10-year long-term survival of a metastatic EGFR-mutated nonsmall cell lung cancer patient

Comparison of Confirmed Cytology Smears and Cell Blocks for Epidermal Growth Factor Receptor Mutation Testing in Non-Small Cell Lung Cancer

INTRODUCTION

Various cytologic specimens have been used to diagnose epidermal growth factor receptor (EGFR) gene mutations in non-small cell lung cancer (NSCLC). However, insufficient samples and lengthy DNA extraction procedures have led to inconsistent diagnostic results. To reduce manipulation losses and improve DNA extraction quality, we provide an improved procedure for DNA extraction from smear samples containing rare tumor cells in NSCLC.

PATIENTS AND METHODS

The effectiveness of this new method for DNA extraction and diagnosis was validated in 8 patients with pleural effusion smears and formalin-fixed paraffin-embedded cell blocks, and another with 2 smears. Smear samples with <5% tumor cells were collected, and visible particles were selected for DNA extraction after centrifugation. Qiagen formalin-fixed paraffin-embedded DNA extraction kit (Qiagen) was used for DNA extraction and the procedure was modified. The EGFR mutation analysis in both types of material used the EGFR mutation analysis kit (Therascreen EGFR RGQ PCR) and real-time polymerase chain reaction (Rotor-Gene Q).

RESULTS

The DNA extraction amount of the smear was 2.6 to 258.8 ng/μL, and that of the cell block was 1.4 to 139.9 ng/μL. The DNA quantity and purity of DNA extracts isolated from both sample sources were sufficient for subsequent EGFR mutation detection, where mutation rates were similar and diagnostic results were consistent when smears or cell blocks were used.

CONCLUSION

This improved method demonstrates that cytology smears can be used as a test material for the detection of EGFR mutations in patients with NSCLC with sparse cells.

Early Application of Next-Generation Sequencing Identifies Pancreatic Mass as Metastasis From an EGFR-Mutated Lung Adenocarcinoma

Pancreatic metastasis of primary lung adenocarcinoma is a rare occurrence, accounting for <0.3% of all pancreatic malignancies. Given that the prognosis and treatment options for primary pancreatic cancer differ greatly from pancreatic metastases from a primary site, an accurate diagnosis is critical. This report presents a unique case of a 65-year-old man who was admitted with significant unintentional weight loss, fatigue, abdominal pain, and jaundice, and found to have a pancreatic mass initially thought to be primary pancreatic adenocarcinoma and subsequently diagnosed as an EGFR-mutated lung adenocarcinoma with metastases to the pancreas via early application of next-generation sequencing (NGS). The use of NGS early in the patient's clinical course not only changed the treatment strategy but also drastically altered the prognosis. Although metastatic pancreatic adenocarcinoma has a poor prognosis and survival rate, treatment of EGFR-mutated non-small cell lung cancer with EGFR tyrosine kinase inhibitors is associated with high response rates. Importantly, our case demonstrates that timely application of NGS very early in the disease course is paramount to the diagnosis, management, and prognosis of solid malignancies.

Systemic Inflammatory Markers of Survival in Epidermal Growth Factor-Mutated Non-Small-Cell Lung Cancer: Single-Institution Analysis, Systematic Review, and Meta-analysis

BACKGROUND

Systemic inflammatory response (SIR) may influence prognosis in epidermal growth factor receptor (EGFR)-mutated (m) non-small-cell lung cancer (NSCLC). Pretreatment SIR markers (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio [LMR], lactate dehydrogenase [LDH], and lung immune prognostic index [LIPI]) were assessed as prognostic factors in NSCLC survival.

PATIENTS AND METHODS

Retrospective survival analysis (overall survival [OS] and progression-free survival [PFS]) of EGFR-mutated NSCLC patients at Princess Margaret Cancer Centre were performed separately for early (I-IIIa) and late (IIIb-IV) stage disease for individual SIR variables, dichotomized by optimal cutoff points by Kaplan-Meier survival analysis and multivariable Cox proportional hazard modeling. A systematic review and meta-analysis of known SIR studies in patients with late-stage EGFR-mutated were also performed.

