Great efficacy of afatinib on a patient with lung adenocarcinoma harboring uncommon EGFR delE709_T710insD mutations: a case report

EGFR exon 18 delE709_T710insD mutated stage IV non-small cell lung cancer treated with osimertinib: a case report

Mutations in tyrosine kinase domain of epidermal growth factor receptor (EGFR) are observed in approximately 15% of non-small cell lung cancer adenocarcinoma. Exon 19 deletions or exon 21 L858R mutations are predominant in frequency and show high sensitivity to EGFR tyrosine kinase inhibitors (TKIs). Exon 18 mutations are extremely rare and the delE709_T710insD mutation accounts for only 0.16% of mutations when occurring as a sole mutation. This specific mutation in exon 18 seems to respond to certain EGFR TKIs such as afatinib. However, given the rarity of this mutation, determining the most effective TKI for its treatment remains unclear. We report a 70-year-old woman diagnosed with stage IV-A lung adenocarcinoma harboring EGFR delE709_T710insD mutation treated in first-line with Osimertinib using standard schedule and doses experiencing renal toxicity and disease progression after 9 weeks of treatment.

Activity of afatinib in patients with NSCLC harboring novel uncommon EGFR mutations with or without co-mutations: a case report

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) represent first-line standard of care in unresectable EGFR mutation-positive (EGFRm+) non-small cell lung cancer (NSCLC). However, 10-20% of patients with EGFRm+ NSCLC have uncommon EGFR variants, defined as mutations other than L858R substitutions or exon 19 deletions. NSCLC harboring uncommon EGFR mutations may demonstrate lower sensitivity to targeted agents than NSCLC with L858R or exon 19 deletion mutations. Prospective clinical trial data in patients with NSCLC uncommon EGFR mutations are lacking. Afatinib is a second-generation TKI and the only Food and Drug Administration-approved drug for some of the more prevalent uncommon EGFR mutations. We present a series of seven case reports describing clinical outcomes in afatinib-treated patients with NSCLC harboring a diverse range of extremely rare mutations with or without co-mutations affecting other genes. EGFR alterations included compound mutations, P-loop αC-helix compressing mutations, and novel substitution mutations. We also present a case with NSCLC harboring a novel EGFR::CCDC6 gene fusion. Overall, the patients responded well to afatinib, including radiologic partial responses in six patients during treatment. Responses were durable for three patients. The cases presented are in line with a growing body of clinical and preclinical evidence that indicating that NSCLC with various uncommon EGFR mutations, with or without co-mutations, may be sensitive to afatinib.

Complete response to first-line osimertinib monotherapy in a complex epidermal growth factor receptor mutant ( L833V / H835L ) lung adenocarcinoma patient: a case report

Although uncommon epidermal growth factor receptor (EGFR) mutations account for 10-15% EGFR mutant non-small cell lung cancer (NSCLC) patients, clinical evidence for uncommon EGFR mutations, such as complex mutations remain limited. In this study, we reported a NSCLC patient harboring complex EGFR L833V / H835L mutation in exon 21, who had a complete response to first-line osimertinib monotherapy. The patient admitted to our hospital for space-occupying lesions of right lower lung during an annual health checkup, and was diagnosed as stage IIIA lung adenocarcinoma. Targeted next-generation sequencing (NGS) on tumor samples showed a complex EGFR mutation: L833V / H835L in exon 21. Therefore, she was treated with osimertinib monotherapy and complete remission achieved soon. During follow-up period, no metastasis was found and serum carcinoembryonic antigen returned to normal. In addition, NGS monitoring of mutations in circulating tumor DNA maintained negative. The patient remain benefitted for osimertinib monotherapy over 22 months with no disease progression. Our case firstly provided clinical evidences of first-line osimertinib therapy in lung cancer patients with rare L833V / H835L EGFR mutation.

Afatinib for the Treatment of NSCLC with Uncommon EGFR Mutations: A Narrative Review

Afatinib, the world's first irreversible ErbB family (containing four different cancer cell epidermal growth factor receptors, including EGFR, HER2, ErbB3, and ErbB4) inhibitor, is a second-generation oral epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI). It can be used as a first-line treatment for locally advanced or metastatic non-small-cell lung cancer (NSCLC) with an EGFR-sensitive mutation or for patients with locally advanced or metastatic squamous lung cancer whose disease progresses during or after platinum-containing chemotherapy. Currently, with the use of third-generation EGFR-TKIs, afatinib is no longer clinically indicated as the first choice for patients with NSCLC who have EGFR-sensitive mutations. However, afatinib showed a considerable inhibitory effect in NSCLC patients with uncommon EGFR mutations (G719X, S768I, and L861Q) according to a combined post hoc analysis of the LUX-Lung2/3/6 trials. With the development of genetic testing technology, the detection rate of uncommon EGFR mutations is increasing. The aim of this paper is to describe in detail the sensitivity of rare EGFR mutations to afatinib and to provide information and a reference for those suffering from advanced NSCLC who have uncommon EGFR mutations.

