JID: CLLC
ARTICLE IN PRESS [mNS;February 24, 2021;12:30]
Precision Treatment of Advanced Lung
Adenocarcinoma With Coexisting EGFR, ALK,
and ROS1 Mutations: A Case Report
Yaping Zhang, Hui Wang, Xiaoyan Wang, Shuai Li, Hongming Fang
Clinical Practice Points
• EGFR, ALK, and ROS1 mutations are typically consid-
ered to be mutually exclusive. EGFR and ALK double
mutations are rare events, and patients who are positive
for 3 driver genes (EGFR, ALK, and ROS1) are even
rarer.
• Although patients with co-mutation of EGFR/ALK or
EGFR/ROS1 have been previously reported, no cases
of co-mutation of EGFR, ALK, and ROS1 have been
reported.
Clinical Lung Cancer, Vol. 000, No.xxx, 1–4 © 2021 The Authors. Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Keywords: Co-mutation, Multiple gene mutations, Driving genes, tyrosine kinase inhibitors
Clinical Information
The patient (male, 80 years old) presented on February 27, 2016
with a complaint of fever with cough and shortness of breath lasting
2 weeks. CT showed abnormalities affecting the left lung. Patient
had a PS score of two points. He reported a history of control-
lable hypertension spanning more than 30 years, a 9-year history
of Type 2 diabetes, and a 2-year history of “diabetic nephropa-
thy, chronic renal insufficiency, and peripheral neuropathy.” Patient
denied any history of smoking or alcohol addiction and denied any
family history of tumors.
Based on a chest CT scan performed on February 27, 2016, it
was concluded that “left upper lung tumors should first be consid-
ered with mediastinal lymphadenopathy, multiple small nodules
in both lungs, and metastasis cannot be excluded.” Lumbar CT
results revealed “metastasis associated with pathological fractures”
affecting the third lumbar vertebrae and accessories. Thoracic CT
revealed “bone changes of the thoracic 11 and 12 vertebrae,” and
the associated report noted that “metastasis needs to be consid-
ered.” On March 9, 2016, the patient underwent lumbar 3 kypho-
plasty. Postoperative pathology records noted a finding of “(Lumbar
3 vertebrae) metastatic adenocarcinoma, in line with lung adenocar-
Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
Submitted: Dec 11, 2020; Accepted: Jan 14, 2021; Epub: xxx
Address for correspondence: Hongming Fang, Affiliated Xiaoshan Hospital, Hangzhou
Normal University, Hangzhou, China.
E-mail contact: fanghongming0412@163.com
1525-7304/$ - see front matter © 2021 The Authors. Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/)
https://doi.org/10.1016/j.cllc.2021.01.008
Please cite this article as: Yaping Zhang et al, Precision Treatment of Advanced Lung Adenocarcinoma With Coexisting EGFR, ALK, and ROS1 Mutations:
A Case Report, Clinical Lung Cancer, https://doi.org/10.1016/j.cllc.2021.01.008
Case Report
• The patient described in this article was diagnosed
with advanced NSCLC with mutations in EGFR (20ins),
ALK, and ROS1.
• First-line treatment with crizotinib resulted in 28 months
of PFS, and second-line treatment with Brigatinib in
an additional 8 months. OS was 38 months, slightly
poorer than anticipated for patients with single driver
gene mutations.
cinoma metastasis combined with immunohistochemistry.” Csmart
gene detection results revealed the presence of an epidermal growth
factor receptor (EGFR) 20 exon insertion mutation (mutation
abundance of 0.21%), an EML4-ALK fusion mutation (mutation
abundance of 3.81%) and an MAGI3-ROS1 fusion mutation
(mutation abundance of 0.2%). From March 25, 2016 to April,
2016, the patient underwent 3-dimensional conformal radiotherapy
(6MVX line: DT: 4000cgy/20FX) for thoracolumbar bone metas-
tases. On March 29, 2016, patient began targeted molecular therapy
with a twice-daily regimen of 250 mg oral crizotinib tablets, and a
partial response was achieved. On April 18, 2018, a reexamination
of the chest CT revealed “obstructive changes in the left lung mass”
and increased mass compared to the previous CT. The curative effect
was evaluated as stable disease. Patient continued to take crizotinib
tablets until July 30, 2018. Reexamination of lung CT was associ-
ated with curative effect evaluation PD. Treatment was changed to
a targeted therapy of twice-daily 60 mg oral brigatinib from August
5, 2018. After 1 month, tumor mass was partially reduced. In April
2019, patient presented with chest tightness, shortness of breath,
nausea and vomiting, and multiple intracranial metastases, and was
considered for head MR. Patient died on April 25, 2019.