RESULTS

From 2012 to 2019, in 530 patients, significant adjusted hazard ratios (aHR) for OS comparing high versus low NLR were 2.12 for early stage and 1.79 for late stage disease. Additionally, late stage cohorts had significant associations, as follows: high versus low derived NLR, aHR = 1.53; LMR, aHR = 0.62; LDH, aHR = 2.04; and LIPI, aHR = 2.04. Similar patterns were found for PFS in early stage NLR (aHR = 1.96) and late stage NLR (aHR = 1.46), while for PFS, only late stage derived NLR (aHR = 1.34), LDH (aHR = 1.75), and LIPI (aHR = 1.66) were significant. A meta-analysis confirmed that NLR, LMR, LDH, and LIPI were all significantly associated with OS and PFS in the late stage.

CONCLUSION

This primary study and meta-analysis demonstrated that LMR and LDH were significantly associated with late stage EGFR-mutated NSCLC outcomes, and the LIPI scoring system was prognostic. NLR remained an independent prognostic factor across all stages and could represent an early marker of immuno-oncology interactions.

Maintained Complete Response and Long-Term Survival in Epidermal Growth Factor Receptor Mutated Metastatic Non-Small Cell Lung Cancer with Erlotinib

The prognosis of advanced non-small cell lung cancer (NSCLC) has significantly improved for certain patients with the development of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs). However, metastatic NSCLC patients with long-term survival are still rare.

Our 66-year-old male patient was admitted to the hospital for treatment of pneumonia. A chest CT scan done revealed a left upper lobe mass; computed tomography (CT)-guided fine-needle aspiration (FNA) was done in 2010 revealing adenocarcinoma. A staging positron emission tomography (PET) scan did not reveal evidence of metastatic disease. He underwent left upper lobectomy and the pathologic stage was IB, moderately differentiated adenocarcinoma with positive angiolymphatic invasion. He was offered adjuvant systemic therapy, but he opted for surveillance. In 2012, a CT scan showed disease recurrence in the left upper lobe, which was confirmed with a biopsy. He was deemed non-surgical by thoracic oncology. Systemic therapy was initiated with carboplatin/pemetrexed and Avastin; after four cycles of treatment, the CT scan showed stable disease. Mutation analysis sent before chemotherapy revealed EGFR mutation for which chemotherapy was stopped and he was started on switch maintenance with erlotinib 150 mg in October 2012, then the dose was reduced to 100 mg secondary to grades 2-3 acneiform rash. Follow-up CT scans in January 2016 showed complete remission, which is maintained with no evidence of disease as of today.

Non-small cell lung cancer (NSCLC) remains the leading cause of cancer-related mortality in the United States. Surgical excision is the standard treatment for stage I disease. Despite the long-term survival without adjuvant therapy, the disease recurrence rate ranges between 27% and 38% after resection. Different histologic subtypes vary in pathologic and molecular features, leading to differences in treatment and prognosis. In the adenocarcinoma subtype, five-year progression-free survival in patients with EGFR mutation treated with an EGFR-TKI is 14.6% as compared to less than 5% in unselected patients with distant-stage NSCLC. The association between exon 19 deletions, which represent about 45% of overall EGFR mutations and half of the sensitizing ones, and prolonged survival in patients with advanced NSCLC treated with EGFR-TKIs has been reported by several groups. Our case reports long-term survival in a patient with EGFR mutation-positive NSCLC with no evidence of disease for eight years since he started erlotinib treatment. Is there an option to discontinue maintenance erlotinib at this point? The answer to this question is not known, but this is a remarkably maintained response that is a good area to study patient’s characteristics leading to differences in response.

Long term follow-up of EGFR mutated NSCLC cases

PURPOSE

A substantial fraction of all non-small cell lung cancers(NSCLC) carry a mutation in the EGFR gene for which an effective treatment with anti-tyrosine kinases(TKIs) is available. We studied the long term survival of these patients following the introduction of TKIs.

EXPERIMENTAL DESIGN

All consecutive cases of NSCLC newly diagnosed with advanced disease were referred for free tumor EGFR mutation testing at Clalit's national personalized medicine laboratory. Mutations and deletions in target codons 18-21 of EGFR were sought using RT-PCR and fragment analysis. Comprehensive EMRs were used to collect full data on treatments and clinical status.