Response to dacomitinib in advanced non-small-cell lung cancer harboring the rare delE709_T710insD mutation: A case report

BACKGROUND

Tyrosine kinase inhibitors (TKI) have been the standard first-line therapy for advanced non-small cell lung cancer (NSCLC) of epidermal growth factor receptor (EGFR) sensitive mutations. Uncommon EGFR mutations are increasingly reported with the development of next-generation sequencing. However, their sensitivity to TKIs is variable with limited clinical evidence.

CASE SUMMARY

Here, we report a patient with the rare delE709_T710insD mutation, who showed the favorable efficacy of dacomitinib and achieved a partial response with a progression-free survival of 7.0 mo.

CONCLUSION

To our knowledge, this is the first report displaying the clinical efficacy of dacomitinib for patients with delE709_T710insD, which may help to provide alternatives in non-classical variant NSCLC patients. Further studies are warranted to make the optimal choice of EGFR-TKI for rare mutations.

Durable response to afatinib in an advanced lung adenocarcinoma patient with an EGFR L858R/G729A compound mutation: a case report

Of the epidermal growth factor receptor (EGFR) mutations in patients with non-small cell lung cancer (NSCLC), 10-15% are uncommon mutations. Most of the EGFR "major" uncommon mutations have shown responses to EGFR-tyrosine kinase inhibitors (TKIs). However, there is a lack of clinical data for other less common types of EGFR mutations and the response to EGFR-TKIs, occurring either alone or in combination with EGFR sensitizing mutations. We reported a 70-year-old Chinese man with no smoking history who was diagnosed with stage IVA lung adenocarcinoma. An exceptionally uncommon EGFR G729A mutation in EGFR exon 19 was detected concomitantly with EGFR L858R in exon 21 in tumor specimens by next generation sequencing (NGS). This patient obtained limited benefit from icotinib and the increase in symptoms of cough and chest tightness, so we decided to switch the treatment to afatinib. Our patient exhibited partial response to afatinib with progression-free survival of 10 months. Subsequently, an EGFR T790M mutation was detected in the second lung biopsy. Then, osimertinib was administered and the symptoms improved significantly and the progress-free survival was nearly 16 months. Our data suggests that patients with NSCLC who are positive for uncommon EGFR G729A mutations may benefit from treatment with afatinib.

Afatinib for the treatment of advanced non-small-cell lung cancer harboring an epidermal growth factor receptor exon 18 E709_T710delinsD mutation: a case report

BACKGROUND

The discovery of epidermal growth factor receptor oncogenic driver mutations has changed the therapeutic landscape of advanced non-small cell lung cancer in the past decade. Since the introduction of next-generation sequencing, uncommon epidermal growth factor receptor mutations are more frequently discovered. Because seldom evaluated in clinical trials, their clinical significance and response on tyrosine kinase inhibitors are less well known.

CASE PRESENTATION

A 58-year-old Caucasian woman with no smoking history presented with advanced non-small cell lung cancer. Liver biopsy revealed an adenocarcinoma with a programmed death ligand-1 tumor proportion score of 30% and no common oncogenic driver mutations. A combination of chemotherapy and immunotherapy was started as first-line treatment. However, treatment was ceased after 18 weeks because of immune-related renal failure and disease progression. In the meantime, the next-generation sequencing results of the liver biopsy had revealed an exon 18 E709_T710delinsD mutation. Therefore, afatinib was administered, which was moderately tolerated with grade 2 paronychia and acneiform skin eruption. After 6 months, a partial response with ongoing decrease of the liver metastasis was retained.

CONCLUSION

Because of the lack of clinical trials, tumor heterogeneity, and a tyrosine kinase inhibitor affinity related to the different mutation types, it is difficult to predict the clinical outcome of tyrosine kinase inhibitor in uncommon mutations. Therefore, a therapeutic trial with tyrosine kinase inhibitor has to be considered, but the expected clinical response is lower than for common mutations.

Complete Response to Afatinib of an EGFR Exon 18 delE709_T710insD-Mutated Stage IV Lung Adenocarcinoma

Introduction

Epidermal growth factor receptor (EGFR) mutations are frequently found in patients with lung adenocarcinomas, 90% being deletions in exon 19 or point mutation in exon 21. Three generations of tyrosine kinase inhibitors (TKIs) targeting EGFR mutations are available and have changed patient prognosis but less data is available on exon 18 mutations and their sensitivity to TKI therapy. Exon 18 delE709_T710insD accounts for 0.06% (16/27,294) of all EGFR mutations and is an oncogenic driver. Several partial responses to afatinib have been described.

Case description

We report the first case, to the best of our knowledge, of the complete response to afatinib of a 57-year-old patient with stage IV lung adenocarcinoma with a delE709_T710insD mutation in the EGFR gene detected by next-generation sequencing. Oral afatinib was prescribed and despite treatment interruptions and dosage tapering due to cutaneous adverse events, a complete response was achieved 12 months after treatment initiation and is currently maintained at 17 months.

