An 63-year-old Chinese man was admitted with a month history of dyspnea and swelling of the face and neck in May 2017. A chest computed tomography (CT) revealed an about 2.7 cm mass in the left upper lobe and enlarged left supraclavicular, mediastinal and hilar lymph nodes, and numbers of nodules distributed on two lungs (Fig. 1A). No other metastasis was observed by abdominal ultrasound examination, whole body bone scan and magnetic resonance imaging of the brain. The patient had no smoking history and family history of malignant tumor. Pathological examination of percutaneous fine needle biopsy of supraclavicular lymph nodes showed lung adenocarcinoma (Fig. 1B). The patient was clinically diagnosed with stage IVa lung adenocarcinoma, cT4N3M1a, with ECOG PS of 0.
The biopsied specimen from this patient was tested for epidermal growth factor receptor (EGFR), Kirsten rat sarcoma viral oncogene homolog (KRAS), and v-Raf murine sarcoma viral oncogene homolog B (BRAF) using amplification-refractory mutation system (ARMS) assay with AmoyDx EGFR29 Mutations Detection Kit, AmoyDx KRAS19 Mutations Gene Detection Kit, AmoyDx BRAFV600E Mutation Gene Detection Kit, and was tested for anaplastic lymphoma kinase (ALK), The c-ros oncogene 1 (ROS1) status using reverse-transcriptase polymerase chain reaction (RT-PCR) assay with AmoyDx EML4-ALK Fusion Gene Detection Kit, AmoyDx ROS1 Fusion Gene Detection Kit (Amoy Diagnostics, Xiamen, China). The findings showed that the patient was negative for EGFR mutations, ALK/ROS1 fusions, and BRAF mutation, but was positive for KRAS mutation (Fig. 1C).
The patient was firstly treated with stent implantation in superior vena cava and carboplatin and pemetrexed chemotherapy in first-line setting. After two cycles of treatment, the disease was stable, but the mass and the lymph nodes were shrink. Then the patient was administered with another two cycles of chemotherapy and palliative thoracic radiotherapy. The disease was still stable with little shrink. Because of the advent of angiogenesis inhibitor, this patient was then treated with two cycles of bevacizumab and carboplatin/pemetrexed, and the disease partially responded (Fig. 1D). After 3 months of maintenance therapy with bevacizumab and pemetrexed, the disease was confirmed partial response (PR). Due to medical insurance restrictions of bevacizumab, it was stopped. The tumors were enlarged but not progressed after 2 cycles of maintenance therapy of pemetrexed. Then we tried to treat the patient with carboplatin and pemetrexed chemotherapy for two cycles, and the tumors were shrink. But once the chemotherapy was stopped for more than two months, the tumors were enlarged, so in the next two years, the patient has accepted for 30 cycles of carboplatin and pemetrexed chemotherapy and the disease is still stable. PFS isn’t reached now, but it will be more than 40 months. Moreover, there was almost no adverse reaction (AE).