RESULTS

A cohort of 3,062 advanced NSCLC cases, included 481(15.7%) somatic EGFR mutation carriers (17.5% of all adenocarcinomas, 26.7% of females with adenocarcinomas). TKIs treatment to EGFR mutation carriers was provided to 85% of all eligible. After a median follow up period of 15.9 months for EGFR mutated cases the hazard ratio for overall survival of EGFR-mutated NSCLC treated with TKIs was 0.55(0.49-0.63, p<0.0001) when compared with EGFR wild-type(WT) tumors under usual care. After adjusting for age, sex, ethnicity, smoking history and tumor histology, all of which had an independently significant effect on survival, the HR for TKI-treated, EGFR-mutated tumors, was 0.63 (0.55-0.71, p<0.0001). Treating EGFR-WT cases with TKIs yielded a high HR=1.32 (1.19-1.48).

CONCLUSIONS

TKIs given to EGFR mutated advanced NSCLC demonstrated a substantial survival benefit for at least five years. Squamous histology, smoking, male sex and Arab ethnicity were associated with higher NSCLC mortality hazard. Treating non-EGFR-mutated NSCLC with TKIs seems detrimental. Statement of Significance: • TKIs given to EGFR mutated advanced NSCLC demonstrated a substantial survival benefit for at least five years but not much longer. • Treating non-EGFR-mutated NSCLC with TKIs seems detrimental and should probably be avoided. • Squamous histology of non-small cell lung cancer, smoking history, male sex and Arab ethnicity were associated with altogether higher NSCLC mortality hazard.

Let-7c regulated epithelial-mesenchymal transition leads to osimertinib resistance in NSCLC cells with EGFR T790M mutations

Epidermal growth factor receptor- tyrosine kinase inhibitors (EGFR-TKIs) have shown promise against non-small cell lung cancers (NSCLCs) in clinics but the utility is often short-lived because of T790M mutations in EGFR that help evade TKIs’ action. Osimertinib is the third and latest generation TKI that targets EGFRs with T790M mutations. However, there are already reports on acquired resistance against Osimertinib. Recent work has revealed the role that miRNAs, particularly tumor suppressor let-7c, play in the invasiveness and acquired resistance of NSCLCs, but the mechanistic details, particularly in Osimertinib resistance, remain elusive. Using two cells lines, H1975 (endogenous T790M mutation) and HCC827-T790M (with acquired T790M mutation), we found that let-7c is a regulator of EMT, as well as it affects CSC phenotype. In both the cell lines, transfection with pre-let-7c led to reversal of EMT as studied through EMT markers e-cadherin and ZEB1. This resulted in reduced proliferation and invasion. Conversely, reduced expression of let-7c through anti-let-7c transfections significantly increased proliferation and invasion of lung cancer cells. Expression of let-7c was functionally relevant as EMT correlated with resistance to Osimertinib. High let-7c expression reversed EMT and made cells sensitive to Osimertinib, and vice versa. WNT1 and TCF-4 were found to be two targets of let-7c which were epigenetic suppressed by let-7c through increased methylation. In vivo, pre-let-7c inhibited while anti-let-7c potentiated tumor growth and WNT1 and TCF-4 were downregulated in xenografts with pre-let-7c. Silencing of both WNT1 and TCF-4 resulted in potentiation of Osimertinib action. Our results suggest an important role of let-7c in regulating EMT and the resulting Osimertinib resistance in T790M NSCLCs. More clinical studies need to be performed to fully understand the translational relevance of this novel mechanism.

Extensive-disease small cell lung cancer, multiple relapses, five lines of therapy and more than 10-year survival

Small cell lung cancer (SCLC) accounts for nearly 18% of lung cancer cases. Most of the patients of SCLC are not surgical candidates, due to advanced stage at presentation hence only viable options are chemotherapy and radiotherapy. Long-term survival in SCLC is extremely rare due to relapses and comorbidities. Ten-year survival has never been reported in cases with extensive disease at presentation and history of relapses. Here we are describing a case of extensive disease SCLC who has survived multiple relapses and has received five lines of systemic therapy apart from radiation and palliative care. This case emphasises on the need of active and strict disease surveillance at each follow-up.

A case report of metastatic lung adenocarcinoma with long-term survival for over 11 years

RATIONALE

This is the first known report in the English literature to describe a case of metastatic non-small cell lung cancer that has been controlled for >11 years.