Conclusion

When EGFR mutation is suspected, complete DNA sequencing of exons 18 to 21 should be carried out and we suggest that afatinib should be the first-line treatment for exon 18 delE709_T710insD-mutated advanced lung adenocarcinomas.

LEARNING POINTS

Rare EGFR gene mutations are not detected by standard diagnostic kits.DNA sequencing is required to diagnose rare mutations of the EGFR gene.delE709_T710insD-mutated stage IV lung adenocarcinomas respond to afatinib.

Efficacy of tyrosine kinase inhibitors against lung cancer with EGFR exon 18 deletion: Case report and pooled analysis

BACKGROUND

Within the exon 18 of EGFR, a complex, in-frame deletion-delE709_T710ins-has been described among pulmonary adenocarcinomas with an estimated prevalence of 0.3%. Available evidences suggest that some EGFR tyrosine kinase inhibitors (TKI) have activity against this cancer. However, due to the rarity of this mutation, it remains unclear which TKI is the most effective.

METHODS

We reported our experience using afatinib followed by osimertinib in a patient with this mutation. We performed a systematic review of literature and conducted a pooled analysis to compare the outcomes of treatment with first generation TKIs vs. afatinib. Cases with compound mutations were excluded.

RESULTS

Our patient achieved a partial response to afatinib with a progression-free survival of 11 months. Upon disease progression, osimertinib failed to control the disease. Literature review identified 14 cases being reported: 8 received first generation TKI and 6 received afatinib. Among those with tumor response assessed, partial response occurred in 2 out of 7 patients (28.6%) treated with first generation TKI compared with 6 out of 6 patients (100%) treated with afatinib, p = 0.03. The median progression-free survival (PFS) was 3.1 months vs. 7.0 months, respectively, p = 0.005. Insufficient evidences were available to assess for the efficacy of osimertinib.

CONCLUSION

Based on currently available data, afatinib was associated with a greater tumor response rate and a longer PFS than the first generation TKIs.

Great Efficacy of Afatinib in a Patient with Lung Adenocarcinoma Harboring EGFR L833V/H835L Mutations: A Case Report

Uncommon mutations account for 10-15% of epidermal growth factor receptor (EGFR) mutations in patients with non-small-cell lung cancer (NSCLC). Most of them are proved to be sensitive or resistant to EGFR-tyrosine kinase inhibitors (TKIs). However, there is insufficient evidence for other less common types of EGFR mutations, such as complex mutations. Here, we present a 65-year-old never-smoking male who was diagnosed with stage IV lung adenocarcinoma. A rare L833V/H835L complex mutation in exon 21 of EGFR was detected in plasma and pleural effusion by next generation sequencing (NGS). Afatinib was used as first-line therapy and showed very good efficacy. To date, the patient is still benefited from afatinib treatment for a total of 10 months, with no signs of disease progression. Our case suggests that a comprehensive screening for EGFR mutations should be conducted before treatment in clinical practice, and afatinib could be a first-line treatment option in NSCLC patients harboring H833V/H835L mutations.

Efficacy and safety of afatinib for non-small-cell lung cancer: state-of-the-art and future perspectives

INTRODUCTION

Afatinib is a second-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, acting as an irreversible and multitarget blocker of ErbB family members. Afatinib is currently approved for advanced non-small-cell lung cancer (NSCLC) harboring common and uncommon sensitizing EGFR mutations and for squamous NSCLC patients progressing after first-line platinum-based chemotherapy.

AREAS COVERED

This review summarizes the efficacy and safety profile of afatinib compared with chemotherapy and other EGFR TKIs, in order to evaluate its characteristics and potential role in the increasingly complex treatment landscape of EGFR-mutant lung cancer. Future perspectives and innovative drug combinations are also discussed.

EXPERT OPINION

Afatinib has been demonstrated to improve efficacy and quality of life compared with chemotherapy with a managed toxicity profile. However, in recent years, the increasing availability of different treatment options for advanced EGFR-mutant NSCLC has made the current treatment scenario more complicated, with an increasing need of new and deeper scientific data. In this light, the identification and validation of potential clinicopathological and/or molecular predictors of benefit, as well as the clarification of resistance mechanisms, may help to clarify the most appropriate treatment strategies and sequences for EGFR-mutant patients.

Long-term Survival With Afatinib in a Patient With Lung Adenocarcinoma Harboring Double Uncommon EGFR L861Q and G719X Mutations

BACKGROUND

In the majority of non-small cell lung cancer (NSCLC) patients with uncommon EGFR mutations, first generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are ineffective. The second-generation TKI, afatinib, is considered effective in patients with uncommon mutations, however, long-term survivors have been rare.

CASE REPORT

We report herein a patient with lung adenocarcinoma harboring double uncommon EGFR L861Q and G719X mutations, who is free of disease 32 months after initiation of afatinib therapy. To our best knowledge, this patient has the longest response among other patients with double uncommon mutations.

CONCLUSION

Patients with this type of NSCLC may obtain long-term survival with afatinib.