Discussion
Lung cancer represents the most prevalent and highest-mortality
form of malignant tumor worldwide. Non-small cell lung cancer
(NSCLC) accounts for more than 80% of all lung cancers, of
which adenocarcinoma is the most common. When NSCLC is
Clinical Lung Cancer 2021 1
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ARTICLE IN PRESS
Precision Treatment of Advanced Lung Adenocarcinoma
diagnosed, about 50% of patients have already metastasized, and the
prognosis is poor. According to reports, the 5-year relative survival
rate is only 5.5%.1 However, in recent years, many advances have
been made in lung cancer, particularly with respect to screening,
minimally invasive diagnosis and treatment technology, and related
research in stereotactic ablation radiotherapy, targeted therapy, and
immunotherapy, all of which have brought significant benefits to
patients. Patients with metastatic lung cancer may have potential
for long-term survival.
EGFR is one of the primary driving genes associated with
lung cancer. The fraction of NSCLC cases that carry EGFR
mutations are reported to be 30% to 50% and 10%, in Asian and
Caucasian populations, respectively.2 EGFR mutations can gener-
ally be categorized into four types: exon 19 deletion mutations,
exon 21 point mutations, exon 18 point mutations, and exon
20 insertion mutations (ex 20ins). The prevalence of the ex
20ins mutation is second only to those of exon 19 deletion and
21 exon L858R, as this mutation accouns for 4% to 12% of
EGFR mutations.3 Patients with EGFR ex 20ins mutations are
mostly resistant to EGFR-TKIs; however, patients with a specific
mutation type (A763 Y764insFQEA) are sensitive to first- and
second-generation epidermal growth factor receptor-Tyrosine kinase
inhibitors (EGFR-TKIs). Currently, there is no standard targeted
therapy for these cases. However, as research progresses, promising
results have been reported for several drugs, including high-dose
Osimertinib,4 bosutinib,5 Luminespib,6 and JNJ372.7
In 2007, the Anaplastic Lymphoma kinase (ALK) fusion type
was discovered for the first time in NSCLC and was confirmed
to be a driver gene of lung cancer. The incidence of ALK fusion-
positive NSCLC is 3% to 7%, with no significant differences
between Eastern and Western cohorts. Research on ALK is devel-
oping rapidly. The PROFILE 1014 study8 demonstrated that the
efficacy of first-line crizotinib was higher than that of platinum-
containing doublet chemotherapy. In addition, median PFS was
significantly prolonged (10.9 months vs. 7.0 months, P < .001),
and ORR was significantly improved (74% vs. 45%, P < .001).
The PROFILE 1029 study9 on ALK-positive Asians also reached the
primary endpoint. Brigatinib can simultaneously inhibit ALK and
EGFR mutations. In a phase II clinical study (NCT02094573),10
patients who were resistant to crizotinib were given Brigatinib, and
the median PFS durations were 9.2 months (Brigatinib 90 mg) and
15.6 months (Brigatinib 180 mg). Based on this study, the FDA
approved Brigatinib in 2017 for the treatment of advanced ALK-
positive NSCLC in patients with crizotinib resistance.
The incidence of ROS proto-oncogene 1 receptor tyrosine kinase
(ROS1) gene mutations in NSCLC is 1% to 2%.11 The OO1201
study12 showed that the median PFS following crizotinib treatment
Fig. 1 Genetic test report of EGFR.
2 Clinical Lung Cancer 2021
Please cite this article as: Yaping Zhang et al, Precision Treatment of Advanced Lung Adenocarcinoma With Coexisting EGFR, ALK, and ROS1 Mutations:
A Case Report, Clinical Lung Cancer, https://doi.org/10.1016/j.cllc.2021.01.008
[mNS;February 24, 2021;12:30]
for ROS1 fusion gene-positive advanced NSCLC is 15.9 months,
with an ORR of 71.7%. Based on this result, crizotinib is currently
recommended as a first-line treatment for stage IV NSCLC in
patients positive for the ROS1 fusion gene.