PATIENT CONCERNS

A 71-year-old man visited our hospital because of dry cough.

DIAGNOSIS

Chest computed tomography revealed a tumor on the left lower lobe with pleural effusion, and thoracic puncture cytology indicated lung adenocarcinoma.

INTERVENTIONS

Four cycles of carboplatin and docetaxel chemotherapy reduced the size of the tumor; however, it increased in size after 8 months, and re-challenge chemotherapy (RC) with the same drugs was performed. Repeated RC controlled disease activity for 6 years. After the patient failed to respond to RC, erlotinib was administered for 3 years while repeating a treatment holiday to reduce side effects. The disease progressed, and epidermal growth factor receptor (EGFR) gene mutation analysis of cells from the pleural effusion detected the T790 M mutation. Therefore, osimertinib was administered, which has been effective for >1 year.

OUTCOMES

The patient has survived for >11 years since the diagnosis of lung cancer.

LESSONS

Long-term survival may be implemented by actively repeating cytotoxic chemotherapy and EGFR-tyrosine kinase inhibitor administration.

Secondary Brain Neoplasm after Stereotactic Radiosurgery in Patients with Metastatic Non-small Cell Lung Cancer

Stereotactic radiosurgery (SRS) using the Gamma Knife (GK) is now being increasingly utilized for the treatment of brain metastases. However, there are a few reported cases of SRS-induced brain neoplasms. We herein report the case of a Japanese woman with metastatic non-small cell lung cancer (NSCLC) harboring epidermal growth factor (EGFR)-mutations who was treated four times with a GK for brain metastases. She developed glioblastoma 5.7 years after the initial GK surgery. Radiation-induced secondary neoplasms generally appear after a latency period of several years. Advances in cancer therapy have improved the survival of patients with NSCLC, providing enough time for secondary neoplasms to appear after SRS.

Factors associated with the prognosis and long-term survival of patients with metastatic lung adenocarcinoma: a retrospective analysis

Background

Outcome of patients with advanced non-small cell lung cancer (NSCLC) treated with platinum-based doublet chemotherapy is usually poor, with overall survival ranges from 8-13 months. However, the overall survival is improved to 21-28 months in the era of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI). This study aimed to explore the prognostic factors to predict long-term survival in the era of EGFR TKI.

Methods

A total 1,030 patients were studied who had been diagnosed with metastatic adenocarcinoma of lung from January 2005 to December 2009 at Linkou Chang Gung Memorial Hospital. Long-term survivors (LTS) were defined as patients who survived five years or more after the initial diagnosis of stage IV disease. Data on patient age, gender, smoking status, performance status at diagnosis, TNM stage, metastatic pattern, number of metastases, and organs with tumor involvement, EGFR gene mutation status, types of treatment received, EGFR TKI treatment and longest EGFR TKI duration were retrospectively obtained from medical charts. We calculated the odds ratio (OR) of long-term survival from collected clinical parameters to predict long-term survival.

Results

In this large retrospective study, we reported a five-year survival of 5.0% among patients with metastatic adenocarcinoma of lung. A total 52 LTS and 978 non-LTS were identified. Patients had more contralateral or pleural/pericardial metastases in the LTS group than in the non-LTS group (51.9% vs. 19.0%, P<0.001), while less extrathoracic spread than in the non-LTS group (42.3% vs. 79.6%, P<0.001). The mutation of the EGFR gene was more frequent in the LTS group than in the non-LTS group (19.2% vs. 7.1%, P=0.006).

Conclusions

In conclusion, our results suggest that an age younger than 60 years, absence of extrathoracic spread and EGFR TKI treatment duration of more than one year play an important role in the long-term for survivors who survive for more than 5 years.

Achievement of Cure with Gefitinib in Advanced Lung Adenocarcinoma Harboring an Activating EGFR Mutation: A Case Report

Tyrosine kinase inhibitors (TKIs) of the epidermal growth factor receptor (EGFR) may achieve long-term survival in selected cases with advanced non-small cell lung cancer harboring activating mutations in the EGFR gene, but a cured case has not been reported yet. Here, we present the first case of EGFR-mutated lung adenocarcinoma cured with an EGFR-TKI, as the 75-year-old Japanese man has achieved complete response with gefitinib treatment and has survived without tumor 10 years after termination of gefitinib treatment.