. All patients underwent a lobectomy or segmentectomy with systematic nodal resection for primary lung cancer. Analyses of gender, smoking history, primary tumor site, tumor location, tumor size, pathological classification, cancer gene, pleural invasion, number of positive lymph nodes, skip N2, single or multiple station N2, progression‐free survival (PFS), and overall survival (OS) were performed.

Result

There were significant differences in tumor size, tumor size distribution, adenocarcinoma subgroup, and number of positive lymph nodes between patients at T1aN2M0 and T1aN0M0 stages. The most common histology of the T1aN2M0 subgroup was adenocarcinoma. Epidermal growth factor receptor mutations were the most common gene mutation in T1aN2M0 stage NSCLC. There were significant differences in five‐year OS and PFS rates between patients with T1aN2M0, T1aN0M0, and T1aN1M0 stages. Multivariate analyses of mediastinal lymph node metastasis showed that gender, tumor size distribution, and histology type were significant predictive factors. Multivariate analyses of OS and PFS rates in the T1aN2M0 subgroup showed that the number of positive lymph nodes was a significant predictive factor.

Conclusion

Gender, tumor size distribution, and histology type were independent predictors of mediastinal lymph node metastasis in patients with T1a stage. The number of positive lymph nodes was significantly associated with OS and PFS rates in patients with T1aN2M0 stage NSCLC.