EGFR and ALK double mutations are rare events, and patients
who are positive for 3 driver genes (EGFR, ALK, and ROS1) are
even rarer. As the two most important driver genes of NSCLC,
EGFR, and ALK mutations are typically considered to be mutually
exclusive. However, as genetic testing has increased in popularity
in recent years, a few instances of co-mutation have been reported
in the literature.13-15 Compared to Caucasian populations, East
Asian populations seem to be more susceptible to co-mutation of
EGFR and ALK. Yang13 conducted immunohistochemical testing
on 977 NSCLC patients and found that 13 (1.33%) had co-
mutation of EGFR and ALK. Furthermore, this study suggested
that the phosphorylation level of EGFR and ALK is related to
the efficacy of treatment with EGFR-TKIs and ALK-TKIs. Of the
study cohort, two patients with baseline expression patterns of “low
EGFR and high ALK” developed resistance to EGFR-TKIs treat-
ment, but ALK-TKI treatment remained effective. In contrast, 2
patients with baseline expression patterns of “high EGFR and low
ALK” responded partially to first-line EGFR-TKI. However, for
these patients, the disease progressed after crizotinib treatment, and
no reduction in tumor size was reported. Won15 performed EGFR
and ALK tests on 1445 cases of NSCLC, and EGFR and ALK co-
mutations were detected in four cases by direct sequencing. When
using PNA real-time PCR and mutant-enriched NGS, the rate of
co-mutation increased to 8.8% (8/91) and 15.4% (14/91), respec-
tively for ALK-translocated NSCLC. Their data may suggest that
an increased incidence of co-mutation can be observed for cases of
NSCLC when advanced molecular genetic technologies are used.
Of 14 patients treated with gefitinib, 3 showed poor response.
However, 8 patients showed a positive response to ALK inhibitor
treatment, with a response rate of 87.5% (7/8 with partial response)
and durable, progression-free survival reported (Figures 1-3).
ROS1 mutations are also more common in patients lacking
mutations in EGFR, ALK, or KRAS.16 A previous study17 demon-
strated that, among 62 patients with ROS1-rearranged NSCLC,
none harbored concurrent ALK fusions or EGFR mutations.
However, a few contradictory reports have been presented in recent
years.18-20 , 22 For example, Wiesweg21 reported that patients with
ROS1 mutations had a high proportion of oncogene mutations.
Immunohistochemical testing of 1345 patients found that 25 cases
were positive for ROS1, 6 of which were accompanied by EGFR
mutations. Similarly, Ju22 reported a patient with co-mutation of
EGFR, KRAS, and ROS1. The patient responded effectively to
treatment with icotinib, but was resistant to crizotinib.
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ARTICLE IN PRESS
Fig. 2 Genetic test report of ALK and ROS1.
Fig. 3 Lung CT scans from (A) March 2016, (B) December 2017, (C) July 2018, and (D) September 2018.
Based on the author’s literature analysis, although patients with
co-mutation of EGFR/ALK or EGFR/ROS1 have been previously
reported, no cases of co-mutation of EGFR, ALK and ROS1 have
been reported. The patient described in this article was diagnosed
with advanced NSCLC with mutations in EGFR (20ins), ALK, and
ROS1. First-line treatment with crizotinib resulted in 28 months of
PFS, and second-line treatment with Brigatinib in an additional 8
months. OS was 38 months, slightly poorer than anticipated for
patients with single driver gene mutations. NSCLC patients can
carry combined gene mutations, and the combined detection of
multiple genes can increase the accuracy and efficacy of targeted
therapies. However, many questions remain to be answered. For
example, is there a connection between coexisting gene mutations?
How do coexisting mutations affect one another (eg, in an activa-
tion relationship)? What is the relationship between mutation
status and clinicopathological characteristics? Further analysis will
be required to address these issues. It is generally believed that
patients with multiple gene mutations have worse prognoses than
those with single driver gene mutations.14 There is currently a lack
of unified consensus regarding first-line targeted therapy for these
cases. Although detection technology, mutation abundance, and
other factors should be considered, the therapeutic effect is incon-
clusive. While the simultaneous use of multiple types of targeted
drugs would address this issue from the perspective of heterogene-
ity, this strategy is associated with increases in both toxicity and
treatment costs, and there is currently no related report with a large
sample population.
Declaration of Competing Interest
We declare that we have no financial and personal relationships
with other people or organizations that can inappropriately influ-
Please cite this article as: Yaping Zhang et al, Precision Treatment of Advanced Lung Adenocarcinoma With Coexisting EGFR, ALK, and ROS1 Mutations:
A Case Report, Clinical Lung Cancer, https://doi.org/10.1016/j.cllc.2021.01.008
[mNS;February 24, 2021;12:30]
Yaping Zhang et al
ence our work, there is no professional or other personal interest
of any nature or kind in any product, service and/or company that
could be construed as influencing the position presented in, or the
review of, the manuscript entitled.
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Precision Treatment of Advanced Lung Adenocarcinoma

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4 Clinical Lung Cancer 2021

Please cite this article as: Yaping Zhang et al, Precision Treatment of Advanced Lung Adenocarcinoma With Coexisting EGFR, ALK, and ROS1 Mutations:
A Case Report, Clinical Lung Cancer, https://doi.org/10.1016/j.cllc.2021.01.008