01/03/2016

ADENOCARCINOMA OF THE LUNG PRESENTING WITH SPINAL

CORD COMPRESSION

15th ESO Masterclass

March 2016

INTRODUCTION
 44 year-old, female.
 Nonsmoker.

 No previous medical condition.

 No familiar history of cancer.

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PRESENTATION

 First symptom (May 2014):

Weakness of lower extremities,
sensory loss and bladder
dysfunction. She also had
diplopia.

 Urgent MRI of the spine: several

vertebral metastases with
epidural extension at T7
associated with spinal cord
compression at that level. Bone metastases and spinal cord
compression (T7)

FIRST TREATMENT
 Urgent laminectomy and thecal sac decompression
followed by palliative radiotherapy (Dose: 20 Gys).

 No neurological improvement was noticed: established

paraplegia and bladder dysfunction.

 Pathological diagnosis (bone tissue): adenocarcinoma of

pulmonary origin. EGFR wild-type. Negative for ALK
translocation.
 EGFR mutation was determined in plasma DNA and was
wild-type as well.

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DIAGNOSIS WORKOUT
 PET/CT scan: 17 mm nodule in lower left lobe suggestive of primary lesion,
ipsilateral pleural thickening with moderate pleural effusion and multiple
bone metastases.

 Brain MRI: single brain metastasis located at the right cavernous sinus next to
internal carotid artery and optic chiasm.

Lung node on PET/CT Brain metastasis

At this point, the patient had poor performance status (PS 3) due to
paraplegia, bladder dysfunction and visual impairment caused by
diplopia (which was worsening)

Question 1:
Taking into consideration the initial available information based on the
vertebral metastasis (EGFR/ALK wild type stage IV lung adenocarcinoma),
would you consider to perform a re-biopsy in order to assess more
accurately the mutational status?

Question 2:
Given the severe functional disability of the patient due to the disease
complications, would you consider to offer her any systemic treatment in
case EGFR was not mutated?

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Despite the initial pathological diagnosis, EGFR mutation/ALK

gene fusion was suspected due to:
 Patient’s characteristics (woman, young, never smoker).
 Histological result obtained from bone tissue which is
known to yield lower DNA quality after decalcification
process.

 Lung biopsy was performed to repeat mutational study.

An exon 19 delection on the EGFR gene was identified.

Radiotherapy vs
systemic treatment?

Question 3:
On lung cancer patients harboring an activating EGFR mutation and
presenting with brain metastasis, would you consider to prioritize brain
radiotherapy or to initiate systemic treatment with an EGFR inhibitor?

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SYSTEMIC TREATMENT
 Erlotinib 150 mg per day was initiated on August 2014.

 Toxicity: Good tolerance. Grade 1 diarrhea.

 Clinical response: Diplopia improved progressively.

 After two months of treatment, a partial response was observed. Reduction

of brain lesion, lung nodule and pleural thickening.

Brain metastasis at Brain metastasis after 2

diagnosis cycles of Erlotinib

FOLLOW-UP
 Patient is still on Erlotinib at the same dose, maintaining a partial
response.
 Her functional status has significantly improved and she is able to
walk short distances at home.
 Mild diplopia.

Chest disease at diagnosis Chest disease on January 2016